Citation Number: 220003849
Citation Date: 4/3/2007
Violation Date: 2/6/2007
Class: AA
Penalty: $ 100000.00

Title 22

72311(a)(2) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.

72523(a)(c) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (c) Each facility shall establish and implement policies and procedures, including but not limited to:

These regulations were not met as evidenced by;

The facility failed to implement the care plan and their policy and procedure for use of the Mechanical Lift (Vanderlift) for two CNA'S to assist with the transfer of Resident 1 from bed to the recliner chair."

The facility's policy states it is the Licensed Nurse who decides whether or not a resident can be moved post fall incident, and only after a thorough post fall assessment has been done.

Resident 1 fell on the floor on 2/4/07 while being transferred with a mechanical lift (Vanderlift) from bed to a recliner chair. The Medical Examiner's report and Certificate of Death dated 2/7/07 indicated the immediate cause of death was "Blunt impact of torso with laceration of liver".

CNA 1 had CNA 2 help her move the Resident back into her bed from the floor. CNA 1 failed to immediately report the fall to the charge nurse before moving her.

Resident 1 was admitted to the facility on 5/23/01 with diagnoses including Alzheimer's disease, coronary heart disease, glaucoma both eyes and osteoporosis. The 3/8/06 Minimum Data Set (an assessment tool) indicated she was totally dependent on staff for all activities of daily living. Resident 1 had limited range of motion and partial loss of voluntary movement on both sides of her arm, hand and leg. Resident's weight was 132 pounds and her height was 58 inches. Resident required more than two staff to assist her during transfer "to/from bed, chair and wheelchair".

The care plan dated 4/13/04 revealed the Resident had "self care deficit" related to Alzheimer's Dementia and required total assistance with activities of daily living (ADLs). One of the approaches on the care plan was to use "mechanical lift for transfers with 2 CNA'S." The DON stated, based on her interview with CNA 1, the Resident was transferred from bed to the recliner chair by only one CNA.

The nurse's notes dated 2/4/07 showed the Resident was not responsive to "pain stimuli". The Resident had skin tears, a bruise on the right hand and elbow, a laceration on the right temple with bleeding and the left forearm had skin discoloration. "After few minutes, the resident stopped breathing, unable to appreciate B/P (blood pressure), PR (pulse rate) and respiratory rate". The Resident's body was released to the mortuary at 12:05 P.M..

The facility's investigative report showed CNA 1 failed to criss cross the sling before hooking the sling to the Vanderlift. The sling was called a "Divided Leg Sling Item # R101." Review of the manufacturer' instructions on the use: "Note: The straps maybe around, crossed between or underneath the patient's legs". CNA 1 failed to cross the sling per the manufacturer's instructions.

During an interview on 2/6/07 at 10:30 A.M., the Assistant Administrator and the Director of Nursing Services (DON) stated Resident 1 fell from the "bag" that was hooked to the Vanderlift. The DON said: CNA 1 failed to crisscross the sling that was placed under the Resident's thighs as per manufacturer's instructions. The DON said on 2/4/07, during patient care in the morning, CNA 1 put the sling under the Resident's thighs and hooked the sling to the Vanderlift machine to "maneuver the Resident to the reclining chair". Resident 1 slid down to the floor and hit her head, right side "against the floor". CNA 1 left the Resident to look for another staff. CNA 2 came to assist. When CNA 2 responded, she asked CNA 1, "Why is the Resident on the floor?" CNA 1 said: "She fell". According to the DON both CNAs put the Resident back to bed using the same Vander lift. The DON also said that the Resident should not have been moved after a fall incident per their policy and procedure. According to the Assistant Administrator, CNA 1 failed to follow nursing procedures. CNA 1 moved Resident 1 with CNA 2 before the licensed nurse had an opportunity to assess the Resident.

Therefore, CNA 1 failed to follow the manufacturer's instructions and failed to implement Resident 1's care plan. This failure resulted in Resident 1 falling from the mechanical lift. In addition, the facility failed to follow its policy and procedure post fall incident not to move the Resident from the floor to bed without the assessment of a licensed nurse.

The above violations presented an imminent danger to the Resident and were a direct proximate cause of the death of the Resident.