HUMBOLDT, TN- BAILEY PARK COMMUNITY LIVING CENTER

Based on policy review, Skills Fair Sign-In Sheet, Daily Staffing Assignments, Employee Education Records, medical record review, observation and interview, the facility failed to ensure staff were trained to use the mechanical lifts correctly and conduct a thorough investigation following an accident with the stand-up mechanical lift involving Resident #18, and complete neurochecks for Resident #28 for 2 of 3 (Resident #18 and #28) sampled residents reviewed for accident hazards. The facility’s failure to ensure staff operated the mechanical Stand-up lift correctly resulted in Resident #18 sustaining an injury during the transfer with the Stand-up lift.

The findings include:
1. Review of the facility policy titled, Mechanical Lifts, dated 4/15/2009, revealed, .In order to facilitate a safe lifting environment for staff and residents, mechanical lifts are to be utilized for lifting and transferring residents whenever possible. The mechanical lift program will include the following components .Resident assessment .Staff training for safety and operation of mechanical lifting devices . assessment will identify the type of equipment needed .and number of staff needed to complete the lift or transfer .will be added to the resident’s plan of care and this information made available to unlicensed personnel .Any staff member responsible for lifting and/or transferring residents will receive training on the operation of mechanical devices, application of slings, and safety measures based on the equipment manufacturer’s recommendations .This training must be completed and competency demonstrated prior to lifting and/or transferring the residents. This facility will provide training and validate competency upon hire and at a minimum annually. Training may also be conducted in the following situations .Staff involved in a resident/lift related incident .Staff members must not attempt operation of the lift without proper training .

Review of the facility policy titled, Fall Risk Management, dated 2/22/2012, revealed .Residents will be assessed for fall risk potential. Interventions will be implemented as needed to help manage the potential for falls and assist in minimizing the risks. Interventions will be re-evaluated for effectiveness during care planning and as needed .

Review of the Facility’s undated Fall Checklist form revealed, .Neurochecks initiated for unwitnessed or witnessed head hit .

2. Review of the Skills Fair Sign-In Sheet dated 9/8/2022 and 9/9/2022, revealed Certified Nursing Assistant (CNA) #1, CNA #2, CNA #3, and CNA #4’s names were not on the Sign-In Sheet.

3. Review of the Employee Education Records revealed the facility was unable to provide documentation of mechanical lift training or staff competencies for CNA #1, CNA #2, CNA #3, and CNA #4.

4. Review of the Daily Staffing Assignment sheet dated 5/17/2023, revealed CNA #1, CNA #2, CNA #3, and CNA #4 worked that day.

5. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses of Chronic Kidney Disease, History of Transient Ischemic Attack, Atrial Fibrillation, Pulmonary Hypertension, Venous Insufficiency and Osteoarthritis.

Review of the Visual/Bedside Individual Care Service Plan Report (CNA Task Care Plan) dated 2/28/2021, revealed, .TRANSFER .assist two persons using stand-up lift .

Review of the Care Plan with a revision dated of 8/3/2022, revealed Resident #18 required two person staff assistance when transferred with the Stand-up lift.

Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact, and was totally dependent on staff for transfers.

Review of the Weekly Body Audit dated 5/13/2023, revealed no new skin alterations.

Review of the Incident Report dated 5/17/2023, revealed .Son present and shown [showed] this nurse an approx [approximately] 5 cm [centimeter] raw area to this resident’s [Resident #18] Left side of her neck .She [Resident #18] stated .I figure it happens when they help me put on or take off my clothes .Resident also reported that during transfer to bed with lift, the right side of her face was slightly bumped. Bruising [bruising] noted to right side of cheek area, resident denies pain to area .Nursing to monitor bruise to right side of face and notify NP [Nurse Practitioner] if area worsens or does not improve .

Review of the Facility Investigation revealed the facility failed to complete a thorough investigation of the injury to Resident #18’s right cheek. Investigation included an Incident Report alone. There were no witness statements, staff interviews, resident statement, progress notes, monitoring of the bruise, or in-services conducted following the incident.

Review of the May 2023 Progress Notes revealed no documentation of the bruise Resident #18 sustained from the Stand-up lift.

