| 2538 |
MILLINGTON HEALTHCARE CENTER |
445425 |
5081 EASLEY AVENUE |
MILLINGTON |
TN |
38053 |
2019-01-27 |
658 |
J |
1 |
0 |
Q97T11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Invacare Reliant 450 (mechanical) Lift (assistive transfer device) manufacturer recommendation review, Oxford University Hospitals Occupational Therapy manual review, Lippincott Manual of Nursing Practice 10th Edition review, Mobility Advisor Wheelchair Ramps review, policy review, medical record review, and interview, the facility failed to ensure staff provided care according to acceptable standards of clinical practice to prevent accidents for 2 of 7 (Resident #1 and #2) sampled residents reviewed for accidents. The facility failed to ensure safe transport was provided for Resident #1 who was transported without staff supervision by a transport company employee, fell out of the wheelchair, sustained facial injuries and a fractured nose which resulted in Immediate Jeopardy. The facility failed to ensure staff appropriately and safely transferred Resident #2 via mechanical lift . On 11/7/18 Resident #2 sustained cheek discoloration. On 12/12/18 after a staff member transferred Resident #2 using a mechanical lift without assistance of another staff member, Resident #2 sustained extensive facial bruising, swelling, swallowing difficulties and had a fractured mandible (jaw) which resulted in actual harm and Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 in the conference room. The facility was cited an Immediate Jeopardy at F658-[NAME] The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the Oxford University Hospitals Occupational Therapy A Guide to Using Your Manual Wheelchair Safely manual dated (MONTH) (YEAR) documented, .Going down a steep slope .It is safer if the wheelchair can be guided down a steep slope backwards by a carer (caregiver) . Review of the Lippincott Manual of Nursing Practice 10th Edition documented, .Ensuring Safety .assess safety .Assess for the patient's personal safety issues-sensory deficits .The nursing process is a deliberate, problem-solving approach to meeting the health care and nursing needs of patients. It involves assessment (data collection), nursing diagnosis, planning, implementation, and evaluation, with subsequent modifications . Review of the Mobility-Advisor. com ADA (Americans with Disabilities Act) Wheelchair Ramps undated article documented, .When the front wheels hit the landing, the wheelchair can come to a sudden stop, causing the wheelchair user to fly forward . Review of the Coordination of Transportation policy dated (MONTH) (YEAR) documented, .The facility will assist in making appointments and safe transport arrangements for the resident .The facility will consider all clinical, physical, mental and financial conditions related to the transportation arrangements . Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 10 out of 15 which indicated the resident had moderately impaired cognition. A Fall Risk assessment dated [DATE] and 12/19/18 revealed a score of 14 and was .at high risk for potential falls. Resident #1's Care Plan initiated on 11/19/18 documented, The resident has an ADL (activity of daily living) Self Care Performance Deficit .Interventions .The resident requires staff participation with transfers. Resident #1's Care Plan initiated on 11/28/18 documented, The resident has impaired cognitive function r/t (related to) Dementia .Interventions .supervise . Resident #1's Nurses note dated 12/19/18 at 2:45 PM documented Patient with dental apt (appointment) today .Patient noted to have left the front door for dentist apt with (Named Transport Company) transport x1 (1 transport employee). A few mins (minutes) later entered the facility with (Named Transport Company) transport .Patient was sitting up in WC (wheelchair) with blood noted on face . Review of a statement completed by Licensed Practical Nurse (LPN #1) on 12/19/18 documented, Transportation personnel stated .we were going down the ramp, he fell forward out of chair . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked if anyone accompanied Resident #1 to the dental appointment. The DON stated, No staff accompanied (Named Resident #1) . The DON was asked the cognitive status of Resident #1 and she stated, .his cognition does come and go .he didn't remember anything after the fall .he has had previous falls . The DON was asked what was expected during transportation if a resident was cognitively impaired and she stated, If a resident is cognitively impaired then either a family member or a CNA (certified nursing assistant) goes with them .There were 2 van transport employees that day 1 stayed in the van . Review of a statement by Transportation Employee #1 and verified on 1/16/19 at 1:00 PM documented, .I went to the desk and got his (Resident #1) face sheet then we continue to leave we went down the ramp to get in the van as we started going toward the van he failed (fell ) forward out of the wheelchair .the driver got out the van help (helped) me pick him up. Interview with Transportation Employee #1 on 1/16/19 at 1:00 PM via telephone, Transportation Employee #1 was asked about the incident and he stated, I helped him (Resident #1) into the wheelchair .I backed him out the front door and down the ramp .turned him and started toward the van and he just fell forward out of the wheelchair like he couldn't hold himself up .we picked him up and got him inside. Interview with Transportation Employee #2 on 1/16/19 at 1:10 PM via telephone, Transportation Employee #2 stated, .I was in the van .I was looking down at phone dialing and then talking to dispatch. I didn't see them come out of the building, go down the ramp or fall. I just happened to look up and see him (Resident #1) on the ground . An Administrator's note dated 12/20/18 documented, .