Parkway Place

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

The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices to prevent accidents for one cognitively intact male resident with multiple risk factors, including benign prostatic hyperplasia, restlessness, agitation, repeated falls, hypotension, and an indwelling urinary catheter. His care plans and assessments documented that he was a high fall risk, required moderate assistance with toileting and transfers, and needed one-person assistance for ADLs and toileting. Occupational therapy records showed he required supervision and partial/moderate assistance for commode transfers and had not met his transfer and toileting goals prior to a recent hospitalization. Upon readmission from the hospital, he returned with a Foley catheter, hematuria, and confusion noted in a progress note, and aspirin had been held due to hematuria. On the evening of the incident, the resident pulled the emergency bathroom call light. According to CNA G, when she responded, the resident was already sitting on the toilet, having transferred himself from bed to wheelchair and then to the commode. He had disconnected the Foley bag from the catheter, was pulling on the catheter, had bloody hands, was bleeding from the penile area, and was agitated, repeatedly asking for the Foley to be removed. CNA G reported that she told him she could not remove the Foley and that she needed to go get LVN M. She then canceled the emergency call light from the bathroom and left the resident alone on the commode to locate the nurse, stating that the call light above the room door only blinked and did not make an audible sound, and that shouting for help would not be heard because the room was at the end of the hall. While CNA G was away, the resident apparently attempted to transfer himself and fell. LVN M stated that as she was coming from another hall after being notified about the Foley issue, she encountered CNA G running back to report that the resident had fallen. LVN M found the resident lying on his back on the floor near his room entrance, gasping for air, with bleeding only from the penile area related to the Foley. She held his hand, placed a pillow under his head, and directed staff to have 911 called; the resident stopped breathing within less than a minute and was later pronounced dead. Other staff interviews indicated that the resident could sometimes transfer himself but that he could fall and hurt himself if left alone in the bathroom while agitated and pulling on his Foley. CNAs B and D both stated that aides were not supposed to leave this resident alone in the restroom when he was agitated and that they would have used a cell phone, emergency light, or yelling to get help rather than leaving him. The DON and Administrator acknowledged that the CNA service plan showed assistance needed for toileting, that there was no facility policy on accident and supervision, that the emergency bathroom call light at the time did not make an audible sound at the nurses’ stations, and that there was no plan in place to prevent leaving an agitated resident alone on the commode. Additional record review showed the emergency bathroom call light was first pulled and canceled by the resident, then pulled again and canceled two minutes later when CNA G responded and then left to call the nurse. The DON confirmed that the only way to cancel the call was from the restroom and that staff would not see the emergency call if they were not at the nurses’ station. The DON also stated that the CNA ADL plan for toileting read assist x1, but she interpreted this as assistance primarily for cleaning after toileting rather than continuous presence in the bathroom. RN C, who initiated the 48-hour care plan on readmission, acknowledged that she had inadvertently checked “independent” along with assist x1 for transfers, and that staff relied on asking the resident if he needed help or waiting for him to pull the call light. The Administrator stated that it was not possible for an aide to stay with every resident on the commode because multiple residents might be in bathrooms at the same time, and confirmed there was no existing policy on accident and supervision at the time of the incident. CNA G’s skills checklist did not show any specific training on toileting residents on the commode. The surveyor’s observation confirmed that, at the time of the incident, the emergency bathroom call light illuminated but did not make a noise at the nurses’ stations, and the facility leadership acknowledged they had no plan to address supervision of agitated residents on the commode. The report states that this failure increased the risk of injury, hospitalization, and death for residents.

Penalty

Inspection fine: $45,741

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 ensure adequate supervision and use of appropriate assistive devices to prevent accidents for three residents. One resident, who was severely cognitively impaired and dependent on staff for transfers, was injured when a CNA attempted a two-person transfer alone using a sit-to-stand lift instead of the required Hoyer lift. The resident, unable to stand, suffered fractures as a result of the improper transfer. The CNA admitted to using the sit-to-stand lift because it was readily available and did not seek assistance, despite knowing the resident required a Hoyer lift and two-person assistance. Another resident, with a history of Alzheimer's disease and repeated falls, was transferred using a sit-to-stand lift with a cracked footrest and without the use of a calf strap for safety. The CNAs involved in the transfer did not apply the leg straps, mistakenly believing them to be restraints. This resident was also supposed to be transferred using a Hoyer lift, as indicated by their care plan, but the staff failed to follow the proper procedure. A third resident, who had severe cognitive impairment and required a Hoyer lift for transfers, was observed being transferred with a Hoyer lift that was improperly set up. The sling was not placed correctly under the resident, leading to inadequate support during the transfer. The CNA involved in the transfer acknowledged the difficulty in positioning the sling correctly due to the resident's condition. These incidents highlight the facility's failure to maintain equipment in good working order and ensure staff adherence to transfer protocols.

