Health inspection·November 16, 2024

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 Based on observation, interview, and record review the facility failed to use extensive assistance of two staff members during a mechanical lift sit-to-stand transfer for one of four residents (R3) reviewed for falls in a sample of eight. This failure resulted in R3 falling during a mechanical lift sit to stand transfer, sustaining a severely painful dislocated left shoulder. Findings include: The facility's Safe Resident Handling/Transfers policy, dated 12/15/22, documents Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable, experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of a mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 10. Two staff members must be utilized when transferring residents with a mechanical lift. R3's current admission Record documents R3 has the following, but not limited to, diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Cerebral Infarction due to unspecified Occlusion or Stenosis of right middle Cerebral Artery, Hyperlipidemia, Essential Hypertension, other Abnormalities of Gait and Mobility, other Lack of Coordination, and Morbid Obesity due to excess calories. R3's MDS (Minimum Data Set), dated 10/3/24, documents R3 is cognitively intact. This same MDS documents, Mobility. 01. Dependent- Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity. (R3) is dependent on toilet transfers and chair to bed/bed to chair transfers. R3's current Care Plan documents R3 has limited physical mobility related to Hemiplegia/Hemiparesis of Left Nondominant Side following a CVA (Cerebrovascular Accident). R3's Progress Note, dated 10/26/24 and signed by V21/RN (Registered Nurse), documents This RN was in another resident's room and was notified by (V8/CNA (Certified Nursing Assistant) that (R3) had a fall in his room. This RN walked into room and noticed (R3) laying on floor with sit-to-stand machine (mechanical lift) pulled back at the base of (R3's) feet, pillow under head. This RN began to physically assess (R3) and (R3) stated nine out of ten left shoulder pain and was unable to move arm. Page 1 of 2 145600 145600 11/16/2024 Loft Rehab & Nursing of Canton 2081 North Main Street Canton, IL 61520

F 0689 Level of Harm - Actual harm Residents Affected - Few V8/CNA's Witness Statement, dated 10/26/24, documents I was transferring (R3) from the toilet to the bed using the sit to stand (mechanical lift). (R3) let go of the hand grips causing (R3) to slide out of the sling. Once (R3) slipped far enough, I couldn't pull (R3) up, so I lowered (R3) down to the ground. R3's Final Report, dated 10/26/24, documents R3 had a witnessed fall with injury resulting in a dislocation of R3's left shoulder. This same Final Report documents, (R3) let go from the arms of the stand aide (mechanical lift) without reporting to staff that (R3) could no longer hold onto stand aide. The support belt was still around (R3), though staff attempted to hold (R3) and call for help, due to (R3's) weight and that (R3) was starting to slide down the support belt. Staff assisted with lowering (R3) the rest of the way to the floor, during the process of getting lowered to the floor, (R3's) arms are above (R3's) head, which contributed to the dislocation. When asked why (R3) let go of the stand aide, (R3) stated that he could not hold on anymore. (R3) had c/o (complaints of) shoulder pain and decreased range of motion. (R3's) shoulder was manipulated at ER (Emergency Room) by physician and returned to the facility. R3's ER Note, dated 10/26/24 documents, (R3) presents after a ground-level fall with left shoulder pain and (R3's) left arm stuck above his head. (R3) denies loss of consciousness, reports no other injury from the fall. (R3) is unable to move his left arm at the shoulder. R3's Left Shoulder X-Ray, dated 10/26/24, documents inferior shoulder dislocation. On 11/15/24 at 10:50 AM R3 was lying in his bed. R3 stated, During my last fall on the sit-to-stand (mechanical lift) my left hand became weak, and I ended up falling to the ground. (V8/CNA) was the only staff member transferring me. Usually, two people transfer me on the sit-to-stand, especially because I have had a stroke that caused my left side to be weak. I was in severe pain and was unable to move my left arm. My left arm was stuck straight up in the air. I ended up having a dislocated shoulder and had to have it put back in place at the Hospital. On 11/15/24 at 11:15 AM V3/ADON (Assistant Director of Nursing) stated V8/CNA was the only one transferring R3 during the toilet to bed transfer on 10/26/24. V3 stated, When using a sit-to-stand (mechanical lift), the staff should always use two staff members when transferring a resident for safety of the resident and themselves. On 11/15/24 at 11:22 AM V1/Administrator verified V8/CNA was the only one transferring R3 when R3's fall occurred on 10/26/24. V1 stated, It was (V8's) last scheduled day of employment at our facility on 10/26/24. I don't believe (V8) cared about anything since it was his last day, so (V8) transferred (R3) by himself with the sit-to-stand mechanical lift instead of using two people for the transfer. Staff should always have two people when transferring with any mechanical lifts. 145600 Page 2 of 2