| 20 |
THE MEADOWS ON UNIVERSITY |
355024 |
1315 S UNIVERSITY DR |
FARGO |
ND |
58103 |
2019-05-16 |
689 |
D |
1 |
1 |
FA2L11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide enough supervision and/or assistive devices for 3 of 10 sampled residents (Resident #35, #45, and #62) observed transferred with staff assistance. Failure to use assistive devices per policy and/or manufacture guidance to transfer a resident safely places residents at risk of accidents with/without injury. Findings include: GAIT BELTS Review of the facility policy/procedure titled Safe Lifting and Movement of Residents occurred on 05/16/19. This undated policy, stated, . 4. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. - Review of Resident #62's medical record occurred on (MONTH) 13-16, 2019. An admission Minimum Data Set (MDS), dated [DATE], identified extensive assistance two or more staff for transfers and toilet use. Resident #62's current care plan identified Transfers: 1 assist, FWW (front wheeled walker). Observation on 05/14/19 at 11:49 a.m., showed the certified nurse aide (CNA) (#12) lifted Resident #62 under her left arm to transfer from the wheelchair to the toilet. After the CNA (#12) provided person cares, the CNA (#12) again lifted under Resident #62's left arm to transfer from the toilet to the wheelchair. The CNA (#12) failed to utilize a gait belt to assist with Resident #62's transfers. - Review of Resident #45's medical record occured on (MONTH) 14-16, 2019. The resident's current care plan stated, . Focus . ADL (activities of daily living) Self care deficit related to physical limitations . Interventions . Transfer: extensive assistance of one with gait belt and pivot . Date Initiated: 05/02/2018 . Observation on 05/14/19 at 10:44 a.m. showed two CNAs (#8 and #13) placed a gait belt around Resident #45's waist and assisted her to transfer to bed. Observation showed the gait belt was loose and slid up the resident's back. The resident did not fully bear weight, and her knees were bent to an almost 90 degree angle. The resident sat on the edge of the bed, and a CNA (#8) stated I don't want her to fall off, as she assisted to the resident to lie down. Observation on 05/15/19 at 11:15 a.m. showed two CNAs (#8 and #9) assisted Resident #45 to sit up in bed and placed a gait belt around her waist. A CNA (#8) stated, I like to have two (staff members). She's so hard (to transfer). Observation showed as the CNAs (#8 and #9)assisted Resident #45 to stand, the resident did not fully bear weight, and her knees were bent. Each CNA (#8 and #9) placed one arm under each of the resident's arms and used their other hand to lift the resident by the waistband of her pants as they transferred her to the wheelchair. MECHANICAL LIFT Review of manufacturer's instructions titled SARA 3000 Instructions for use, occurred on 05/16/19. These instructions stated, . Warning: The sling chest support strap must always be applied and fastened when using the sling. Lower Leg Straps . used to ensure that the lower parts of the resident's legs stay close to the knee support. - Review of Resident #35's care plan occurred on all days of survey. The quarterly minimum data set, ((MDS) dated [DATE], identified extensive assistance of two staff members for transfers. [DIAGNOSES REDACTED]. The residents current care plan stated, . standing lift with two assist to transfer into bathroom. Review of an occupational therapy note dated 04/22/19 stated, . Patient and Caregiver Training: Education to pt. (patient) and CNA on continued toilet transfer without standing lift. Observation on 05/14/19 at 10:32 a.m., showed a certified nursing assistant (CNA) (#10) and a licensed practical nurse (LPN) (#6) utilize a mechanical sit-to-stand lift to transfer Resident #35 from the wheelchair to the bathroom. The CNA (#10) applied the sling under the axilla (underarms) area and then attempted to secure the sling chest support strap. Resident #35 stated, You don't need to use that, I've been here for 6 months I think I know how its done by now. They don't use that thing. The staff failed to apply the sling chest support strap and the leg straps. Observation on 05/15/19 at 9:38 a.m., showed two CNAs (#11 and #12) utilize a mechanical sit-to-stand lift to transfer Resident #35 from the wheelchair to the bathroom. The CNA (#11) applied the sling under the axilla area and then attempted to secure the sling chest support strap. Resident #35 stated, oh no you've never used that before why do you want to use it now, I'm not using it. The CNA (#11) told the resident it was for safety and the resident stated, no you've never used it before, raise me up now. The staff failed to apply sling chest support strap and the leg straps. During an interview on 05/16/19 at 9:00 a.m., a certified occupational therapy assistant (COTA) (#14) agreed that Resident #35 is unsafe using the standing lift without the sling chest support and leg straps. Failure to correctly use the sit-to-stand mechanical lift per manufacture's instructions places the resident at risk for falls and injury. |
2020-09-01 |