| 63 |
WEISER CARE OF CASCADIA |
135010 |
331 EAST PARK STREET |
WEISER |
ID |
83672 |
2016-10-21 |
323 |
J |
0 |
1 |
224111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of manufacturer's recommendations, and staff interviews, it was determined the facility failed to ensure 2 of 3 residents (#4 and #6) requiring the use of mechanical devices for assistance with transfers, were monitored and re-evaluated for the continued appropriateness and safety of the devices; and staff were trained how to use the devices. These failures placed the health and safety of Residents #4 and #6, who required the use of a sit-to-stand device for transfers, in immediate jeopardy of serious injury, harm, or death. Findings include: 1. Resident #4 was admitted to the facility on [DATE]. Resident #4's MDS assessment, dated 3/4/16, included [DIAGNOSES REDACTED]. The assessment further noted Resident #4 had functional impairment to both sides of his upper and lower 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. LN #1 was present during the above transfer of Resident #4 on 10/18/16 at 9:30 am, utilizing the sit-to-stand device. LN #1 did not provide guidance to the CNA related to supporting Resident #4 during the preparation for transfer, appropriate height of the bed, or the inappropriateness of Resident #4's transfer position on the lift. An incident investigation, dated 8/7/16, involving Resident #4, documented 2 aides (CNA #6 and CNA #7) were assisting Resident #4 to sit on the edge of the bed to attach the (sling) harness, when he fell backward on the bed. According to the report, Resident #4, at that time, complained of mild ache-like pain between his shoulder blades. The PI (Performance Improvement) Recommendations noted on the incident documented no change to plan of care, CNA re-education. Resident #4's care plan, revised on 10/7/16, included a focus on Impaired physical mobility related to CV[NAME] An accompanying goal was for Resident #4 to maintain independence in wheelchair locomotion. There was no mention of transferring him utilizing the sit-to-stand. During an interview with the Physical Therapy Director, on 10/18/16 at 2:38 pm, the therapist said the sit-to-stand was still the appropriate method of transfer for Resident #4. She said after the staff told her about the transfer observed at 9:30 am earlier on the same day, she provided training on the correct way to transfer Resident #4. When the surveyor asked if she observed the staff perform the transfer prior to providing the training, she said she had not. The therapist was asked if she was aware of the resident's previous (8/7/16) accident resulting in the same outcome during a transfer. The therapist said she was not aware that this type of accident had occurred before with Resident #4. During an interview on 10/19/16 at 6:30 pm, the SDC stated the licensed nursing staff were not required to complete a competency evaluation for the use of the sit-to-stand mechanical lift. The SDC further shared the licensed nursing staff were responsible for signing off the CNAs for the use of the sit-to-stand. LNs having no evaluation of their own competency for the use of the sit-to-stand, were required to evaluate competency for the CNAs. 2. Resident #6 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. Prior to the transfer, Resident #6 was observed sitting in a wheelchair at bedside. The staff placed the sit-to-stand device in front of Resident #6 and proceeded to secure the harness. They instructed Resident #6 to hold onto the handgrips on the device. After securing Resident #6, the sit-to-stand was engaged to lift her from the wheelchair. As she 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 CNAs 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, included a focus on ADL (activities of daily living) Self Care Performance deficit r/t (related to) end stage renal failure with hemodialysis. A related goal was to improve transfers. The care plan not include interventions related to the sit-to-stand device used for the transfer. On 10/19/16 at 6:30 pm, an interview was conducted with the Staff Development Coordinator (SDC). During the interview the SDC was informed of the observations of Resident #4 and Resident #6's transfers with the sit-to-stand. The SDC stated the CNAs would be the first to notice a decline in residents' transfer status. She indicated an assessment to determine appropriateness of a transfer method or a change in that method, would depend on the CNAs or nurses noticing and reporting a decline. The SDC further stated if injuries were noted, part of the investigation would be a review of the transfer equipment. She was unaware of any consistent follow-up observations of the aides demonstrating competency of the mechanical devices, specifically the sit-to-stand, or to determine the continued appropriateness for the device for the residents. The manufacturer's handbook for the sit-to-stand, copyright 2014, stated the sit-to-stand device should only be used for residents/patients who can support at least 20% of their body weight. The manual further instructed the facility to assure only trained personnel was permitted to operate the lift. The manual further noted Untrained operators can cause injury or be injured. The manufacturer's instruction were not followed prior to 10/20/16. The SDC was not trained in the use of the device until 10/20/16 and competencies with return demonstrations were not completed for LNs or CNAs prior to 10/20/16. Removal of Immediate Jeopardy: The Administrator, DON, SDC, and Corporate Representative were informed of the Immediate Jeopardy on 10/20/16 at 12:23 pm. Subsequently, the facility responded by providing a performance improvement action plan for removal of the Immediate Jeopardy situation. The plan included: * The Rehabilitation Program Director to oversee lift transfer program. Rehabilitation Program Director will train the SDC on the sit-to-stand transfer. * The SDC will complete training to 1 LN and 1 CNA with return demonstration with satisfactory outcome. The trained LN and CNA to assist in training other LN and CNA staff. Therapy to assist. Staff will be able to verbalize what to do if a patient (resident) is not able to complete a sit to stand transfer safely. * The SDC and RN Supervisors will train LNs and CNAs on sit-to-stand transfer prior to their next scheduled shift, utilizing the skills checklist. LNs and CNAs will complete a return demonstration and must complete all areas as satisfactory before competency is completed. Staff will be able to verbalize what to do if the patient (resident) is not able to complete a sit to stand transfer safely (10/20/16 start and will continue until all staff are trained). * Surveillance observations to occur during sit-to-stand transfer at least weekly for 4 months, bi-weekly for 2 month, monthly for 6 month by SDC or RN Supervisor. * Sit-to-stand competencies for CNAs and LNs will be completed on hire, annually, and as needed, by SDC or designee. * The Rehabilitation Program Director or therapy designee will assess the competencies of trainers annually. * Residents transferred using a sit-to-stand will be observed quarterly, and as needed with change of condition, by physical therapy and SDC or RN Supervisor. * Training for new hires will utilize skills checklist and include return demonstration with satisfactory outcome from SDC or RN Supervisor. * Therapy will provide demonstration to new hires in general orientation and quarterly x2 during general staff meetings on how to complete a sit-to-stand transfer and what to do when a sit-to-stand transfer does not go well. * Unsafe sit-to-stand observations will be reported to the physical therapist and/or designee for immediate review and intervention. * Sit-to-stand competencies and surveillance outcomes will be reviewed at monthly performance improvement meetings for 6 months. Along with the action plan, the facility provided proof of competencies for all staff, and return demonstrations of competencies. The plan was reviewed, the evening shift was trained prior to working, and the night/day shifts were called in for training and told they would not be able to work until the training/competency was completed. The SDC was trained and completed return demonstration. Surveyors then observed her as she trained staff. The SDC was observed performing a sit-to-stand transfer with a CN[NAME] All nursing staff were required to take a competency test prior to working their next shift. After everything was validated, the Administrator, DON, and Regional Nurse Consultant, were informed the Immediate Jeopardy was removed on 10/20/16 at 4:40 pm. |
2020-09-01 |