Longleaf Neuro-medical Treatment Center

Penalty

Inspection fine: $19,9206 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care in a safe manner and did not ensure adequate supervision to prevent accidents for two residents. In the first incident, a resident with severe vascular dementia and a movement disorder, who was dependent on staff for all activities of daily living and required a two-person assist for transfers, fell from a mechanical lift during a transfer from bed to chair. The fall occurred after the resident was lifted in the air and one of the sling's shoulder straps became undone, causing the resident to fall to the floor and sustain a 4-centimeter scalp laceration that required emergency room evaluation and wound closure with staples. Staff interviews revealed inconsistencies in the handling of the mechanical lift, with one health care technician having already attached the resident to the lift before calling for assistance, and the other technician arriving after the resident was already suspended. The mechanical lift protocol, which required two staff members and proper securing of the sling, was not followed as expected. In the second incident, another resident with a progressive neurological condition, cervical spinal stenosis, and severe cognitive impairment, who was non-verbal, non-ambulatory, and totally dependent on staff, fell from a shower bed during a shower. The resident began to squirm and slid down the shower bed when the head of the bed was lowered, ultimately falling through an opening at the end of the bed onto the floor. The resident sustained an occipital hematoma, a reddened area on the left elbow, and an abrasion to the left buttocks, requiring emergency room evaluation. Staff interviews indicated uncertainty regarding the correct positioning of the shower bed's head during use, and the health care technician was unable to prevent the resident from sliding off the bed. The shower bed was observed to have side rails only in the middle, leaving open spaces at both ends, including the area where the resident fell. Both incidents involved residents who were severely cognitively impaired and fully dependent on staff for mobility and personal care. In each case, staff failed to ensure the proper use of equipment and adequate supervision during transfers and bathing, resulting in significant injuries that required emergency medical evaluation. The deficiencies were identified through observations, record reviews, and interviews with staff, residents, and physicians.