cms_WV: 11349
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11349 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 323 | G | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, review of the facility's self-reported injuries of unknown source and allegations of resident abuse / neglect, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents with injury for one (1) of eleven (11) sampled residents. Resident #147, who had partial loss of voluntary movement with limitations to range of motion in both legs and feet and who was totally dependent on staff for bed mobility, transfers, and locomotion, was assessed as needing the physical assistance of two (2) persons and a mechanical lift for safe transfers between surfaces. On 09/02/10, Resident #147 was manually transferred on three (3) separate occasions (from wheelchair to shower chair; from shower chair back to wheelchair; and from wheelchair to bed); she complained of leg pain during the second and third manual transfers. In response to her complaints of leg pain during the third manual transfer, the aides notified the nurse; the nurse contacted the physician, who ordered a stat x-ray. The x-ray revealed a displaced acute fracture of the fibula with no indication that the fracture was clinically avoidable, and the resident was subsequently transferred to the hospital on the early morning of 09/03/10. Resident identifier: #147. Facility census: 144. Findings include: a) Resident #147 1. Closed record review, on 12/21/10, revealed this [AGE] year old female was originally admitted to the facility in 2004; her most recent readmission / return to the facility occurred following a hospital stay from 12/03/08 to 12/17/08. - Her most recent comprehensive assessment was an annual assessment with an assessment reference date (ARD) of 02/24/10, in which the assessor recorded the resident as having both short and long-term memory problems with moderately impaired cognitive skills for daily decision-making, and she was able to make herself understood to others and usually understood what others said to her. According to the assessor, Resident #147 had partial loss of voluntary movement with limitations to range of motion in both her legs and her feet; tests for standing and sitting balance were not able to be attempted; she required the extensive physical assistance of one (1) person for bed mobility, bathing, dressing, and personal hygiene; she was totally dependent on two (2) or more persons for transferring, locomotion, and toilet use; she was to be transferred using a mechanical lift; and she was non-ambulatory. Her [DIAGNOSES REDACTED]., anxiety disorder and depression, and chronic obstructive pulmonary disease. The assessor did not identify, as active diagnoses, either osteoporosis or pathological bone fracture, and the assessor did not identify the resident as having any acute episode or flare-up of a recurrent or chronic problem, nor did the assessor indicate the resident had an end-stage disease. As other the ARD of 02/24/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - In Resident #147's most recent abbreviated quarterly assessment, with an ARD of 08/11/10, the assessor noted there had been no changes in her memory, cognitive functioning, or ability to communicate. She continued to have partial loss of voluntary movement with limitations to range of motion in both legs and feet; a test for standing balance was not able to be attempted, and a test for sitting balance revealed the need for partial physical support. According to the assessor, she was now totally dependent on one (1) person for bed mobility and toilet use; she was totally dependent on two (2) or more persons for transferring; she required the extensive physical assistance of one (1) person for locomotion, dressing, bathing, and personal hygiene; and she remained non-ambulatory. As other the ARD of 08/11/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - Review of her most recent comprehensive care plan (with a print date of 08/18/10) revealed the following problem statement (with a created date of 11/28/07 and a revision date of 10/08/08): "ADL (activities of daily living) Self (sic) care deficit as evidenced by need of (sic) staff support to complete her self care activities related to physical limitations, trremors (sic), pain and dementia." Goals associated with this problem statement were: "Will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing. Will receive assistance necessary to meet ADL needs. Will participate in self-care tasks at the highest practicable level of functioning." Interventions to meet these goals included: "Tranfer (sic) with 