Observation and interview in the resident’s room on 5/22/2023 at 11:07 AM, revealed Resident #18 sat in a wheelchair at her bedside. There was a faint yellowish green bruise noted to her right cheek bone area, slightly below her right eyeglass lens. Resident #18 stated, I know how this [bruise on right cheek] one did [happened] .right side strap on the lift they were using flew off .little balls on there .1 of the straps was not anchored good, [the strap] slipped and hit me [indicated the right cheek with the visible bruise], it was an accident .she [staff member] reported it . Resident #18 indicated the left side of her neck where a reddened area with dried blood was observed and stated, This one is a mystery don’t know how it happened .

Observation in the resident’s room on 5/23/2023 at 8:17 AM and 3:31 PM, 5/24/2023 at 8:32 AM and 4:11 PM, and 5/25/2023 at 7:22 AM and 1:00 PM, revealed Resident #18 had a faint yellowish green bruise on her right cheek, slightly below her right eyeglass lens.

During an interview on 5/24/2023 at 2:02 PM, the Director of Nursing (DON) was asked how she was made aware of the incident where Resident #18 was injured while being transferred with the Stand-up lift. The DON stated, .looking at .our Risk Management System .Resident interview . The DON was asked was the incident reported to her by Registered Nurse (RN) #1, who had completed the Incident Report. The DON stated, No, not immediately .my next day coming in I check [named electronic medical record] .because we know what happened it wasn’t something like a bruise of unknown origin that needed an immediate investigation .[named RN #1] did the incident report, the son was here and knew .her family is very involved .

The DON confirmed that she interviewed Resident #18. The DON was asked what Resident #18 told her happened with the lift. The DON stated, During transfer the strap had popped off .used the Stand-up lift . goes around her body, hooks on the machine, machine is what manually pulls her up and the strap got her right cheek . The DON was asked did she interview the staff who provided care to Resident #18 on 5/17/2023. The DON stated, No, ma’am. The DON was asked did she obtain a written statement from the staff who provided care to Resident #18. The DON stated, No, ma’am. The DON confirmed that she was unsure which staff worked 5/17/2023 and would have to look at the Daily Staffing Assignment sheet. The DON was asked where her investigation of the incident was. The DON stated, That’s [Incident Report] really it, I read it, agreed with it, there was nothing fishy, no injuries of unknown origin .I talked to the resident, the
Incident Report matched up to what the alert and oriented resident said .[Resident #18] adamant that it was purely an accident, there wasn’t any intent of harm that would have prompted me to investigate . The DON confirmed the incident happened on 5/17/2023. The DON stated, .it just didn’t trigger that I needed to do re-education on all staff with the .lift [Stand-up lift].

During an interview on 5/24/2023 at 4:02 PM, the DON was asked did she complete a thorough investigation of the incident where Resident #18 was injured during transfer with the Stand-up lift. The DON stated, No ma’am. The DON confirmed that the CNA staff receive a skills competency check-off that included use of the mechanical lift on hire and annually.

During an interview on 5/25/2023 at 12:50 PM, Resident #18 was asked did it hurt her when the lift pad popped off and hit her cheek. Resident #18 stated, It was a shock, it hurt just a minute .

Resident #18 was asked did she know which staff member was in the room when the injury with the lift occurred. Resident #18 stated, No, I don’t know half of their names. Resident #18 was asked was the staff member who transferred her aware that her cheek had been hit by the lift pad. Resident #18 stated, Yeah, she was sorry about it and went and reported it for me .

During an interview on 5/25/2023 at 1:08 PM, the Administrator was asked when she was made aware of the incident where Resident #18 had been hit on the face by the lift strap. The

Administrator stated, .don’t know the exact date, every morning we have our daily stand up .we reviewed the occurrences .[named DON] had gone down there [Resident #18’s room] and talked about it. She [Resident #18] told [named DON] what happened .it would have been the next morning [5/18/2023]. The Administrator was asked what else was done following the incident. The Administrator stated, She’s [Resident #18] alert and oriented .there was no suspicion of anything, wasn’t an incident of unknown origin .once we review [named DON] does her
post-investigation .fairly straight forward of knowing what happened on it . The Administrator was provided the facility investigation of the incident which only consisted of the Incident Report RN #1 documented and was asked did she consider an Incident Report to be a complete and thorough investigation of the incident. The Administrator stated, I think there could be some more detail .doesn’t have the witness names in here . The incident is missing the staff involved . The Administrator confirmed that witness statements should have been obtained from the employees involved and employee education provided on use of the mechanical lift
following the incident.

