cms_WV: 11419
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11419 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 225 | D | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to conduct a thorough investigation, and make a report to the Nurse Aide Registry of two (2) nursing assistants, of neglect involving one (1) of eighteen (18) sampled residents who was injured during an unsafe transfer. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The facility's internal investigation into this fall was not thorough as evidenced by a failure to conduct an interview with the affected resident, who was alert and oriented and available for interview upon her return from the hospital to the facility; when interviewed by a surveyor, the resident related information markedly different from what had been reported by staff involved in the incident. The facility also failed to identify during its investigation that the sit-to-stand lift was not used in accordance with the manufacturer's instructions. The two (2) nursing assistants who were involved in the transfer failed to ensure the legs of the sit-to-stand lift were in the maximum open position for stability prior to attempting to transfer the resident. The facility did not identify this as neglect and/or report the individuals involved to the appropriate State agencies as required. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion with one (1) leg with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 296#. According to her most recent abbreviated quarterly assessment with an ARD of 05/12/10, in Section G, the assessor noted Resident #54 required the extensive physical assistance of two (2) or more staff for bed mobility, and she was totally dependent on two (2) or more staff for transfers. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion in both legs with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 298#. Review of her care plan revealed the following problem statement with an initiation date of 05/18/10: "Resident at risk for falls r/t (related to) decreased mobility and weakness. (sic) hx (history) of falls and med usage." The goal associated with this problem statement, with a target date of 08/18/10, was: "Will have no injury r/t falls thru next review." Interventions to achieve this goal included: "up (sic) with sit to stand lift for all transfes (sic) wbat (weight bearing as tolerated) per orders." Review of her physician orders [REDACTED]." -- A nursing note, recorded by Employee #104 (a registered nurse) and dated 08/15/10 at 12:45 p.m. revealed, "Called to resident room. Resident was holding onto bar of sit to stand with hands. Left leg was stretched under bed and right leg was twisted with knee cap facing out and foot up by chin. Resident was lowered to floor. Unable to move by staff and squad called to assist resident. 4 squad members and 2 RN (sic), 1 LPN, (sic) 2 CNA (sic) assisted resident on back board and stretcher. Support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated, I am not in w/c (wheelchair) right. Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor. Unable to obtain VS (vital signs) due to positioning. ..." -- A review of the facility's Fall Investigation / QA Report found Resident #54 fell from a sit-to-stand lift at 12:45 p.m. on 08/15/10. The resident was transported to local hospital where she was diagnosed with [REDACTED]. She was subsequently readmitted to the facility on [DATE], and she was discharged to another nursing facility at her request on 10/22/10. -- The facility's investigative report of the fall on 08/15/10 included statements from staff present during the fall and from staff summoned to the resident's room after the fall, as follows: In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: "We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor." In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: "When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more." In a statement dated 08/15/10 at "12:15 about" (per the author of the statement), Employee #22 (a nursing assistant) wrote: "I (name) was called to (initials) by another CNA (certified nursing assistant). When I entered (sic) resident was lying on floor face down with lift still attached to her. With help from 3 RNs & CNAs we lowered her to the floor completely to try to make resident as comfortable as possible until emergency squad arrived, then was (sic) asked to assist squad members to get resident on back board & out to emergency squad (sic)." In a statement dated 08/15/10 (no time noted), Employee #81 (a nursing assistant) wrote: "CNA yelled for help. I entered room and resident had slipped through the sit to stand sling. We lowered (sic) to floor. Ambulance arrived." In a statement signed on 08/18/10, Employee #135 (a registered nurse - LPN) wrote: "Called to resident's room by CNAs. Resident was in position of left leg stretched behind her & right leg twisted /c (with) foot by chin. When questioned what happened (sic) resident stated 'I slid in the lift, I let go of bar.' Denied pain @ (at) that time. Was sent to ER (sic) for eval." In a statement dated 08/16/10 at 12:30 p.m., Employee #109 (a licensed practical nurse - LPN) wrote: "On 8/15/10 ~ 12:45 p called to residents (sic) room by staff. Resident lying on abdomen in center of floor /c (R) (right) leg bent & extended out & upwards towards (R) side. Multiple staff members in room to assist. Squad notified, arrived & called for extra squad members to assist /c transport. ... Upon arrival of 2nd squad & instructions received from their Command Center, resident transferred onto backboard on abd (abdomen) /c leg supported by 8 staff & squad to cot. ..." There was no evidence to reflect the facility had interviewed the resident during their internal investigation of this fall, even though she was alert and oriented, she had been determined to possess the capacity to make her own informed medical decisions, and she returned to the facility after her hospital stay on 08/24/10. -- An interview with Employee #121 (a registered nurse), on 11/15/10 at 12:55 p.m., revealed the RN was called to the resident's room. She walked into the room and saw the resident lying on her abdomen with her right leg under her and her foot up under her chin. The other staff in the room told the nurse that the resident was being transferred from the bed and the resident changed her mind about getting up in the chair. She felt weak and let go of the bar on the sit to stand and slipped through the sling. She further stated, "The resident sustained [REDACTED]." -- An interview with the administrator, on 11/15/10 at 2:00 p.m., revealed the resident had been transferred to the wheelchair from her bed and slid out of the sit-to-stand lift when she requested to be put back to bed. He stated his belief that the two (2) nursing assistants did the transfer the resident properly, and the fall was an accident. He believed the staff involved was not negligent during the transfer, and he verified the two (2) nursing assistants were not reported to the Nurse Aide Registry. -- An interview with the physical therapist, at 9:15 a.m. on 11/16/10, revealed he had discharged Resident #54 from therapy in June of 2010, and the therapy staff had utilized the sit-to-stand lift for transferring the resident. He further stated if a resident was feeling weak, the staff should use a Hoyer lift, because the resident needed to have the strength to hold onto the bars with the sit-to-stand lift. -- In a telephone interview on 11/16/10 at 9:55 a.m., Resident #54 (who now resided in another facility) reported that she looked down during the transfer while seated in the lift and noticed the back wheel bending under. The next thing she remembered was the bar on the lift moving at an angle and then she was on the floor. She stated that the sit-to-stand lift was broken and was placed out of service for repair and, somehow, the lift was used the day she was injured. She stated, "I never said that I was weak and did not change my mind about sitting in the chair. The lift was not working properly and turned over with me still in the sling." -- An interview with the maintenance supervisor (Employee #70), on 11/16/10 at 10:00 a.m., revealed he thought that a sit-to-stand lift was taken out of service in August and there would be a work order for the repairs. He further stated the spring apparatus was not working properly and would not allow the legs to stay in the open position. He said he would go and look for the work order. At 3:00 p.m., the maintenance supervisor stated that a Hoyer lift was the equipment that needed to be repaired, not the sit-to-stand lift. -- An interview, on 11/16/10 at 10:35 a.m., with the two (2) nursing assistants involved in the transfer (Employees #92 and #134) revealed, "The resident was being transferred in the sit-to-stand lift from the resident's bed. The resident was in an electric bed, and when we had her get into the sit-to-stand lift, she said she was not in the seat right. We situated her in the seat again and moved the lift with the resident seated from under the bed. We had the legs of the lift in the straight position. The legs were not opened, and we attempted to move the resident. She let go of the bars on the lift and slid out onto the floor." -- A review of the "Owner's Operating and Maintenance" manual for the Invacare Stand Up Lift - Model RPS350-1(referred to by staff as the "sit-to-stand lift") revealed, in the section titled "Transferring From" on page 10, under the heading "Lifting the Patient (Figure 1)", the following instruction to be performed before raising a resident above the surface being transferred from: "F. Make sure the legs (of the lift) are in the maximum open position and the shifter handle is locked in place." In the above noted interview, Employees #92 and #134 stated the legs of the lift were closed (not in the "maximum open position") during the transfer of Resident #54. -- At 11:40 a.m. on 11/16/10, the director of nursing (DON - Employee #88) demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. The DON stated, "When a resident is in the lift, the legs (of the lift) are to be opened to the maximum width. The staff knows that they never have the legs closed with a resident in the sit-to-stand." She further stated, "We have some electric beds, and the sit-to-stand lift will not fit under the bed with the legs in the maximum open position. The legs will not go under the bed or you can't remove the sit-to-stand (lift) from under the bed in the open position." Observation of an electric bed verified the bed frame would not permit the legs of the sit-to-stand lift to open when placed under the bed. . | 2014-03-01 |