PHOENIX, AZ- NORTH MOUNTAIN MEDICAL AND REHABILITATION CENTER

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45634

Based on clinical record reviews, staff interviews, facility documentation, policies and procedures, the facility failed to ensure a safe transfer using a mechanical lift for one resident (#55). The deficient practice could result in resident sustaining an injury.

Findings include:

Resident # 55 was admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, cerebral infarction, dependence on ventilator, and hemiplegia.

The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of two persons with bed mobility, transfers and toileting. The MDS also included the resident had impairment to both upper and lower extremities.

Review of a care plan included the resident required assistance with Activities of Daily Living (ADLs) related to activity intolerance muscle weakness, limited mobility and fluctuate in ADL self-performance with interventions to include a Hoyer lift for transfers.

The Hoyer Sling Inspection log revealed that the Hoyer slings was inspected by staff January 31, 2023. A change of condition note dated February 4, 2023 included that at approximately 2:30 p.m., the nurse entered that room and found the resident on the floor mat on her back. per the documentation, the CNAs (certified nurse assistants) in the room reported that the resident was being transferred from her bed to the shower bed by 2 CNAs and the RT (respiratory therapist).

According to the documentation, the resident slide and fell on the floor mat at bedside; and that, the resident was assessed with no injuries but was sent to the hospital for further evaluation.

A physician order on February 4. 2023 revealed that the resident was sent to Emergency Department for CT of head status post fall.

A RT progress notes which was marked as an incorrect and duplicate entries were struck out in the clinical record on February 4 and 6, 2023. The documentation revealed that the RT was called into the room to assist with ventilator while resident was being transferred from to the shower bed. Per the documentation, the resident was a few inches from the bed and fell from the sling head first and onto the floor. The documentation also included that when the RT looked up, the front left loop was off of the Hoyer with the rest of the loops still attached to the Hoyer. Per the documentation, the resident was left in the same position until the fire department arrived; and that, the lead RT and lead RN (registered nurse) with two CNAs (certified nursing assistant) were in the room with the resident. It also included that the NP (Nurse Practitioner) was also notified.

The IDT note dated February 6, 2023 included that according to the two CNAs and one RT who were inside the resident’s room, the resident was being transferred from her bed to the shower bed when resident slid out of the Hoyer sling and onto the floor mat. It also included that priori to putting the resident on the sling the CNAs and the RT inspected it and ensured the size was appropriate for the patient and there were no concerns noted. Per the documentation, the CNAs and RT doubled check to ensure that all sling loops were connected when they lifted the resident above the bed; and that, the resident was balanced appropriately.

The staff proceeded to move the resident away from the bed when they noted that the resident started to slide. The note included that all three staff members attempted to assist the resident when the resident slid out onto the floormat. Per the documentation the resident was assessed with no injuries; and was send out to the emergency room for CT scan of the head.

The facility documentation included that on February 6, 2023, the Hoyer lifts at Station 1 East and West units were tested ; and both Hoyer were working properly and passed the test.

In an interview with two certified nursing assistants (CNA/ staff #15 and #20) conducted on February 15, 2023 at 3:30 p.m., both CNAs stated that it is always takes two and sometime three persons to use a Hoyer transfer. They both said that they received education on Hoyer transfers and felt comfortable using a Hoyer lift.

An interview conducted on February 15, 2023 with a licensed practical nurse (LPN/staff #25) who stated she was the unit manager on the unit when the accident with resident #55 happened. The LPN stated that resident #55 slid from the Hoyer sling and onto the floor mat at bedside. She stated that the resident was assessed and 911 was called; and that, the resident was sent out to the emergency room . The LPN stated that there should always be two or three staff to assist with transfer using a Hoyer if residents are on a ventilator. She further stated that it should be done by one person.

A review of the facility’s policy titled Transfer of a Resident, Mechanical Lift revealed to check all the lift’s attachments before attempting to lift the resident and always reevaluate the resident’s position, the location of slings and the security of the attachments before moving away from the bed or chair.

A review of the facility’s policy titled Incidents and Accidents included that it is their policy to implement and maintain measures to avoid hazards and accidents.