| 91 |
AVAMERE HEALTH SERVICES OF ROGUE VALLEY |
385024 |
625 STEVENS STREET |
MEDFORD |
OR |
97504 |
2019-06-20 |
689 |
G |
1 |
0 |
90J611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to ensure resident care equipment was in safe operating condition for 1 of 3 sampled residents (#5) reviewed for falls. This resulted in Resident 5 being sent out to the hospital for uncontrolled pain and a right [MEDICAL CONDITION]. Findings include: Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. A complaint was received on [DATE] indicating Resident 5 had a fall on [DATE] in the facility that resulted in a [MEDICAL CONDITION]. Witness 5 (Complainant) indicated in the letter she received a phone call around 4:00 AM from Resident 58 and the resident was in distress. She found out Staff 43 (CNA) was in the resident's room to assist the resident to the bathroom by herself. The resident was suppose to be a two person assist when utilizing the sit to stand machine (an assistive device to be transferred between a bed and a chair or other similar resting places). Witness 5 called the resident and while talking with the resident she/he stated All I know is that one leg went this way and one leg went that way. And then the resident started screaming like crazy for help and was in terrible pain. She/he then said, Here talk to the nurse and handed the phone to Staff 44 (LPN). Staff 44 indicated the resident was complaining of pain in her/his leg and thought it might have been a blood clot and was sending the resident to the emergency department for further evaluation. An undated Kardex (a form utilized by CNAs to provide care to residents) indicated Resident 5 was a two person assist with all ADLs including transfers. A Fall Investigation dated [DATE] at 11:00 AM by Staff 36 (Interim DNS) revealed the following: -The resident was sent out to the hospital for uncontrolled pain and agitation. The resident had a right [MEDICAL CONDITION]. Witness 5 (Complainant) reported the resident had a fall. -The investigation indicated Resident 58 stated about 3:30 AM Staff 43 (CNA) was walking to take the resident to the bathroom. Staff 43 went into the room and the resident started yelling like in pain. Resident 58 heard the resident state she was falling and stated it was after this the resident started yelling. -The investigation indicated Staff 36 was informed Resident 5 was sent out to the hospital at 3:30 AM and the day shift nurse stated the emergency department informed the staff the resident would not return due to a right [MEDICAL CONDITION]. -Per chart review Witness 5 reported Resident 5 was placed in the sit to stand lift to be toileted and only one CNA, Staff 43 was available and the resident started to slip down. The patient fell down to the floor and complained of leg pain. -Witness 5 reported Staff 44 (LPN) called Witness 5 and was worried the resident may have had a blood clot so Staff 44 sent the resident out to the hospital. Witness 5 then found out the resident had fractured her/his hip. -Interviews completed on [DATE] indicated Staff 43 and Staff 40 (CNA) were both transferring the resident to the bedside commode when the battery on the sit-to-stand machine died . Staff 40 left the room to exchange the batteries. Upon Staff 40s return the resident stated My legs are giving out and instead of using the sit-to-stand machine to lower the resident Staff 43 and Staff 40 both manually lowered the resident to her/his knees and then laid the resident down with pillows under her/his head. -Staff 44 came down the hall and saw Staff 40 getting new batteries for the sit to stand machine. When Staff 44 entered the room the resident was on the floor with a Hoyer (mechanical lift) sling (a device used to suspend the resident in the Hoyer) by the resident's bed. They had difficulty rolling the resident due to her/his leg pain. Staff 44 assessed the resident and gave the resident a pain pill after they used the Hoyer to get the resident back into bed. -The resident was in bed for approximately 20 to 30 minutes and began calling out in pain and Staff 44 was advised to send the resident to the hospital. Staff 44 reported to Staff 36 that Staff 40 and 43 indicated to her the resident did not fall. Staff 44 indicated to Staff 36 she did not know how to use the sit to stand machine. -X-rays from the hospital revealed a mildly displaced right intertropchanteric (hip) fracture. Non-displaced (the broken bones remain aligned) right proximal (just below the knee) fibular (the smaller shin bone) fracture. The report indicated irregularity in the posterior aspect of the medial tibial (large shin bone) plateau may represent a non-specific fracture, given the amount of osteopenia, consider non-emergent MRI (magnetic resonance imaging) of the right knee for further characterization. -The root cause: Fracture during transfer. It is reasonable to believe related to statements that the fracture occurred either upon rising with sit to stand or lowering to floor related to [MEDICAL CONDITION] (degeneration of the joints) and osteopenia (reduced bone mass). The care plan and Kardex (a tool utilized for CNAs to provide care) were followed and abuse and neglect could not be substantiated or unsubstantiated related to the sit to stand machine and Staff 40 leaving the room to get the battery. An undated form had three separate statements from Staff 44, Staff 40 and Staff 43 and revealed the following: -Staff 43 stated she and Staff 40 were using the sit to stand machine to get the resident up and transferred to the bathroom. The battery on the machine died . Staff 40 went down the hall to exchange the battery. The resident stated to Staff 43 my legs are giving out and at that point Staff 40 returned and instead of using the machine they both manually lowered the resident to her/his knees and then laid the resident out with a pillow under her/his head. Staff 44 arrived and helped move the resident's bed away from the wall so they could used the Hoyer lift instead. -Staff 40 stated he went to the end of the hall to obtain a new battery for the sit to stand machine. When he returned he helped Staff 43 slowly lower the resident to her/his knees and then to the ground with pillows under the resident's head. Staff 40 stated they had difficulty rolling the resident due to her/his leg pain. Staff 44 assessed the resident and gave her/him a pain pill. The resident was still in pain after they moved the resident into bed. -Staff 44 stated she came around the corner and saw Staff 40 down the 200 hall and could hear the resident yelling at the end of the hall. Staff 40 was getting a new battery for the sit to stand machine. Staff 44 entered the room and the resident was on the floor with the Hoyer sling by her/his bed. The resident was complaining of leg pain. Staff 44 assisted the two CNAs with getting the resident back into bed. Resident 5 was watching TV comfortably for ,[DATE] minutes until the resident began calling out in pain. Staff 44 called the on call physician and was advised to send the resident to the hospital. Staff 44 stated the aides told her the resident did not fall, and Staff 44 did not know how to use the sit to stand machine. A Fall investigation dated [DATE] completed at 9:05 PM by Staff 44 revealed Resident 5 continued to have behaviors, yelling at staff and very forgetful. Resident was up in a sit-to-stand machine to be transferred to bed. Battery to the sit-to-stand dead x 3. Resident yelling, so staff lowered Resident to floor onto blue mesh sling for Hoyer transfer to bed. Resident hoyered to bed with 3 staff assist. No noted injury at this time. Resident continue to complain of pain, 'pain all over honey.' Observed bilateral lower extremity for injury, increased [MEDICAL CONDITION], redness and heat. No noted changes. Resident does not use her/his lower extremity so no range of motion was not observed. Reassured and redirected without success. Pain medication was given, yet resident continues to yell and states staff doesn't like her. Call made to on call physician and resident was sent out to the emergency department for evaluation and treatment. Resident was aware of the plan, Witness 5 was notified. Hospital records dated [DATE] through [DATE] revealed Resident 5 had a history of [REDACTED]. The resident resided at an assisted living facility and said that she/he had an incident when they were transferring her/him to the bathroom. According to Witness 5 the resident had been non-ambulatory since 2012. On [DATE] at 9:51 AM Staff 43 stated she worked night shift, which started at 10:00 PM. She recalled on [DATE] the resident needed to use the bathroom. Staff 43 indicated she and Staff 40 got the resident up in the sit to stand machine and the battery went dead in the machine. Staff 40 went out and got a battery just outside the hallway and that battery was not good either. Staff 40 had to go a little farther down the hall to get a second battery and that one was also not working. She indicated the batteries were often dead in the sit-to stand machine you never knew when they were going to stop working until you used them. The battery worked just fine to get the resident up into the sit to stand and then went dead prior to being able to lower the resident back down onto the resident's bed. Staff 42 indicated Resident 5 was only in the sit to stand for about two minutes before she and Staff 40 lowered the resident to the ground manually, and they took the resident out of the