| 8286 |
MARTHA FRANKS BAPTIST RETIREMENT CENTER |
425334 |
ONE MARTHA FRANKS DRIVE |
LAURENS |
SC |
29360 |
2012-02-08 |
323 |
G |
0 |
1 |
6G5L11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews and interviews, the facility failed to ensure that 2 of 6 sampled residents reviewed for falls remained free from accident hazards by providing adequate supervision and assistance devices to prevent accidents. For Resident #1 the facility failed to implement interventions to prevent recurrence and reduce risk after a fall. Resident #8 sustained 3 falls resulting in a shoulder dislocation and tibial fracture on separate occasions resulting from failure of the facility to provide appropriate training, supervision, and/or changes in the care plan interventions to prevent recurrence. The findings included: The facility admitted Resident #8 on 06/12/06 with [DIAGNOSES REDACTED]. Record review on 02/07/12 at 3:30 PM revealed that an incident report was written on 12/31/11 at 10:10 PM which stated, Resident was laying on floor in front of recliner chair. Staff attempted to use the lift to transfer, no connection was made. Resident slide out of recliner onto floor. The documented equipment being used at the time of the incident was lift. Nurses Notes for 12/31/11 stated that Resident #8 was complaining of right knee pain, left and right ankle pain. Resident #8 was sent to the emergency room for evaluation. Nurses Notes on 1/1/12 at 3:40 AM revealed that Resident #8 returned from the emergency room with a [DIAGNOSES REDACTED]. The second incident report, for Resident #8, which was dated for 10/21/11 at 11:15 AM stated, staff getting res (resident) off toilet on stand-up lift. Res slid out sling lowered to floor by staff. C/O (complaints of) R (right) shoulder pain, cannot move R arm and c/o R knee to ankle pain can move R leg. The documented equipment being used at the time of the incident was a stand-up lift. Nurses Notes revealed Resident #8 was sent to the emergency roiagnom on [DATE] at 12:40 PM for evaluation of right shoulder and right knee pain. Nurses Notes revealed that Resident #8 returned to the facility on [DATE] at 1:00 AM with the [DIAGNOSES REDACTED]. Continued review of the Nurses Notes dated 10/23/12 revealed that Resident #8 was wearing a sling on the right arm and mild discoloration was seen from right shoulder to neck. The third incident report for Resident #8, which was dated for 8/25/11 at 10:00 AM stated, Staff taking res (resident) to bathroom. Started sliding out of harness. Slid to floor. no injuries noted. The documented equipment being used at the time of the incident was a stand-up lift. Review of the Nurses Notes confirmed that Resident #8 slid out of the harness of the stand-up lift while going to the bathroom and that there were no apparent injuries. Upon review of the Therapy Screening Referral dated 8/25/11, regarding Resident #8's fall, it was documented on the referral wrong lift (sling) used for this transfer. Documented on the therapy screening referral dated 10/21/11 regarding Resident #8's fall out of stand-up lift was noted max assist with all transfers use full body lift per safety. Documented on the Rehab Pre-Admission Worksheet dated 10/25/11 was that Resident #8 was total assistance for transfers and total body lift staff assistance times two. There were two additional undated Rehab Pre/Admission Worksheets documenting that Resident #8 required total assistance with stand lift for all transfers with two staff and maximal/total assistance for transfers with Hoyer lift for bed to chair and bed to toilet. Physical Therapy and Occupation Therapy daily notes for 10/21/11 noted Resident #8 required maximal assistance for activities of daily living and transfers. During an interview with the acting Director of Nursing (DON) on 2/7/12 at 4:30 PM the surveyor requested the facility's policy and inservice training documentation for the staff who were assigned to transfer the residents requiring either a stand-up or Hoyer lift. The inservice documentation sheets provided by the DON completed on 9/1/11, 4/1/11, and 3/2/11 did not contain the signatures of the individuals listed on the incident reports from 8/25/11, 10/21/11 and 12/31/11. The facility's policy and procedure for lifts provided by the DON included directions: at least two people are present