State Findings:
Based on record review, resident and staff interviews, and review of facility policy titled, Resident Lift the facility failed to ensure that one of three residents (R A) was transferred appropriately using a Hoyer lift with two-person assist. Actual harm was identified on 11/25/18 when CNA EE transferred R A by herself without the assistance of any other staff or mechanical lift, as care planed, and the resident fell and suffered a fractured tibia and fibula which required open reduction internal fixation surgery.
Review of a typed statement dated 12/3/18 documented the following, in pertinent part: CNA EE and the Administrator visited with RA in the hospital on [DATE] . RA said, when the CNA (CNA EE) placed me on the bed, my knee buckled or gave way, I slid off the bed with the CNA helping me down to the floor. That is when my knee started hurting. This statement was signed by the CEO and CNA EE.
Interview with RA on 8/7/19 at 2:20 p.m., revealed that she felt that staff did not do their job because she was a two person assist for a Hoyer lift, and a Hoyer lift wasn’t used on the day that she fell . RA said that the Certified Nursing Assistant (CNA) did the transfer by herself even after she mentioned to her that she was a two person assist. RA stated that the CNA said she could do it by herself. The resident stated that the fall resulted in a fracture of her right knee, which she had to be hospitalized for [REDACTED].>Interview with CNA CC, on 8/8/19 at 10:30 a.m., revealed that the resident was a two person assist at the time of the fall, as well as now
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