sit-to-stand station and down to the floor. She and Staff 40 then had a Hoyer sling that was not underneath the resident when they lowered the resident manually to the floor, so they log rolled the resident on the floor to get the Hoyer sling underneath the resident. They then lifted the resident up into bed. Staff 43 further indicated Staff 40 was in the room when the resident was put into the sit to stand machine prior to trying to get the resident to the bathroom. Staff 43 stated the resident was screaming the whole time, that she/he was hurting, hurting for months. She indicated the resident was a screamer, did not like to use the call light and pounded on the walls. She stated Staff 44 came into the room and sent the resident out to the hospital. On [DATE] at 8:00 AM Staff 17 (CNA) stated she worked night shift and worked on the evening of [DATE] when Resident 5 had her/his fall, however she was assigned another hallway. She indicated she had worked with the resident on multiple occasions and the resident was alert and oriented and on occasion would have some confusion. Staff 17 stated the resident did not scream and holler to her knowledge during the night shift. The resident was a two person sit to stand transfer and indicated the batteries for the sit to stand machine were located at the front of the hallway next to the scale and the resident's room was at the very end of the hall. She indicated when the batteries start to run low the machine would stop and go. She always carried an extra battery pack with her for a back up. On [DATE] at 9:29 AM Staff 5 (CNA) stated she worked with Resident 5 on multiple occasions, however was not present on [DATE]. She stated the resident was a two person sit to stand transfer. She stated they utilized an under arm sling for the resident when in the sit to stand, the resident bared weight with her legs, although could not for very long. If the batteries in the sit to stand ran low the machine would get more sluggish and a few of them would make a chirping noise. She stated if the batteries died the sit to stand had an emergency lever to utilize and you could get the resident back to a safe area and lower the resident back down safely. She indicated the batteries were to be changed at beginning of every shift, however this did not always happen. An observation on [DATE] at 8:34 AM revealed the sit to stand, and hoyer lifts, scale and batteries were located at the front of the 200 hall. There were four batteries on the wall adjacent to the scale. The batteries were all plugged in the outlet and all four revealed a small green light indicating charge/on. Below that green light was another light and a word next to it that indicated charge. The batteries and the sit to stand station was approximately ,[DATE] feet from Residents 5's room. Resident 5's room was at the very end of the hallway on the right hand side. On [DATE] at 9:11 AM Witness 18 (Family Member) visited Resident 5 often and indicated she went to the hospital after Resident 5 had a fall on [DATE] and Witness 18 was told the resident needed to use the bathroom and only one CNA was present. The CNA attempted to get the resident up in the sit to stand machine, which the resident required two CNAs for a transfer. She stated Resident 58, who was up that night, heard what was going on and recorded the incident. Witness 18 stated apparently the batteries went dead on the sit to stand machine and the resident was only half way in the sit to stand machine and screaming she was falling. Resident 5 was 300 pounds and there would be no way the resident would have a graceful fall to the floor. Witness 18 stated a call was placed to Witness 5 regarding the resident having a possible infection and the facility sent the resident out to the hospital. Witness 18 indicated she found the facts disturbing and not adding up. The recording she listened to she could hear the resident screaming in pain and only heard one CNAs voice on the recording. On [DATE] at 5:17 PM Staff 44 worked night shift, was familiar with Resident 5 and indicated she/he was alert most of the time with mild confusion. She recalled the incident on [DATE] and stated Resident 5 was hollering in the hallway and she saw Staff 43 take the resident into her/his room. She did not recall seeing any other staff with Staff 43 at that time. The resident continued screaming so she finally went down to the room to see what was going on and both Staff 40 and 43 were in the room with the resident on the floor and on a Hoyer sling. They preceded to get the resident back up using the Hoyer and she supported the resident's head as the two CNAs moved the resident back into bed. Staff 44 indicated she did not witness Staff 40 or 43 lowering