(Named Resident #1) .was asked if he could recall any events from the incident .He( Resident #1) did not know specifically if he was turned forward or not but recalled that the wheelchair stopped .He remembered the wheelchair stopping but he kept coming out of the wheelchair .Resident recalled hitting his face on the cement .he believes that his weight shifted . Interview with Resident #1 on 1/16/19 at 1:40 PM in his room, Resident #1 was asked to describe the events on the day he fell in the parking lot and he stated, .1 transport guy came to room .the transport guy took me out the front doors and down the ramp, at the bottom he stopped but I didn't, I slid out (of the wheelchair) in the driveway and landed on my knees, hands and hit my face .He took me out forward and took me down that ramp forward . Interview with Facility Staff #1 on 1/16/19 at 2:25 PM in the conference room, Facility Staff #1 stated, .I saw the transport guy push (Named Resident #1) forward through the front exit doors .he was not pulling him through the doors backwards, he pushed him forward out the front doors . The failure of the facility to ensure acceptable standards of practice were provided to Resident #1, a cognitively impaired resident with a history of falls and mobility deficits, resulted in actual harm and Immediate Jeopardy when Resident #1 was transported out of the facility by a transport company employee, was unaccompanied and unsupervised by facility staff. Resident #1 fell out of the wheelchair, sustained lacerations and a fractured nose. 2. Review of the Invacare Reliant 450 Lift manufacturer recommendation (undated) revealed, .Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures . Review of the facility Lift Management Program policy dated (MONTH) (YEAR) documented, .Our Lift Management Program is designed to meet the following goals: .To protect .residents from injury .Each co-worker is expected to support this program 100% (percent) .This procedure is always done with 2 people . Medical record review for Resident #2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was assessed with [REDACTED]. Resident #2's Care Plan initiated on 4/4/18 documented, The resident has an ADL (activities of daily living) Self Care Performance (deficit) .r/t (related to) stroke .dementia .[MEDICAL CONDITION] .Interventions .Hoyer (mechanical) lift with assist of 2 for transfers . Interview with the DON on 1/26/19 at 11:10 AM in the conference room, the DON was asked why Resident #2 was to have mechanical lift transfers by 2 people and the DON stated, We determined to use the lift and 2 people because of her size and debility. She was a large lady and completely out (paralyzed) except for a slight amount of movement in 1 arm and head. She'd had a stroke and was total care . Interview with the DON on 1/26/19 at 1:15 PM in the conference room, the DON was asked what was determined to be the cause of the discolored area (found on Resident #2's left cheek) and she stated, (Named Certified Nursing Assistant #1) had gotten her up via lift around 5:30 (AM) that morning .the sling brushing her face was the only thing we could come up with that caused the area (discoloration to cheek on 11/7/18) . An Incident Report dated 12/12/18 at 10:06 AM documented, .Witnesses Statement 12/12/18 Phone interview with (Named CNA #1) states she believes she did not have adequate assist with Hoyer lift . Interview with CNA #1 on 12/28/18 at 12:57 PM via telephone, CNA #1 was asked how she transferred Resident #2 and she stated, .I get her up in the morning, 1 person .since I've been there, I've always transferred by myself . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked what she expected staff to do during lift transfers and the DON stated, .2 people are to transfer with lifts. The facility failed to ensure staff followed the facility policy and acceptable standards of practice for an appropriate and safe transfer of Resident #2 via mechanical lift. Resident #2 was assessed to require 2 people transfers via mechanical lift. Resident #2 was found on 11/7/18 with a discoloration on her left cheek determined to have been caused during lift transfer. During a second incident on 12/12/18 Resident #2 developed significant facial bruising, swelling, deterioration of swallowing status and was found to have a fractured right mandible (jaw) on 12/12/18 after being transferred by 1 staff member via mechanical lift. This resulted in actual harm and Immediate Jeopardy to Resident #2. |
2020-09-01 |