Huntington Hills Center for Health and Rehabilitation
October 16, 2018 Complaint Survey

Standard Health Citations

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 16, 2018
Corrected date: December 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review during an abbreviated survey (Complaint # NY 805 and # NY 127), the facility did not provide the supervision and proper use of assistance devices necessary to minimize risk of avoidable accidents with serious injuries for two of four residents reviewed for accidents (Resident #1, Resident #2). Specifically, 1) Resident #1 required assistance to two persons for transfers according to the Comprehensive Care Plan (CCP). Two Certified Nursing Assistants transferred the resident using a mechanical lift (stand-up lift) without the resident having been assessed for use of a stand up lift. Resident #1's foot got caught in the bedframe resulting in an open tibia fibula (lower leg) fracture. 2) Resident #2 required use of a stand-up mechanical lift with assistance of two persons for transfer. One of two CNAs assisting the resident left the room in the middle of a transfer procedure with Resident #2 positioned in the stand-up lift. The remaining CNA continued the transfer independently. The resident fell and was diagnosed with [REDACTED]. This resulted in actual harm for Resident #1 and Resident #2 that is not Immediate Jeopardy. The findings include: The Facility Policy titled Stand Up Lift dated 4/2000 documented residents must be assessed by the unit coordinator before using the stand-up lift, two staff members must be involved in the transfer of a resident with the stand-up lift and do not use with severely comatose residents. The Facility Policy Titled Transfer Technique dated 11/2000 documented, prior to transferring the resident, staff member will check the CNA assignment/accountability/and or care plan to determine the method of lifting and transferring the resident. Disciplinary action will be taken upon employees who do not perform resident transfers according to the designated plan of care. The Facility Policy titled Resident Abuse dated 12/2016 documented the facility must ensure that all alleged violations involving neglect; including injuries of unknown source are reported immediately to the administrator and Director of Nursing Services (DNS) of the facility utilizing the chain of command. Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. Immediate action; notify administrative staff or the nursing supervisor on duty, protect the resident from alleged abuse, suspend the employee pending investigation. Investigation; immediate notification of the Administrator and Director of Nursing (DON) and/or designee, immediate investigation into alleged incident (during the shift it occurred on). 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS, a resident assessment tool) dated 06/08/2018 documented the resident had severe cognitive impairment and required extensive assistance of two persons to transfer. The untitled, undated CNA Kardex (CNA care plan) documented Resident #1 required extensive assistance of two persons to move between surfaces. The Activities of Daily Living (ADL) Comprehensive Care Plan (CCP) dated 06/01/2018 documented the resident had an ADL self-care deficit related to advanced dementia, per Physical Therapy (PT) non-ambulatory on the unit; two assists with transfers. Interventions included; extensive assist of two by staff to move between surfaces, the resident is non- ambulatory. The CCP and the CNA care plan lacked documented evidence to use a stand-up lift as an intervention for Resident #1. The Accident Report dated 08/15/2018 7:30 PM documented the Registered Nurse Supervisor (RNS) was called to evaluate Resident#1 who sustained trauma during a stand-up lift transfer into his bed. The residents' left lower leg had an open one-inch x 0.5-inch laceration/trauma with raised skin/bone area medial side of skin. Pain, swelling and change in range of motion was documented. The medical doctor (MD) was on the unit and examined the resident at 7:45 PM. Emergency care was given and the resident was transferred to the emergency room (ER). The Medical Progress Note (MPN) dated 08/17/2018 (late entry) documented the MD evaluated Resident #1 on 08/15/2018, there was blood on the floor and bed and there was bleeding on the left leg. The left leg was contracted inwards, positive wound on the left shin area. Advised to transfer the resident to the hospital for further evaluation and management. The Nursing Progress Note (NPN) dated 08/16/2018 at 8:15 AM documented Resident #1 was admitted to the hospital with [REDACTED]. The hospital untitled consultation dated 08/16/2018 documented surgical fixation was performed on 8/16/18. The Risk Manager Review (facility investigation, summary and conclusion) dated 08/16/2018 documented Resident #1 required assistance of two persons with transfers. On 08/15/2018 at 7:30 PM the resident was being transferred to his bed from his wheelchair via a stand-up lift by two CNAs (CNA #1 and #2). The resident's bed was not in low position prior to the transfer. During transfer both CNAs realized the bed was too high, it was lowered (by CNA #2) while the transfer was occurring (CNA #1 was lowering the stand-up lift). CNA #1 noticed that the resident's left leg was bent back, and bleeding and the foot was caught in the bed frame. Both CNAs were suspended for not following proper procedure for transferring the resident. The investigation also documented that there was no reasonable cause to believe any