Based on review of facility policies, incident report documentation, clinical records and staff interview, it was determined that the facility failed to provide adequate assistance with a transfer, resulting in actual harm (right tibial fracture) for one of six residents (Resident R1).
The facility "lift limiting" policy last reviewed 8/5/19, indicated any resident who is not able to bear weight to transfer or walk will always be lifted via mechanical lift unless contraindicated by a physician. High risk transfers include bed to chair transfers.
Resident R1 admission documentation indicated she was admitted to the facility on 8/15/19.
Review of Resident R1 5-day Minimum Data Set assessment (MDS-periodic assessment of care needs) dated 8/22/19, indicated Resident R1 had diagnoses that included urinary tract infection, diabetes, abnormal gait, and cervical disc disorder. Review of Section G0110B Transfer Section was coded "3-Self Performance" and "3-Support" indicating Resident R1 was a transfer extensive assistance with two person physical assistance.
Review of Resident R1 care plan dated 8/15/19, indicated staff would transfer Resident R1 with assistance of two staff persons. The care plan indicated staff would maintain safety precautions as ordered.
Review of a physician order dated 8/15/19, indicated Resident R1 was to be transferred with the assistance of two staff members.
Review of nurse progress notes dated 8/16/19, indicated Resident R1 was admitted after a c5-c6 spinal fusion (surgery to connect two or more vertebrae of the spine ).
Review of a Resident R1 Physical Therapy assessment and plan of treatment document dated 8/16/19, indicated Resident R1 had impaired right and left hips and she needs maximum assistance of two staff persons for transfers.
Review of a Resident R1 Physical Therapy notes dated 8/22/19, indicated Resident R1 was a maximum assistance of two persons with bed mobility and nursing staff is to use a hoyer lift.
A facility incident report dated 8/24/19, indicated at 1:45 p.m. Nurse Aide (NA) Employee E2 attempted to transfer Resident R1 from her bed to a wheelchair, without additional assistance. Resident R1's legs gave out and she fell to the floor. Resident R1's right leg bent behind her. Resident R1's doctor and family were notified, and she was sent to the hospital. In the incident report, Nurse aid Employee E2 stated she received information that Resident R1 was a transfer assist of two-persons prior to the incident.
Review of an X-ray report dated 8/24/19, indicated Resident R1 sustained a fracture of the right tibial tuberosity (right knee bone).
During an interview on 9/18/19, at 11:00 a.m. the Director of Rehabilitation Employee E3 stated that Resident R1 was recommended to be transferred with two staff person assistance.
During an interview on 9/18/19, at 11:02 a.m. the Director of Nursing confirmed that the facility failed to provide adequate assistance with a transfer as per physician orders, resulting in actual harm to Resident R1 (fractured tibia).
The facility failed to make certain Resident R1 was provided with adequate staff assistance during a transfer resulting in actual harm to the resident.
28 Pa Code: 201.18 (b)(1)(2) Management.
28 Pa Code: 201.29 (a) (c)(d)(j)(m) Resident Rights.
28 Pa Code: 211.10 (c)(d) Resident care policies.
28 Pa Code: 211.11 Resident care plan.
| ||Plan of Correction - To be completed: 10/03/2019|
This plan of correction constitutes my written allegations of compliance for the deficiencies cited. However, submission of this plan of correction is not admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.
A verbal reeducation occurred on day of incident, 8/24/19 with CNA employee E2. E2 also received discipline on day of incident including a written warning with any further incidents resulting in immediate termination. E2 was also re-educated, with return demonstration, on proper transfer techniques and using correct assistance levels before return to direct care work assignment.
An audit to ensure E2 was correctly transferring residents with correct transfer status at 100% compliance that day on return to work.
Additional random audits were performed on all CNA's on all floors and shifts to ensure CNA's were using the proper transfer and assist on all residents.
Education was provided to CNA's on importance of using the correct transfer with correct assistance level for resident safety.
Education was also provided to nurses reminding them of the importance to supervise CNA's ensuring that proper transfer status and assist levels are being followed
Additional audits will be conducted on each floor, 6 residents per floor, covering all CNA resident assignments each shift weekly x8 weeks then monthly x3 months and ongoing as needed.
Any discrepancies for wrong transfer assist or transfer technique will be corrected immediately and education and discipline will be provided immediately.
All audits will be reviewed quarterly with the quality assurance committee meeting this meeting is overseen by the NHA
A directed in-service education has been planned in conjunction with the Lewis Litigation Support and Clinical Consulting Group LLC. The in-service is planned for October 1, 2019 during 4 scheduled times and will be recorded for training purposes. This in-service will be for RNs, LPNs, and CNAs.
***This resident is no longer resides in the facility. Audits and training will act to protect others in similar situations.
****Education with the staff included the way to obtain the correct transfer orders of the residents before they provide care. The staff gets the information from shift to shift report and from our care information EMR sysytem called MyUnity.