Powerback Rehabilitation 1526 Lombard Street (August 2nd)
Based on staff interviews, review of facility policy, and clinical record review it was determined that the facility failed to follow nursing home policies and procedures regarding resident transfers, resulting in an injury to a nursing resident. Findings included the following: A review of the resident care plan dated July 10, 2012 indicated the resident required assistance for all activities of daily living and particularly required extensive assistance with transfers using the Sit to Stand equipment. A further review of the resident’s quarterly Minimum Data Set dated June 28, 2013 also indicated the resident required extensive assistance during transfers with a two person assist during that procedure. A review of the facility incident report dated July 12, 2013 indicated that the nurse aide was attempting to transfer the resident to a seat in the shower room using the Sit To Stand equipment at 5:30 p.m. Review of the incident report also indicated that the resident was described as screaming, anxious and very agitated during this time. The resident reportedly screamed out in pain and the aide saw blood running down the resident’s left leg.
The nurse aide called for assistance and the resident was examined and found to have a linear laceration measuring 2.0 centimeters x 0.1 centimeters x 0.1 centimeters with bloody drainage and localized swelling to the area. The incident report identified the issue of the resident’s unsettled and aggressive behavior during this transfer and the need to allow the resident to regain calm and composure before using the equipment. Review of facility policy entitled the use of Sit to Stand Lift, dated January 1, 2013 indicated that in preparing the equipment specific instructions regarding use of equipment were to be reviewed prior to use. The findings of the incident and direction in the nursing home policy regarding the equipment use were acknowledged by Employee R1 in an interview on August 2, 2013 at 11:55 a.m. The facility failed to ensure the safety and care of this resident during a transfer, inadequate preparation of staff as directed in the facility policy, and insufficient personnel to provide extensive assistance as required by the facility care plan resulting in a treatable injury sustained by the resident.