|§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.|
Based on review of incident/accident investigation information and clinical records, as well as staff interviews, it was determined that the facility failed to maintain essential resident care equipment in a safe manner for 55 residents that required the use of mechanical lifts, (Residents 1 through 55), which resulted in actual harm to Resident 2 when the lift broke and the resident fell to the floor and struck his head. The resident was sent to the hospital and diagnosed with a brain bleed. .
Review of the manufacturer service manual for the Viking M lift, dated December 27, 2012, revealed, "The lift must be thoroughly inspected when the Service Light at the control unit CBL illuminates (a display on the equipment that indicates serving is required), or at least once per year. Viking with other control unit shall be thoroughly inspected at least once per year. Inspection and service must be carried out by (distributorauthorized personnel."
Review of the manufacturer instruction guide for the Uno 102 lift, dated August 22, 2013, revealed, "A periodic inspection of the lift should be carried out at least once per year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (distributorand using original (manufacturer) spare parts."
Review of the manufacturer instruction guide for the Sabina II sit-to-stand lift, dated March 12, 2012, revealed, "Sabina should be periodically inspected at least once a year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (manufacturer) and using original (manufacturer) spare parts."
Review of an incident/accident investigation information form provided by the facility dated February 2, 2019, revealed that on February 2, 2019, at approximately 8:38 PM Resident 2 was being returned to bed, when the Viking M lift, which was being used broke, and the resident fell to the floor and struck the back of his head on the floor, resulting in a laceration to the left posterior (back) of the head with bleeding present. Resident 2 was assessed and transported to the hospital where Resident 2 was diagnosed with an intraparenchymal hemorrhage of the brain (intracerebral bleeding), a subdural hematoma (blood gathering between the inner layer of the dura mater and the arachnoid mater surrounding the brain), and a subarachnoid hemorrhage (bleeding into the area between the arachnoid membrane and the pia mater surrounding the brain).
An interview with the Facilities Director on February 14, 2019, at 3:42 PM revealed, "they (the lifts in the facility) have not been serviced by the manufacturer" and that the facility staff had not been trained by the lift manufacturer to service the lifts.
During an interview with the Nursing Home Administrator (NHA) on February 14, 2019, at 4:50 PM the NHA revealed that the facility did not have a contract with an authorized service company to inspect and service the lifts in the facility annually, as specified in the Instruction Guides and Service Manuals for the three types of lifts being utilized in the facility. When asked for her expectation regarding the contracts she replied, "we should have had them."
The facility failed to ensure that the mechanical lifts were maintained, inspected and serviced by authorized service providers which resulted in actual harm to Resident 2 when the lift broke and the resident fell to the floor and striking his head, resulting in a brain bleed.
28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 1/31/19, 1/12/18.
28 Pa. Code 201.18(b)(1)(3) Management.
Previously cited 1/31/19, 7/19/18.
28 Pa. Code 201.18(e)(1) Management.
Previously cited 7/19/18.
28 Pa. Code 207.2(a) Administrator's responsibility.
| ||Plan of Correction - To be completed: 03/07/2019|
Development and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed by provisions of Federal and State Law.
1.R2's health status is back to baseline.
R1 and R3-R55 were not affected.
Facility will continue quarterly preventative maintenance on the lifts.
Upon further investigation it was determined that the lift broke due to a manufacturer defect.
2.Lift Maintenance Policy updated.
3.NHA/designee educated maintenance personnel on updated Lift Maintenance Policy.
LW Consulting completed a directed in-service on 3/6/19 and 3/7/19 with nursing staff, maintenance and administration. Staff who did not attend the meetings will be required to watch a recording of the directed in-service prior to their next scheduled shift.
4.NHA/designee will complete annual audits to ensure lift inspections are completed by authorized personnel annually.
Findings of the audits will be reported to the facility Quality Assurance/Performance Improvement committee to determine need for additional actions and or monitoring.
5.Date of Compliance: 3/7/19