LAKELAND, FL- THE CLUB AT LAKE GIBSON

*NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, it was determined the facility failed to 1.) ensure staff implemented training received related to usage of a transfer lift, which resulted in a fractured right arm for one (Resident #50) of seven residents reviewed for falls; and 2.) assess, document, and treat an staff/resident incident, which resulted in a right elbow skin injury for one (Resident #322) of thirteen residents reviewed for accidents.
Findings included:
1. Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)]. Review of nurses’ notes, written on 11/22/2022 at 1527 (3:27 p.m.), revealed the resident had been sent to the hospital due to a right arm dislocation. The note identified the resident as alert and oriented with a pain level of 10 out of 10.
An additional nurse’s note, identified as a late entry and dated and timed at 11/22/2022 at 1506 (3:06 p.m.), indicated the resident had been assessed by an RN (registered nurse) and the Physician had been notified. Orders were received to transfer the resident to the ED (emergency department). Staff were in-serviced on proper lift transfer and abuse/neglect, according to the note.
Records revealed the resident was readmitted to the facility on [DATE] with a cast to her right upper arm. Upon readmission from the hospital, a nurse’s admission note dated 11/25/2022 revealed Resident #50 would need more assistance with her activities of daily living due to general weakness and decreased mobility.
Review of hospital records revealed an initial note indicating: 11/22/2022 1553 (3:53 p.m.): per EMS [emergency medical system] personnel, staff at facility assisting patient to lift, felt a pop, right upper arm deformity. The resident was identified as alert and oriented, with a pain score of 10 out of 10. Diagnoses included [CONDITION(S)] and right arm pain with swelling. Hospital records identified a second description of the incident which read: using lift to place patient on toilet, patient felt a pop, immediate pain in right upper extremity. She did not fall. The physical exam at the hospital documented: obvious deformity at level of elbow with swelling. Moderate tenderness upon palpation with decreased range of motion at level of elbow and shoulder. Distal neurovascular and sensory function is intact. X-ray results indicated a diagonal displaced fracture seen through distal diaphyseal humerus; displacement measures up to 1.1 cm [centimeters]. The hospital record continued: right distal humerus fracture adequately reduced to near anatomic alignment.
An interview was conducted with Resident #50 on 11/30/2022 beginning at 10:00 a.m. The resident was sitting up in her wheelchair at the side of her bed, brushing her hair with the brush in her left hand. She cradled her right arm, which was wrapped in an off-white cast. Her fingers on her right hand were noted to be discolored and swollen. When asked, the resident confirmed she was in pain, said she was always in pain, and stated she was waiting for her morning medications. When asked about her arm, the resident adamantly said she had not fallen, and said she did not want to talk about it.
An interview with Staff O, Certified Nursing Assistant (CNA), who transferred the resident by herself on 11/22/2022, was conducted on 12/07/2022 beginning at 9:30 a.m. Staff O confirmed she was a facility CNA and had been trained on using the lifts and asking for assistance when doing so as two staff were required during transfers. She reported on the day she transferred Resident #50 by herself, she could not find other staff to assist her. She reported the resident was asking to go to the bathroom, and she decided she could transfer the resident by herself. She said everything went smoothly and she had no concerns until the resident was sitting on the toilet and she cried out in pain. When she asked the resident what happened, the resident said she heard a pop and felt pain. The CNA said she had not heard a pop and thought the transfer went well. Staff O reported she called for the nurse and the nurse said right away she could tell her arm was broken. Staff O said she remembered that five CNAs were working that day on her unit, and everyone was busy.
A review of the schedule during the days of the survey – 11/28/2022 through 12/02/2022 – revealed on the day shift, which is when the incident with Resident #50 occurred, there were more than 5 CNAs working on each hall. On 11/28/2022 there were 8 CNAs working on the rehabilitation unit and 7 CNAs working on the long-term unit. The facility census was 115 residents on 11/28/2022.
An interview was conducted with the resident’s nurse, Staff K, Licensed Practical Nurse (LPN), on 12/01/2022 beginning at 10:35 a.m. Staff K reported she entered Resident #50’s room when the CNA called for help. The LPN said when she saw the resident’s arm, she knew something was obviously not right. She reported that the CNA confirmed she had got the resident up to go into the bathroom by herself using the sit to stand lift. The nurse reported she was not familiar with the sit to stand lift, but the protocol was always to use two staff when residents are transferred.
