The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Based on a review of clinical records, select facility policies, and incident/accident reports and observations and staff interviews it was determined the facility failed to use the correct resident care equipment necessary to perform safe transfers of individual residents requiring the use of a mechanical lift, which resulted in a fall with serious injury, a fractured pelvis, to one resident (Resident 1) out of nine sampled. This failure also placed other residents requiring the use of a mechanical lift for transfers in immediate jeopardy to their health and safety with the potential for serious bodily injury or death as a result of a similar incident (Residents 2, 3, 4, 5, 6, 7, 8, and 9).
A review of the facility's current Mechanical Lift Use policy indicated that the mechanical lift will be used for those residents who cannot be transferred comfortably and or safely by a normal transfer technique. Two staff members are to be present during the transfer to stabilize and support the resident. The specific instructions for transfers are found in the nursing instructions under the transfer category. The policy further indicated that staff should check the manufacturers guide for specific instructions regarding setup and use of the equipment. The policy also indicated it is required to always have two persons perform the lift.
A review of the clinical record of Resident 1 revealed she was admitted to the facility on December 10, 2020, with diagnoses which included fracture of the lower end of the right femur, fracture of the left humerus, and fracture of the right tibia, weakness of the right side of the body and a history of falls.
A review of the resident's quarterly Minimum Data Set Assessment ( MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 3, 2022, revealed that the resident was severely cognitively impaired with a BIMS score (brief interview for mental status - section of MDS that assesses cognition) of 3 (a score of 0 -7 indicates severely impaired cognition). The MDS noted that she requires extensive assistance of two persons for bed mobility, transfers, and toileting.
A mechanical lift evaluation completed by the facility on January 27, 2022, indicated that the resident did not require a mechanical lift for transfers. However, the resident's status changed according to a lift evaluation dated May 16, 2022, noting that she now required the use of mechanical lift with assistance of 2 persons for transfers.
A progress note dated May 29, 2022, at 6:30 PM, revealed that during a mechanical lift transfer, the resident slid out of the lift sling and onto the floor. Staff observed the right side of her head resting on the right leg of the mechanical lift and her right side was resting between the legs of the mechanical lift. Her ankles and lower legs were resting on the left leg of the mechanical lift. The resident's upper and lower extremities were contracted.
The resident was transferred to the hospital for evaluation on that date and it was determined the resident had a right iliac fracture (the largest bone in the pelvis this forms the iliac crest which gives strength to the structure of the pelvis) and a hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel) of her right chest wall measuring 6.0 cm x 4.2 cm x 10.6 cm.
The resident returned to the facility on June 1, 2022, following her hospitalization for these injuries sustained during the fall from the mechanical lift.
Employee statements obtained on the date of the incident of May 29, 2022, at 5:15 PM revealed that Employee 1, a nurse aide, stated that she was using the mechanical lift with Employee 2, a nurse aide and the resident slid out of the sling. She contacted the nurses and they came to help them.
Employee 2's witness statement indicated that she was transferring the resident with Employee 1, via the mechanical lift. Employee 2 stated that the lift was moved from underneath the bed and it stalled. The resident slipped out of the sling onto the floor.
The facility's investigation, written by Employee 3, the Registered Nurse supervisor, indicated that the resident slid out of the sling and was transferred to the hospital and admitted for a pelvic fracture. The intervention to be implemented in response to this incident was to have the resident properly sized for the correct sling and to have a Physical and Occupational therapy evaluation completed.
The facility's investigation into the incident revealed that the nurse aides, Employee 1 and Employee 2, did not use the correct sized sling for the mechanical lift when transferring Resident 1 on May 29, 2022.
On June 14, 2022, a telephone interview was conducted at 12:45 PM with Employee 1. Employee 1 stated that she was transferring the resident with another staff member on the night of the incident. Employee 1 stated she used the sling that was already in Resident 1's room at the time the transfer. Employee 1 stated that she assumed that it was the proper sling because it was left in the room by someone who must have used it in the past for this resident. Employee 1 stated that the sling looked odd to her, because it was square looking and she stated that the other slings she has seen do not appear to be square. When asked if she knew what size lift sling this resident required, Employee 1 stated that she was not sure, she just used what was available to her at the time of transfer. Employee 1 was also unable to state where the information as to what size sling a resident required for use with the mechanical lift could be located in the facility.
Employee 2 was unavailable by telephone and unable to be interviewed at the time of the survey ending June 14, 2022.
An interview conducted with Employee 3, the RN supervisor, on June 14, 2022, at 4:15 PM revealed that after the resident's fall, Employee 2, who was also an agency nurse aide, had expressed reservations to Employee 3, and explaining that she was not familiar with the lift sling pad used to transfer Resident 1. Employee 3, RN Supervisor, stated that he told Employee 2, nurse aide, that it's imperative to use the right size lift sling for the resident and if she wasn't comfortable, she should have stopped the resident's transfer and went to the nurse to see if it was the correct lift sling pad. Employee 3 stated that is why his planned intervention after the resident's fall was to contact therapy for an evaluation for sizing for the resident. Employee 3 stated that when he looked at the sling on the night of the resident's fall, there was no strap for the resident's legs and as a result the resident slid right out of the front of the sling. Employee 3 stated that this was the reason that he believed the sling used to transfer the resident that evening was probably not correct for Resident 1.