During an interview on 5/25/2023 at 2:05 PM, CNA #5 confirmed that she worked day shift on 5/17/2023. CNA #5 confirmed the lift incident did not occur on day shift. CNA #5 stated, That was second shift . CNA #5 was asked had she ever had problems with the lift strap popping off. CNA #5 stated, No ma’am, I think a lot of them might be new and not [have] been trained .I don’t know what happened.

During an interview on 5/25/2023 at 2:08 PM, CNA #6 was asked how she heard about the incident where Resident #18 was hit in the face with the lift strap. CNA #6 stated, I saw her face .it was bruised. CNA #6 confirmed that she reported the bruise to LPN #2 on 5/18/2023.

During an interview on 5/25/2023 at 2:16 PM, LPN #2 confirmed that she worked day shift, on Monday through Thursday every week. LPN #2 confirmed that CNA #6 reported the bruise on Resident #18’s right cheek to her on 5/18/2023. LPN #2 stated, There was already an incident on it and I’m guessing when she [CNA #6] got report they didn’t mention it, but I knew about it .there was an incident from the day before [5/17/2023] on 2nd shift. LPN #2 was asked what she was told had happened. LPN #2 stated, They said the sling had hit it [Resident #18’s cheek] .during transfer. LPN #2 confirmed that she worked on 5/17/2023 and 5/18/2023, and she observed that Resident #18’s cheek was bruised on 5/18/2023. LPN #2 was asked did she see the bruise on Resident #18’s cheek on 5/17/2023. LPN #2 stated, No.

During an interview on 5/25/2023 at 2:21 PM, CNA #3 confirmed that she was familiar with and provided care for Resident #18. CNA #3 was asked did she transfer Resident #18 with the Stand-up lift alone. CNA #3 stated, Off the commode and out [of] the chair I do .[and] when I put her in the bed .I’ve never got her out of the bed by myself . CNA #3 was asked were they supposed to always use 2 people to transfer a resident with the mechanical lift. CNA #3 stated, We usually use 2 people .On her chart she likes to be laid down between 5:30 and 6:30 .when I hook her up, I make sure she’s comfortable, check the lift strings before I lift her up, make sure everything is steady .never had any problems or anything like that . CNA #3 was asked did the lift strap slip off when she transferred Resident #18 on 5/17/2023. CNA #3 stated, I didn’t have her when it happened .I didn’t notice the bruise until Tuesday [5/23/2023] .I hadn’t heard anything about it [the incident] until I worked with her Tuesday . CNA #3 was shown the Daily Staffing Assignment sheet dated 5/17/2023, which indicated she was assigned to Resident #18, and asked was the assignment sheet incorrect. CNA #3 stated, I might have had her that day, but didn’t nothing happen .I always watch [named Resident #18] because I’m in there by myself .if you bump her or something like that she’s gonna [going to] tell you .I would’ve told the nurse . CNA #3 was asked had anyone in Administration talked to her about the incident. CNA #3 stated, No, If I hadn’t come in Tuesday, I probably wouldn’t have known it . CNA #3 was asked had she received training on use of the mechanical lift. CNA #3 stated, I’ve been certified 22 or [AGE]
years. CNA #3 confirmed that she had not had any recent inservices on use of the mechanical lift. CNA #3 was asked how she knew what care the residents required. CNA #3 stated, I usually just ask the nurse .get a report about them . CNA #3 was asked was there a CNA plan of care. CNA #3 stated, I don’t know. I know we do chart online .I never go through their stuff [Residents’ medical records] .back in the day we used to have a chart [paper chart] and nobody had a problem .

During a telephone interview on 5/25/2023 at 2:45 PM, RN #1 confirmed that Resident #18’s son reported a skin tear on the left side of Resident #18’s neck to her on 5/17/2023. RN #1 was asked about the bruise to the right side of Resident #18’s cheek. RN #1 stated, She said it was nobody’s fault it just happened. RN #1 confirmed that she saw the bruise and it looked different than the areas that Resident #18 usually has come up on her skin. RN #1 stated, .It was out of the ordinary, it looked worse .it looked different, more of a bruise. RN #1 was asked did she report the skin tear and the bruise to anyone. RN #1 stated, .whenever I have a skin tear, bruise, or anything, [named the Nurse Practitioner] .I did contact her .when I contacted the Director of Nursing I threw her a text . RN #1 was asked was she aware if any of the CNAs were interviewed about the incident. RN #1 stated, I talked to them but I can’t remember who it was .it would have been [named CNA
#3] .remember telling the CNA that particular day that was assigned to her, and they were very much aware of how fragile her skin was, to be extra careful .that when she goes to bed tonight be extra careful .have someone kind of hold the straps away from her upper body like her head and neck .

