ASTA CARE CENTER OF PONTIAC
Facility ID Number: 0043968
300 West Lowell
Pontiac, Illinois 61764
Survey Date: 9/8/99
Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
All nursing Personnel shall assist residents with safe transfer activities.
All necessary precautions shall be taken to assure the safety of residents at all times.
These requirements are not met as evidenced by:
1. R15 was admitted 8-19-99 with diagnoses of Cerebral Vascular Accident (CVA), Arthritis and Chronic Obstructive Pulmonary Disease (COPD). R15 is 75 years old and is alert and oriented. Admission nursing assessment documented continuous use of oxygen at 3 liters/minute; "limitation in ROM" (range of motion) of the right and left leg; "loss of voluntary movement" of the right and left leg; and "Res is able to use bil. UE well but sometimes feigns weakness" (bilateral upper extremities). Interview with Z3 confirmed R15 had weakness of the right extremities due to the CVA and was unable to hold a glass of coke independently with the right hand due to this weakness.
R15's admission weight was listed as 275 pounds. R15 had an admission order to transfer with two assists. Staff were utilizing a Sara Lift for transfers. The Sara Lift has one strap which is positioned around the resident's abdomen and a second strap which goes across the resident's back and under the resident's arms. The resident holds on to the lift frame with both hands and bears weight on the footrest during transfers. Manufacturer instructions for the Sara Lift listed the following precaution, "CAUTION A professional assessment should be carried out before lifting patients who are non weight bearing. This also applies to patients who have limited shoulder movement or cannot hold on with one or both hands." The instructions also direct two staff assist with the Sara Lift for "those patients who have suffered a stroke or who can only hold with one hand, or patients who cannot hold on at all".
R15's record documented R15's refusal for a rehab assessment on 8-27-99. Interview with E1 confirmed R15 had not been assessed by Physical Therapy for the use of the Sara Lift, but E1 had observed R15 transferred with the Sara Lift with two assists and determined the Sara Lift to be appropriate for R15's needs.
On 8-29-99 at 11:00 a.m. an incident occurred involving R15 and E7. Interview with E7 revealed that R15 had been incontinent of urine and requested her incontinent pad be changed. R15 resides on the West Wing, which was staffed by two Certified Nurse Assistants (CNA) and one nurse. The nurse was also responsible for the residents on the Central Wing. At the time R15 requested to be changed, the nurse was on Central Wing and one CNA was on lunch break, leaving E7 alone to cover the West Wing. E7 stated R15 would have had to wait 30 minutes until the other CNA returned from lunch, so E7 made the decision to utilize the Sara Lift alone to change R15. E7 stated she raised R15 approximately 8 inches off the wheelchair seat using the Sara Lift to enable E7 to change the incontinent pad. During this procedure R15 was unable to maintain the hold with her hands, R15's knees buckled and R15 fell to the floor. E7 stated that when R15 let go with her hands the sling went out from under R15's arms and the abdominal belt rose up towards R15's neck and over R15's head, yet under R15's arms. E7 stated E7 was afraid the abdominal strap would catch on R15's neck so E7 pulled the strap forward allowing it to go over R15's head. E7 stated R15 was "suspended for a while" by the strap under the axillas, then eventually went to the floor. E7 stated, "She (R15) won't stand like she is suppose to with the machine. She doesn't like the machine." During interview, R15 stated staff "dropped me" from the lift, and confirmed only one staff was present during the incident.
Nurses note dated 9-1-99 documented, "Res c/o Rt hand et arm (with) cont severe pain. Rt hand noted to be edematous. c/o pain (upper) arm into neck. 3 cm. dark bruise noted in Axilla/(upper) arm area of her Rt arm." R15's right hand and forearm were x-rayed on 9-1-99, with no fracture noted. Interview with R15 on 9-1-99 revealed R15's right hand had hurt since the incident on 8-29-99 and the hand first became edematous on 9-1-99. R15 was observed with pitting edema of the right hand on 9-1-99.
Nurses notes of 9-5-99 documented, "Res cont. to c/o (R) arm pain." On 9-7-99 R15 was observed to have continued pitting edema of the right hand and to cry out in pain whenever the right arm was moved during care. R15 complained of pain in the right arm and shoulder area upon any movement. X-rays taken 9-8-99 of the right shoulder were negative. ---Facility's failure to conduct a professional assessment for the use of the Sara Lift and failure to use two staff during a transfer resulted in an unsafe lift with injury to R15.