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Based on medical record review, grievance review, staff interview, and policy review, the facility failed to ensure a registered nurse supervises and evaluates the nursing care for each patient (A395). The facility failed to ensure that the nursing staff develops a nursing care plan that reflects the nursing care to be provided to meet the patient's needs (A396).

Based on medical record review, grievance review, staff interview, and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care of one of ten patients reviewed (Patient #4). The census was 244.

Findings include:

Review of Patient #4's medical record revealed the patient had arrived in the Emergency Department (ED) on 10/21/23 at 9:46 AM with a chief complaint of nausea and vomiting with abdominal pain. Diagnosis included small bowel obstruction. Past medical history included quadriplegia C5-C7 level spinal cord injury, severe protein-calorie malnutrition, osteoarthritis of left shoulder, chronic osteomyelitis of left hip, muscular atrophy, contracture of muscle of left upper arm, chronic pain syndrome, neurogenic bladder, and osteoporosis (2012).

Review of the Functional Assessment completed on 10/21/23 revealed the Patient #4 was totally dependent for transfers and required total assistance for activities of daily living (ADL). The patient's fall risk assessment indicated he was a high risk for falls.

Review of the Patient #4's care plan dated 10/21/23 revealed the plan did not address the individual needs related to transfer assistance for a total dependent with high risk factors.

Review of a portable Xray dated 10/25/23 revealed an impacted fracture of the left humeral head and neck. Review of the computed tomography (CT) scan of the left shoulder revealed an impacted left humeral neck fracture with extension to greater and lesser tuberosity, no displacement.

Review of the Orthopedic Nurse Practitioner assessment dated 10/25/23 revealed the patient suffered severe pain and fracture of the left shoulder.

Review of the Physical Therapy (PT) evaluation dated 10/31/23 at 10:24 AM and post incident, revealed the Patient #4 was not seen due to clinical appropriateness (does not require a PT eval as he is dependent care and unable to participate in therapy). The patient requires a Hoyer (mechanical) lift pad that wraps around upper extremity as opposed to underneath the arm.

Review of the Occupational Therapy (OT) evaluation on 11/01/23 and post incident, revealed the patient required assistance with meals, medication management, safety, self-care, wheelchair mobility, transportation, transfers, cleaning, and laundry. Prior Functional Level revealed the patietn was diagnosed with quadriplegia since 2006 and reported home care staff assists with activities of daily living. The patient reported on "bedrest" for past year and use of a home Hoyer lift ceiling system for transfers and power wheelchair for mobility.

Review of a Grievance filed on 10/26/23 revealed the patient reported the following concern: The patient contacted the Ombudsman Office with concern that during his inpatient stay on 10/25/23 proper steps were not taken to ensure his safety when five nursing caregivers attempted to transfer him from his bed to a chair. The patient expressed that during the transfer they lost control of him, and in doing so they caused him to fracture his shoulder.

Review of a Grievance resolution letter dated 11/15/23 revealed Staff L acknowledged the patient's concern, reviewed the medical record, and shared the experience with the Clinical Risk Department who investigated the concern. After review, it was determined that there were no concerns with the transfer of the patient from the bed to the chair, and that use of a mechanical lift would not be considered the standard of care in this situation. Further, a safe plan was in place to have a team of caregivers transfer the patient upon request of the physician, and unfortunately the patient had an underlying condition which contributed to the injury.

Interview on 02/06/24 at 11:20 AM with Staff H revealed she filed a report on 10/26/23 regarding Patient #4's incident dated 10/25/23. Staff H stated a surgeon gave staff a verbal order during rounds for the patient to be out of bed and up to a chair. Staff H stated four or five staff went to the patient's room to assist with transfer (Staff N, Staff O, Staff X, and two unnamed staff available for additional standby assistance). Staff H stated the patient had never been transferred by staff before. Staff H stated she spoke with Staff N and Staff O who reported the patient's bottom had come off the bed during the transfer and the weight shift from bed to the chair caused Staff O to feel the left shoulder crack. Staff N, Staff O, and Staff X lowered the patient to the recliner. The staff proceeded to call the physician who placed an order for a portable Xray of the left shoulder. Staff H stated the patient was alert and oriented and was able to make his own medical decisions and he did not object to the plan of transfer. Staff H further stated immediate one on one education was provided to Staff N, Staff O, and Staff X regarding transfer assistance and techniques, however the education provided had not been documented. Staff H verified the step-down unit had no specific transfer policy and transfer assistance was at the discretion of the nurse's judgement.

