|§483.35 Nursing Services|
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).
§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.
§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Based on observations, a review of clinical records, a facility investigation report and manufacturer's directions and staff interviews it was determined that the facility failed to ensure that nursing staff possessed the skills and competencies to assure resident safety and perform emergency operation of a mechanical when necessary as evidenced by one resident out of six residents reviewed (Resident CR1).
A review of the clinical record revealed that Resident CR1 was admitted to the facility on September 28, 2015, with diagnoses to include dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), diabetes (group of metabolic diseases in which there are high blood sugar levels over a prolonged period), atherosclerotic heart disease (plaque in arteries in or leading to the heart) and congestive heart failure (heart muscle does not pump blood as well as it should causing shortness of breath).
A review of a quarterly Minimum Data Set Assessment ( MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 7, 2022, revealed that Resident CR1 was severely cognitively impaired and totally dependent on two person physical assist for toileting, and required extensive assistance of two person physical assistance for dressing and bed mobility. The resident was totally dependent for transfers with two persons assistance and not steady during surface to surface transfers.
A review of the resident's comprehensive plan of care dated June 21, 2021, indicated that the resident was assessed to require the use of an Arjo Hoyer lift (mechanical device used to transfer residents between surfaces) for all transfers with two person physical assistance.
A review of information submitted by the facility dated June 3, 2022, revealed that staff placed Resident CR1 in the mechanical lift and transferred the resident into the bathroom for incontinence care. Employee 1 a licensed practical nurse (LPN) and Employee 2 a nurse aide (NA) transferred the resident into the bathroom via the mechanical lift.
A documented statement from Employee 1 indicated that resident was raised up in lift (from his Broda chair) to be transferred to a shower chair for incontinence care. When these staff members were lowering the lift, the resident appeared to be turning red in his face and he became unresponsive. Staff then attempted to lower the resident from the lift back into his chair, but lift had become lodged into the ceiling soffit. The lift started "beeping" and it would no longer function. As a result, the staff were unable to lower the resident from the lift.
Employee 10, a Registered Nurse (RN), was summoned to the bathroom and attempted to pull the pin to release the lift in order for it to be lowered. However, the lift continued to beep and would not lower. Employee 3, LPN, arrived and was able to pull the lift from underneath the shower ceiling soffit.
A review of the facility's timeline and observation of video footage revealed the following;
Ar 7:06 PM on June 3, 3022 Resident CR1 was observed being transferred to the bathroom with Arjo lift by Employee 1, LPN, and Employee 2, nurse aide.
Three minutes later at 7:09 PM Employee 10, RN, was observed to enter the bathroom then leaves the room and returns at 7:10 PM with a battery pack.
At 7:12 PM Employee 10, RN, left the bathroom and returned with a step stool.
At 7:16 PM Employee 10 brought oxygen.
At 7:20 PM the Resident was transferred out of the bathroom in his Broda hair accompanied by Employee 1 LPN, Employee 4, RN and Employee 5, RN.
Interview with the NHA on June 16, 2022, and review of facility's investigation determined that the resident remained suspended in the lift for approximately 10-11 minutes.
Through investigation and interviews it was determined facility's nursing staff had difficulty releasing the emergency release on the mechanical lift in order to safely lower the resident back into his chair.
According to manufacturer's directions if electrical power fails due to battery power loss or any other electrical malfunction the jib (an extension of the arm, operation arm of the mechanical lift) can be lowered by first raising the red colored emergency lowering level found on the rear section of the mast (actual mechanical structure that allows the lift to reach to specified heights). The the locking pin is to removed from its location beneath the red colored emergency lowering level. Then using the red lever as a crank it is to be turned clockwise rotation one full clockwise turn. One full clockwise rotation of the shaft will lower the mast by 3/8 of an inch. A warning note in the manufacturer's recommendations indicate if the mast is in a high position and the wind down function must be used ensure that suitable and safe measures are taken to gain access to the cover.
It was determined that the mast of the lift where this emergency equipment was located was wedged underneath the ceiling making it difficult for the operator to access the emergency lowering function. It caused the electrical buttons not to function electrically to automatically lower the lift.
An interview with Employee 10, RN, on June 16, 2022 at 10:41AM indicated that it was not until other nursing staff arrived in the room and physically pulled the lift out from underneath the ceiling that they were able to use the lift and lower the resident into his broda chair. She stated she knew that there was an emergency release on the top of the mast but could not reach it.
Employee 6, LPN, who was in the room at 7:11 PM stated during telephone interview on June 16, 2022, at 11:30 AM that she and other staff were trying to get to the red handle to turn it, but they were unable to reach it. Employee 6 stated that the lift was stuck on the ceiling and they tried desperately to operate the lift, but it failed.
At the time of the survey the facility had a total of 10 Arjo maxi lifts. According to facility documentation there were 37 residents in the facility that utilized this specific lift.
Multiple interviews conducted with nursing staff on the day of the survey of June 16, 2022, revealed that not all nursing staff interview were knowledgeable in the use of the emergency function of the lift. Interviews with Employee 7, nurse aide, Employee 8, nurse aide, and Employee 9, nurse aide, were unaware how to properly release the lift if the battery power failed.
An interview with the nurse educator on June 16, 2022 at 1:00PM revealed she does explain the process of releasing the lift in the event of an emergency to staff. However she stated she did not have each of them practice the task or return demonstration on the lift and physically show her they are able to release it properly. The facility failed to ensure that all staff operating a mechanical lift were trained and competent in the use of the mechanical lift in an emergency situation.
28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services
28 Pa. Code 211.10(a)(d) Staff development
28 Pa Code 201.19 Personnel policies and procedures
| ||Plan of Correction - To be completed: 08/09/2022|
1 - Employees #1, 2, 3, 4, 6 and 10 were re-educated on utilizing the dependent mechanical lift to ensure safety and proper functioning including suitable and safe measures are taken to gain access to lift equipment for emergency techniques function and have completed a mechanical lift competency assessment including written and return demonstration of emergency techniques.
2 – All nursing staff in facility, including employee # 5, 7, 8, and 9, are being re-educated on utilizing the dependent mechanical lift to ensure safety and proper functioning including suitable and safe measures are taken to gain access to lift equipment for emergency techniques function and have completed a mechanical lift competency assessment including written and return demonstration of emergency techniques.
3 – Mechanical Lift transfer policy & procedure (Safe Lifting and Movement of Residents) has been reviewed and revised to include completion of lift competency assessment including written and return demonstration of emergency techniques
4 – DON/Designee will conduct audits of staff demonstration of emergency techniques of dependent mechanical lifts of 15 staff per week X 4 weeks
5 - Date Certain August 9, 2022.