Observations:
Based on observations, review of facility policy and clinical record, and staff and resident interviews, it was determined that the facility failed to safely transfer a resident using a mechanical lift for one of one residents reviewed (Resident R9).
Findings include:
Review of a facility policy entitled "Safe Resident Handling/Transfers" revised 6/01/24, revealed that two staff members must be utilized when transferring residents with a mechanical lift.
Resident R9's clinical record revealed an admission date of 6/14/24, with diagnoses that included Rheumatoid Arthritis (condition where the body's immune system attacks its own tissue, typically in the hands and feet, and causes painful swelling), Lymphedema (tissue swelling caused by any type of problem that blocks the drainage of lymph fluid, most commonly affects the arms or legs), lack of coordination, weakness, and abnormal gait and mobility.
Resident R9's Kardex (documentation system that provides information regarding necessary resident care) included special instructions to utilize a sit-to-stand lift to transfer to power wheelchair, and his/her task indicated he/she was non-ambulatory and included sit-to-stand lift to transfer to power wheelchair.
Observation on 7/18/24, at 11:53 a.m. revealed Nurse Aide (NA) Employee E1 lowered Resident R9 into the power wheelchair without the assistance of a second staff member.
During an interview on 7/18/24, at 11:54 a.m. NA Employee E1 would not confirm utilizing the sit-to-stand lift without the assistance of another staff member.
During an interview on 7/18/24, at 11:57 a.m. NA Employee E2 confirmed that he/she did not assist NA Employee E1 with operating the sit-to-stand lift to place Resident R9 into his/her power wheelchair.
During an interview on 7/18/24, at 12:00 p.m. Resident R9 confirmed that usually there are two staff, but today the aide did not get help to use the lift.
During an interview on 7/18/24, at 12:10 p.m. Licensed Practical Nurse Employee E3 confirmed that staff are supposed to have two people when using the mechanical lifts.
During an interview on 7/18/24, at 12:39 p.m. the Assistant Director of Nursing confirmed that all mechanical lifts are to have two staff to operate at all times.
During an interview on 7/18/24, at 2:45 p.m. the Nursing Home Administrator also confirmed that mechanical lifts require two staff to operate.
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 211.10(c)(d) Resident Care Policies
28 Pa. Code 211.12(d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 08/23/2024
The "Safe Resident Handling/Transfers" policy was reviewed and remains appropriate. At the time of surveyor identification, all clinical staff were re-educated that two staff members must be utilized when transferring residents with a mechanical lift per facility's policy.
All clinical staff will be re-educated on the "Safe Resident Handling/Transfers" policy and procedure. All clinical staff will complete staff competencies with return demonstration on the proper procedure for transferring residents with mechanical lifts per the "Safe Resident Handling/Transfers" policy. These competencies will be completed no later than 8/23/24. This will be the responsibility of the Director of Nursing and/or designee.
To ensure ongoing compliance, a weekly audit of 10 random resident transfers, that provides a sampling all shifts, during which a mechanical lift is utilized will occur to ensure compliance with policy & procedure. This audit will occur weekly x 4 weeks, then every other week for a month, then monthly until practice is determined to be in compliance. This will be the responsibility of the Director of Nursing and/or designee. Corrective Action will be taken at the time of identification.
Audits will be reviewed no less than quarterly by Quality Assurance Performance Improvement committee.
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