Removal Plan

• DON and ADON will develop and in-service staff regarding the appropriate lift to be used on each resident.
• The procedure on how to use a sit-to-stand lift and a Hoyer lift. The DON and ADON will read the instructions for use when new stands arrive and will In-Service the staff based upon these instructions.
• The number of staff required to use any lift.
• Using the correct pad during lift transfers and any calf straps that are required for the sit-to-stand lifts.
• Inspect the lifts and pads before use to ensure that they are in good condition.
• What to do if a lift or pad is found to not be in good condition.
• Central Supply Director inspected all pads and removed any knots in the slings and inspected all for wear and tear. All not found to be in good condition were thrown away.
• The two sit to stand lifts that were found to not be in good working order were removed from the floor immediately and discarded.
• The Maintenance Director created a TELS work order and inspected all current Hoyer lifts in the facility.
• The Maintenance Director placed an order for two new sit to stand lifts for the facility.
• The Maintenance Director has ordered the lifts and is awaiting a delivery date confirmation.
• The Maintenance Director placed an order for 25 additional slings (in various sizes) to have on hand at the facility when needed.
• All residents that used a sit to stand lift were assessed by their nurse for any adverse effect or injury.
• Therapy evaluated the 4 current residents using a sit-to-stand lift and recommended that they could use a Hoyer lift until the new sit to stands arrive. All residents, responsible parties and MD were notified.
• All Care Plans for these current residents were updated to reflect the change in lift to be used.
• The facility is currently evaluating the current policy/procedure for transfers and or lift use and revising as necessary in consultation with the Medical Director.
• The facility is currently evaluating the root-cause of the system break down related to the lifts not being in working order and putting a system in place for future evaluation of lifts.

Penalty

Inspection fine: $45,741

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 immediately consult with a resident's physician and notify the resident's representative when there was a significant change in the resident's condition. This deficiency was identified during a review of an incident involving a resident who suffered a fall. The resident, who had severe cognitive impairment and was dependent on assistance for transfers, fell when a CNA attempted a two-person transfer alone using a sit-to-stand lift instead of the required Hoyer lift. The resident sustained fractures to the arm and knee as a result of the fall. The incident occurred when the CNA, without assistance, used the sit-to-stand lift to transfer the resident from the bed to a shower chair. During the transfer, the resident began to slip, prompting the CNA to call for help. A nurse assisted in lowering the resident to the floor and then transferring her to the shower chair. The nurse did not report the incident or notify the physician or family, as his shift was ending. The following day, bruising was observed, and the resident was eventually sent to the hospital, where fractures were confirmed. Interviews and record reviews revealed that the CNA was aware that the resident required a two-person transfer and that the Hoyer lift was necessary due to the resident's inability to bear weight. The nurse involved did not follow proper procedures for documenting and reporting the incident, leading to a delay in medical assessment and treatment. The facility's failure to adhere to its policies for notifying changes in a resident's condition resulted in a deficiency being cited.

Penalty

Inspection fine: $45,741

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 provide timely radiology services for a resident who suffered a fall, resulting in fractures to her arm and knee. The resident, who had severe cognitive impairment and was dependent on staff for transfers, fell during a transfer using a sit-to-stand lift. The incident was not immediately reported as a fall, and the resident was initially assessed without any noted bruises or pain. However, the following day, bruises were observed, and the resident's family was informed. Despite the presence of bruises and a suspected fracture, the facility did not obtain the necessary x-rays promptly. An x-ray order was placed but was not prioritized as a stat order, leading to a delay in the radiology service. The resident was eventually sent to the hospital, where fractures were confirmed. The delay in obtaining radiology services was attributed to a lack of clear communication and follow-up regarding the urgency of the x-ray order. Interviews with staff revealed a lack of awareness about the fall and the severity of the resident's condition. The facility's failure to act promptly on the resident's change in condition and the delay in obtaining diagnostic services could have resulted in delayed diagnosis and treatment. The incident highlighted deficiencies in the facility's processes for handling falls and obtaining timely medical evaluations.