the resident to the floor but arrived after the incident and both the CNAs were very upset about all three batteries being dead and having to lower the resident to the ground manually. Once the resident was back in bed the resident was complaining of back pain so she asked the resident if she/he wanted a pain pill, which the resident accepted. Staff 44 stated the resident continued to holler about being painful and needing to use the bathroom, however they did not get the resident back up. She stated after 30 minutes the pain medication was not effective and she then completed an assessment on the resident, although since the resident did not walk she did not do any range of motion testing to the the lower extremities. The resident continued complaining and pointing to her/his low back area and she sent the resident out to the hospital, she had a feeling it may have been the resident's leg. In an interview and observation on [DATE] at 8:39 AM Staff 41 (CNA) stated she was familiar with Resident 5 and indicated she/he could direct her/his own care but at times could be forgetful. She was not present when the fall occurred on [DATE] though indicated the resident was a two person sit to stand for all transfers. They would utilize the sit to stand to get the resident to the bathroom. The resident could bear weight on her/his feet when in the sit to stand and also utilized her/his arms for support. She indicated the sit to stand lifts are battery operated and she would personally change the batteries out at the beginning of her shift. When the batteries are getting low some would make a beeping noise. She further stated they also had an emergency lever you could utilize to lower the resident down safely if the battery went dead. Staff 41 showed the surveyor the sit to stand machine and the red emergency lever that was on each one and demonstrated how to utilize the button. The machine lowered down once a CNA pressed the emergency lever. On [DATE] at 2:09 PM Resident 58 stated she/he was awake the night of [DATE] when Resident 5 fell . She/he stated her/his door was partially cracked open and she/he saw Staff 43 walking in front of the resident who was in her/his electric wheelchair and they were going to the resident's room. Resident 58 stated she/he was across the hall and down a couple doors. She/he indicated she/he could hear the resident hollering I am falling, I am falling and Staff 43 stated your not falling, you always say this. She/he then heard Staff 43 hollering that she needed help and stated this a couple of times. The resident saw Staff 40 running down the hall towards the resident's room. The resident was crying out in pain and asking for Witness 5 so Resident 58 phoned the witness and alerted her of what she/he heard. On [DATE] at 2:44 PM Staff 36 (Interim DNS) stated both Staff 40 and Staff 43 reported to him they were both in the room at the time the resident had the fall. The CNAs both reported the batteries died in the sit to stand machine and they had to manually lower the resident to the floor. Staff 36 stated as the CNAs lowered the resident to the floor, the resident's hip could have spontaneously fractured. Neither Staff 40 or 43 utilized the emergency lever on the sit to stand machine to his knowledge. When asked the question how would Staff 40 and 43 get the resident out of the sling from the sit to stand? Staff 36 stated both CNAs would have to be able to lift the resident up, then the straps would have to be removed and then lower the resident down to the floor. Staff 36 further indicated both CNAs got the resident back into bed and Staff 44 administered pain medication to the resident and the resident had pain for approximately ,[DATE] minutes and then the resident started screaming in pain and the resident was sent out to the hospital. On [DATE] at 11:33 AM Staff 2 (DNS) was present and Staff 1 (Administrator) stated he helped with the investigation and interviews. Staff 40 and 43 had similar statements regarding the controlled fall on [DATE]. He indicated neither Staff 40 or 43 explained how they removed Resident 5 from the sit to stand machine other than they manually lowered the resident to the floor. He acknowledged they did not have a system in place to ensure batteries were charged appropriately or changed out after each shift by CNAs. He also indicated maintenance should check the batteries on a regular basis but was unable to find any documentation this occurred. On [DATE] at 3:14 PM Staff 1 stated maintenance did weekly checks to assure batteries were working and charged appropriately. When asked when the system was put into place for maintenance to check batteries Staff 1 indicated that was implemented the week prior to [DATE]. |
2020-09-01 |