cms_ID: 60
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 60 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 280 | D | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined the facility failed ensure interventions on residents' care plans related to mobility/ transfer status were reviewed and revised to reflect their current status. This was true for 2 of 18 sampled residents (#4 and #6). This deficient practice placed residents at risk for injuries related to improper transfers. Findings include: 1. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment further documented Resident #4 had functional impairment to both sides of his upper and lower limbs. According to Resident #4's quarterly MDS assessment, dated 8/29/16, he required extensive assistance of 2 staff for transfers and was totally dependent on 2 staff for bed mobility. The assessment further stated Resident #4 had impaired range of motion to all limbs. On 10/18/16 at 9:30 am, in Resident #4's room, he was observed during a transfer from his bed to the wheelchair. LN #1 and CNA #5 utilized a sit-to-stand device to perform the transfer. During preparation for the transfer the previously mentioned staff positioned Resident #4 in a seated position on the edge of the bed, while the bed was in a raised position. While they were working with the harness (harness is secured around the resident to assist in supporting the resident), they were discussing how they needed to apply the harness. Resident #4, who later said he was 6 feet and 1 inches tall, abruptly fell backward across the bed. Resident #4 yelled as he fell backward onto the bed. The staff returned him to sitting on the edge of the bed. They then assisted Resident #4 to grab the sit-to-stand handgrip, and applied the harness. After securing Resident #4, the staff engaged the lift and transported him to his wheelchair. During the transfer Resident #4 did not stand. He was transferred in a squat like position. Resident #4's care plan dated 5/21/16 and revised on 10/7/16, with a focus on Impaired physical mobility related [MEDICAL CONDITION] a goal that Resident #4 would maintain independence in wheelchair locomotion. There was no mention of transferring him utilizing the sit-to-stand. The only mention of a sit-to-stand in Resident #4's care plan was related to his potential for skin impairment. The intervention documented the use of Geri-sleeves during the sit-to-stand transfers to protect his skin from abrasions and lacerations. Resident #4 did not have Geri-sleeves on during the aforementioned observation of his transfer. The care plan was not revised to include current interventions. 2. Resident #6, according to her admission MDS dated [DATE], was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/19/16 at 1:17 pm, in Resident #6's room, CNA #3 and CNA #4 were observed transferring Resident #6 to provide incontinence care. As Resident #6 was lifted from the wheelchair, her legs remained bent and she never stood or bore weight on her legs. Her bottom remained at the level of the chair or below as the 2 aides provided incontinence care. At one moment during the care, Resident #6 moaned out loud. CNA #4 told her they were almost done with the care and they were hurrying. As Resident #6 dangled from the sit-to-stand, her bottom was at or below the level of the wheelchair she had just been removed from. The harness was up around the upper chest area and her arms were extended up above her chest. After the care was completed, Resident #6 was assisted back to the wheelchair. Resident #6's care plan, dated 4/14/16 and revised on 9/26/16, that focused on ADL (activities of daily living) Self Care Performance deficit r/t (related to) end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT] included a goal to improve transfers. However, the care plan had not been revised to include use of the sit-to-stand device for transfers. On 10/20/16 around 8:30 am, the SDC provided updated care plans, with revision dates of 10/19/16, for Resident #4 related to his impaired mobility, which now included an intervention for a mechanical lift Hoyer with sling until therapy recommended transfer changes, and for Resident #6 related to her need for the use of a Hoyer lift for transfers. An Occupational Therapy (OT) Treatment Note, dated 10/20/16, documented Resident 6's sit-to-stand mechanical transfer safety assessment had been performed. The note confirmed Resident #6 demonstrated a poor performance with transfer secondary to decrease in range and strength during transfers. | 2020-09-01 |