alleged resident abuse, mistreatment or neglect regarding this resident had occurred. There was no documented evidence that the resident was assessed for the use of the stand up lift. The MD was interviewed on 08/27/2018 at 11:31 AM and stated he was in the building on 8/15/18 and was called by the Registered Nurse Supervisor to assess Resident #1. The resident was lying on the bed with blood on the floor in his room. Upon assessment the resident's leg had a wound that was bleeding. A dressing was applied. The resident was noted to be sleepy and lethargic. The left leg was rotated toward the body and had pain with movement. The resident had moderate blood loss. The resident was transferred to the hospital. The 3:00 PM-11:00 PM LPN #1 was interviewed on 08/27/18 at 12:30 PM and stated that she was the assigned nurse for the resident on 8/15/18. CNA #1 informed her that the resident got injured during transfer. The resident was observed with a cut on the leg. LPN #1 stated that CNA #1 or CNA #2 did not notify her of a decline in transfer status for the Resident #1. The 2:30 PM - 10:30 PM CNA #1 was interviewed via telephone on 08/27/2018 at 12:00 PM, and stated she was the assigned CNA for Resident #1 and cared for this resident often. She did not check the Kardex for his transfer status and was not aware of the resident's transfer needs. CNA #1 stated that she had cared for this resident prior and had used the stand-up lift to transfer him. On 8/15/18 the resident was sick and was not himself, the resident looked tired and was not talking. CNA #2 assisted her with the transfer utilizing the stand-up lift. The resident was hooked up to the stand-up lift. While CNA #1 was lowering the resident onto the bed, CNA #2 went around to lower the bed as it was too high to place the resident in it. CNA #1 looked down and one of his legs was not visible. The leg was under the bed and the resident was still in the air hooked to the standup lift. She asked CNA #2 to raise the bed. The resident was lifted to the bed by both CNAs. They notified the LPN #1 after they placed the resident in bed. The resident was noted with an open wound on his leg and there was blood on the bed. CNA #2 was interviewed via telephone on 08/29/2018 at 10:15 AM and stated on 8/15/18 she assisted CNA #1 with a stand-up lift transfer for Resident #1. Prior to this incident she had also assisted CNA #1 with the stand-up lift transfer for Resident #1. The resident was hooked to the lift and his knees were against the knee support. CNA #1 lifted the resident from his wheelchair and she (CNA #2) removed the wheelchair from under the resident. The height of the bed was too high; CNA #1 stayed with the resident, CNA #2 went on the opposite side of the bed and lowered the bed. At that time CNA #1 told her to raise the bed because the resident was injured. The resident did not make any sound. CNA #2 thought the resident had a skin tear, she held the resident's shoulder while the resident was sitting at the edge of the bed. She did not see the blood. The In-service Coordinator (IC) was interviewed on 08/27/2018 at 1:30 PM and stated that she participated in the investigation related to the 08/15/2018 incident. She conducted a reenactment of the stand-up lift transfer with CNA #1 and CNA #2. CNAs were supposed to be next to the resident throughout a transfer with the stand-up lift. During the reenactment it was noted that the resident's bed was too high, CNA #2 left the resident and went on to the other side of the bed to lower the bed. CNA #1 was with the resident and was operating the lift and continued lowering the resident while CNA #2 was lowering the bed. The IC stated that the transfer was not done correctly. If the resident's feet were positioned properly on the lift the feet would not get under the bed frame. The IC stated that she was unable to discern how Resident #1's leg got under the bed frame. The IC stated that she educated the staff related to transfers and utilizing the stand-up lift. The staff was instructed of the proper procedures. The staff was also instructed to not use a lift without an assessment by the RNS or the therapist. If the resident was declining in transfer status, the CNAs were to notify the nurses. The 9:00 AM - 5:00 PM RN Risk Manager was interviewed on 08/27/2018 at 2:00 PM and stated she participated in the investigation related to the incident with Resident #1 on 8/15/18. CNA #1 and CNA #2 told her Resident #1's leg was crushed under the bed frame during a transfer. When the CNAs were transferring the resident, they realized that the bed was too high, CNA #2 lowered the bed while CNA #1 was placing the resident on the bed utilizing the stand-up lift. CNA #1 told her that she was not paying attention to the resident's legs and was looking at the intravenous pole. The Risk Manager stated that the CNAs were supposed to ensure that the bed was at the correct height prior to the transfer; the resident's limbs were secured and both CNAs were expected to be by the resident during the entire transfer process. CNA #1 and CNA #2 also told her that they used the stand-up lift for Resident #1 previously and did not make anyone aware that resident had declined in his transfer status. The Risk Manager stated that the CNAs could not use the stand-up lift without an assessment by the RNS or the physical therapy department. