Health inspection·November 27, 2023

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, hospital documentation review, resident and staff interview, review of a personnel file, review of a disciplinary action document, review of an investigation, policy review, and review of facility initiated corrective action, the facility failed to ensure appropriate care and assistance was provided to prevent a resident fall. This resulted in actual harm when Resident #104 was transferred by a mechanical (Hoyer) lift using only one staff member to assist, and subsequently fell, causing a facial laceration requiring sutures and a fractured right leg which required hospitalization and surgical intervention. This affected one (#104) of three residents reviewed for falls. The facility census was 113. Findings include: Review of Resident #104's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus, acute kidney failure, and multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/28/23, revealed Resident #104 was assessed as cognitively intact, and was dependent on two staff members for transfers. Review of the plan of care, dated 11/07/21, revealed Resident #104 had a potential for falls related to chronic disease process with an intervention to include the use of a mechanical (Hoyer) lift with two staff members for all transfers. Review of a nursing progress note dated 11/19/23 at 3:00 P.M. revealed Resident #104 fell during a transfer and sustained an injury to his head and had complaints of right hip pain. Resident #104 was transferred to the hospital via emergency medical services (EMS), and Resident #104's family and doctor were notified. Review of an incident investigation dated 11/19/23 revealed State Tested Nurse Aide (STNA) # 207 transferred Resident #104 via Hoyer lift by herself and the resident fell from the lift. Resident #104 was transferred to the hospital via EMS for evaluation due to a head injury and complaints of right hip pain. Review of a written statement from STNA #207 revealed on 11/19/23 she took Resident #104 back to his room to sit in his recliner. STNA #207 admitted to using the Hoyer lift without another staff Page 1 of 5 365093 365093 11/27/2023 Good Shepherd The 622 Center St Ashland, OH 44805

F 0689 Level of Harm - Actual harm Residents Affected - Few member present to assist in the transfer. STNA #207 indicated she made sure the mechanical lift transfer pad was strapped properly, and during the transfer the lift pad strap fell off the Hoyer lift and Resident #104 fell to the floor. STNA #207 immediately called for Licensed Practical Nurse (LPN) #210, and LPN #210 along with STNA #211 and STNA #212 came to Resident #104's room. STNA #207 indicated she did not mean for Resident #104 to fall and was trying to keep Resident #104 from disturbing other residents. Review of a hospital document revealed Resident #104 was admitted to the hospital on [DATE] following a fall in the nursing home. Resident #104 was found to have a closed fracture of the right femoral neck, right periorbital ecchymosis (bruising around the right eye), and a right eyebrow laceration with sutures placed on 11/19/23. On 11/20/23, Resident #104 was taken to the operating room for a closed reduction with intramedullary rod fixation of the right subtrochanteric femur fracture. Resident #104 was stabilized and returned to the nursing home on [DATE]. Observation and interview on 11/27/23 at 10:34 A.M. with Resident #104 revealed Resident #104 had several stitches over his right eye and his face was bruised but did not appear to be in pain. Resident #104 stated an STNA was not doing her job correctly when he fell. Resident #104 stated he was lifted with the Hoyer lift and then fell to the floor. Resident #104 stated his fall from the Hoyer lift on 11/19/23 was the only time there was only one staff member to operate the lift, and verified there was usually always two staff members to assist with his transfers. Resident #104 stated he liked the facility. A telephone interview on 11/27/23 at 12:00 P.M. with LPN #206 stated on 11/19/23 around 2:00 P.M., STNA #207 was very upset and adamant about LPN #206 coming to Resident #104's room. LPN #206 stated STNA #207 was crying and was hard to understand. LPN #206 stated upon arrival to Resident #104's room, the resident was laying on the floor with blood noted and the resident was in pain. A telephone interview on 11/27/23 at 12:16 P.M. with Registered Nurse (RN) #208 stated he was on another unit, when he was asked to go to Resident #104's room. When RN #208 got to the room, there were two nurses and two STNAs already in the room. RN #208 stated Resident #104 was alert and oriented but in pain, and STNA #207 was crying and really upset. RN #208 stated he pulled STNA #207 from the floor and asked her to calm down to write a statement. RN #208 stated STNA #207 indicated she did not want Resident #104 to disturb the other residents. A telephone interview on 11/27/23 at 2:04 P.M. with LPN #210 stated she was sitting at the desk when STNA #207 ran up the hall and stated Resident #104 was on the floor. LPN #210 stated STNA #207 was really upset and crying. LPN #210 stated she told STNA #207 to go get the other nurse (LPN #206), and told STNA #211 and STNA #212, who were at the nurses' desk, to go to Resident #104's room. LPN #210 stated she found Resident #104 lying on the floor in his room with some blood noted and he was in pain. LPN #210 stated she did not know why STNA #207 would have transferred Resident #104 using the Hoyer lift by herself, and stated there were enough staff members working to safely transfer the resident and there were no other problems that day. Review of STNA #207's personnel file revealed on 09/14/22, STNA #207 was provided an in-service on mechanical lift safety guidelines which included there must be two people assisting with mechanical lift transfers. Review of a disciplinary action document dated 11/20/23 revealed on 11/19/23 at approximately 1:30 P.M., STNA #207 took a resident (#104) to his room to lay him down in a recliner after lunch. STNA 365093 Page 2 of 5 365093 11/27/2023 Good Shepherd The 622 Center St Ashland, OH 44805

