Huntington Living Center

Based on observations, resident, family, and staff interviews, and record reviews conducted during the Abbreviated Survey (complaint #NY00101892) at Huntington Living Center completed on 6/14/11, it was determined that for three of three residents reviewed for comprehensive care planning, the facility did not ensure that care was provided in accordance with the resident's written plan of care. The issues involved improper transfers for Residents #1, #2, and #3. This resulted in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #1 has diagnoses including dementia, contractures, and essential tremors. The 3/29/11 Minimum Data Set (MDS) Assessment indicated that the resident has severely impaired cognitive skills. Review of the 1/14/11 Resident Comprehensive Care Flow Sheet revealed the resident was to be transferred with a stand lift but does not indicate the type of sling to use. Review of Occupational Therapy (OT) evaluations and notes revealed that the last evaluation was completed on 7/16/09 and revealed the resident had abnormal (weak) upper extremity strength. The 6/25/10 Physical Therapy (PT) evaluation included that the resident was to be transferred with a full lift for all transfers.

On 6/14/11 at 10:00 a.m., the resident was observed sitting in a recliner with his feet elevated. Two Licensed Practical Nurses (LPNs) used the full lift and full sling to transfer the resident back to bed. The resident was observed to have no ecchymosis or swelling of the penis or scrotum. The resident's left thigh was bruised with a greenish, yellow, and purple bruise which was extending from the posterior to the inner thigh and around to the anterior thigh in a band approximately 10 inches long (around thigh) x 6 inches wide (from knee to top of thigh).

Review of the facility Event Investigation Report, dated 5/21/11, revealed an injury of unknown origin, a dark purple bruise on Resident #1's left inner thigh measuring 14 to 19.5 centimeters (cm) in length and 18 to 22 cm in width. On 5/22/11 it was added that the resident had bruising and blistering on the left side of the scrotum and on the left side of the penis. The report revealed that on 5/21/11 two Certified Nursing Assistants (CNAs) transferred the resident using a toileting sling and kept him suspended in the sling while they changed his incontinence brief and yanked the brief out from under him. The report further revealed that all toileting slings have been removed from the resident units.

During an interview on 6/14/11 at 9:20 a.m., the Administrator stated that all toileting slings have been removed from all residential units and PT/OT is now required to assess a resident before toileting slings can be used again. He stated that toileting slings are not addressed in the facility transfer policy.

On 6/14/11 at 1:35 p.m., the Physical Therapist stated she completed the 6/25/10 evaluation on Resident #1 and that she expected the staff to use a full sling on a full lift with the assistance of two staff. She further explained that when a full lift is ordered, a full sling is always used.

When interviewed on 6/14/11 at 2:50 p.m., the Registered Nurse (RN) Manager stated she was not aware that the resident's PT evaluation indicated full lift.

2. Resident #2 has diagnoses including renal failure and chronic obstructive pulmonary disease. The 5/27/11 MDS Assessment indicated that the resident scored 9 of 15 in the Brief Interview of Mental Status indicating moderate impairment. Review of the 11/9/10 Resident Comprehensive Care Flow Sheet revealed the resident was to be transferred with a full lift but does not indicate the type of sling to use. The 11/9/10 PT evaluation included that the resident be transferred with a full lift for all transfers.

During an interview on 6/14/11 at 1:45 p.m., the CNA stated two residents on the unit can be transferred with a toileting sling, and she named Residents #2 and #3.

When interviewed together on 6/14/11 at 2:10 p.m. and 2:45 p.m., Resident #2 and his wife stated that the staff transfer the resident using a full lift with a toileting sling. The full sling and toileting sling were brought into the room and the resident and his wife pointed out the toileting sling as the one always used for transfers.

Review of the memo by the RN Manager that she stated was written oon 5/27/11, revealed Resident#2 and #3 "may use toileting sling."

On 6/14/11 at 2:50 p.m., the RN Manager stated she did not know why her memo lists this resident for a toileting sling, "He is a full lift with a full sling."

3. Resident #3 has diagnoses including right below the knee amputation and left transmetatarsal (across the foot) amputation. The RN Manager identified the resident as being interviewable on 6/14/11 at 2:20 p.m. Review of the 1/24/11 Resident Comprehensive Care Flow Sheet revealed the resident was to be transferred with a full lift but does not indicate the type of sling to use. Review of the 6/6/11 OT evaluation included that the resident be transferred with a toileting sling when wearing the left lower extremity prosthesis.

When interviewed on 6/14/11 at 2:31 p.m., Resident #3 stated that the staff transfer him using a full lift but with a toileting sling. The full and toileting sling were brought into the room and the resident pointed out the toileting sling as the one always used for transfers. The resident added that it is used whether he is being toileted or being transferred to the chair or back to bed, and it is used whether or not he is wearing his prosthesis.

On 6/14/11 at 2:40 p.m., the Physical Therapist stated that Resident #3 is the only resident on the third floor evaluated by OT to use a toileting sling.

During an interview on 6/14/11 at 2:50 p.m., the RN Manager stated she usually writes changes to the Resident Comprehensive Care Flow Sheet in red and dates it but did not do it for Resident #3. She added that she expects the staff to use the toileting sling only for toileting, not for transfers to and from the chair and bed.

Review of the facility policy entitled, "Lift and Transfer Policy," dated June 2005, does not address the toileting sling.

[10 NYCRR 415.11(c)(3)(ii)]