Health inspection·September 17, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based of observation, interview, record review,Self-Reported Incident (SRI) , and facility policy review, the facility failed to ensure all staff followed Mechanical lift protocol. This affected one (Resident #135) of three residents reviewed for safe transfer with Mechanical lift. This had the potential to affect 33 residents that required the use of a mechanical lift for transfers (Resident #1, #3, #9, #10, #18, #27, #37, #38, #39, #44, #48, #49, #51, #54, #56, #57, #64, #68, #70, #71, #78, #81, #85, #88, #89, #94, #110, #114, #115, #122, #123 and #135). The facility census was 122. Findings include: Review of the closed medical record for Resident #135 revealed an admission date of 02/01/24 and discharged on 08/22/24. Diagnoses included diabetes, chronic kidney disease, morbid obesity, spinal stenosis and osteoarthritis. Resident #135 had intact cognition. Resident #135 was dependent on transfers and used a mechanical lift (Hoyer) for transfers. Review of the progress note dated 08/19/24 at 1:28 P.M. revealed the Unit Manager Licensed Practical Nurse (LPN) #309 reported to the Director of Nursing (DON) that resident had fallen from the Hoyer lift. LPN #309 was approached by the State Tested Nurses Aide (STNA) #310 which stated the Hoyer lift scale detached from the Hoyer and Resident #135 dropped into her wheelchair. The Hoyer scale hit resident in the forehead. Resident did not fall at any time during the transfer. Emergency Medical Service (EMS) arrived and took resident to ER with paperwork in hand. Interview on 09/16/24 at 9:45 A.M. with LPN #309 stated she was the unit manager on when Resident #135 was transferred with one assist and the Hoyer broke, and she was put down in wheelchair hard by STNA #312. LPN #309 stated she tried to assess Resident #135 but, she refused. She asked Resident #135 if she was hurting and stated no, she had a cut on her forehead with a little blood, but it was not bleeding at that time. She was told the Hoyer arm dropped fast and she dropped into her wheelchair. LPN #309 stated the son called 911 and they took her to the nearest hospital. Resident #135 did not return to the facility. Interview on 09/16/24 at 11:06 A.M. with Maintenance Assistant #311 stated he checks all mechanical lifts monthly to ensure they are working properly. On 08/19/24 he was told Hoyer #4 broke. He stated when STNA #312 was lowering Resident #135 the weight scale had to of got caught on something and the Hoyer bar was still being lowered but could not lower and when the weight box finally bent and broke the Hoyer bar dropped until it reached were the hydraulic was lowered too. Page 1 of 3 365192 365192 09/17/2024 Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130

F 0689 Level of Harm - Minimal harm or potential for actual harm Observation on 09/17/24 at 10:07 A.M. of Resident #27 being Hoyer lifted from her bed to her motorized wheelchair with State STNA#307 and #308 revealed no safety concerns were noted. Review of the facility policy Mechanical Lifts and Transfer, not dated revealed use two employees to assist and for support in the safe use of a total transfer. Residents Affected - Few Review of the employee corrective action form dated 08/19/24 revealed STNA #312 received a final written warning for safety/carelessness related to Hoyer lift protocol when transferring Resident #135 by herself, subsequently Resident #135 dropped into her wheelchair. Review of the self-reported incident (SRI) 250989 revealed on 08/19/24 STNA #312 was using the Hoyer by herself, and Resident #135 dropped about six inches quickly when the arm on the Hoyer dropped. A full investigation, training and correction actions were done. The deficient practice was corrected on 08/21/24 when the facility implemented the following corrective actions: • On 08/19/24, a SRI was opened, and investigation was started. • On 08/19/24, Hoyer slings inspected per Maintenance #311 with no negative findings. • On 08/19/24, STNA #312 received a final written warning for safety/carelessness related to Hoyer lift protocol when transferring Resident #135 by herself, subsequently Resident #135 dropped into her wheelchair. • On 08/19/24, Audits of mechanical lift transfers three times a week for four weeks per the DON or designee. • On 08/20/24, Education on mechanical lift safety was conducted to all nursing staff per the DON. • On 08/21/24, Resident skin checks completed by LPN #303 and LPN #320. • On 08/21/24, Resident statements for abuse and mechanical lift resident statements completed by LPN #303 and LPN #320 with no negative findings. 365192 Page 2 of 3 365192 09/17/2024 Greenbrier Health Center 6455 Pearl Rd Parma Heights, OH 44130

F 0689 • Level of Harm - Minimal harm or potential for actual harm On 08/21/24, Mechanical lift competency for all nursing staff was started and completed on 08/28/24 by DON and Assistant DON. Residents Affected - Few • On 08/21/24, Quality Assurance meeting was held for root cause analysis with DON, Medical Director #400, Administrator, Assistant DON, LPN #320, LPN #309, LPN #303, and Social Service Director (SSD) #304 with no changes. • On 08/21/24, Review of general guidelines for Hoyer by RDCO Registered Nurse (RN) #402, [NAME] President of Clinical Operations RN #403, Administrator, and RDCO Administrator #404. • Interviews on 09/16/24 and 09/17/24 from 8:30 A.M. through 3:00 P.M. with LPN #303, #306, #307, #309, RN #305, STNA #300, #301, #302 and #308 revealed knowledge of the Mechanical Lift Policy and procedures of two staff members for all mechanical lifts. Staff stated knowledge of change of condition and what is expected of them. • Observations on 09/16/24 revealed all Mechanical Lifts were functioning properly. This deficiency represents noncompliance investigated under Complaint Number OH00157258 and OH00157113. 365192 Page 3 of 3