The RN stated that he provided education to Employee 1 and Employee 2 after the incident. The education was verbal training, which indicated that Employee 3 educated Employee 1 and Employee 2 on the appropriate attachment of the mechanical lift sling to the resident and the proper mechanical lift procedures along with the appropriate size sling. However, the education did not indicate how the nurse aides were to determine which size sling was required for the resident during the use of the mechanical lift and where to locate that information for residents requiring mechanical lift transfers.
As of the date of the survey June 14, 2022, the facility had nine residents who currently utilized a mechanical lift for transfers Residents 1, 2, 3, 4, 5, 6, 7, 8, and Resident 9.
A review of the care plans and visual bedside Kardex reports (resident information system available to nurse aides to provide proper care) of these nine residents revealed that each resident required a mechanical lift for transfers, but included no indication of what size lift sling pad was required for each resident.
An interview with Employee 7, the director of rehabilitation, at 10:39 AM on June 14, 2022, revealed that therapy does not choose a size for the lift sling pad for residents. Employee 7 stated that nursing staff determines the size and therapy will evaluate proper positioning of the resident on the lift pad.
An interview with Employee 4, a nurse aide, at 11:10 AM on June 14, 2022, revealed that the employee was asked how he knows what size lift sling pad to use for a resident's transfer with the mechanical lift. Employee 4 stated that he "just knows." Employee 4 acknowledged that the facility has multiple lift pads, but that he just knows what his residents require.
Interviews at 12:00 PM on June 14, 2022, with Employees 5, a nurse aide, and Employee 6, an agency nurse aide, revealed that these employees stated that the lift sling pads are color coded, but they were unaware of where they could find the information to determine what size each resident requires for a lift transfer.
An interview with Employee 7 and Employee 8, both agency nurse aides, at approximately 12:15 PM on June 14, 2022, revealed that these employees were new to the facility and were unaware of where they could find the information regarding the correct size lift sling pad for each resident.
An interview with the assistant director of nursing (ADON) at 1:30 PM on June 14, 2022, indicated that the sizes of the mechanical lift sling pads required by each resident, as assessed by nursing staff, were not present on the Kardex available to nurse aides. When asked about the wrong lift pad present in Resident 1's room on the day of the incident, the ADON was unable to explain why the incorrect size lift sling pad was present in that resident's room at that time. She stated that the particular lift pad used to transfer Resident 1 on the night of her fall, was no longer used in the facility and no longer available in the facility for the surveyor to observe.
Immediate Jeopardy was called on June 14, 2022, due to the facility's failure to ensure that all residents are assessed for the lift sling pad size, that all applicable staff who perform resident transfers are aware of the correct size lift sling pad for each resident requiring mechanical lift transfers, and where staff may access that information to ensure the correct size and type lift pad is used for these residents during transfers to prevent accidents and injuries.
The facility was notified of the Immediate Jeopardy on June 14, 2022, at 3:40 PM and the IJ template provided to the facility at 3:45 PM.
An immediate plan of correction was requested and received on June 14, 2022. The plan included:
All direct care staff was educated on June 14, 2022 for all shifts days, evening, and nights at the beginning during or at the end of their shifts. Education included proper use of mechanical lift and proper sling size.
The sling size will be documented in the care plans and the care cards. The new care cards will be printed and placed in the resident's closets. They will be visible on the point of care system (POC) which is the nurse aide documentation system this would be completed on June 14, 2022.
When all staff entered the building they would be told to review the care cards. This would be completed on June 14, 2022.
All residents utilizing a mechanical lift would be assessed with licensed staff and therapy this will be completed on June 14th 2022
The Immediate Jeopardy was lifted on June 14, 2022, at 5 PM when implementation of the plan of correction was verified.
483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices
Previously cited 1/28/22
28 Pa. Code 211.10 (a)(d) Resident care policies
28 Pa. Code (a)(b) Staff development
28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services
| ||Plan of Correction - To be completed: 07/18/2022|
Residents 2,3,4,5,6,7,8 and 9 were all assessed for the proper lift size pads. On 06/14/2022, all residents had the appropriate lift pad in place.
All their care plans and care cards reflect the appropriate lift pad for easy access to all caregivers.
An audit was completed on all residents that is recommended for a mechanical lift that the care plans and care cards reflect the appropriate lift pad.
The mechanical lift policy was reviewed and updated by the interdisciplinary team and approved by the medical director.
All direct care givers were in-serviced and educated on the revised mechanical lift policy and procedure and show competency on the above.
Audits will be completed that residents using a mechanical lift had the appropriate lift pad available and that it is on the POC, that it is on the care card and that the direct care givers know how to find the information for the resident 3 x a week x 2 months.
All findings will be reported to the facility QA/QAPI team for review and recommendations.