Health inspection·August 3, 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, record review and interview the facility failed to ensure Resident #49 was transferred safely between the bed and the wheelchair. Actual harm occurred on 07/02/23 when Resident #49 began complaining of pain in her right leg after her leg got caught between her bed and wheelchair during a staff assisted transfer. X-ray results dated 07/04/23 indicated Resident #49 had a right tibia and fibula fracture. The facility investigation determined this injury was caused from the staff assisted transfer. This affected one resident (#49) of six residents reviewed for accident hazards. The total census was 143. Findings include: Record review for Resident #49 revealed the resident was admitted to the facility on [DATE] and had diagnoses including diabetes, spinal stenosis, and venous insufficiency. A plan of care, dated 11/04/22 revealed staff were to provide assistance with transfers as needed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/04/23 revealed the resident was cognitively intact and required extensive two-person assistance for transfers. Review of a nurse's note dated 07/02/23 at 10:00 P.M. revealed the authoring nurse asked an STNA to assist Resident #49 to bed. The same STNA came to the nurse to tell her Resident #49 was complaining of arthritis pain and wanted some cream for it. The nurse completed a skin check and found no redness, bruising or edema in the right lower extremity. Between 11:00 P.M. to 11:30 P.M. the STNA told the nurse Resident #49 wanted to see her. Resident #49 told the nurse she had pain in her right leg, the nurse completed an assessment, offered Tylenol, and called the physician who ordered a STAT x-ray. The nurse completed another skin check and found no bruising, redness or swelling. Review of a nurse's note dated 07/03/23 at 12:30 A.M. revealed a late entry indicating Resident #49 had told the nurse during the transfer by the STNA she had hurt her leg. The resident declined to go out to the hospital for evaluation at that time but agreed to a STAT x-ray order. The resident was given Tylenol for pain and fell asleep. Page 1 of 3 365305 365305 08/03/2023 Willoughby Post Acute 37603 Euclid Ave Willoughby, OH 44094

F 0689 Level of Harm - Actual harm Residents Affected - Few Further review of nurse's notes revealed the x-ray was documented as completed on 07/03/23 and reported 07/04/23, which identified an acute fracture to Resident #49's right tibia and fibula. She was sent to the emergency room on [DATE] and returned the same day with orders for follow-up orthopedic appointments. The resident's plan of care was updated on 07/05/23 to include having two staff assisting when providing transfers for Resident #49. Review of the facility investigation documentation into Resident #49's injury revealed an undated statement by STNA #938 stating she transferred Resident #49 to the wheelchair for a visit with family the morning of the event, and she had no complaints of pain. While trying to transfer her to the bed after the visit, the resident said ou so she stopped, sat the resident down in her chair, and retrieved another aide. The resident did not complain of pain until she was in the bed and staff notified the nurse. A documented interview with Resident #49 dated 07/03/23 revealed she stated her leg got caught between the wheelchair and the bed when the aide tried to transfer her and she said ouch. Later while lying down she began having pain again and informed the nurse. Undated documentation of a family interview revealed they denied any events occurred during the visit which could have resulted in injury. Review of physician's orders revealed an order dated 07/06/23 for the resident to be non-weight bearing on her right lower extremity and an order dated 07/11/23 for an immobilizer to her right lower extremity. Interview with Resident #49 on 07/31/23 at 10:06 A.M. revealed around the 4th of July, she suffered a broken leg when a single staff member tried to transfer her from the wheelchair, and her leg became caught between the wheelchair and the bed. She said the aide left after the transfer, and she called the nurse for pain medicine which was given. The next day the facility ordered x-rays and identified the leg had a fracture. Observation of Resident #49 at the time of the above interview revealed her right leg to be in a removable cast. Interview with the Director of Nursing (DON) on 08/02/23 at 8:05 A.M. revealed the facility had previously investigated Resident #49's alleged injury event. The nurse aide (STNA #938) who did the transfer no longer worked at the facility. The DON revealed during the investigation, STNA #938 said the resident complained of pain as soon as she tried to stand up during the transfer on 07/02/23. Resident #49 said her leg got caught between the bed and the wheelchair during the transfer, which STNA #938 denied. Interview with the Administrator on 08/02/23 at 5:11 P.M. confirmed the above findings. He said the facility did not determine the event to be an injury of unknown origin, as the facility concluded the injury occurred during the bedside transfer. Interview with STNA #871 on 08/03/23 at 3:58 P.M. revealed she was called into Resident #49's room on the evening of 07/02/23 to assist STNA #938 with providing positioning care. The STNA indicated Resident #49 did not complain of pain to her during the care. The deficiency was corrected on 07/06/23 when the facility implemented the following corrective actions: o On 07/03/23 an x-ray was completed and reported 07/04/23, which identified an acute fracture to 365305 Page 2 of 3 365305 08/03/2023 Willoughby Post Acute 37603 Euclid Ave Willoughby, OH 44094

F 0689 Resident #49's right tibia and fibula. Level of Harm - Actual harm o On 07/04/23 Resident #49 was sent to the emergency room and returned the same day with orders for follow-up orthopedic appointments. Residents Affected - Few o A fall investigation was completed including a statement by Resident #49. o On 07/05/23 Resident #49's plan of care was updated to include having two staff assisting when providing transfers. o On 07/06/23 and 07/11/23 Physician's orders were obtained related to Resident #49's injury. o On 07/06/23 a QAPI Plan was developed including the root cause was identified, education and audits were developed, and the Medical Director was notified. o On 07/06/23 an in-service was completed related to appropriate resident transfers by all State Tested Nurse Aides (STNAs) and Nurses. Education was provided by the Director of Nursing and Nursing Scheduler. o On 07/06/23 a house wide audits was completed for all residents' transfer status. o On 07/10/23 audits of transfers continued via observation of three residents three times a week for four weeks. The audits will be completed by the DON/designee. Audit findings will be presented to Quality Assurance and Performance Improvement (QAPI) committee for recommendations. Three weeks of audits (07/10/23, 07/19/23 and 07/26/23) were reviewed with no concerns noted. o On 07/31/23, during the interview with Resident #49, she voiced no current concerns related to inappropriate transfers. o During the course of the survey from 07/31/23 to 08/03/23 no current identified concerns related to inappropriate transfers were identified related to the regulation at F689. 365305 Page 3 of 3