Interview on 02/06/24 at 2:42 PM with Staff Y stated a therapy consult was not ordered for the patient prior to the incident and the patient was unable to help due to limited mobility and risk factor of osteoporosis. The Staff Y confirmed the appropriate transfer for a total dependent with risk factors was a Hoyer lift.

Interview on 02/07/24 at 3:01 PM with Staff N revealed on 10/25/23 she was unable to use a Hoyer lift or assistive device to assist Patient #4 with a safe transfer due to none being available on the floor. Staff N stated during Patient #4's transfer, Staff O proceeded to lift the patient from the edge of the bed and the patient was sliding through Staff O's arm. Staff N confirmed the patient's transfer had initially been a one assist transfer by Staff O. Staff N confirmed the patient was at minimum a two-person transfer and Staff N was unable to articulate the process.

Interview on 02/07/24 at 3:13 PM with Staff O revealed on 10/25/23 the plan for transfer of the patient was to sit the patient on the edge of bed, stand and pivot the patient utilizing a "bear hug" transfer technique. Staff O confirmed he was unaware the patient was unable to stand and stated post incident that a Hoyer lift should have been used. Staff O was unable to articulate a two-person transfer assist.

Interview conducted on 02/08/24 at 10:34 AM with Staff Q confirmed no specific transfer criteria was listed in the care plan for Patient #4. Staff Q stated the nurse and experienced care team was to use clinical judgement for safe transfers and used online Lippincott application for reference. Staff Q stated PT/OT was to be on board for dependent patients and nursing was responsible to ask the physician to place an order. Staff Q was unable to provide access to Lippincott for review and was unable to demonstrate use of the Lippincott application per request.

Interview on 02/08/24 at 10:38 AM with Staff P revealed she was unable to demonstrate the Lippincott application for transfer assistance. The Staff P stated she used Lippincott for patient education and patient handouts. Staff P stated she assessed patients for transfer by interview, asking the patient about strengths and weakness, reviewing mobility scores, functional assessments, and then utilized nursing judgment to develop a plan for safe transfer. Staff P verified PT/OT may be used to consult on mobility and transfers but would need to contact the doctor for an order.

Interviews conducted on 02/08/24 between 11:05 AM through 11:50 AM via zoom meeting with Staff Q revealed the goal for patient transfer was a safe patient transfer. Staff Q stated a Hoyer lift was designed to mobilize patients and Staff Q would not consider that an option. Staff Q stated no policy or procedures stated a Hoyer lift was to be used for standard operating procedures. Staff Q stated a Hoyer lift transfer would be appropriate if it was the patient's preferred way to transfer and the patient did not object to being manually transferred.

Interviews conducted on 02/08/24 between 11:05 AM through 11:50 AM via zoom meeting with Staff U confirmed the clinical team or witnesses had not been interviewed regarding the patient's incident on 10/25/23. Staff U stated she relied on Staff H for the details. Staff U further explained she was unaware of safe transfer techniques and how the patient was transferred from bed to chair.

Follow up interview conducted on 02/08/24 at 3:08 PM with Staff H revealed a thorough investigation had not been completed regarding Patient #4's incident on 10/25/23. Staff H stated she was unaware of the transfer technique used for transfer and confirmed the "bear hug" technique was not appropriate for patient transfers. Staff H stated she did not document the witness statements or interviews and received miscommunication regarding how many staff assisted "hands on" with the patient's transfer. Staff H confirmed the patient did not have an individualized care plan related to the mode of transfer for a total dependent patient and stated staff was responsible for formulating a safe transfer plan.

