Health inspection·June 28, 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** Based on observation, medical record review, staff interview, mechanical lift customer service technician interview, review of the facility investigation, review of hospital records, review of manufacturer's recommendations, and policy review, the facility failed to ensure mechanical lift equipment was maintained in a safe and working condition to prevent an avoidable fall for Resident #244. This resulted in Actual Harm on 06/20/23 when Resident #244 was lifted in the mechanical lift by State Tested Nursing Assistant (STNA) #573 and STNA #592 who failed to ensure the integrity of the mechanical lift pad which led to mechanical failure when the lift pad ripped resulting in Resident #244 descending three to four feet to the floor. Subsequently, Resident #244 was hospitalized with five left posterolateral rib fractures and a minimal left pleural effusion with adjacent atelectasis (a complete or partial collapse of the lung or portion of the lung). This affected one resident (#244) of three residents reviewed for mechanical lift transfers. The facility census was 78. Findings Include: Review of the medical record for Resident #244 revealed an admission date of 09/24/21. Resident #244 was discharged to the hospital on [DATE] and currently remained in the hospital. Resident #244 had diagnoses including diastolic heart failure, type II diabetes mellitus, stage III chronic kidney disease, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #244 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The assessment revealed Resident #244 required total dependence of two (staff) for transfers. Review of the physician's order for Resident #244 revealed he required a Hoyer (mechanical lift) for all transfers. Review of Resident #244's care plan revealed he had a self-care deficit. Interventions included a mechanical lift and two staff assistance for transfers. Review of the current weight for Resident #244 revealed he weighed 325 pounds. Review of a facility investigation, dated 06/20/23 revealed STNA #573 and STNA #592 were attempting to transfer Resident #244 from the bed to his wheelchair in the mechanical lift. Review of the witness statement from STNA #573 revealed around 10:45 A.M. on 06/20/23 following hooking Resident #244 Page 1 of 3 365758 365758 06/28/2023 Parma Care Center 5553 Broadview Rd Parma, OH 44134

F 0689 Level of Harm - Actual harm Residents Affected - Few up to the mechanical lift with assistance from STNA #592, they began to turn the lift. The lift pad strap broke and Resident #244 fell to the floor. Review of the witness statement from STNA #592 revealed she came to assist STNA #573 with the mechanical lift transfer of Resident #244 around 10:45 A.M. When they began to turn the lift, the strap snapped, and he fell to the floor, but she was able to keep him from hitting his head. Review of the witness statement from Licensed Practical Nurse (LPN) #559 revealed on 06/20/23 she heard a loud noise and responded to Resident #244's room where she observed the resident laying on his left side with the lift pad underneath him. LPN #559 assessed Resident #244 for injuries, and he was sent out for evaluation and treatment. Review of the hospital admission record dated 06/20/23 for Resident #244 revealed he arrived at the local hospital at 11:45 A.M. Resident #244 was noted to have fallen three to four feet to the floor after a mechanical lift strap broke and dropped him to the ground. Resident #244 landed on his left side. Resident #244 complained of left lateral rib pain and left upper arm pain with movement. The physician impression for Resident #244 revealed he had several acute, minimally displaced left posterolateral rib fractures involving left ribs six through ten, associated minimal left pleural effusion presumed hemorrhagic with minimal adjacent atelectasis. Interview on 06/27/23 at 9:52 A.M., with STNA #573 revealed she was in Resident #244's room around 10:00 A.M. on 06/20/23 to give him a bed bath, get him dressed and up to his wheelchair. She requested the assistance of STNA #592 to use the mechanical lift to transfer Resident #244 from his bed to his wheelchair. STNA #573 and STNA #592 hooked up Resident #244 to the mechanical lift using the green strap on the lift pad. They proceeded to lift Resident #244 off the bed and the left side strap broke clean through and Resident #244 fell three to four feet to the ground falling on his left side on top of the metal stabilization bar of the mechanical lift. Interview on 06/27/23 at 8:52 A.M., with