During an interview on 5/25/2023 at 4:09 PM, the DON was asked how CNAs know the extent of care the residents required. The DON stated, Their task care plan [named electronic medical record) where they log in. The DON confirmed that every CNA had access to that Task Care Plan. The DON was asked did the facility’s protocol for resident transfers with the mechanical lift require 1 person or 2-person assistance. The DON stated, 2 person for the Hoyer or the Stand-up lift. The DON confirmed staff should never use the Stand-up lift alone. The DON was asked should staff follow the resident’s plan of care for the Stand-up lift. The DON stated, Yes, for anything they should follow the whole plan of care. The DON confirmed Resident #18’s Care Plan should reflect the bruise she obtained from the Stand-up lift.

During a telephone interview on 5/26/2023 at 11:44 AM, the Nurse Practitioner (NP) was asked on 5/17/2023, was she notified that Resident #18 reported to staff that she was hit in the face with the lift strap and had a bruise on her right cheek. The NP stated, They just told me about the skin tear . The NP was asked she examine Resident #18’s bruised cheek. The NP stated, I didn’t. I just went in and saw her a couple of days ago and did not write a note up .she [Resident #18] said .don’t get excited about it. The NP was asked did she see the bruise and what it looked like at that time. The NP stated, It was very faint. The NP was asked should an investigation have been conducted on the bruise Resident #18 sustained in an attempt to identify who conducted the transfers and what occurred. The NP stated, Yes .maybe should have.

During an interview on 5/26/2023 at 12:05 PM, the DON was asked when the last in-service was conducted with facility staff on use of the mechanical lift. The DON stated, Didn’t cover the lifts in April [Skills Fair] .try to cover yearly .I had a Skills Fair last September [2022].

During an interview on 5/26/2023 at 12:55 PM, the DON confirmed that she could not locate the staff competencies and in-service records regarding use of the mechanical lift for CNA #1, CNA #2, CNA #3, and CNA #4. The DON stated, I don’t know what to tell you .I have looked everywhere .

6. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses of Pancreatitis, Dementia, Osteoarthritis, Hallucinations, Hypertension, Osteoporosis, Fracture of Shaft of Humerus Right Arm, and Diabetes.

Review of the significant change MDS dated [DATE], revealed Resident #28 had a BIMS of 5, which indicated she had severe cognitive impairment, required extensive to total staff assistance for all activities of daily living, and had sustained 1 fall since the prior assessment.

Review of the Incident Report dated 3/20/2023, revealed, .This nurse was called to resident’s room by [named CNA #7]. Upon entering the room, I found the resident on her hands and knees. [Named CNA #7] stated .resident was walking to bathroom when she slipped and fell into the floor onto her knees and caught herself with her hands .Resident did not hit her head .complaining of pain in her RT [right] arm .Resident was not wearing proper footwear at the time of the incident .had an incontinent episode while walking to the bathroom .

Review of the Health Status Note dated 3/20/20233, revealed, .Bruise above resident’s Left eye.

During an interview on 5/23/2023 at 5:23 PM, the DON confirmed CNA #7 did not write a witness statement following Resident #28’s fall on 3/20/2023. The DON confirmed that Resident #28 fell forward, caught herself with her forearms, and hit her forehead on the floor.

During a telephone interview on 5/25/2023 at 5:45 PM, CNA #7 confirmed that she witnessed Resident #28 fall on 3/20/2023. CNA #7 stated, I was walking past her room, she was walking toward her bathroom and as she was walking, she fell .[I] didn’t have time to get to her .she was saying her arm hurt .went and got the nurse . CNA #7 was asked did Resident #28 hit her head on the floor. CNA #7 stated, I believe so . CNA #7 confirmed that she told LPN #3 what had happened following the fall.

During an interview on 5/24/2023 at 11:14 AM, the DON confirmed neurochecks were not completed following Resident #28’s fall on 3/20/2023 because the resident hit her forehead, not the back of her head. The DON was asked are neurochecks only required when a resident hits the back of their head. The DON stated, I wouldn’t consider it [indicated her forehead] the head .policy is not specific .I would consider anything within my hair line [as a hit to the head] .