MARION, OH – HEARTLAND OF MARION

Based on medical record review, review of hospital records, staff and resident interview, the facility failed to ensure a safe transfer for a resident. This resulted in actual harm when the resident sustained [REDACTED]. This affected one Resident (#10) of three reviewed for accidents. The facility census was 107.

Interview with STNA #120 on 12/23/19 at 1:04 P.M. revealed she transferred Resident #10 out of bed on 12/05/19 by herself and into her wheelchair. Then later the STNA revealed the resident requested to be transferred to the commode. STNA #120 revealed she, STNA #121, and four STNAs in training, used a gait belt to transfer the resident out of the wheelchair and onto the commode. The STNAs left the room to provide privacy for the resident. STNA #120 stated the next shift was informed to use the Sit to Stand lift to transfer the resident from the commode back to the resident’s wheelchair when the resident was ready. STNA #120 revealed when she and STNA #121 were leaving for the day and passed Resident #10’s room, they saw the resident on the floor of the bathroom with STNA #122 and STNA #123 in the room. The resident was on the floor in front of the toilet with her right leg extended straight out in front of her and her left leg was bent at the knee against the floor in a V shape.

The STNA revealed she straightened the resident’s left leg out and bent both resident’s legs at the knees, so her feet were flat on the floor. The STNA revealed then she and STNA #121 then used the gait belt to lift the resident off the floor and transferred her back into her wheelchair.

Interview with Resident #10 on 12/23/19 at 2:34 P.M., revealed the resident was alert and oriented. Resident #10 revealed on the day of the fall two STNAs had helped her to the bathroom and when she was finished, the staff transferred her back into her wheelchair but did not push her all the way back in the chair and she went to the floor. The resident stated she started sliding and the STNAs could not hold her up and her legs folded underneath of her. Resident #10 revealed one of the STNAs said she was leaving and left her with the other STN[NAME] The STNA attempted to assist her to her wheelchair, however was not able to hold her up and she fell on the floor. Resident #10 revealed she yelled out in pain immediately and stated the pain was in her left leg. Several other STNAs then arrived at her bathroom to help her off the floor and back in her wheelchair. She revealed she always had two staff members to help her with transfers and would never attempt to transfer by herself due to weakness. The resident confirmed she had a fracture in her lower left leg and remained non-weight bearing at this time.

Interview with the Director of Nursing (DON) on 12/23/19 at 5:13 P.M. confirmed Resident #10 should have been transferred with a Sit to Stand lift. She revealed STNA #120 and STNA #121 failed to follow the Kardex instructions for transfers for the resident. The DON further revealed there was a delay in reporting the incident because LPN #124 failed to complete an incident report regarding the fall. She revealed STNA #120 and STNA #121 were given written disciplinary action for not using the proper assistance to transfer Resident #10. LPN #124 also received disciplinary action for not following the facility policy for reporting an incident.

This deficiency substantiated Control Number OH 899.