Health inspection·January 31, 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 safely operate a mechanical lift transfer for one resident (R5) and failed to transfer one resident (R6) via mechanical lift as identified in the plan of care of three residents reviewed for mechanical lift transfers in the sample of seven. Findings include: Facility Policy/Mechanical Lift dated 2/2017 documents: A (full) mechanical lift should be used for heavy residents or for those who are disabled. Two staff members are required for this procedure. This policy's procedure for placing the sling under the resident does not include removing the sling once the resident is placed into a chair. Facility Policy/Mechanical Lifts dated 5/17 documents: Staff are not to operate the mechanical lift by themselves when a resident does not have independent sitting balance. Current Physician Orders indicate R5 was admitted to the facility on [DATE] with diagnoses that include Muscular Dystrophy, Diabetes Mellitus, Lymphedema and Obesity. Current Comprehensive assessment dated [DATE] indicates R5 has mild cognitive impairment. Current Care Plan indicates R5 is at risk for falls related to difficulty with balance, use of wheelchair; requires assist of two staff for sit-to-stand transfers (dated/edited 1/15/24). Fall Incident Report dated 1/4/24 indicates R5 fell during transfer with a sit-to-stand mechanical lift while being toileted and received an elbow abrasion. Report indicates R5 stated she fell back and could not hold onto the lift. Report Conclusion indicates R5 had a fall due to non-compliance of proper lift use. On 1/30/24 at 1:15pm R5 stated When I fell through the sling, it wasn't on the hooks right and I didn't have a safety strap on. On 1/30/24 at 1:45pm surveyor entered R5's room and observed V4 (Certified Nursing Assistant/CNA) Page 1 of 2 145950 145950 01/31/2024 Generations at Rock Island 2545 24th Street Rock Island, IL 61201

F 0689 Level of Harm - Minimal harm or potential for actual harm lowering R5 into a wheelchair with a sit-to-stand lift and then removing the lift sling. No other staff were present in R5's room. At that time V4 stated Another CNA was in the room assisting with (R5's) transfer just before you entered. No staff were seen in the hallway or exiting R5's room prior to surveyor entering R5's room. V4 was unable to recall the CNA's name who was assisting with the transfer. After V4 left R5's room, R5 stated that V4 did not have any assistance with her transfer, that V4 alone transferred R5. Residents Affected - Few On 1/30/24 at 1:55pm R6 (R5's spouse) was sitting in the resident's room in a wheelchair. V4 stated that she needed to transfer R6 into bed. At that time V4 stated she needed to get the (sit-to-stand) lift back to get R6 into bed. On 1/30/24 at 2:00pm V3 (Assistant Director of Nursing) entered R5 and R6's room and stated that they were going to use a full mechanical lift to transfer R6 back into bed from the wheelchair. V3 stated that would be the safest method of transfer for R6 as he is not consistent in his ability to stand, is at risk of his knees buckling and/or letting go of the hand grips as he cannot consistently follow directions. At that time, V4 (CNA) and V5 (CNA) lifted R6 to a standing position by going under each of R6's arms, while V3 placed a full mechanical lift sling into R6's wheelchair and then lowered R6 back down into the wheelchair. V3, V4 and V5 confirmed that R6 did not get out of bed in the morning with a full mechanical lift transfer as the sling would have been left in the chair. At that time, R5 (spouse) stated that R6 can sometimes stand, and this morning two CNAs just got under each of R6's arms and did a (pivot) transfer from the bed to the wheelchair. On 1/31/24 at 11:30am V13 (Restorative Nurse) stated Both of the aides (V16, V20) involved in the fall were newer. (R5) told V16 and V20 that she didn't want the sling safety strap so V16 and V20 didn't use it. Both were educated that residents don't get to decide about the safety equipment. V13 stated if a resident refuses safety interventions they don't transfer the resident and immediately notify the nurse. V13 stated I honestly didn't take into account that V16 is not a CNA (Certified Nurse Assistant) when I did the fall review. NA's (Nursing Assistants) should only be observing, can't be the 2nd person with a transfer. Current Care Plan indicates R6 has an inability to transfer self-related to generalized weakness. (R6) is a full mechanical lift for transfers. (dated1/30/24) 145950 Page 2 of 2