| 1 |
BOUNDARY COUNTY NURSING HOME |
135004 |
6640 KANIKSU STREET |
BONNERS FERRY |
ID |
83805 |
2019-01-31 |
689 |
D |
0 |
1 |
N5WL11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, manufacturers guidelines, policy review, and record review, it was determined the facility failed to ensure staff utilized mechanical lifts properly to reduce potential injuries. This was true for 2 of 2 residents (#1 and #6) reviewed for supervision and accidents. These failed practices placed residents at risk of bone fractures and other injuries related inappropriate use of a mechanical lift. Findings include: The facility's The use of Mechanical Lifts Policy, revised 12/13/18, documented staff utilized mechanical lift equipment when residents could no longer support their weight on their own. The policy documented the facility used a Arjo Maxi Move Mechanical lift device and staff needed to demonstrate and verbalize the correct procedure to operate the lift. The facility's Transfers Policy, revised 10/17/18, documented a resident's ability to transfer was assessed at the time of admission. The policy documented wheelchair brakes needed to be locked during all transfers. The Arjo Maxi Move Instructions for Use, dated (MONTH) 2010, documented the Arjo was designed for safe usage with one caregiver. The instructions documented there were circumstances that dictated the need for a two-person transfer such as combativeness, obesity, contractures etc The instructions documented it was the responsibility of the facility to determine if a one or two person transfer was more appropriate based on the task, resident load, environment, capability, and skill level of the staff members. a. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 11/4/18, documented Resident #1 had severe cognitive impairment and she was dependent on one staff member for bed mobility, transfers, and toilet use. The MDS documented Resident #1 weighed 185 pounds. Resident #1's Care Area Assessment, dated 11/2/18, documented she was considered obese. The care plan area addressing Resident #1's Activities of Daily Living (ADL), revised 11/6/18, documented Resident #1 required extensive to total assistance with all ADL's and cares. The care plan documented Resident #1 had a history of [REDACTED]. The care plan documented she used a Geri chair for positioning. The care plan documented Resident #1 required the assistance of one to two staff with bed mobility depending on her cooperation, mood, or anxiety. The care plan documented Resident #1 required the assistance of one staff for all transfers with the Arjo lift, and the assistance of two staff when she was uncooperative or agitated. On 1/29/19 at 9:57 AM, CNA #7 was observed assisting Resident #1 to the bathroom with the use of the Arjo lift. CNA #7 was the only staff member in the bathroom. Resident #1's Geri chair was near the left-hand side wall approximately one inch from the wall. Resident #1's Geri chair brakes were not locked as CNA #7 raised Resident #1 off her seat. The Geri chair slid forward approximately two to three inches. After Resident #1 was free of the chair CNA #7 placed her onto the toilet. After Resident #1 finished using the restroom, CNA #7 raised her with the Arjo lift and assisted her back into her Geri chair. Resident #1's Geri chair brakes were not locked, and as Resident #1 was lowered into the Geri chair the chair moved back and forth and back again and rested against the wall as Resident #7 was situated into the chair. According to the Arjo's manufacturer instructions, the facility was to assess Resident #1 for the use of one to two staff personnel based on Resident #1's size. Resident #1's clinical record did not contain documentation the assessment was completed. Facility staff failed to complete an assessment according to the manufacturer's instructions. and ensure Resident #1's Geri chair brakes were locked prior to transferring Resident#1. b. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 11/3/18, documented Resident #6 had severe cognitive impairment and documented she was dependent on one staff member for dressing, transfers, and toilet use. The MDS documented Resident #6 had bilateral range of motion impairments to her lower extremities and a range of motion impairment to one of her upper extremities. The care plan area addressing Resident #6's ADLs, revised 8/7/18, documented Resident #6 required extensive to total assistance of one to two staff with all ADLs and cares, depending on her behaviors and resistance. The care plan documented Resident #6 required two staff personnel for all transfers with the Arjo lift if she was agitated or combative and she needed transferred. On 1/28/19 at 1:12 PM, CNA #6 was observed assisting Resident #6 from her wheelchair and into her bed with the use of the Arjo lift. Resident #6 was observed with severely contracted legs and left hand. CNA #6 attached Resident #6's sling onto the Arjo lift and after she finished attaching the sling, she moved to stand in front of the controller of the Arjo lift. CNA #6 did not lock Resident #6's wheelchair brakes. CNA #6 was standing near the controller of the Arjo lift while Resident #6 was lifted into the air with the lift. CNA #6 moved Resident #6 over to her bed and assisted her into bed. On 1/29/19 at 9:39 AM, CNA #5 was observed assisting Resident #6 from her wheelchair and into her bed with the use of the Arjo lift. CNA #5 attached Resident #6's sling onto the Arjo lift and then locked Resident #6's right brake of her wheelchair, the brake closest to her. CNA #5 moved to stand in front of the controller of the Arjo lift. CNA #5 did not lock Resident #6's left wheelchair brake. CNA #5 was standing near the controller of the Arjo lift while Resident #6 was lifted into the air with the lift. CNA #5 moved Resident #6 over to her bed and assisted her into bed. According to the Arjo's manufacturer instructions, based on Resident #6's contractures the facility was to assess Resident #6 to determine if one or two staff were needed to safely transfer her. Resident #6's clinical record did not contain documentation the assessment was completed. Resident #6's wheelchair brakes were not locked when she was transferred and she was not assessed consistent with Arjo's manufacturer's instructions, to determine if one or two staff were needed when transferring her. On 1/30/19 at 10:53 AM, Registered Nurse (RN) #1 stated residents' transfers plans were determined based on multiple factors. RN #1 stated staff assessed a residents' fall risk, if they could stand, if they were resistive with cares, and their body tone. RN #1 stated the assessment was on the care plan. On 1/30/19 at 11:00 AM, LPN #2 stated the facility did not have a documented assessment as to if residents were safe with one or two staff transfers. LPN #2 stated what was on the care plan was how residents should be transferred. LPN #2 stated Resident #1's and #6's care plans stated they could be assisted by one or two staff, and the CNAs had the option to use two people. LPN #2 stated Resident #1 and Resident #6 could be resistive with cares at times. LPN #2 stated the manufacturer guidelines for the Arjo lift documented only one person was required for use. LPN #2 stated staff competencies related to the proper mechanics of the Arjo lift were reviewed annually. On 1/30/19 at 2:28 PM, the DNS stated residents' wheelchair brakes should always be locked during transfers. The DNS stated the nurses assessed residents' needs often and the facility did not have documented assessment for the Arjo lift to determine if one or two staff were required to safely transfer the residents. |
2020-09-01 |