2 person / Mechanical Lift (sic)." (This intervention was created / initiated on 01/18/10.) -- 2. A review of Resident #147's nursing notes revealed the following consecutive entries: - On 09/02/10 at 10:20 p.m. - "Resident c/o (complained of) pain to (L) (left) leg. MD aware. N.O. (new order) for Stat xray (sic) to left leg. MPOA (medical power of attorney representative) aware. Assessment completed to left leg. (Symbol for 'no') bruising, (symbol for 'no') scratches, (symbol for 'no') edema, (symbol for 'no') redness noted. Resident states 'I can't feel my legs'. Xray (sic) obtain (sic) per order. Resident didn't complain of discomfort during x-ray. Xray (sic) to be faxed to nurses (sic) station." The author, registered nurse (RN) supervisor Employee #134, struck through this entry and labeled it "error", although the author did not note the date / time when this correction was made. - On 09/03/10 at 1:00 a.m. - "C/O (complaint of) pain in left leg. PRN (as needed) analgesic x 1 per order /c (with) No (sic) relief." - 09/03/10 at 2:30 a.m. - "Xray (sic) results called to Dr. (name) /c new order noted to send to ER (sic) (emergency room ) for evaluation & ortho (orthopedic) consult d/t fx (fracture) of left fibula. ..." - 09/03/10 at 3:15 a.m. - "Left unit via gernie (sic) accompanied by two attendants from ems (emergency medical service) en route to (name of local hospital)." - After the resident's transfer to the hospital on [DATE], Employee #134 recorded the following series of late entries: - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 7:30 p.m. Resident complaint (sic) of pain to left leg. Assessment completed to left leg. (Symbol for 'no') bruising noted. (Symbol for 'no') redness. (Symbol for 'no') edema, or scratches noted to left leg. resident (sic) c/o pain in the knee area. Resident stated 'I can't feel my legs.' Call placed to MD. resident (sic) medicated for pain per order. Will continue to monitor." - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 8:00 p.m. MD return (sic) call obtain (sic) order for stat xray (sic). POA (power of attorney) aware. (Name of mobile imaging company) aware." - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 8:45 p.m. Xray's (sic) obtained, daughter /c resident at bedside. (Symbol for 'no') complaints of pain at this time. Will continue to monitor resident and await the report." - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 10:20 p.m. Resident resting in bed. (Symbol for 'no') discomfort noted. (Symbol for 'no') complaints of pain noted. Awaiting xray (sic) to be faxed to nurses (sic) station. (Symbol for 'no') edema, (symbol for 'no') bruising, (symbol for 'no') redness noted to left leg. Will continue to monitor." This was the last entry in the resident's nursing notes; she did not return to this facility after being transferred to the hospital on [DATE]. -- 3. The radiology report for Resident #147 from the mobile imaging company, with a "date of exam" of "2010-09-02" (09/02/10) contained the following impression: "Left tibia-fibula - Mildly displaced acute fracture of the proximal fibular shaft and fibular head demonstrated." There was no evidence to reflect this acute displaced fracture of the left fibula of this non-ambulatory resident, who was totally dependent on staff for bed mobility, transferring, and locomotion, was clinically unavoidable (e.g., the result of osteoporosis or a pathological bone fracture). -- 4. A review of the facility's self-reported allegations of resident abuse / neglect and injuries of unknown source, on 12/21/10 beginning at approximately 11:00 a.m., revealed the facility reported Resident #147's fracture as an injury of unknown source to the State survey and certification agency and other State agencies on 09/03/10 as follows: "Resident complained of 'not being able to feel' her leg. Obtained xray (sic) of left leg and results showed fracture. ..." The date of the incident was noted to be on 09/02/10 during the 3:00 p.m. to 11:00 p.m. shift (no specific time stated); the location of the incident was noted to be "Unknown". - Review of the facility's internal investigation into this fracture of unknown source revealed that, although a discreet causal event could not be isolated, three (3) nursing assistants (Employees #152, #141, and #170) transferred the resident on 09/02/10 without using a mechanical lift as identified in the resident's comprehensive assessment and care plan. - According to a handwritten witness statement by the former interim director of nursing (Employee #171), dated 09/08/10: "During the termination phase of the disciplinary process for (Employee #152, CNA (certified nursing assistant), regarding (Resident #147) (sic). The employee made the following verbal statements: "'About 4 pm (sic) (Resident #147) was sitting in w/c (wheelchair) in hallway crying. I asked her what was wrong and (Employee #141, another nursing assistant) said she always cries when she looses (sic) at Bingo. I ask (sic) her if she wanted to take a shower. I took her to the shower room in the wheelchair.' "'(Employee #170) had stayed until 7:00 PM (sic) to do showers; (Resident #147) was still crying. (Employee #170 and I stood (Resident #147) and pivoted her to the shower chair. I left and came back when shower was done; we dressed her, stood and pivoted her from the shower chair to the wheelchair. I took her back to her room, she usually is only out of bed for an hour. I was going to put her in bed; I did a face to face lift; she wasn't bearing weight but she started saying 'my leg, my leg, set me down. (sic) I set her down and called to (Employee #141) to help me. We transferred her to bed with (Employee #141) behind her, me in front; we stood her and pivoted. "We didn't use a gait belt; we didn't use a mechanical lift. "'I did not check the Patient information worksheet.' "'I know we are a no lift company.' "'I have used the lift in the past.' ..." -- 5. Upon request, the facility provided a copy of the policy titled "Mechanical Lift" (dated 03/10/10). According to this document, the purpose of the policy is "(t)o move immobile or obese patients for whom manual transfer poses potential for staff or patient injury". Review of the facility's employee handbook revealed, under the heading "Safety Rules" on page 38: "1. Report all accidents immediately, no matter how minor, to your supervisor. Your supervisor is required to make a thorough investigation and to complete an Accident Investigation Report. You are required to complete an Employee Incident Report for on-the-job accidents. "2. Utilize appropriate lifting techniques and body mechanics for all lifting, including patient / resident transfers. All lifting must be performed in accordance with location procedures. Utilize mechanical lifting equipment where appropriate. ..." -- 6. On the Patient Information Worksheet, Resident #147 was listed as requiring "2 person / Mechanical Lift". -- 7. In an interview on 12/22/10 at approximately 3:00 p.m., Employee #134 stated she did work on 09/02/10. She came back to work on 09/09/10 and recorded additional documentation in Resident #147's medical record, after she realized she had made an error regarding the time of the incident in her original note. Employee #134 stated a nurse aide did inform her that the resident complained of pain on the evening of 09/02/10. She assessed the resident's leg, and the resident did not appear to have any swelling, redness or tenderness to her leg during the assessment. She assisted the mobile imaging company during their x-ray of the resident's leg, and the resident did not appear to be in any pain at that time. -- 8. In an interview on 12/22/10 at approximately 3:30 p.m., Employee #141 stated his employment was terminated after this incident, but he was later asked to return to work. He reported he was not the aide assigned to Resident #146 on 09/02/10, but he did assist his co-worker (Employee #152) on that day. He verified they did not use a mechanical lift to transfer the resident from her wheelchair to her bed. He agreed he should have looked to see what type of assistance the resident needed for transferring before he assisted Employee #152, but he reiterated that he had his own assignments and had just agreed to help out a co-worker with a transfer on 09/02/10. -- 9. The assistant director of nursing (ADON - Employee #139) confirmed, during an interview on the afternoon of 12/22/10, the facility was a "no lift company". The ADON also confirmed that no incident / accident report was completed related to the events that took place on the evening of 09/02/10 involving Resident #147. -- 10. Although it could not be ascertained at what time the fracture occurred on 09/02/10, staff manually transferred Resident #147 on three (3) separate occasions on this date (from the wheelchair to the shower chair; from the shower chair back to the wheelchair on the evening; and from the wheelchair to the bed), contrary to the resident's comprehensive assessment, comprehensive care plan, and the Patient Information Sheet. The resident complained of leg pain during the second and third manual transfers, and the fracture was identified via x-ray in response to the resident's complaints of leg pain after the third manual transfer occurred. . | 2014-04-01 |