Health inspection·August 25, 2022

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to secure a foot strap during a sit to stand mechanical lift transfer for 1 of 10 (R23) residents reviewed for falls in a sample of 27. This failure resulted in R23 receiving 4 sutures to the left 3rd and 4th toes. Findings Include: R23's Face Sheet documents R23 is a male resident with a date of birth of [DATE] and an admission date of [DATE]. R23's Face Sheet documents diagnoses including: Type 2 diabetes Mellitus, Chronic Diastolic heart failure, Unspecified Atrial Fibrillation, Vascular Dementia with behavioral Disturbance and Bell's Palsy. R23's Minimum Data Set (MDS) dated [DATE] Section C documents a Brief Interview For Mental Status (BIMS) score of 13, indicating R23 is cognitively intact. Section G documents: Extensive assistance with a one-person physical assist for transfers. A final report sent to the Department on [DATE] documents in part, On Friday [DATE] at 4PM, R23 was being assisted up from the bed using a Sit to Stand mechanical lift. His foot slipped and he received lacerations under the third, fourth, and fifth toes of the left foot. He was transported to the E.D (Emergency Department) for treatment. He received dissolvable sutures to third and fourth toe. R23's Emergency Department Summary of Care printed [DATE] documents in part, 79 y/o (year old) M (male) presents with lac (lacerated) plantar 3rd and 4th toes from sit to stand device Repair #1, Wound closed with: Sutures; Number Sutures/Staples Placed: 4 R23's Departmental Notes dated [DATE] at 9:27 PM document: sent resident to emergency room at approximately 4:15 PM. Resident's foot slipped while CNA (Certified Nurse Aide) was getting him up on the sit to stand. There is a laceration to left 3rd, 4th, and 5th underneath the toes. Two sutures to the 3rd, an 4th toes that will dissolve on their own were administered. On [DATE] at 10:10 AM during the demonstration of the use of the sit to stand, while securing the leg strap, R23 stated to V8 (Certified Nursing Assistant/CNA), Is this new? On [DATE] at 3:57 PM, V4 (Certified Nurse Aide/CNA) stated, during the incident with R23 she did not utilize the leg strap when she was lifting him. She went to set him back down and his foot slid off of the foot plate. V4 (CNA) stated, after she set him down she noticed blood on his foot and went and got the nurse. R23 did have non-skid socks on when the incident occurred. V4 (CNA) stated, the leg strap is supposed to be used, she does use it now, but she did not then. Page 1 of 3 145499 145499 08/25/2022 Fayette County Hospital 650 W Taylor St Vandalia, IL 62471

F 0689 Level of Harm - Actual harm Residents Affected - Few On [DATE] at 4:40 PM, V5 (Certified Nurse Aide/CNA) stated, when she utilizes the sit to stand she has the resident sit on the side of the bed, she will already have the sit to stand there, she will put the harness on the resident, bend down to belt the legs down, attach the harness to the sit to stand and then begin the lift. V5 (CNA) stated, she would always use the foot strap, it would help them from stepping back. The sit to stands usually take one person to utilize it however, if the person is really shaky she may have another person assist her. The facility usually goes over one topic a month for training. The facility keeps a paper on each resident at the nurse's station that will give any needed information or any changes to a resident that is updated daily and there is a space to document if there was something with that resident on that shift. On [DATE] at 5:03 PM, V6 (Certified Nurse Aide/CNA) stated, when using the sit to stand you place the resident's feet on the foot plate and put the leg strap on, put the harness on, and make sure they hold on. She was trained at the facility on how to use the sit to stand. She always uses the leg strap. On [DATE] at 1:05 PM, V2 (Director of Nursing /DON)) stated, they do competencies every year, in fact they are going on right now. Newly hired Certified Nurse Aides (CNAs) are trained by senior CNAs that have been deemed trainers. The trainers will go through a check list with the new CNAs and sign off when a skill has been completed. They have 90 days to get through the checklist. If there is an item they still feel uncomfortable with or a resident they feel uncomfortable with individually, they are encouraged to have another CNA assist them. V2 (DON) stated, she is the one that is in charge of the training and does train CNAs. V2 (DON) stated, when the CNAs are trained to use the sit to stand, they are always trained to utilize the leg strap and footwear or gripper socks to help secure their feet. They are instructed to use the leg strap in every situation. They do not have a CNA competency checklist for V4 (CNA). V2 stated V4 started at the facility as a Nurse Aide and became a CNA then left shortly after due to not being vaccinated, she was then vaccinated and was rehired at the facility. During this timeframe, her 90 had expired and her 90 days have not passed since her rehire. On [DATE] at 1:30 PM, V1 (Administrator) stated, all CNAs are trained to secure the leg strap when utilizing the sit to stand. V1 (Administrator) stated, V4 has been trained on the sit to stand and if she felt uncomfortable with utilizing the sit to stand she should have had another CNA assist her. We are in-servicing all CNAs on utilizing the sit to stand. On [DATE] at 1:42 PM, V7 (CNA) stated, she is a CNA trainer for the facility. She trains the new CNAs to utilize the leg strap on the sit to stand every time. The leg strap is supposed to be secured on the resident with the sit to stand before lifting the resident. R23's Care Plan dated [DATE] for [DATE] under the heading Risk for Pressure Ulcers (handwritten in) documents: My foot slipped off the sit to stand lift platform when staff were transferring me. I have laceration to the under side of my left 3rd, 4th, and 5th toes. I went to the emergency room and have some stitches that will dissolve on their own. The interventions listed include: Treatment to laceration under the left 3rd, 4th, and 5th toes as ordered per doctor. Monitor for healing of the lacerations under my left 3rd, 4th, and 5th toes. Notify medical doctor with updates as needed. [DATE] Continue to use sit to stand for transfers. Ensure proper staff training of foot placement, sling placement, and preventing total weight left of device. [DATE] Treatment to top of left great toe nail area. Monitor top of left great toenail for healing. Notify medical doctor with updates as needed. Notify podiatrist with updates as needed. 145499 Page 2 of 3 145499 08/25/2022 Fayette County Hospital 650 W Taylor St Vandalia, IL 62471

F 0689 Level of Harm - Actual harm Residents Affected - Few The undated facility document titled, Safe Patient Handling and Movement states: Purpose: This policy is intended to ensure that employees use safe patient handling and movement techniques to reduce patient and employee injury. Statement of policy: #301 Direct care staff will be trained in patient handling and movement techniques, and identification of the safest methods to employ based on patient assessment and categorization. Additionally, mechanical lifting equipment and/or other approved patient handling aids should be utilized to prevent the lifting and handling of patients/resident except when absolutely necessary, such as a medical emergency. Zero-lift Policy: III. Staff Competency A. All direct care staff will receive education/training on this policy and proper use of the associated equipment upon hire and then, annually to ensure competency. 145499 Page 3 of 3