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 dated 05/19/2018 documented the resident's cognitive status as intact. The ADL CCP documented on 06/07/2018 stand-up lift with two assists to transfer. The Accident Report dated 06/28/2018 documented at 6:45 PM the resident was being transferred to bed with the stand-up lift, she pulled her hand out of the sling and slid out lying on her back. The CNA lowered her to the floor. The resident complained of pain to the right hip and right knee. The MD was notified and ordered an x-ray of the right hip and knee. The Radiology Results Report dated 06/28/2018 documented an acute fracture lateral tibial articular surface (a break of the upper part of the tibia (shinbone) that involves the knee joint) with slight displacement. The hospital x-ray right tibia and fibula dated 06/29/2018 documented diffuse osteopenia (bone loss is not as severe as in [MEDICAL CONDITION]) and right-sided lateral tibial fracture. The Radiology Results Report dated 06/28/2018 documented an x-ray of the right knee. Impression included an acute fracture lateral tibial articular surface (a break of the upper part of the tibia (shinbone) that involves the knee joint) with slight displacement. As compared to the study on 06/06/2018 this was not definitely identified. Severe [MEDICAL CONDITION] is present. The right hip x-ray documented mild [MEDICAL CONDITION] changes and no acute fractures noted. The Hospital History and Physical (H&P) assessment dated [DATE] documented patient had x-ray done yesterday results showing acute [MEDICAL CONDITION] lateral tibial plateau and right [MEDICAL CONDITION]. The Risk Manager Review (facility investigation summary) dated 06/29/2018 documented the investigation revealed that there may be reasonable cause to believe alleged resident abuse, mistreatment or neglect regarding this resident had occurred. On 06/28/2018 the resident was being transferred back to bed via the stand-up lift with assistance of two CNAs. CNA #5 did not stay (it was past her break time) and told CNA #4 she was leaving. CNA #4 did not insist that CNA #5 stay and assist her until the transfer was complete. While the resident was close to the bed, the resident removed her hand from the sling/strap of the lift and started to slide off the bed. The CNA put one foot against the resident to break her fall and lowered the resident to the floor in sitting position. The Nurse and MD were called and x-rays were obtained showing an acute fracture to the right lateral tibial articular surface. The MD ordered to send the resident to the hospital. The hospital Patient Discharge Instructions dated 06/30/2018 documented [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The 2:30 PM - 10:30 AM CNA #4 was interviewed via telephone on 08/31/2018 at 9:30 AM and stated CNA #5 came to the room to help transfer the resident. CNA #4 began to raise the resident while CNA #5 removed the wheelchair for her. The resident started crying, CNA #5 told her every time she was placed in the stand-up lift she cried. The resident continued to cry as she was pulled up from the wheelchair. The resident's feet were shaking and when she was lifted her heels did not lay flat on the base pedal of the machine. CNA #4 started to lower the resident and noticed the bed was too high. CNA #5 was by the door at that point and told CNA #4 that it was time for her break, CNA #5 left the room. The resident's bed was still high, CNA #4 tried to adjust it with one hand. The resident removed her hands from the machine strap. CNA #4 saw the resident was going to fall, and she slid her down in a sitting position. CNA #4 removed the belt as the resident was sliding. CNA #4 stated she did not ask CNA #5 to stay. CNA #5 was interviewed via telephone on 08/31/2018 at 1:49 PM and stated she assisted CNA #4 transfer Resident #2 using the stand-up lift. The resident said ow as she was lifting her up, the resident didn't complain anymore while she was in the air and did not cry. CNA #4 was fixing the resident's pants; the resident was at the side of the bed in the air when CNA #5 asked CNA #4 if she could go on her break and she said ok. When she left the room, the resident was still on the lift. LPN #2/Charge Nurse was interviewed on 08/28/2018 at 2:38 PM and stated CNA #4 reported that CNA #5 had left her during Resident #2's transfer. The resident was on the floor, next to her bed. She expressed pain to the right leg upon movement. The 2:30 - 10:30 PM RNS #2 was interviewed via telephone on 10/05/2018 and stated she was called to the resident's room by LPN #2. She responded to the room and saw the resident was on her back, on the floor next to the bed. Resident #2 complained of right knee and hip pain. She called the MD and he ordered x-rays that revealed right tibial fracture. Both CNAs were supposed to be with the resident during a stand-up lift transfer until the transfer was complete. CNA #5 did not follow the facility policy related to stand-up lift transfer and left the resident during the transfer. 415.12(h)(1)

Plan of Correction: ApprovedNovember 16, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1
1.
The resident was immediately assessed by MD and RN supervisor and transferred to hospital on [DATE].The resident did not return back to facility.
The CNA assigned to the resident and the CNA who assisted in the transfer of the resident were identified on 8/15/18,removed from the assignment on 8/16/18,suspended immediately on 8/16/18, pending investigation, were subsequently terminated from employment for not following the transfer protocol.
Resident #2
The resident was assessed by MD and RN supervisor and transferred resident to hospital immediately for further assessment and treatment on 6/28/18.The resident is currently stable.
