Failure to Assess and Monitor Resident After Fall and Mechanical Lift Use
Penalty
Summary
The facility failed to properly assess, monitor, and evaluate a resident following a fall and during the use of a mechanical sit-to-stand lift, resulting in a delay in treatment for an arterial bleed. The resident, who had a complex medical history including Alzheimer's disease, morbid obesity, osteoarthritis, a history of falls, and was on anticoagulant therapy, was totally dependent on staff for all activities of daily living and was severely cognitively impaired. After a fall, staff documented complaints of hip pain and some bruising, but did not provide thorough or ongoing assessments, including measurements or detailed documentation of the bruises. There was also no documented assessment for the safe and appropriate use of the sit-to-stand lift for this resident. Over the following days, staff observed increasing bruising and changes in the resident's condition, including shortness of breath, pallor, and further extension of bruising, but failed to promptly escalate care or reassess the situation in a timely manner. Communication between staff and the physician was inadequate, with the physician not being fully informed of the extent of the bruising and the resident continuing to receive anticoagulant medication. Staff also did not consistently document or measure the progression of the bruising, and there was a lack of clear documentation regarding the appropriateness of the mechanical lift for the resident's condition. The resident's condition deteriorated, with significant bruising and a drop in hemoglobin, eventually requiring emergency hospital care for a large subcutaneous hematoma and arterial bleed. The injury was determined by a hospital interventional radiologist to be consistent with trauma from a sit-to-stand lift. The resident ultimately died from complications related to blood loss anemia due to the chest wall hematoma. Staff interviews revealed uncertainty about the cause of the injury, lack of proper assessment protocols, and failure to communicate changes in the resident's condition effectively.
Removal Plan
- Nursing leaders and Administration will review a plan to remediate the Immediate Jeopardy.
- A Lift Assessment will be conducted on all residents who require the use of a mechanical lift, completed by the Restorative Nurse and Therapy Staff.
- Education will be provided to the nursing staff regarding the use of mechanical lifts and the new assessment process; all staff working the floor will be required to sign off on the in-services and staff not in attendance will be contacted to complete the in-service.
- If a CNA feels the lift process is unsafe, the CNA will report this to the charge nurse, who will assess and may downgrade the mechanical lift; this will then be reviewed by DON / ADON / Restorative Nurse / and Therapy.
- The Restorative Nurse will obtain Certification of Restorative Nursing; Therapy Staff will oversee Restorative Nursing programs until certification is obtained.
- Policies are being updated regarding the monitoring of bruising for all residents on anti-coagulant therapy: if a new bruise is identified, the MD will be notified and the nurse on duty will monitor and reassess the bruise; measurements will be taken and recorded; any signs of the bruise increasing in size will be reported to the MD; a Progress Note will be completed to include measurements, vital signs, and a description of the bruising and/or change of condition.
- The TAR was updated for all residents on anti-coagulant medication to observe for adverse reactions.
- The Lift Assessment will be completed for all residents who need a mechanical lift upon admission, or as needed if their transfer status is changed, by the Restorative Nurse and Therapy Staff.
- Following a change in lift status, DON / ADON / Restorative Nurse or Designee will monitor and reassess.
- If a resident shows signs of bruising and is on an anti-coagulant, the MD will be notified and the nurse on duty will monitor and reassess the bruise; if bruising increases and/or there are signs of a change in condition, the MD will be notified.
- All above education will be provided by the Education Nurse for all new hires.
- Random audits on mechanical lift transfers will be conducted by Nurse Leadership.
- Random audits on nursing documentation regarding residents on anti-coagulant medications will be completed by nursing leaders to ensure proper orders are in place and appropriate follow-up for signs/symptoms of adverse reactions are documented.
- Lift Assessments and Transfer Status will be added to the IDT QA reporting for review, presented by the Restorative Nurse and/or Therapy.
- Any injuries noted in relation to a transfer with a mechanical device will be reviewed in the QA meeting with the IDT, presented by the IDT Nurse Leaders.
- Residents on anti-coagulants and with new bruising will be added to the IDT QA reporting for review by the IDT Nursing Leaders.
- Any incidents regarding the monitoring of residents on anti-coagulant medications will be reviewed at the QA meeting with the IDT and presented by the IDT Nurse Leadership.