| 48 |
HANDMAKER HOME FOR THE AGING |
35016 |
2221 NORTH ROSEMONT BOULEVARD |
TUCSON |
AZ |
85712 |
2018-06-28 |
689 |
G |
1 |
0 |
KWBO11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of facility policies and procedures, the facilty failed to ensure that one resident (#1) was transferred appropriately to prevent a fracture to her humerus. The sample size was three. Findings include: Resident #1 was admitted to the facility on (MONTH) 19, 2012 with [DIAGNOSES REDACTED]. Review of an ADL (activities of daily living) care plan dated (MONTH) 13, (YEAR) revealed Resident requires extensive assist with ADLs with two staff members for transfers .due to debility, due [MEDICAL CONDITION] and right sided sensory impairment. A goal documented was Resident will .have daily needs met by staff. Approaches documented were Two staff members for all transfers. Patient and her daughters refuse gait belt use. They have been educated but continue to state their refusal . Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), section G Functional Status revealed the resident required the extensive assistance of 2 for transfers and support. Nursing Note dated (MONTH) 23, (YEAR) documented Resident was being transferred by CNA (certified nursing assistant) from bed to wheelchair. When resident's legs touched the front wheel of the wheelchair and CNA was unable to complete transfer safely that's when CNA lowered resident gently to the floor and called for help. Nursing Note dated (MONTH) 23, (YEAR) documented Resident x-rays came back abnormal for RUE (right upper extremity). Orders were received and transcribed. Family is aware of transportation to (name of hospital) emergency room for further evaluation . An Accident/Incident Report dated (MONTH) 23, (YEAR) by the CNA who transferred the resident when she fell , staff #91, documented We were pivoting to sit in chair. Then she said oh. I looked down and seen her left foot slide behind her small front wheel. I could not hold her up and get her right foot in the right place so I slowly slid down my leg to a soft sit then held her up till nurse came and helped. I only held her under her arms. Got her feet in right place. I lifted her up and nurse had her legs. We sat her in the chair. Have never had a transfer go this way . A hospital History and Physical dated (MONTH) 23, (YEAR) documented .she had a fall while she was being lifted from the bed on her right side, complaining or right hip pain, right arm pain, about 7 out of 10 .Humerus fracture . Review of a nurse practitioner progress note dated (MONTH) 29, (YEAR) documented .Her right side is her weak side affected [MEDICAL CONDITION] when purposely moved with transfers or care, the area remains painful for patient .[MEDICATION NAME] increased to BID (twice a day) . An interview was conducted with a CNA, staff #41 on (MONTH) 28, (YEAR) at 9:02 a.m. The CNA stated that if she is unsure how a resident should be transferred she asks the nurse or physical therapist prior to transferring the resident. The CNA stated that the licensed nurse documents on the Report Sheet how a resident should be transferred. The CNA stated that if a new staff person or agency staff is working we always tell them how a resident should be transferred. An interview was conducted with a CNA, staff #21 on (MONTH) 28, (YEAR) at 9:10 a.m. The CNA stated that when a new resident is admitted we get report on how to care for them. The CNA stated that he always checks with the nurse first to see how a resident should be transferred. The CNA further stated that he would never transfer a resident without checking with the nurse first because you could do more harm than good. An interview was conducted with the DON (director of nursing), staff #64 on (MONTH) 28, (YEAR) at 9:15 a.m. The DON stated that the CNA who transferred the resident when she fell was an agency CNA but that she had been familiar with the residents. The DON stated that she thought the resident required the assistance of one person for transfers. When the resident's care plan was reviewed with the DON, the DON acknowledged that it was the assistance of two for transfers but stated that the facility usually used a mechanical lift if the resident required the assistance of two for transfers. The DON further stated that the MDS coordinator develops the care plan and then refers the information to the licensed nurse on the unit. An interview was conducted with the MDS coordinator, staff #15 on (MONTH) 28, (YEAR) at 9:30 a.m. The MDS coordinator stated that she completed the MDS and the care plan prior to the resident's fall and the resident was assessed to require two staff for transfers because of her [MEDICAL CONDITION]. The MDS coordinator further stated as far as I know she should have had two CNA's to transfer her at the time of the fall. An interview was conducted with the CNA, staff #91, who transferred the resident at the time of the fall on (MONTH) 28, (YEAR) at 10:50 a.m. The CNA stated that she worked at the facility as an agency CNA quite a few times. The CNA stated that she asked and was told that the resident was weight bearing and a one person transfer. The CNA stated that she always checked with facility staff first before she transferred a resident. The CNA stated that she did not want the resident to fall so she lowered her to the floor. The CNA stated she found out later that the resident was not feeling good that day. The CNA further stated the resident did not fall, she was an assist to sit. Another interview was conducted with the DON, staff #64 on (MONTH) 28, (YEAR) at 1:00 p.m. The DON stated that the facility did not have a specific policy regarding safe transfers but that she would expect staff to transfer residents safely and follow the care plan. A review of the facilty's policy Managing Falls and Fall Risk documented Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . |
2020-09-01 |