Solaris Healthcare Osceola

Penalty

Inspection fine: $19,036

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent an avoidable accident with major injury for a physically impaired resident by not ensuring the care plan was followed for transfers with mechanical lifts. A certified nursing assistant (CNA) disregarded the prescribed transfer method for a resident who was dependent on mechanical lifts for mobility. This resulted in the resident sustaining a left knee fibular head fracture. The incident occurred when the resident requested to use her personal four-wheel walker instead of the mechanical lift for a transfer from bed to wheelchair. The CNA assisted the resident with the walker, leading to the resident's fall and subsequent injury. The resident involved was a female with multiple diagnoses, including congestive heart failure, severe morbid obesity, and generalized muscle weakness. She was assessed as requiring the assistance of two or more staff members with a mechanical lift for transfers. Despite this, the CNA allowed the resident to attempt a transfer using a walker, which was against the care plan. The resident's medical records and physical therapy notes indicated that she was non-ambulatory and required a mechanical lift for safety during transfers. The CNA admitted to not checking the resident's Kardex for updated transfer status and relied on the resident's verbal assurance of feeling strong enough to use the walker. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that the resident's care plan required a three-person assist with a mechanical lift due to her physical condition. The CNA involved was aware of this requirement but chose to honor the resident's preference not to use the lift. This decision was made without consulting the resident's care plan or seeking assistance from other staff members. The facility's policies and procedures clearly outlined the need for mechanical lifts and staff assistance during transfers, which were not followed in this case.

Removal Plan

• Resident #1 was transferred to the hospital.
• The facility was made aware that resident #1 sustained a left fibular fracture.
• CNA A was removed from her assignment, interviewed about the incident, and then suspended pending investigation. Law enforcement was notified and they reported the incident to Department of Children and Families.
• All staff were in-serviced on following care plans for transfers, how to access information on the Kardex, and following appropriate transfer status for each resident. All CNAs were either trained in-person or via Onshift messaging and all nurses were trained. Observations of mechanical lift transfers were completed with CNA groups to ensure transfers were completed correctly.
• The facility reviewed all residents who required a mechanical lift for transfers, those who were interviewable, were questioned to determine if the care plan was being followed.
• All staff involved were interviewed and witness statements were taken. A review of CNA A's personnel file was completed to ensure there was education and competencies related to transfers and mechanical lifts present. Competencies had been completed.
• A Quality Assurance and Performance Improvement meeting was held to discuss the event and adequate follow up. The Medical Director, Administrator, DON, Risk Manager, and other department heads attended the meeting.
• CNA A was terminated and reported to the Board of Nursing due to her not following resident #1's care plan for transfers and admitting she was aware the resident required a mechanical lift, and three person assist but chose to not follow the care plan.