Do failure to follow a facility’s policy requiring two trained persons to operate a mechanical lift resulting in an accident/fall (F689); alleged failure to provide treatment/services to prevent and heal pressure ulcers (F686); and alleged failure to notify of changes in condition (F580) constitute substandard quality of care that may result in submission of claims that are in violation of the False Claims Act?
Compliance Perspective – Resident Death
Policies and Procedures: The Compliance Officer with the DON and Administrator will review the facility’s policies and procedures regarding protocols for operating mechanical lifts and the treatment/services for preventing and healing pressure ulcers. Education and Training: Staff will be educated regarding the number of trained persons required for transferring residents when using a mechanical lift, and the necessity of following residents’ care plans when providing care. Training will also include care and prevention of pressure ulcers through frequent repositioning, regular skin checks, and notifying the attending physician and family members of changes in a resident’s condition. Auditing: An audit will be conducted to determine staff proficiency in operating mechanical lifts to transfer residents. Another audit will focus on performing skin checks for all residents with mobility issues and recording the frequency of repositioning that residents receive to help prevent pressure ulcers. All residents will have their fall risk assessments reviewed to ensure that they are current, that preventive measures are in place, and that care plans are followed. The results of the audits will be summarized and submitted to the QAPI/QAA Committee for review and recommendations.
On November 2, 2016, a resident in an Illinois nursing home died after falling from the mechanical lift being used to transfer her from her wheelchair. The suit alleges that, according to the nursing home’s policy, there should have been two trained staff assisting in the use of the lift to transfer the resident from her wheelchair. However, on October 20, there was only one nursing assistant involved in making the transfer when the resident fell.
The resident struck her head in the fall, sustained a severe injury, and was hospitalized on Nov. 1. Additionally, the suit alleges that the resident had been designated as a high risk for falling, and the facility failed to respond and act appropriately to her “fall risk” designation. The suit is seeking damages of at least $50,000 for each of the two allegations. This lawsuit is the second to be filed against the nursing home this year.
A suit filed earlier in May by the estate of another resident claimed the facility failed to prevent pressure wounds and infection that were reasonable and foreseeable and that led to the resident’s death. The suit also alleges that the facility was negligent in providing necessary care and did not inform the resident’s family about changes in her condition. Additional claims include that the facility did not provide treatment for pressure ulcers, did not provide adequate staff, and did not conduct weekly skin checks to monitor the resident’s skin.
