HospitalInspections.org

Based on record review and interview facility staff failed to follow the Physical Therapy (PT) Plan of Care regarding patient transfers and patient baseline ability in 1 of 1 (Patient #1) Physical Therapy Plan of Care in a total sample of 10 medical records reviewed.

Findings include:

A review of facility policy "Safe Patient Handling" dated 8/23/2023 revealed, "...I. Patient Handling Requirements A. Patient care staff will evaluate the patient and environment then select the safest equipment, techniques, and number of staff needed before completing patient handling tasks...II. SPH Program Compliance,...B. Patient care staff shall use appropriate patient handling equipment and aids as well as safe body mechanics to avoid manual lifting, transferring, and repositioning of a patient's weight..."

A review of facility online training titled "Safe Transfer Techniques" revealed, "...Outcomes: Upon completion of this course, you will be able to: *Recognize why safe transfer techniques are important *Recall how to identify weight limits associated with equipment *Recall appropriate techniques to assist patient from bed to chair, chair to toilet, or chair to chair *Identify appropriate techniques to perform a lateral transfer from bed to stretcher *Recall appropriate technique to reposition patient in bed or chair *Recall appropriate technique to transfer patient up from floor..."

A review of Patient #1's medical record revealed Patient #1 was admitted from their long term care residential facility to the Med/Surg unit on 3/31/2024 at 11:46 PM. Patient #1's chief complaint was increased shortness of breath and weight gain of 10 lbs over the previous week's time. Patient #1's pertinent medical history includes chronic congestive heart failure, chronic lung disease, chronically impaired mobility and activities of daily living. Patient #1 was diagnosed with acute congestive heart failure and was hospitalized at this facility from 3/31/2024 to 4/3/2024. Physician admitting orders for activity were "Up ad lib."

A review of Patient #1's medical record revealed a PT Plan of Care dated 4/1/2024 at 1:13 PM, "...Transfers: Sit to Stand EZ Stand w/2 (with 2). Stand to sit: EZ Stand. Bed to chair: EZ Stand w/2. Transfer device: Mechanical Sit to Stand... Assessment... At baseline, (Patient #1) uses EZ Stand for transfers..."

A Plan of Care Addendum dated 4/2/2024 at 3:30 PM revealed, "...Twisted left knee when assisted back to bed with 2 assist pivot this evening. (Patient #1) reported he/she was able to pivot transfer, but then after getting into bed, stated he/she should only use the EZ stand. Reporting sharp left knee pain rated 8/10. PRN (as needed) Tylenol administered and ice applied. No pain relief with ice and Tylenol. Rating pain 9/10. MD (physician) notified of situation and pain. X-ray ordered and obtained. PRN Tramadol (pain medication) ordered and administered. (Patient #1) reports pain is 0/10 upon re-assessment "as long as I'm not moving." (Complainant A/Child of Patient #1) called and updated on situation. Admin (administrative) supervisor notified of situation..."

A review of Patient #1's medical record revealed no documentation that Patient #1 had been transferred at any other time while hospitalized without using the EZ Stand.

An Opportunity for Improvement Report #124982 revealed, "...4/2/2024 (Date of Service) (Patient #1) requested to be assisted back to bed. Stated he/she would be able to pivot into bed. RN requested assistance and PT was able to assist. 2 assist and gait belt utilized to assist (Patient #1) back to bed. While transferring, (Patient #1's) foot got stuck and his/her knee twisted...(Patient #1) then states, "I should only use the EZ Stand. I don't know why everyone keeps hurting me." MD notified...(Complainant A) called with concerns of transfer method as '(Patient #1) is only an EZ Stand transfer and this same thing happened at the nursing home 1.5 years ago and he/she hasn't been able to walk since.'...Concerned how to prevent this from happening again and ensuring it is communicated that (Patient #1) should only utilize an EZ Stand. Response: 4/3/2024 (Manager D) Comment: Spoke with (RN Q) at 10:38 AM about this event. (RN Q) stated that (Patient #1) was sitting in the wheelchair and had wheeled him/herself close to the bed and then had requested help to get back into bed. (RN Q) said he/she was going to find someone to assist and then get the EZ Stand. (Patient #1) said if there were two people he/she would be able to "just do it that way." (RN Q) applied the gait belt. PT was in front of (Patient #1) and instructed (Patient #1) to hold onto their shoulders as they assisted (Patient #1) to stand. (RN Q) was standing at the rear of (Patient #1) holding the gait belt. (RN Q) stated that (Patient #1's) foot didn't move and his/her leg was twisted. They were able to assist (Patient #1) back in bed... 4/9/2024 (PT Manager G)...Investigation/Review Completed; Plan to Educate Staff; Process Improvement Implemented...(Manager D) and I discussed how this situation could have been prevented and how similar situations should be approached in the future. I will work with PT staff so they know how to fully understand patient limitations and their baseline transfer methods prior to attempting the transfer. The patient should also be included in the discussion about their preferred transfer method and whether or not they have any safety concerns...."

Staff involved in this event were not available for interview during this survey.

An interview was conducted with Certified Nursing Assistant (CNA) H on 4/30/2024 at 11:10 AM. When asked what should be done if a patient wanted to transfer from a chair back to bed but stated they could not pivot, CNA H stated that there should first be communication with the Registered Nurse to confirm a patient's activity order and transferring ability and if necessary have Physical Therapy called to advise of safe transferring instructions. "I would not force them. You just don't know what could happen."

An interview was conducted with Physical Therapist (PT) I on 4/30/2024 at 11:16 AM. When asked what devices should be used for a patient that is unable to pivot from a chair to a bed, PT I stated it would depend on whether or not the patient was weight bearing. "If they were weight bearing we could use the EZ Stand or Sara Steady, but if not we could use the mechanical lift (EZ Lift)."

An interview was conducted with Registered Nurse (RN) J on 4/30/2024 at 11:21 AM. When asked how to transfer a patient from bed to chair if the patient says they cannot pivot, RN J stated, "I would refer to their most recent PT evaluation or ask PT to see the patient. They might do well with the EZ Stand."

An interview was conducted with Registered Nurse K on 4/30/2024 at 11:32 AM. When asked how to transfer a patient from bed to chair if the patient says they cannot pivot, RN K stated, "I would use the EZ Stand if they are weight bearing."