HOUSTON, TX – TEXAS INSTITUTE FOR CLINICALLY COMPLEX CARE

Based on interview, observation, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 12 residents (Resident #4) reviewed for accident hazards, in that: Resident # 4 fell from a mechanical lift to the floor, fracturing her back. This failure affected one resident, placing her at risk for further trauma, pain, and hospitalization .

Observation on 08/22/19 at 1:10 p.m. of the Hoyer lift machine revealed that Resident #4 had fallen from being brought from the broken storage room. The Hoyer lift had a sign on machine indicating out of use, with last inspection date of 07/19/19. There was a sticker on machine reading up to 300 pounds. The legs on the machine were un-even. The leg on the left side was not even with the right leg.

Record review of Resident #4’s Hospital Record dated 08/09/19 revealed that Resident #4 told hospital staff that she had a fall at Skilled Nursing Facility about 2 weeks previously; no further work up at that time. Computed [NAME]ography (CT) Scan was done on 08/09/19 indication: Chronic back pain, fall with an impression of a nondisplaced left lateral sacral fracture. Interview on 08/15/19 at 2:05 p.m., the DON said Resident #4 was being transferred by 2 (two) CNAs from the bed to the wheelchair and the Hoyer lift machine tilted and Resident #4’s upper body hit the floor. The 2 CNAs lowered the rest of Resident #4’s body down to the floor. Resident #4 was assessed by the nurse and denied pain. The DON said, later, Resident #4 started to complain of pain to her abdomen and back. The DON said Resident #4 already had chronic back pain. The nurse gave her something for pain when Resident #4 complained of pain. The DON said the MD was called and orders were given to get a stat X-ray. Resident #4 had to be sent out to the hospital for an accurate X-ray because she weighed too much for the mobile Xray equipment.

Further interview with the DON said an in-service was started on Hoyer lift transfer when the NF found out that Resident #4 had a fracture. The DON said the Physical Therapy Department started a more formal in-service with the Nursing staff 2 days ago, she believed. The DON said when she first started working at the NF she learned that the state came to the NF regarding Resident #4’s fall so she began in-servicing the staff on Hoyer lifts and transfers. The DON said prior to Resident #4’s fall on 08/09/19 was her second fall from the Hoyer lift during transfers. Resident #4’s fall in (MONTH) 2019 was due to a CNA transferring Resident #4 by herself. The DON said that CNA was terminated immediately. Resident did not verbalize pain with the first fall when the nurse assessed her. The DON said the NP was notified and gave orders to do labs.