Rehabilitation Center of Winter Park

In the surveyor’s words

From the most serious findings on record at Rehabilitation Center of Winter Park, in the surveyor’s own words.

• Immediate jeopardy, patternF600Feb 5, 2022

  Based on observation, interview, and record review, the facility neglected to determine appropriate size slings for full body mechanical lifts; neglected to assess and dispose of damaged lift slings and ensure compatibility of slings with lifts per manufacturers' recommendations, for 14 of 15 residents reviewed for accidents, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15); and neglected to conduct a post fall assessment for injury prior to lifting resident from the floor for 1 of 15 residents reviewed for accidents (#1) of a total sample of 42 residents who required mechanical lifts for transfers. On [DATE] at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. […]

• Immediate jeopardy, patternF689Feb 5, 2022

  Based on interview and record review, the facility failed to prevent an avoidable fall with subsequent death for 1 of 15 residents reviewed for accidents with injury; and failed to identify safety hazards related to use of mechanical lifts and slings for 14 of 15 residents reviewed for accidents, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) of a total sample of 42 residents requiring mechanical lifts for transfers. On [DATE] at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. The Certified Nursing Assistants (CNAs) who performed the task failed to inspect the sling prior to use. They did not notice one of the loops had frayed edges. […]

• Immediate jeopardy, patternF726Feb 5, 2022

  Based on observation, interview, and record review, the facility failed to ensure nursing staff were competent in evaluating residents for the appropriate type of mechanical lift, selecting sling size to maintain safety, ensuring compatibility of slings with lifts, and identifying issues with the integrity of slings, for 14 of 15 residents reviewed for accidents, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15): and failed to ensure CNAs did not move a resident after a fall before being assessed for injury by a clinician for 1 of 15 residents reviewed for accidents, (#1) of a total sample of 42 residents. On [DATE] at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. […]

• Immediate jeopardy, patternF835Feb 5, 2022

  Based on interview and record review, the facility failed to effectively use its resources to identify safety hazards related to the use and maintenance of mechanical lifts and slings; and failed to ensure staff were knowledgeable of mechanical lift transfer techniques, selection of appropriate size slings and the need to inspect equipment and report issues immediately for 14 of 15 residents reviewed for accidents and mechanical lift use, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #15); and failed to develop and/or implement policies and procedures to ensure the safety of all residents who required mechanical lifts for transfers. On [DATE] at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. […]

• Immediate jeopardy, patternF908Feb 5, 2022

  Based on observation, record review, and interview, the facility failed to maintain resident equipment in safe operating condition; failed to follow manufacturers' directions for use; failed to ensure full body mechanical lifts were paired with the correct slings, and failed to ensure staff were using the correct sling size for 14 of 15 residents reviewed for accidents, of a total sample of 42 residents, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15). On 1/31/22 at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. The Certified Nursing Assistants (CNAs) who performed the task failed to inspect the sling prior to use. […]