Health inspection·November 26, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was transferred with two people while using a mechanical lift as shown in the facility's policy. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 5. The findings include: On November 25, 2024 at 9:01 AM, R1 was sitting in the dining room in a high back wheelchair. R1 was unable to answer questions due to her cognitive status. On November 25, 2024 at 10:28 AM, R1 was transferred to her bed from the high back wheelchair using a mechanical lift. V8 (CNA-Certified Nursing Assistant) provided incontinence care to R1. As V8 removed R1's pants, a four-by-four-inch dressing was visible on R1's left shin. The date 11/24 was written on the dressing. The dressing was dry and intact. No bruising was noted. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, senile brain degeneration, dementia with agitation, depressive episodes, dysphagia, hypertension, and restlessness and agitation. R1's MDS (Minimum Data Set) dated October 16, 2024 shows R1 has severe cognitive impairment, requires substantial/maximal assistance with eating, personal hygiene, and bed mobility, and is dependent on facility staff for transfers between surfaces, lower body dressing, showering, toilet hygiene, and oral hygiene. R1 is always incontinent of bowel and bladder. R1's mechanical lift care plan, initiated on March 16, 2024, and revised on May 17, 2024 shows multiple interventions. The goal of the mechanical lift transfer care plan, also initiated on March 16, 2024 shows: I will be able to transfer with the use of the [total body mechanical lift] safely from bed to chair and vice versa with 2-person assist. The following intervention was initiated on March 16, 2024: There will always be 2 staff to assist resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface. The following intervention was initiated on May 17, 2024: Updated room signage related to [total body mechanical lift] transfers x 2 assist. On November 3, 2024 at 2:59 AM, V7 (RN-Registered Nurse) documented R1 was being transferred using a total body mechanical lift by the CNA on November 2, 2024 at 9:00 PM. R1 slid out of the mechanical lift to the floor between the bed and the mechanical lift. V7 noticed a skin tear on R1's left Page 1 of 2 145458 145458 11/26/2024 Alta Rehab at Oak Brook 2013 Midwest Road Oak Brook, IL 60521

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lower extremity. R1 denied discomfort or pain, the skin tear was cleaned with normal saline, and a dressing was applied. R1 was assessed by facility staff and hospice nursing staff, and no further injuries were identified. On November 25, 2024 at 11:17 AM, V2 (DON-Director of Nursing) said, On November 2, 2024, [R1] was transferred from the chair to the bed using a [total body mechanical lift]. [V3] (Agency CNA) failed to ask another staff member to assist her. There are supposed to be two CNAs present when using a mechanical lift, but [V3] was alone. All agency staff are educated on our transfer protocols. She was trying to get [R1] back into bed as quickly as possible. There was an issue where the sling came unhooked on one side and [R1] fell from the sling onto the floor and sustained a skin tear to her shin. V2 continued to say R1 did not sustain any other injury following the fall from the mechanical lift. The facility's policy entitled, Transfers - Manual Gait Belt and Mechanical Lifts revised 1-19-18 shows: Purpose: In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lift devices for the lifting and movement of residents. Guidelines: 1. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted.5. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: 0 = Independent. 1 = 1 person transfer. 2 = 2 person transfer with gait belt (only when use of mechanical lift is not possible). SS = sit-to-stand lift with 2 caregivers. H = Mechanical lift [total body mechanical lift] with 2 caregivers.8. Failure to comply with the lifting guidelines may result in disciplinary action as deemed appropriate. 145458 Page 2 of 2