Health inspection·December 5, 2023

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 interview and record review, the facility failed to follow the manufacturer's recommendations by ensuring the sling for a mechanical lift was secure, prior to transfer, for 1 of 3 residents (R2) reviewed for incidents/accidents, in the sample of 5. Findings include: R2's Care Plan dated 4/20/23 documents R2 is transferred via a mechanical lift with the assistance of two staff. It further documents R2 is at risk for falls and the goal is for R2 to be free of falls. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired and requires extensive assistance from two staff members for transfers. On 11/30/2023 at approximately 11:45 AM, V10, Certified Nursing Assistant (CNA) stated, (V7, CNA) and I were transferring (R2) to bed after lunch. I was on (R2's) left side and (V7) was on the right side. We hooked the top and bottom two straps. I swore I pulled down on the sling to make sure it locked into place. I went to raise the machine and (V7) pulled the chair out (from under R2). It happened out of nowhere (R2 falling). (V7) went to the floor to catch (R2's) head and I caught her back/hip area. We lowered her to the floor. The plastic piece from the sling was off. We've had problems with these machines before with other residents. She did have a small little bump on the back side of her head. The front of her leg was bad. It had 3 or 4 shears. (R2's) leg was hanging in the sling. (R2) has paper thin skin. On 11/30/2023 at 1:11 PM, V11, Registered Nurse/Physical Therapy Assistant stated, I have been going around observing the staff using the lift. They are supposed to ensure the sling is hooked in all the way and raise the resident above the surface and then move the chair. I am thinking one of the straps wasn't correctly hooked and became un-hooked during the transfer. On 11/30/2023 at 1:32 PM, V12, R2's daughter, stated R2 fell from the lift during a transfer and added, It could have been really bad if (V7) hadn't caught her (R2's) head. She fell from 4 or 5 feet in the air. On 12/4/2023 at 10:23 AM, V3, Registered Nurse (RN) stated, When I entered the room, (R2) was on the floor and the top left side of the sling was unlatched and hanging down. It was fine when they started to lift her up and pulled the wheelchair out from under her. She fell from a pretty high height, so we sent her to the ER (Emergency Room) for x-rays. Page 1 of 3 146025 146025 12/05/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0689 Level of Harm - Minimal harm or potential for actual harm On 12/4/2023 at 10:45 AM, V7, CNA stated, (V10) was on the left and I was on R2's right side. We hooked her up and as she was going up, I pulled the wheelchair out. Next thing you know, I saw her going down. It was the top left part of the sling. It happened so fast. It was just loose and not hooked all the way. Normally we double check by pushing down on them. It wasn't all the way fastened. It was a complete accident. I did see blood on her legs. Her skin is so thin. Residents Affected - Few R2's Progress Notes dated 11/24/2023 at 4:06 PM documents, This nurse was notified by other nurse that pt (Patient) fell out (mechanical) lift. This nurse went to room and noted pt laying on floor supine (on her backside) head was on pillow and pt was laying on back . Nurse assess pt- neuro (neurological) checks WNL (within normal limits). VS (Vital Signs)- 98/58, P- 98, R- 20, spo2 97% 97.0F. R2's Progress Notes further documents R2 sustained multiple skin tears to her left thigh and lower legs and was sent to the local emergency room for evaluation. The Facility's Untitled document dated 11/24/2023 documents the mechanical lift hook came undone or was not latched all the way. The Facility's Untitled Document dated 11/24/2023 documents, I immediately went to her (R2's) room where she was laying on the floor with a pillow under her head. (Mechanical lift) was above and only 3 hooks were attached. This document was signed by V6, Licensed Practical Nurse (LPN). The Facility's Untitled Document dated 11/24/2023 documents, (V6) came and told me the (R2) fell out of the (mechanical lift). I went to check on her to find out why this happened. (R2) was laying on the floor on her back. She had skin tears to her legs and (V4) was taking pictures of all the wound obtained from the sling when her feet slid out going down. The (mechanical lift) was still in the air above bed level. The left top latch to the sling was hanging down. The latch was no defective or broken. It was strong and intact. (V10) and (V7) said that the top latch came off and (V7) went to the ground to try and protect her head while (V10) caught her mid-section and lowered her to the floor. This document was signed by V3, Registered Nurse (RN). The Facility's Untitled Document dated 11/24/2023 documents, Around 1 PM after lunch, (V10) and I took (R2) back to her room to lay her down. (V10) was on the left side of her and I was on the right. (V10) lowered the (lift) down close enough to hook the pad to (the lift). We then hooked the top first then lowered more to fasten in between the legs. (V10) then lifted the (lift) enough to where she pulled the (pad) out and I pulled back the wheelchair. As (R2) was being lifted and chair was being moved, she stared sliding out from the left side (top). It further documents V4 and V6 provided wound care. It continues to document, I believe the hook on the left side was not all the way fastened causing (R2) to slide out of the lift pad. I am always very careful to check to make sure all hooks are tightly fastened. This document was signed by V7, CNA. The Facility's Untitled Document dated 11/24/2023 documents R2 was observed on the floor underneath the mechanical lift laying on her back and slightly to the left. It further documents V7 and V10 stated the lift hook slipped off. It continues to document, I questioned if it was double checked and both CNAs stated they thought they did. This nurse re-educated CNAs on importance of both staff to check all equipment prior to using. This document was signed by V4, LPN. The Facility's Untitled Document dated 11/24/2023 documents, I was getting the machine up in the air so the (V7) could move the wheelchair out from the (lift). As I was raising the sling a bit more and was ready to move the (lift), I just so happened to see the left should of the sling drop to the floor. This document was signed by V10, CNA. 146025 Page 2 of 3 146025 12/05/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Facility's Performance Skill-Transfer Using a Mechanical Lift document, undated, documents staff should ensure they are using the appropriate lift for the resident, applying the correct sling, attaching the sling to the lift and to check to ensure all 4 hooks are completely latched. It continues to document, Staff must verbally confirm that each hook is latched properly before beginning the transfer. The two staff pull down on the sling for a triple check that the hooks are completely slipped into position before raising the (full body mechanical lift). On 12/4/2023 at 2:16 PM, V2, Director of Nurses (DON) stated the incident was user error and she would expect staff to follow the manufacturer's instructions for the mechanical lift. On 12/4/2023 at 2:34 PM, V1, Administrator stated the piece to the sling wasn't completely in place and that V3 checked to ensure the sling wasn't torn and the plastic was in good condition. The Facility's Hoyer Lift Sling Safety undated, documents, Two staff must check all four hooks to make sure they are completely latched. Two staff must make sure the hooks are in the correct position (must be touching and in the top curve pictured below). Two staff must verbally confirm that each hook is latched properly before beginning transfer. Two staff are to pull down on sling for a triple check that the hooks are completely slipped into position before raising lift. Two staff then raise resident using the lift above the surface transferring from before moving away from the surface. Do not pull the wheelchair away before raising the lift. The Manufacturer's Information for the mechanical lift documents, (Mechanical lift) must always be handled by a trained care giver and in accordance with the instructions outlined in this manual. Failure to understand and follow these instructions may result in injury to yourself and others. It continues to document, Caution: Always check that all the sling attachment clips are fully in position before and during the lifting cycle and in tension as the patient's weight is gradually taken up. 146025 Page 3 of 3