Health inspection·May 21, 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interview and facility policy review, the facility failed to ensure Resident #10 was transferred in a safe manner and as per the resident's plan of care and facility policy with two staff via a mechanical (Hoyer) lift to prevent a potential accident. This affected one resident (#10) of four residents reviewed for accident hazards. The facility census was 59. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/12/2023 with diagnoses including chronic obstructive pulmonary disease, spinal stenosis lumbar region, and dementia. Review of the plan of care dated 07/26/2023 revealed Resident #10 had an activity of daily living (ADL), self-care performance deficit related to decreased mobility, weakness, memory loss/confusion, and required assistance for ADLs and mobility needs. Interventions included providing two staff assist with transfers using a Hoyer (mechanical) lift. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Resident #10 was noted to be free from bilateral upper and/or lower extremity impairment and required a wheelchair for mobility. The assessment noted the resident was dependent on staff with all transfers. Review of the Fall Risk Assessment completed for Resident #10 dated 04/28/2024 revealed resident was alert only with one to two falls in the past three months. Resident #10 was noted to be chair bound and was noted to require the use of assistive devices for gait and balance. Interview on 05/08/2024 at 2:00 P.M. with the Administrator revealed there was a staff member, State Tested Nursing Assistant (STNA) #335 who was still in training who transferred Resident #10 (on 05/06/24) by himself with the use of a mechanical lift. The Administrator revealed the management team was made aware of the incident by Resident #8's daughter. Interview on 05/08/24 at 4:30 P.M. with the daughter of Resident #8 revealed she was concerned an STNA (STNA #335) was transferring Resident #10 via a Hoyer lift by himself, without a second person present on 05/06/24. The daughter indicated she asked the STNA if he needed a spotter since she stated she was aware he was a new employee. The daughter indicated the STNA replied to her he had 25 Page 1 of 2 365399 365399 05/21/2024 Westerwood Rehabilitation 5757 Ponderosa Drive Columbus, OH 43231

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few years experience, knew what he was doing, was very strong and didn't need help. The daughter indicated the STNA also reported everyone was busy right now. The daughter indicated she reported the situation to staff but continued to have concerns related to the safety of the resident without a second staff person present for the transfer with the Hoyer lift. Attempts to reach STNA #335 during the investigation on 05/08/24 at 3:10 P.M. and 05/20/24 at 11:40 A.M. were unsuccessful. Record review/review of Resident #10's medical record revealed no written documentation of the incident/transfer on 05/06/24. There was no written statement from STNA #335 available or provided to review during the survey. Review of an undated facility policy titled Hoyer (Sling) Lift Transfer, revealed at least two staff members were needed when using a mechanical lift. The deficiency was corrected on 05/07/24 when the facility implemented the following corrective actions: Review of requested documents related to education and corrective action taken by the facility related to this incident revealed the facility provided a Hoyer (Sling) Lift Transfer policy and procedure and a re-training document (dated 05/07/24) for STNA #335 and all staff related to the incident that occurred on 05/06/2024. The facility implemented a plan to audit resident transfers to ensure residents who required a Hoyer lift were transferred with two staff. Following this incident on 05/06/24, no additional incidents had occurred related to a staff member completing a single mechanical lift transfer. This deficiency represents non-compliance investigated under Complaint Number OH00153624. 365399 Page 2 of 2