during transferring . An interview was conducted on 07/08/12 at 1:45 PM with Physical Therapy Assistant (PTA) #1 regarding when Resident #8 was changed from a stand-up lift to a Hoyer lift. After record review PTA #1 stated that she could not determine since two of the Rehab Admission Worksheets had not been dated. The PTA did identify that Resident #8 was assessed for use of a Hoyer lift on 10/25/11. When asked who was responsible for training the staff regarding the proper use of the stand-up and Hoyer lift, PTA stated therapy staff does the training only when nursing staff asks the therapy department for the training. The surveyor interviewed Certified Nurses Assistant (CNA) #3 (listed on the incident report dated 10/21/11) about who she had received her training from regarding the use of the stand-up lift. CNA #3 stated she was instructed by former DON approximately one year previously. When asked who instructed CNA #3 on how to use the Hoyer lift, she stated she learned from other CNA's on the floor. The facility failed to provide evidence of initial and ongoing training related to use of resident care equipment. Record review revealed a care plan that the resident was at risk for fall/injury which contained two added hand written interventions. The interventions were not dated and intervention #14 stated use appropriate lift according to therapy recommendations. The care plan was not specific as to which lift was to be used and there were no changes in interventions following the 3 falls. The care plan was not updated following the most recent fall incident dated 12/31/11. The facility admitted Resident # 1 on 2/08 and readmitted her on 3/18/10 with [DIAGNOSES REDACTED]. During record review on 2/7/12 skin sheets were noted with multiple documentation's of bruising to the resident's arms, legs, and toes. Incident reports were requested for the periods of documentation; however, only two reports were provided by the facility. A report dated 8/13/11 documented a fall in the day room with a skin tear to right hand. The report documented as steps taken to prevent recurrence : Morse Fall Scale Complete, Res.(resident) may need around the clock sitter. The Post Fall Assessment showed at the time of the fall no alarms were being used for this resident. The report noted the resident was on Lexapro 20 mg (milligrams), Trazadone 50 mg, and Lorazepam 0.5 mg. The Falls Prevention Follow-up had 2 areas checked: care plan updated to reflect fall , additional interventions added to care plan, and continue POC (plan of care). Report to Risk Committee. No other recommendations were made by the committee. Morse Fall Scale Assessments were also noted in the medical record dating back to 3/18/11. The resident scored as a high risk for falls. Sensor alarm i.e.: bed alarm and/or chair alarm initialed with low bed also initialed on the 3/18/11 assessment. Other Morse Fall Scale assessments dated 6/6/11, 6/19/11, 8/13/11, 9/18/11, and 12/18/11 also scored the resident as high risk for falls. Each of the sheets had lines drawn to include all the interventions listed for low risk and high risk, but never any new interventions. Review of the Resident's Care Plan for risk of falls documented falls on 6/6/11, 7/13/11, and 8/13/11. Interventions # 8, #9, #10, and #11 had been added to the care plan but there were no dates as to when the intervention had been added. A chair alarm when up in chair was added as an additional intervention. ( #10). An interview with the Unit Manager (RN #1) revealed that the resident had a bed alarm and a chair alarm. Review of the Physicians Orders only revealed and order for a bed alarm. The nurse stated an order would have been obtained in order to apply a chair alarm. Actual visual inspection at 11 AM on 2/8/11 of the resident seated in her wheel chair by the nurse and surveyor revealed no chair alarm in place. The sitter staying with the resident stated, She has never had a chair alarm. She has a bed alarm. During the two days of the survey, the resident was always noted up in her wheel chair. Interviews revealled the sitter only stays during the day leaving the facility responsible for the resident's supervision and safety. The sitter was not oberved during the supper meal. The incident on 8/13/11 occurred at 5:30 PM and the sitter was not present. |
2016-06-01 |