An interview was conducted with the Director of Nursing (DON) on 12/01/2022 beginning at 12:00 p.m. The DON confirmed the CNA had transferred the resident to the toilet with a lift and had not got assistance from another staff member. The DON reported the resident said once she was seated, she heard a pop and felt pain. The DON reported the facility protocol is to always have two staff to transfer residents and the manufacturer’s guidelines for the lift suggest two staff also. The DON reported the CNA told her everyone was busy, and she knew she could transfer the resident using the lift by herself. The DON reported interviews with other staff who were working at that time revealed they had not been asked to assist with the transfer. The DON confirmed the CNA had been trained on using the lift and providing transfers to residents, and she had passed her competency on the use of lifts and transferring residents. The DON said the CNA had acted appropriately by getting the nurse when the resident called out in pain, but she was wrong to transfer the resident by herself.
A review of the resident’s Minimum Data Set (MDS) Assessment revealed the resident had been assessed for a significant change on 11/30/2022. The resident’s Brief Interview for Mental Status was scored at a 10 indicating the resident’s cognition was moderately impaired. The resident’s functional status to transfer was assessed as requiring total assistance with two staff. Both dressing and toilet use were assessed as requiring extensive assistance with two staff.
A review of an annual MDS completed on 10/19/2022 identified the resident’s functional status when transferring as requiring extensive assistance with two staff. Toileting and dressing required extensive assistance with two staff.
A review was conducted of the resident’s care plan. The care plan listed as a focus area the resident’s ADL (activities of daily living) self-care performance deficit related to limited range of motion related to impaired balance and weakness. The care plan was revised on 12/01/2022 to include her fractured right arm contributing to her self-care performance deficit and limiting her range of motion.
Further record review revealed at initial admission to the facility, on 10/11/2021, the resident required limited assistance with one staff for both transfers and toilet use. The ADL care plan had not been revised to reflect the resident’s assessment on the Annual MDS dated [DATE] when the resident’s transfer and toilet use declined to the need for extensive assistance with two staff. Prior to the revision dated 12/01/2022, the care plan directed staff to use one staff due to the limited assistance the resident needed.
A review of the CNAs Kardex (resident’s plan of care) revealed information indicating the use of a mechanical lift and two staff for transfers, but on the same page, the resident was identified as requiring limited assistance of one staff for transferring.
2. Record review revealed Resident #322 was admitted on [DATE]. The Admission Record included diagnoses not limited to fracture of superior rim of left pubis subsequent encounter for fracture with routine healing, history of falling, encounter for other orthopedic aftercare.
An observation was made on 11/28/22 at 10:18 a.m. of a white woven island dressing attached to Resident #322’s right elbow. The dressing was undated, and a slight amount of drainage was observed through the dressing. Resident #322 reported that approximately 2 weeks ago, Wednesday a staff member was pushing the resident in wheelchair, went around the corner to fast, and the residents’ right elbow was banged and scraped across the wall.
Review of the ‘export ready’ Admission Minimum Data Set (MDS) for Resident #322, dated 11/15/22, indicated a Brief Interview of Mental Status score of 12 out of 15, indicative of moderate cognition impairment.
A review of Resident #322’s Treatment Administration Record (TAR) did not include physician orders for the right elbow dressing until 11/30/22 at 7:00 a.m., 2 days after the observation of the undated dressing.
Review of the progress note, dated 11/28/22 at 7:15 a.m., indicated Resident #322’s memory was intact and did not identify any skin issues. The progress note, dated 11/29/22 at 7:15 a.m., identified that Resident #322’s memory was intact, nursing interventions were provided throughout the day and the nurse observed for changes in status; the note did not indicate the resident had any skin issue to the right elbow. A progress note, dated 11/30/22 at 7:15 a.m., identified an assessment was completed, the resident s’ memory was intact, nursing interventions were provided throughout the day and the resident was observed for changes in status; the note did not identify any skin conditions for the resident. A review of the progress notes did not identify an assessment was completed related to Resident #322’s right elbow wound, that the physician or family were notified of the change in condition.
Review of Resident #322’s care plan indicated the following:
– Resident was at risk for altered skin integrity, initiated on 11/9/22 and revised on 11/29/22. The interventions instructed staff to complete skin evaluation upon admission, weekly, and as needed and to notify nurse immediately of nay new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care.
– Resident had a skin tear of the right elbow, initiated, and revised on 12/1/22. The interventions instructed staff to administer/apply medications, ointments, creams as ordered – see MAR [medication administration record]/physician orders, and to report changes in skin status (i.e. [that is] s/s [signs/symptoms] infection, non-healing, new area to nurse/physician.
During an interview on 12/1/22 at 2:22 p.m., the Director of Nursing (DON) stated she was unaware of the incident regarding Resident #322’s right elbow. She reviewed the resident’s clinical record and confirmed there was no documentation regarding how and when the skin tear to the resident’s right elbow had occurred and that no incident investigation had been initiated.