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Based on observation, interview and record review, the facility failed to ensure nursing staff followed facility policy and procedure to safely supervise and manage one of 30 sampled patients' (Patient 29) tracheostomy tube (an artificially created airway which a breathing tube is inserted into), intravenous (IV, tube inserted into the blood vessel to provide fluid and medication) lines and percutaneous endoscopic gastrotomy tube (PEG, a tube inserted through a surgically created hole through the abdomen to deliver food/medications/fluids directly into the stomach) lines during a hoyer lift (portable electric patient lift) transfer from chair to bed.

This failure had the potential for Patient 29's tracheostomy tube, tube feed line and/or IV line to be pulled out which had the potential for injury, delay in medication administration or respiratory failure which could lead to death.

Findings:

A review of Patient 29's admission record indicated Patient 29 was admitted with a diagnosis of acute and chronic respiratory failure with hypoxia (failure of the respiratory system resulting in low oxygen in the blood), dysphagia (impaired ability to swallow), and subdural hematoma (bleed in a specific region of the brain).

During a record review of Patient 29's physician's history and physical assessment (H&P) titled, "History and physical, performed 10/09/24," dated 11/7/24, the H&P indicated Patient 29 had a tracheostomy and was receiving oxygen through a trach collar (collar which delivers oxygen to the tracheostomy opening). The H&P indicated Patient 29 had a PEG tube and was receiving nutrition and medications through the PEG tube.

During a record review of Patient 29's physican's order set untitled, dated 11/7/24, the order set indicated Patient 29 had orders for "oxygen therapy ...aerosol t-collar (trach collar): FIO2: 28%," dated 10/7/24, and "meropenem (an antibiotic medication): IVPB (IV piggy back, an IV solution infused in conjunction with a carrier fluid) ...for antimicrobial order-bone infection," dated 11/2/24. The order set indicated Patient 29 received medications through the tracheostomy, PEG and IV routes and did not indicate Patient 29 received oral medications.

During a concurrent observation and interview on 11/4/24, at 1:08 p.m., with Restorative Nursing Aid 1 (RNA 1), RNA 1 was alone in Patient 29's room positioning a hoyer lift to transfer Patient 29. Patient 29 was in a chair sitting on a sling (a mat which attaches to the hoyer lift to raise the patient up). Patient 29 was attached to a trach collar which was delivering oxygen, a tube feeding line which had paused feeding solution and an IV line infusing saline (a salt water solution for intravenous hydration). RNA 1 attached Patient 29's sling and then used the hoyer lift to transfer Patient 29 from the chair to bed. RNA 1 stated two staff would typically be needed for the transfer but staff were not available. RNA 1 stated a second staff member would assist to ensure lines would not get caught and prevent falls by guiding the patient down.

During an interview on 11/5/24, at 9:28 a.m., with Registered Nurse 1 (RN 1), RN 1 stated hoyer lift transfers required at least two staff to safely transfer the patient. RN 1 stated for any patients who had IV lines, a tracheostomy or tube feeding, a registered nurse would be expected to disconnect running IV solutions, tube feed lines and to guide the patient to ensure tracheostomy tubes and other lines would not be dislodged. Dislodged lines could impair a patient's ability to breath, receive nutrition and medication.

During an interview on 11/7/24, at 5:10 p.m., with the Director of Nursing and Clinical Services (DNCS), the DNCS stated a minimum of two staff were needed to safely transfer patients to and from bed. The DNCS stated a RN was required to manage patients with tracheostomy collars and to pause running tube feed or IV lines.

During a record review of Patient 29's care plan titled, "Risk for injury," dated 11/7/24, the care plan indicated staff "implement decannulation precautions; ...at least two staff for turning, repositioning, and transferring patient."

During a record review of Patient 29's care plan titled, "Impaired transfer ability," dated 11/7/24, the care plan indicated "transfer OOB [out of bed] to chair using hoyer lift as tolerated under nursing supervision."

During a concurrent interview and record review on 11/7/24, at 6:05 p.m., with DNCS and Director of Quality Management (DQM), the facility policy and procedure (P&P) titled, "Lifting the Patient," undated, the P&P indicated "[hoyer lift manufacturer] recommends two assistants be used for all lifting preparation and transferring to/from procedure ...the use of one assistant is based on the evaluation of the health care professional for each individual case." The DNCS and DQM stated the P&P was the only facility document for hoyer lift usage and was unable to find a policy which described the RN's role during a hoyer lift transfer..