Heartland Health Care Center Galesburg
Facility I.D. Number: 0041806
Date of Survey: 02/10/03
Incident Report Investigation of 1/17/03
The facility must provide the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of the resident, in accordance with each residents comprehensive assessment and plan of care. 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 necessary precautions shall be taken to assure that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
Based on observation, record review and interview the facility failed to ensure that each mechanical lift sling was inspected according to their inspection policy. R1, one of five residents requiring the use of a mechanical lift for transfer, fell to the floor when the lift sling straps broke during a transfer.
According to a nursing evaluation dated 01/28/03, R1 is semi-comatose, chair bound, bedfast, nonverbal, and requires the use of a mechanical lift with the assist of two persons for transfers.
During an observation at 2:40 p.m. on 02/03/03 R1 was lying in her bed in a partially contracted fetal position on her right side. When talked to by E1 (Administrator) R1 would only respond non verbally with grimacing facial expressions.
According to the incident report dated 01/17/03 at 9:50 a.m., R1 was being transferred from a bathing gurney to her bed by E5 (certified nursing assistant, CNA) and E6 (CNA). When R1 was positioned approximately eighteen inches from the bed, the right shoulder strap of the lift sling (number 15) broke completely free from the sling pad and the right hip strap partially broke allowing R1's body to shift sideways and begin to fall.
Interview with E5 at 1:05 p.m. on 01/30/03 and 1:40 p.m. on 02/04/03 and E6 at 1:25 p.m. on 01/30/03 verified the above events. E5 indicated that by using her legs and hands she caught R1 by the head and E6 caught R1's feet with her hands. They lowered R1 to the floor, so that R1 did not fall directly from the sling to the floor. E5 also verified that the sling numbered fifteen was the one which broke during use with R1 on 01/17/03.
E5 stated that she had inspected sling number 15 by pulling on each of its four corner straps before using it for R1, but had not noticed any fraying of the canvas on the sling straps. E5 verified that she had been inserviced two or three times during the past year concerning the use of the lift and the checking of the slings. E5 stated that she used the lift and slings in approximately ten transfers a shift.
During an interview at 1:45 p.m. on 02/03/03 E8 (Registered Nurse) stated that she conducted an extensive body check of R1 at the time of the incident and again later that day and found no injuries.
Interview at 10:15 p.m. on 01/30/03 with E1 and review of the lift sling inspection procedure, dated 02/21/02 verified that E4 (central supply clerk) was the staff person assigned the duties of conducting a weekly check of the mechanical lifts and lift slings. This lift sling inspection policy and procedure was implemented after a previous sling strap breaking incident.
These inspections were to be conducted one time a week for each of the slings. The inspection date was to be documented on a computerized form adjacent to a number that corresponded with numbers on each sling. The procedure specifically identified that the slings were to be inspected for fraying on any part of the sling and that any questionable slings would be inspected by the nurse manager.
A review of the facility's computerized inspection sheets for the months of October 2002 through January 2003 revealed that there were dates corresponding to each of seventeen numbers on each monthly sheet once a week until 01/10/03. The dates were always the same date for each number on the sheet for each week such as, 01/10/03 by each of the seventeen numbers. Observation verified that there was a date adjacent to the number fifteen on each of the sheets for four weeks each month. Each of the sheets was initialed by E4. Interview at 9:30 a.m., on 02/03/03 with E2 (Director of Nurses) verified that the completed inspection sheets had been turned in to her every week by E4 and that no questionable slings had been given to her for further inspection.
Interview at 1:45 p.m. on 01/30/03 with E4 verified that she inspected the lift slings on each Friday and documented the dates on the computer form next to the corresponding numbers. E4 also stated that on some occasions not all of the numbered slings could be found for inspection. Some slings may have been in the laundry or in a closet. E4 indicated that when she entered the date of inspection for any one of the numbered slings on the computer form, the same date automatically transferred to all of the numbers on the form.
E4 verified that when she could not find a specifically numbered sling on any one occasion for inspection she did not notify any other staff that it had not been inspected on that date. E4 said that she could not guarantee that sling number 15 was inspected personally by her on any specific date.
Interview at 10:15 a.m. on 01/30/03 with E1 verified that E4 had not notified her that some, if any, of the numbered slings were not inspected each week . She also verified that the completed inspection report sheets were turned in as directed. E1 also stated that after the incident of 01/17/03, E4 told her that not all of the slings could be found for inspection each week and that the computer automatically entered the dates behind the numbers. E1 stated that she immediately had all of the slings collected. It was discovered that there were two slings that were not numbered and may not have been inspected each week.
Observation was made at 1:30 p.m. on 02/04/03 of a sling with the number 15 on it. E1 verified that this was the one that broke during the 01/17/03 incident. The two canvas connecting straps that attach to the right shoulder corner of the sling were frayed and broken completely at the stitching approximately one inch from where the straps were to connect to the pad part of the sling. At the right hip corner of the sling, one of the two canvas straps was frayed and broken completely free from the pad. The other strap was frayed on both sides of the stitching at the same point one inch from where they connect to the pad.
At the left shoulder and left hip corners of the sling the four canvas connecting straps were frayed on both sides of the stitching one inch from where they connect to the pad. It was also noted that two of four, eight inch pleated seams on this pad had stitching missing for approximately four inches. The blue canvas strap attached to the outer center of the pad was broken completely. During an interview at 1:40 p.m. on 02/04/03 E5 stated that the blue strap was to be used to position residents when in the sling.