Review of the facility policy titled, "Fall Minimization and Post Fall Care, Adult Protocol," dated 06/14/23 revealed the purpose is to define nursing's role in the management of adult patients at risk for falls and post fall care. This document provides a universal protocol that applies to all patients. Universal Moderate/High Risk Interventions include implementing individualized plan of care and consult resources as needed/as available (e.g., Physical/Occupational Therapy - requires order, Pharmacy, Social Work, etc.). The facility failed to implement the policy.

Review of the facility policy titled, "Safe handling policy SOP," dated 05/12/21 revealed the registered nurse (RN) is responsible for the assessment, planning and implementation of the progressive mobility plan. The RN may delegate select interventions to unlicensed personnel. The caregiver team will aid the patient in achieving progressive mobility providing physical assistance and/or the use of mobility assist device as indicated to safely accomplish the mobility tasks. The facility failed to implement the policy.

Review of the facility policy titled, "Lippincott Nursing Online Resource Policy," dated 05/31/22, revealed Lippincott Nursing Online Resource is used as a reference for nursing practice when a written documentation covering the same information is not available. The facility failed to implement the policy.

This deficiency represents non-compliance investigated under Substantial Allegation OH00150528.

Based on medical record review, grievance review, staff interview, and policy review, the facility failed to ensure nursing staff developed a nursing care plan that reflects the nursing care to be provided to meet the patient's needs for one of ten patients reviewed (Patient #4). The census was 244.

Findings include:

Review of the Patient #4's medical record revealed the patient had arrived in the Emergency Department (ED) on 10/21/23 at 9:46 AM with a chief complaint of nausea and vomiting with abdominal pain. Diagnosis included small bowel obstruction. Past medical history included quadriplegia C5-C7 level spinal cord injury, severe protein-calorie malnutrition, osteoarthritis of left shoulder, chronic osteomyelitis of left hip, muscular atrophy, contracture of muscle of left upper arm, chronic pain syndrome, neurogenic bladder, and osteoporosis (2012).

Review of the Functional Assessment completed on 10/21/23 revealed the Patient #4 was a total dependent for transfers and required total assistance for activities of daily living (ADL). The SP's fall risk assessment indicated high risk for falls.

Review of the Patient #4's care plan dated 10/21/23 revealed the plan did not address the individual needs related to transfer assistance for a total dependent with high risk factors. Occupational and Physical therapy were not consulted upon admission.

Review of a portable Xray dated 10/25/23 revealed an impacted fracture of the left humeral head and neck. Review of the computed tomography (CT) scan of the left shoulder revealed an impacted left humeral neck fracture with extension to greater and lesser tuberosity, no displacement.

Review of the Orthopedic Nurse Practitioner assessment dated 10/25/23 revealed Patient #4 suffered severe pain and fracture of the left shoulder.

Review of a grievance filed on 10/26/23 revealed the patient reported the following concern: Patient #4 contacted the Ombudsman Office with concern that during his inpatient stay on 10/25/23 proper steps were not taken to ensure his safety when five nursing caregivers attempted to transfer him from his bed to a chair. The patient expressed that during the transfer they lost control of him, and in doing so they caused him to fracture his shoulder.

Review of the Physical Therapy (PT) evaluation dated 10/31/23 at 10:24 AM and post incident, revealed Patient #4 was not seen due to clinical appropriateness (does not require a PT eval as he is dependent care and unable to participate in therapy). Patient #4 requires a Hoyer (mechanical) lift pad that wraps around upper extremity as opposed to underneath the arm.

Review of the Occupational Therapy (OT) evaluation on 11/01/23 and post incident, revealed Patient #4 required assistance with meals, medication management, safety, self-care, wheelchair mobility, transportation, transfers, cleaning, and laundry. Prior Functional Level revealed the Patient #4 was diagnosed with quadriplegia since 2006 and reported home care staff assists with activities of daily living. The Patient #4 reported on "bedrest" for past year and use of a home Hoyer lift ceiling system for transfers and power wheelchair for mobility.

