COLORADO SPRING, CO-COLONIAL HEALTH AND REHABILITATION CENTER

Resident #4 was dependent on staff for most activities of daily living and transferred with a mechanical Hoyer (mechanical) lift by staff according to their Kardex (computerized overview of each resident’s care summary information) and comprehensive plan of care. Resident #4 was transferred on 2/4/22 by a nurse and certified nurse aide using a gait belt, which resulted in a fall with a right femur fracture and associated pain. The facility neglected to transfer Resident #4 according to her plan of care.

CNA #4 was interviewed by phone on 3/14/22 at 5:01 p.m. She said the resident did not fall. She said herself and RN #2 transferred the resident with a gait belt. The resident was also being supported under each arm. The wheelchair kept moving and they were unable to support the resident and they lowered the resident to the floor very gently. The resident’s right knee was rotated and there was a big pop sound. She said she knew they were to use the mechanical Hoyer lift to transfer the resident and it was stupid of them not to use the lift. She said the resident yelled out in pain and the screaming was unbearable. She said RN #2 did an assessment before the resident was moved. She said a Hoyer lift was in the hallway, just outside the resident’s room. She said she had access to the resident’s Kardex and care plans.

The NHA, DON and RNC were interviewed on 3/15/22 at 2:38 p.m. The NHA said RN #2 and CNA #4 came and told the DON immediately after the incident that they did not use a mechanical Hoyer lift, as they should have. The NHA said the resident’s Kardex and care plan for transfers revealed the use of a mechanical Hoyer lift for all transfers. She said the RN #2 and CNA #4 were not following the resident’s Kardex or care plans for transfers. She said the resident’s Kardex and care plan for transfers were in place to prevent this type of incident from occurring. The NHA said at the time of the incident, there were no visible injuries and the resident did not hit her head when she was slowly lowered to the floor by staff. She said the facility used the non-verbal pain scale when the resident pointed her finger at her right knee and hip area. The NHA said RN #2 and CNA #4 were educated by the DON immediately to follow a resident’s transfer status. The NHA said the resident had a STAT x-ray of the right knee on 2/5/22. The NHA said an unplanned change in elevation was considered a fall.

The facility substantiated neglect, however the initial report to the State Agency was not made until 2/11/22 which was eight days after the incident on 2/4/22 (cross-reference F609 reporting timely to State Agency).