Licensed Practical Nurse (LPN) #559 revealed she was providing care across the hall from Resident #244's room when she heard a loud noise and Resident #244 shout. LPN #559 immediately ran to Resident #244's room and found Resident #244 in the lift sling but laying on his left side on the floor. LPN #559 yelled for help and began to assess Resident #244 for injuries. The nurse at the desk alerted the Director of Nursing (DON) and the Administrator and called for emergency medical services (EMS). Interview on 06/27/23 at 11:00 A.M., with STNA #592 revealed STNA #573 was lifting Resident #244 with the mechanical lift, and she was guiding his legs. Once they raised him off the bed they began to turn, and the lift pad strap ripped and Resident #244 fell to the floor falling on his left side onto the metal frame of the mechanical lift. Resident #244 expressed pain on his left side. LPN #559 came to assess Resident #244, and EMS was called. Interview on 06/27/23 at 10:14 A.M., with the Laundry Staff #548 revealed the mechanical lift slings in the laundry were undated and the staff member was unsure how long they had been in service. Laundry Staff #548 revealed some of the lift slings were faded and had bleach discoloration spots on them. Interview on 06/27/23 at 10:48 A.M., with Medical Supply Staff #502 revealed prior to the incident on 06/20/23 involving Resident #244, the facility was going by visible fraying or strings of the lift slings to indicate the need to replace them and was unsure how long the lift slings had been in use. Observation following the interview of Resident #212's lift sling revealed it appeared faded. Observation in Resident #265's room of her lift sling revealed it appeared to be faded. Observation in Resident #215's room of his lift sling revealed it was faded and appeared to have some bleach spots 365758 Page 2 of 3 365758 06/28/2023 Parma Care Center 5553 Broadview Rd Parma, OH 44134

F 0689 on it. Medical Supply #502 verified the above observations. The facility was unable to provide the most current order date of mechanical lift slings/pads. Level of Harm - Actual harm Residents Affected - Few Observation on 06/27/23 at 12:06 P.M. with the Director of Nursing (DON) and the Administrator of the lift sling used in the 06/20/23 incident involving Resident #244 revealed the left green hook broke and severed the black strap attached to it. The strap on the other side had visible fraying up near the top above the purple loop. The DON and Administrator verified they were unsure how long the blue mechanical lift sling had been in service, the green hook appeared worn, and the actual pad had discolored pink spots on it that appeared to have been from use of bleach. The weight limit of the pad was not able to be visualized as the tag was worn off. Telephone interview on 06/27/23 at 1:32 P.M., with Customer Services Technician #800 at Invacare (the mechanical lift company) revealed after each laundering of a Hoyer sling, they should be inspected for wear, tears, loose stitching, discoloration, or bleach stains which could weaken the integrity of the fabric. A follow-up interview on 06/28/23 at 11:01 A.M., with the Administrator revealed the staff would visualize the mechanical lift sling to check for any signs of wear and remove items if they appeared to be worn and notify administration for them to be replaced. Review of the Invacare Reliant 600 RPL600-1 user manual revealed under Using the Sling section; after each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching, bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. Review of the Emerald Supply Slings Manual for the Hoyer sling revealed do not use padded standing slings as a transport device. Its intended purpose is to transfer a resident from one seated or resting position to another. The anticipated usable product life was six months. Bleached, torn, cut, frayed or broken slings are unsafe and could result in injury. Destroy and discard. Do not wash slings with bleach. Bleach will damage the material. Slings can suffer damage during washing and drying. Review of the policy titled Hoyer Lift, dated July 2022 revealed the procedure involved ensure the mechanical lift if appropriate with respect to weight restrictions, examine sling and attachment areas for tears, holes, and frayed seams. Do not use sling with any signs of wear. Sling with any sign of wear should be removed from service and discarded immediately. Notify administrator of need for replacement. This deficiency represents noncompliance discovered in Complaint Number OH00143999. 365758 Page 3 of 3