Title 22 Division 5 Article 3 Section 72517 (a) (5): Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: Accident prevention and safety measures.
The facility failed to provide an ongoing educational program which included staff instruction to follow manufacturer's safety guidelines for the use of the full body sling on the Hoyer Lift. As a result of this failure to provide this training to staff, Patient 1 fell from the Hoyer Lift when CNA 1 failed to fully engage the hooks into the swivel bar of the Hoyer Lift which led to Patient 1's serious injury, head trauma and bleeding. Patient 1 subsequently died within two days of the fall.
Entity Reported Event CA 00300289 was investigated during an unannounced visit to the facility on 2/23/12.
Patient 1's admission record included information that Patient 1 was a 90 year old female admitted to the facility on 4/17/10. Patient 1's diagnoses included Alzheimer Disease (Cognitive Disorder marked by confusion) and Osteoporosis (disease that weakens the bones).
Patient 1's Minimum Data Set (MDS) Assessment, dated 1/3/12, indicated Patient 1 required total assistance by staff for Activities of Daily Living (ADLs) and extensive assistance with transfers. Patient 1's total dependence on staff during transfers required the assistance of a Hoyer Lift for transfer.
The "Interdisciplinary Post-Fall Assessment" dated 2/19/12, indicated, two Certified Nursing Assistants had transferred Patient 1 from the wheelchair (w/c) to the bed using a Hoyer Lift. This document included information that the loop of the sling, used for Patient 1 to sit on while on the lift, came off one side of the Hoyer Lift. Patient 1 then fell to the floor and hit her head on the legs of the Hoyer Lift. Patient 1 was documented as "confused" and "disoriented." Patient 1 sustained a laceration under the chin and an injury to her nose. The document indicated Patient 1's nasal septum had been deviated to the left with blood clots in the nares. The facility called 911 for emergency transport to the acute care hospital immediately after Patient 1's fall from the Hoyer Lift.
The "Nurse's Notes" dated 2/19/12 at 1:30 p.m., contained documentation, "Heard a CNA yell for help. Resident on floor face down... with face in pool of blood (sic). ABC's (Airway, Breathing, Circulation) compromised ...bleeding from chin cut, + (and) bleeding from cut above R [right] eye. Called for crash cart (cart with emergency resuscitation [reviving] supplies) ... 02 sats (blood oxygen saturation level) 80's (normal 97%- 99%) 02 applied at 2 LPM (liters per minute) simple mask, sats continued to decrease to low 70's, resident [Patient 1] became unresponsive ...placed on the bed in preparation for CPR (cardiopulmonary resuscitation) ...sats continue to drop ..."
On 2/23/12 at 11:10 a.m., during a concurrent observation and interview, CNA 1 stated she had been one of the two CNAs who had transferred Patient 1 using the mechanical lift on 2/19/12. CNA 1 then demonstrated the use of the Hoyer Lift (as would be performed in the transfer of a totally dependent patient). During the demonstration, CNA 1 did not demonstrate how the mesh of the body sling would be safely engaged on the swivel bar hooks in order to prevent a fall. The sling pad used for Patient 1 had four loops with secured metal rings in each of the four corners. Each loop was color coded from the farthest to the closest proximity to the body of the sling in the order of black, pink, green and blue. CNA 1 stated all of the loops had been intact and there had been no defect or weakened part.
CNA 1 stated she and CNA 2 entered Patient 1's room on 2/19/12 at 1:10 p.m. and had taken in the Hoyer lift to transfer Patient 1 from the wheelchair to the bed. CNA 1 stated the purple mesh sling had been placed on the wheelchair. Patient 1 had then been transferred to the wheelchair seat and her bottom placed on the sling pad. CNA 1 stated that CNA 2 hooked the two loops which supported Patient 1's head and upper body to the top part of the bar which held the loops of the sling. The hooks of the sling had been placed on the top part of the bar rather than the lower bar where the hooks would have been fully engaged. One loop was placed toward the left side of Patient 1's head, and the other loop to the right side. CNA 1 stated she then hooked the two loops which had supported Patient 1's lower part of the body. Patient 1 had been lifted three feet high from the ground when Patient 1's left leg slid off of the sling pad. At this time, CNA 1 stated the left lower corner of the loop of the sling had disengaged from the hook on the Hoyer Lift. CNA 1 stated she tried to grab Patient 1's leg, but Patient 1 slid, tumbled forward, and hit her head and nose on the leg of the left side wheel of the Hoyer Lift. CNA 1 stated checking the status of full engagement of sling strap had never been a part of procedures ever before, and no one ever fell off before till now. CNA 1 acknowledged the sling strap placed to support Patient 1's lower left side had been placed on the hook, but disengaged on the lower part of the bar.
On 2/13/12 at 12:10 p.m., during an interview, the Director of Staff Development (DSD) stated the standard procedure for use of the Hoyer Lift, but did not include the step (from the manufacturer's guidelines) how to ensure the sling straps were fully engaged on the lowest part of the bar prior to the operation of the Hoyer lift.
The manufacturer's guidelines for the Hoyer [mechanical} Lift use of the full body sling (provided by the facility's administrator on 2/23/12) indicated, "Sling straps must be fully engaged on swivel bar hooks."
The facility's Lesson Plan for training provided to Certified Nursing Assistants (CNAs) dated 5/25/11 titled, "Proper Lifting + Use of Mechanical Lifts" did not include the steps of the manufacturer's guidelines for safe use of the body sling on the Hoyer Lift in order to prevent a fall.
On 2/23/12 at 1:40 p.m., during a concurrent interview and observation, CNA 3 verbalized how to use the Hoyer Lift step by step, but did not describe how to ensure the sling straps would be fully engaged on the swivel bar. During a demonstration CNA 3 was observed to hook the sling strap on top of the swivel bar and did not ensure it was fully engaged.
On 2/23/12 at 1:50 p.m., during a concurrent interview and observation, CNA 4 described how to use the Hoyer Lift step by step. CNA 4 did not state how she would ensure the sling straps had been fully engaged on the swivel bar prior to transferring a patient on the Hoyer Lift. During a demonstration CNA 4 was observed to hook the sling strap on top of the swivel bar and did not ensure it was fully engaged.
Patient 1 was sent to the hospital on 2/19/12. A review of the "Hospitalist (MD who works in the hospital) Discharge Summary" dated 3/8/12 contained documentation, "...Patient was found to have multiple facial fractures, subarachnoid hemorrhage (bleeding in the subarachnoid space of the brain), ...and cardiac dysrhythmia..." The facility failed to effectively instruct and follow safety guidelines from the manufacturer's guidelines for use of the full body sling on the Hoyer Lift. Patient 1 fell from the Hoyer Lift when CNA 1 failed to fully engage the hooks into the swivel bar which led to Patient 1's serious injury, head trauma and bleeding. Patient 1 died within two days of the fall.
Review of Patient 1's Coroner's Autopsy Report, dated 3/13/12 indicated, " ...AUTOPSY FINDINGS: 1. Subarachnoid hemorrhage ...2. CAUSE OF DEATH: Cardiac arrhythmia due to a combination of hypertensive heart disease and blunt trauma to the head and face..."
These violations, either jointly or separately, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient and therefore constitutes a Class "AA" Citation.