Yadkin Nursing And Care Center

Penalty

No penalty information released

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

Surveyors identified a deficiency related to the facility’s failure to maintain a clean, safe, and homelike environment in multiple resident rooms on one hall. In one private room, observations on two consecutive days revealed a large area of removable black residue on the floor beside the bed, a napkin, dental floss pick, and empty medication cup under the bed, crumbs and a heavy layer of dust under the head of the bed and on and under the PTAC unit, and a used glove on the floor. The overbed table surface was covered with sticky residue and its base with a raised white residue. On the second day, the trash can in this room was full of trash without a liner and had a pink raised residue on most sides, indicating that routine cleaning and trash handling tasks described by housekeeping staff were not being carried out as stated. In a shared room occupied by two residents, surveyors twice observed a heavy layer of dirt and dust behind one bed, and food, paper particles, pieces of an artificial flower, and a thick layer of dust and dirt under the PTAC unit. A thick layer of dust was present on the top and bottom surfaces of the baseboards throughout the room. In the shared bathroom, a wallpaper patch behind the toilet that did not match the surrounding wallpaper had been stapled in place. When later reviewed with the Maintenance Director, this patch was identified as an improperly completed repair related to a major plumbing issue, and he stated he had not received a work order or notification about it. In another shared room, surveyors twice observed a trash can without a liner containing used gloves and food particles, with thick splatters of dried pink material on the sides and base of the can. In the bathroom, an approximately 6‑inch area of wallpaper under the sink had been cut and was held in place with two thumbtacks; when lifted by the Maintenance Director, this exposed a hole and water pipes. Housekeeper #1, who was assigned to this hall on the days in question, stated that her daily responsibilities included pulling trash and replacing liners, cleaning bathrooms, dusting, sweeping and mopping under beds, and cleaning under window units, and she reported having completed daily cleaning for the affected rooms. The Director of Housekeeping described similar daily expectations, including cleaning overbed tables and sweeping under each bed, and acknowledged during joint observations that the rooms did not meet facility standards. The Maintenance Director stated he did not conduct routine room inspections and was unaware of the wallpaper repairs, and the Administrator reported she was unaware of both the substandard repairs and the unclean room conditions.

Penalty

Inspection fine: $8,018

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 safely transfer a resident from a wheelchair to a bed, resulting in an accident. A nurse aide, who was working her first shift alone, attempted to assist a resident with a sit-to-stand lift transfer. The resident, who had severe cognitive impairment and required one-person physical assistance with transfers, was not properly secured with the lift's sling or leg straps. As a result, the resident fell backward, sustaining a laceration to the back of her head, which required sutures. The nurse aide admitted to not being familiar with the resident's limitations and using the lift for the first time by herself. She did not follow the proper procedure, as the resident was not standing completely upright and was not strapped in securely. The resident fell during the transfer, hitting her head and causing significant pain. The nurse aide realized her mistake after discussing the incident with the Director of Nursing and received retraining on the use of lifts. The incident was investigated, and the root cause was identified as the failure of the staff to follow the lift policy. The nurse aide had received training and completed a competency check-off prior to using the lift, but did not adhere to the procedures during the transfer. The facility's investigation confirmed that the accident was due to the improper use of the lift, as the resident was not secured with the necessary equipment, leading to the fall.

Removal Plan

• The resident was assessed in the facility by the nurse on duty. Bleeding was noted to be coming from the resident's posterior head and the nurse applied pressure to affected area, completed a neurological assessment, obtained vital signs, and the On call Provider was called and an order was received to send to the local hospital for evaluation and treatment.
• The Director of Nursing (DON) identified residents that were potentially impacted by this practice by completing a 100% audit on all current working mechanical lifts in the facility. This audit was completed by the maintenance director. The results revealed 8 of 8 mechanical lifts were in appropriate and safe working order.
• The DON inspected all lift pads for tears, frays, or broken parts. The audit revealed 100 of 100 lift pads were in good repair and working order, there were no frays, tears, or broken parts.
• The DON audited careplan/kardexes for all current residents to ensure appropriate mechanical lifts were present on the Kardex to ensure proper transfer status. The results revealed 24 of 98 residents used a mechanical lift and had the type of lift identified on the careplan/kardex correctly.
• The DON audited all nurses (Registered Nurses (RNs) and Licensed Practical Nurses (LPNs)) and nurse aids to ensure lift training with skills checklist had been completed upon hire. The results concluded 62 of 62 RNs, LPNs, and nurse aids had received lift training upon hire using the mechanical lift transfer safety education and skills checklist completed.
• The DON and Staff Development Clinician (SDC) began inservicing all nursing (RNs and LPNs) and certified nurse assistants including agency on the mechanical lift safety policy. This training included all current staff and agency.
• The DON will ensure that any of the above identified staff who does not complete the in-service training will not be allowed to work until the training is complete.
• The DON or designee will randomly monitor mechanical lift transfers to ensure staff are properly transferring residents. The Quality Assurance (QA) tool: ADL Care Provided for Dependent Residents will be used.
• Reports will be presented to the weekly QA Committee by the Administrator or DON to ensure corrective action is initiated as appropriate.
• Compliance will be monitored and ongoing auditing program reviewed at the weekly QA meeting. The weekly meeting is attended by the Administrator, DON, Minimum Data Set (MDS) Coordinator, Therapy, Health Information Manager (HIM) and the Dietary Manager (DM).