The CNA who assisted the assigned CNA to care for resident #2 was immediately identified and removed from assignment on 6/28/18, suspended on 6/29/18 pending investigation and ultimately terminated from employment for not following the residents plan of care.6/29/18
The CNA assigned to resident#2 was immediately identified and re-inserviced on following resident's plan of care and to ensure the other CNA assisting the assigned CNA remains with the CNA until resident's transfer is completed; disciplinary action given for the same.6/29/18
All A/I for the period of (MONTH) (YEAR) to (MONTH) (YEAR) were reviewed by the DNS to ensure there were no additional A/I occurred related to the use of stand Up Lift.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice.
The unit Coordinators/designee will identify all residents who require assistance with transfer ,including those who require the use of Mechanical Lift. The rehabilitation staff will assess all residents requiring transfer assistance with Stand Up Lift to ensure each resident continues to require the use of Stand Up Lift. Any changes to Plan of care related to transfers will be documented in the medical record and the Plan of Care /Kardex updated to ensure the change in transfer status is included.
The IDCP team will review and revise ,as needed, the plan of care for all identified residents related to their transfer status and physical assistance, devise needed to complete a safe transfer. The unit coordinators will update, as needed, the CNA Kardex and will provide education to the unit staff on any revisions to the plan of care.
All stand Up Lifts were inspected by Plant Operations to verify proper working conditions. Documentation of inspections in plant Operations Office.
On 11/15/18 the facility contracted with CMS Compliance Group.Inc.to provide services related to the Directed Plan of Correction and Directed Inservice training.
A CMSCG RN Consultant will provide education on 11/19/18 and 11/20/18 regarding the facility's protocols related to Accident Prevention and provision of adequate supervision and assistance to prevent accidents, including protocols related to the use of Stand Up Lifts and required assistance with transfers. Education of the nursing staff will include a focus on safe transfers utilizing a Stand Up lift and following the plan of care. This education will continue to be provided until all staff receive this required education.
III. The following system changes will be implemented to assure continuing compliance with regulations.
The Administrator, Medical Director, Director of Rehabilitation and Director of Nursing will review and revise, as needed , the facility's policies and procedure related to accident prevention, including protocols related to resident transfers, assistance during transfers and use of Stand Up Lift used in the facility.
The policy and Procedure on Transfer Technique was reviewed and revised to include that the use of a Stand Up Lift to transfer a resident is determined only by the Rehabilitation Department.
All CNAs will have competencies completed during orientation and minimally on an annual basis on Mechanical Lift transfers including stand Up Lift.
The competency will include assessing the CNA's knowledge of what should be done when a resident is weak or noted with a change in transfer ability and that the CNA is responsible to report the changes to the RN/Charge Nurse immediately.
The RN/Charge Nurse will determine the level of transfer assistance needed including use of Mechanical Lift for transfer and will notify the Rehabilitation Department of the change in resident's transfer status. The competency will include the CNA/Charge Nurse understanding that they will not use the Stand Up Lift to transfer the resident until rehab assesses the resident to be a candidate for the use of Stand Up Lift.

IV. The facility's compliance will be monitored utilizing the following quality assurance system.
As per Directed Plan, a Quality Assurance Committee meeting co-chaired by the CMS Compliance Group, Inc. RN Consultant will be convened on 11/20/18 to discuss the deficiency. If needed , additional corrective actions related to accident prevention for any newly identified concerns will be implemented with education provided.
An audit tool was created to monitor staff competencies and knowledge base related to proper transfer technique and use of Mechanical Lifts including Stand Up Lift for transfer per resident's plan of care.

The Unit Coordinators and Charge Nurses will conduct a weekly audit of 2 residents on the day shift and 2 residents on the evening shift on each unit to ensure compliance with safe transfers using a lift for the next 4 weeks with all findings being reported to the Administrator and Director of Nursing. If staff noted to be using inappropriate technique to transfer resident, the nurse immediately intervenes, assists resident with the transfers and uses the opportunity to re educate the identified CNA immediately. Following the 4 weeks of auditing of transfers being performed and no issues being identified, the frequency of auditing will be reduced to 2 resident transfer observation on the day shift and 2 residents on the evening shift monthly for the next 3 months . Corrective actions, such as an additional competency evaluations being completed or re-education on safe transfer, will be implemented, as needed.
The Director of Nursing will report safe transfer and use of mechanical lift audit findings at the next QAPI Committee meeting for evaluation and follow-up discussion. Reporting will continue for the next 3 months with a determination made at the end of this period if auditing needs to continue and at what frequency.
The Director of Plant Operations will continue to inspect all mechanical lifts for proper functioning as outlined in the Preventive Maintenance Program for those pieces of equipment. Reports will be made on an as needed basis to the QAPI Committee for identified lift issues for foolw-up discussion and corrective action.
Responsible Person: Director of Nursing