| 1130 |
SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, |
425112 |
807 SOUTH EAST MAIN STREET |
SIMPSONVILLE |
SC |
29681 |
2020-01-15 |
656 |
D |
1 |
0 |
62ZU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, policy review, and medical record review, it was determined the facility failed to ensure that the care plan was followed for 1 of 19 sampled residents (Resident #16). On [DATE] Certified Nurse Aide (CNA) #3 and CNA #4 transported Resident #16 back to his/her room. CNA #3 and CNA #4 stated although Resident #16 was a mechanical lift for transfer, they transferred Resident #16 back to bed without using a mechanical lift by supporting Resident #16's legs and back. Findings include: The Face Sheet, located in the Electronic Medical Record (EMR) stated Resident #16 was admitted to the facility on [DATE] and his/her [DIAGNOSES REDACTED]. An The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in the EMR stated Resident #16 had significant cognitive impairment and had not been transferred out of bed. Review of the Nurse Aide's Information Sheet that was undated, located in the EMR stated Resident #16 was confused and required a mechanical lift with two persons for transfer. During an interview with the Assistant Director of Nurses (ADON) on [DATE] at 12:30 PM, he/she stated a mechanical lift was to be used for residents who were not able to weight bear. The ADON stated Resident #16 was not able to weight bear and a mechanical lift and two staff were to be used for any transfers. The ADON stated Resident #16 was rarely out of bed. The Safe Lifting and Handling of Residents policy, dated July 2019, stated that staff lifting of residents shall be eliminated when feasible. A lift assessment should be completed on admission, quarterly, and annually, or with significant change. The Nursing Lift Evaluation Form, dated 11/4/19, located in the EMR stated Resident #16 was non weight bearing and was a full lift transfer. During an interview with CNA #1 on [DATE] at 2:30 PM and with CNA #2 on [DATE] at 9:28 AM, they stated prior to [DATE], Resident #16 had not requested they transfer him/her out of bed. CNA #1 and CNA #2 stated that on [DATE], Resident #16 requested to be transferred out of bed. CNA #1 and CNA #2 stated Resident #16 required a mechanical lift for transfers. CNA #1 and CNA #2 stated that on [DATE], they used the mechanical lift and transferred Resident #16 to a recliner chair. CNA #1 and CNA #2 said they left the lift pad under Resident #16. During an interview with CNA #3 on 01/14/20 at 2:48 PM and with CNA #4 on [DATE] a 12:59 PM, they stated on [DATE], they transported Resident #16 back to his/her room. CNA #3 and CNA #4 said although Resident #16 was a mechanical lift for transfer, there was no lift pad under Resident #16. CNA #3 and CNA #4 said they did not notify the nurse and they both carefully transferred Resident #16 back to bed, supporting Resident #16's legs and back. CNA #3 and CNA #4 said the transfer was smooth, Resident #16 did not bump his/her leg, and had no signs of pain. During an interview with the Director of Nurses (DON) on [DATE] at 1:35 PM, the DON stated Resident #16's Nursing Lift Evaluation Form, dated 11/4/19, stated the staff were to use a mechanical lift when transferring Resident #16. The DON confirmed that on [DATE] during the evening shift, CNA #3 and CNA #4 transferred Resident #16 back to bed with two staff and did not use the mechanical lift. |
2020-09-01 |