Health inspection·June 9, 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. Based on observation, interview and record review, the facility failed to maintain resident safety during a transfer utilizing the mechanical lift by failing to have two staff present during a transfer and failed to ensure the correct size mechanical lift sling is used during transfers as recommended by the manufacturer. This affected two of two residents (R2-R3) reviewed for safety and the mechanical lift. Findings Include: 1.) R2 alert and oriented with a BIMS score of 14 (Cognition Intact), Weigh 141.0 lbs. on 5/1/24. On 6/8/24 at 2PM, Mechanical lift transfer with 2 staff assistance was observed. V4 and V13 (CNAs) placed the Mechanical lift sling in bed behind R2. Mechanical lift sling is big in size and light bluish in color. V4 and V13 folded the bottom end to fit R2's body then hooked up and transferred R2 in wheelchair. V4 operated the machine and V14 assisted in guiding R2 in her wheelchair. R2 stated I have never seen a sling so big. Interviewed R2 and R2 stated that the sling they used today is bigger than R2 was used to. R2 then reported that sometimes they transfer me with the machine with only one staff present. V4 still in the room and confirmed that the sling that was used is big for R2. V4 stated that staff cannot find her small Mechanical lift sling pad. V4 also stated they probably washed it in the laundry, and we cannot find it. V4 stated that they usually used a small Mechanical lift sling pad for R2, which is blue in color. On 6/8/24 at 2:21PM, V13 (CNA) We cannot find Mechanical lift sling. Usually, we use the small one and this sling was big for her. V13 stated that today they don't have the right size for R2. Mechanical lift has to be 2 person assist, or more than two. But not less than 2. Our sling pad comes in blue or gray color. I think the one that we used for R2 was from the hospital. Too big for the patient. Maybe the one use for weights, maybe. We folded the bottom end of the sling pad because R2 needs to have her legs hanging. Usually, we don't have to fold it if the Mechanical lift sling is the right size for the resident. 2.) On 6/8/24 at 1:55PM, R3 is up in the wheelchair in her room, playing cards. Alert and oriented. When asked how many staff in assistance with Mechanical lift transfer, R3 stated at times one or two staff assistance. Today there was only one that transfer me using the machine. R3 has a BIMs score of 13 (cognition intact). Facility Mechanical lift transfer list provided by the facility. R2 and R3 are listed as transferring x 2 assist via Mechanical lift. Confirmed under task tab in residents' medical record and both shows that R2 and R3 are transferring via mechanical lift x 2 assistance. Page 1 of 2 145907 145907 06/09/2024 Alden Estates of Evanston 2520 Gross Point Road Evanston, IL 60201

F 0689 R2 and R3 also have a care plan for requires the use of a mechanical lift for transfers. Level of Harm - Minimal harm or potential for actual harm On 6/9/24 at 10:45AM V16 (Minimum Data Set Coordinator/Covering Restorative Nurse) stated that Mechanical lift task is a two-person transfer assist. For the mechanical lift sling appropriate sizing the facility follows the manufacturer recommendation. If an inappropriate sizing was used to a resident, it may compromise the resident safety. Residents Affected - Few Mechanical lift user manual provided by the facility, reads in part: Mechanical lift is a fully electric mobile lift, with ability to raise and lower the lift arm and the width adjustment of the base. The list is intended to give caregivers the ability to lift a patient safely and take them to pre-determined destination. The lift is designed to be used in conjunction with the Mechanical lift Company's brand accessories and slings. Sling sizing: small 34-68kg, 75 to 150 lbs. Large 55-90kg, 120-200 lbs. Before every lifting situation, always make sure the following: Correct selection of sling (type, size, material) and accessories safely meet the patients' needs. Total Mechanical Lift policy dated 1/14/21, reads in part: 2 care givers are required to operate the mechanical lift. 145907 Page 2 of 2