Observations:
Based on observations, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that one of five residents reviewed (Resident R1) was transferred from bed to chair with the assistance of two staff members. This failure resulted in actual harm to Resident R1 whose left foot twisted under the resident and sustained a trimalleolar fracture of the left ankle. (Resident R1)
Findings include:
Review of Resident R1's clinical record review revealed that the resident was admitted to the faciltiy on September 17, 2020 with the diagnoses of Alzheimer's Disease (progressive degenerative disease of the brain) and chronic kidney disease, osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and underlying bone) unsteady feet and spinal stenosis.
Review of Resident R1's Minimum Data Set (MDS- assessment of resident's needs) dated May 30, 2024, revealed that the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) for mobility with the assistance of two or more helpers. Continued review of the MDS revealed that the resident was assessed required substantial/maximum assistance to roll left and right; sit to lying, lying to sitting on side of bed, sit to stand, and bed-to-chair transfers.
Review of occupational therapy notes dated May 15, 2024, and end of care dated May 31, 2024, indicated a discharge plan of maximum assistance x 2 (76-99% assist with 2 people), maximum assistance x 2 (76-99% assist with 2 people) for transfers from bed to wheelchair.
Review of Resident R1's care plan initiated December 15, 2023 and updated on June 3, 2024, revealed that the resident required extensive to total assistance of two staff persons to move between surfaces.
Review of nursing note dated July 17, 2024, at 7:09 a.m. revealed that while Resident R1 was being transferred from bed to the wheelchair "the residents legs gave out and resident twisted her left foot under her while being lowered to the floor. Residents leg bent under her with her foot under residents bottom and Resident sitting against side of bed. Resident did not hit her head when lowered to the floor. This nurse called for assist of CNA (nurse aide). When we layed resident down on her back, to use hoyer lift (mechanical device use to transfer a resident from one surface to another), it was noted that her left ankle was bleeding and was not aligned properly. Resident noted with a 3 inch open laceration to her ankle. Dressing applied and ankle supported while assisted onto bed with hoyer lift. 911(Emergency Medical Services) called.
Continued review of nursing notes dated July 17, 2029 at 1:33 p.m. revealed that the resident was admitted to hospital with a diagnosis of type 1 or 2 trimalleolar fracture (a break on the lower leg-sections of the ankle joint). Nursing note dated July 17, 2024 at 3:45 p.m. stated that the "resident had surgery to ankle which is now casted and is NWB ( non weight bearing).
Interview with Employee E4, the Registered Nurse on July 31, at 12:32 p.m., who transferred Resident R1, on July 17, 2024, at 6:05 a.m. revealed that while the resident was being transferred from bed to the wheelchair her legs gave out and twisted her left foot under her, when being lowered to the floor. Resident R1's leg bent under her with her foot under her bottom, and Resident R1 sat against the side of the bed. Resident R1 did not hit her head. Resident was then assisted back to bed. Resident R1 was sent out via 911, to the hospital. Registered Nurse, Employee E4 added that she was unaware of the care plan updates pertaining to Resident R1, at the time of the incident.
The facility failed to to ensure that Resident R1 was transferred from bed to chair with the assistance of two staff members. This failure resulted in actual harm to Resident R1 whose left foot twisted under her and sustained a trimalleolar fracture of the left ankle.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 211.12 (d)(1) Nursing services
28 Pa. Code 211.12 (d)(3) Nursing services
| | Plan of Correction - To be completed: 08/31/2024
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law.
DON/RNAC reviewed care plans and interviewed regular full-time staff on each shift in reference to resident's transfer status. While no other instances were found, we found areas to be addressed regarding ensuring communicating changes to the care plans to staff.
Staff re-educated on Careplan compliance.
Transfer status changes will be communicated to the charge nurse and Clinical Nurse Educator at the time of change. Therapy/Designee will provide education to immediate care staff as appropriate. Clinical Educator/Designee will provide additional education as needed to staff.
Therapy updates or changes to transfer status will be reviewed daily at Morning Meeting with the interdisciplinary team.
RNAC will review at Morning Meeting, any care plan updates that she has been provided.
Therapy staff, and nursing staff will be re-educated on transfer status notifications.
Care Plan "transfer status" will be reviewed quarterly per their MDS schedule for accuracy. Primary care staff will be monitored randomly for care Plan compliance.
The QAPI – Performance and Improvement team will review audits weekly for the next 90 days.
Results of monitoring and audits will be presented to the QAPI steering committee for further recommendation.
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