Interview on 02/06/24 at 11:20 AM with Staff H revealed she filed a report on 10/26/23 regarding the patient's incident dated 10/25/23. Staff H stated a surgeon gave staff a verbal order during rounds for the patient to be out of bed and up to a chair. Staff H stated four or five staff went to the patient's room to assist with transfer (Staff N, Staff O, Staff X, and two unnamed staff available for additional standby assistance). Staff H stated the patient had never been transferred by staff before. Staff H stated she spoke with Staff N and Staff O who reported the patient's bottom had come off the bed during the transfer and the weight shift from bed to the chair caused Staff O to feel the left shoulder crack. Staff N, Staff O, and Staff X lowered the patient to the recliner. The staff proceeded to call the physician who placed an order for a portable Xray of the left shoulder. Staff H stated the patient was alert and oriented and was able to make his own medical decisions and the patient did not object to the plan of transfer. Staff H further stated immediate one on one education was provided to Staff N, Staff O, and Staff X regarding transfer assistance and techniques, however the education provided had not been documented. Staff H verified the step-down unit had no specific transfer policy and transfer assistance was at the discretion of the nurse's judgement.

Interview on 02/06/24 at 2:42 PM of Staff Y stated a therapy consult was not ordered for the Patient #4 prior to the incident and the Patient #4 was unable to help due to limited mobility and risk factor of osteoporosis. Staff Y confirmed the appropriate transfer for a total dependent with risk factors was a Hoyer lift.

Interview conducted on 02/08/24 at 10:34 AM with Staff Q confirmed no specific transfer criteria was listed in the care plan for Patient #4. Staff Q stated the nurse and experienced care team was to use clinical judgement for safe transfers and utilize online Lippincott application for reference. Staff Q stated PT/OT was to be on board for dependent patients and nursing was responsible to ask the physician to place an order. Staff Q was unable to provide access to Lippincott for review and was unable to demonstrate use of the Lippincott application per request.

Interview on 02/08/24 at 10:38 AM with Staff P revealed she was unable to demonstrate the Lippincott application for transfer assistance. Staff P stated she used Lippincott for patient education and handouts. Staff P stated she assessed patients for transfer by interview, asking the patient about strengths and weakness, reviewing mobility scores, functional assessments, and then utilized nursing judgment to develop a plan for safe transfer. Staff P verified PT/OT may be used to consult on mobility and transfers but would need to contact the doctor for an order.

Follow up interview conducted on 02/08/24 at 3:08 PM of Staff H stated she was unaware of the transfer technique utilized for transfer and confirmed the "bear hug" technique was not appropriate for patient transfers. Staff H confirmed Patient #4 did not have an individualized care plan related to the mode of transfer for a total dependent and stated staff was responsible for formulating a safe transfer plan.

Review of the facility policy titled, "Fall Minimization and Post Fall Care, Adult Protocol," dated 06/14/23, revealed the purpose is to define nursing's role in the management of adult patients at risk for falls and post fall care. This document provides a universal protocol that applies to all patients. Universal Moderate/High Risk Interventions include implementing individualized plan of care and consult resources as needed/as available (e.g., Physical/Occupational Therapy - requires order, Pharmacy, Social Work, etc.). The facility failed to implement the policy.

Review of the facility policy titled, "Safe handling policy SOP," dated 05/12/21, revealed the registered nurse (RN) is responsible for the assessment, planning and implementation of the progressive mobility plan. The RN may delegate select interventions to unlicensed personnel. The caregiver team will aid the patient in achieving progressive mobility providing physical assistance and/or the use of mobility assist device as indicated to safely accomplish the mobility tasks. The facility failed to implement the policy.

Review of the facility policy titled, "Lippincott Nursing Online Resource Policy," dated 05/31/22, revealed Lippincott Nursing Online Resource is used as a reference for nursing practice when a written documentation covering the same information is not available. The facility failed to implement the policy.

This deficiency represents non-compliance investigated under Substantial Allegation OH00150528.