PEORIA, AZ – FREEDOM PLAZA CARE CENTER

Based on clinical record review, facility documentation, staff interviews and policy review, the facility failed to ensure one resident (#7) was free from neglect, due to an unsafe transfer.

A care plan for activities of daily living dated (MONTH) 4, (YEAR) revealed the resident had a self care performance deficit related to weakness, decreased mobility and left side [MEDICAL CONDITION]. The goal was for the resident to maintain her current level of function. Approaches included the resident utilizes a wheelchair for mobility and requires two staff to assist when being transferred in the Hoyer lift.

A nurse’s progress note dated (MONTH) 20, (YEAR), revealed the nurse was called by a certified nursing assistant (CNA/staff #218) to the resident’s room. The resident was laying on her left side near the foot of the bed, with her head resting on the bed frame. The Hoyer lift was noted to be in a high position and the sling was on. Staff #218 reported to the nurse that the resident had slipped out of the sling. Per the note, there was blood underneath the resident’s head and the resident was not responding. The nurse called EMS to have the resident transported to the hospital. The resident became more responsive and complained of pain to her left hip.

Review of the facility’s investigative report revealed that resident #7 was non-ambulatory and required the use of a Hoyer lift for all transfers. On (MONTH) 20, (YEAR), staff #218 attempted to transfer the resident from the bed to the wheelchair, without a second staff member. During the transfer, the resident slid out of the sling and landed on the floor, hitting the right side of her head on the floor. The resident lost consciousness for 1 to 2 minutes. When the resident regained consciousness, a neurocheck was completed and the resident was within normal limits. The resident was then assessed by two nurses and had a hematoma/laceration to the left side of her forehead, and a laceration to her left elbow.

The resident also complained of pain to her right hip. 911 was called and the resident was transferred to the hospital.

The facility’s investigative report further included that staff #218 was interviewed by the Administrator (staff #180) and stated that she had received training on using the Hoyer lift and knew that two staff were always needed when transferring a resident. Per the report, staff #218 was involuntarily terminated on (MONTH) 22, (YEAR) for not following facility policy and best practice, when transferring a resident in the Hoyer lift.

Review of the hospital discharge summary dated (MONTH) 24, (YEAR) revealed that resident #7 had a left femur fracture, a left elbow laceration and a scalp laceration which resulted from a fall, while being transferred in the Hoyer lift.