F 0689 Level of Harm - Actual harm Residents Affected - Few #207 reported she utilized the Hoyer lift alone and the lift pad sling came loose from the Hoyer lift causing the resident to fall to the floor resulting in major injuries. STNA #207 was terminated from employment on 11/20/23. Review of the facility policy titled, The Good [NAME] Transfer Policy, with an implementation date of 12/15/22, revealed two staff members must be utilized when transferring residents with a mechanical lift. The deficient practice was corrected on 11/24/23 when the facility implemented the following corrective actions: • On 11/19/23 at 1:30 P.M., STNA #207 was caring for Resident #104, who tends to yell out, so STNA #207 decided to bring him back to his room after eating lunch and transfer him to his recliner. STNA #207 elected to transfer Resident #104 by herself in a Hoyer lift even though the facility had adequate staffing available to assist. STNA #207 ran to get LPN #210, STNA #211, and STNA #212 to Resident #104's room. STNA #207 indicated the Hoyer lift pad strap by the right side of Resident #104's head popped off the bar and the resident then slid out onto his right side to the floor. LPN #210 called EMS as soon as she saw Resident #104 on the floor with a head laceration. • On 11/19/23 at 1:33 P.M., EMS arrived at the facility and LPN #206 performed a visual inspection of the lift pad that was under Resident #104, and found the straps were completely intact with no tears or fraying. • On 11/19/23 at 1:55 P.M., RN #208 performed a visual inspection of the Hoyer lift in use, and discovered the lift was in good working condition with no defects. • On 11/19/23 at 1:59 P.M., RN #208 informed LPN Staff Development #209 of the incident with Resident #104 and indicated once STNA #207 completed a written statement regarding the incident and STNA #207 would be sent home. • On 11/19/23 at 2:11 P.M., LPN Staff Development #209 notified the DON of the incident with injury to Resident 104 and was informed STNA #207 would be going home once her written statement was completed. • On 11/19/23 at 2:30 P.M., the DON called RN #208 to review the incident and to verify that STNA #207 was going home once her statement was completed. 365093 Page 3 of 5 365093 11/27/2023 Good Shepherd The 622 Center St Ashland, OH 44805

F 0689 • Level of Harm - Actual harm On 11/19/23 at 2:35 P.M., RN #208 called Resident #104's representative and informed him of the fall with injury. Residents Affected - Few • On 11/19/23 at 2:37 P.M., STNA #207 finished her written statement while being supervised by RN #208 then clocked out and went home. • On 11/19/23 at 3:17 P.M., the DON emailed an education and followed up with a phone call to RN #208 to immediately in-service staff on proper transfer via Hoyer lift. All staff were educated by 11/24/23. • On 11/19/23 at 6:17 P.M., RN #208 informed the DON that Resident #104 was admitted to the hospital. • On 11/19/23, STNA #200 and STNA #201 checked Hoyer lift pads to ensure there were no frays, rips, or tears with no concerns noted. A second check of the Hoyer lift pads was completed by STNA #204 and STNA #205 on 11/20/23 with no concerns. Additional audits of all Hoyer lift pads on 11/21/23, 11/22/23, 11/25/23, and 11/26/23 revealed no concerns. • On the morning of 11/20/23, Maintenance Director #216 did a visual inspection of all facility Hoyer lifts and hanger bars and found them to be intact, without defect, and functioning properly. Audits will continue weekly for four weeks and then monthly for three more months to ensure compliance. • On 11/20/23 at 2:45 P.M., the DON and Assistant Director of Nursing (ADON) #213 met with STNA #207, and STNA #207 admitted to knowing the facility's policy and practice was to perform all mechanical lifts with two staff members. STNA #207 indicated although staffing was good, she attempted to perform Resident #104's transfer by herself to be efficient. STNA #207 was terminated from her position on 11/20/23. • On 11/20/23, resident care plans were reviewed to ensure residents who required a mechanical lift for transfers had appropriate interventions in place. All care plans were reviewed and updated by 11/22/23. • 365093 Page 4 of 5 365093 11/27/2023 Good Shepherd The 622 Center St Ashland, OH 44805

F 0689 Level of Harm - Actual harm On 11/20/23, Hoyer lift pads were labeled and tracked by Laundry Aide #217 with each time they were laundered and were inspected and logged. Any Hoyer pad with fraying or tears were immediately taken out of circulation and were destroyed. Residents Affected - Few • On 11/20/23 at 9:00 A.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with the DON, ADON #213, the Administrator, and LPN Staff Development #209 to discuss Resident #104's fall. The Medical Director was in the facility at 4:00 P.M. and was updated on the facility's action plan. • On 11/20/23, Hoyer lift transfers were observed by LPN #214 with no concerns. LPN #214 made additional observations of Hoyer lift transfers on 11/21/23 and 11/24/23 with no concerns observed. LPN #214 and ADON #213 will continue to observe a minimum of two mechanical lift transfers each week for four weeks then twice monthly for two months to ensure compliance. • Interviews on 11/27/23 from 6:40 A.M. through 3:30 P.M. with STNA #200, STNA #201, STNA #202, STNA #204, and STNA #205 all verified they were educated on the need for two staff members for all Hoyer lift transfer and confirmed appropriate knowledge of the facility's mechanical lift policy and procedure. All STNAs verified they check Hoyer lift pads for defects before use and indicated nurses will assist with Hoyer lift transfers when necessary. This deficiency represents non-compliance investigated under Complaint Number OH00148536. 365093 Page 5 of 5