Health inspection·February 8, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of the facility policy the facility failed to ensure staff followed the resident's care plan regarding Hoyer lift transfers. This affected one (Resident #12) of three residents reviewed for Hoyer lift transfers. The census was 86. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed an admission date of 10/29/21 with diagnoses including dementia, psychotic disturbances, mood disturbances, and cerebral infarction and a discharge date of 01/22/24. Review of the care plan for Resident #10 dated 01/01/23 revealed the resident was resistive to care and was at risk for falls and required a Hoyer lift for transfer. Review of the progress notes for Resident #10 dated 1/15/24 at 1:00 A. M. revealed Resident #10 had swelling and bruising and pain upon range of motion to her right lower extremity. Resident #10's physician ordered a mobile x-ray which showed a fracture to the right tibia. The resident was sent to the hospital for further evaluation. Review of the investigation of Resident #10's bruise dated 01/15/24 revealed the facility investigated the bruising and swelling to the resident's right lower extremity. The investigation determined STNA #115 had not used a Hoyer lift when transferring Resident #10 on 01/14/24. STNA #115 received disciplinary action for failure to use a Hoyer lift to transfer Resident #10. Review of the hospital progress notes for Resident #10 dated 01/16/24 revealed the resident did not have a fracture to her tibia and returned to the facility with no new orders. Review of the written statement per State Tested Nursing Assistant (STNA) #115 dated 01/19/24 revealed on 01/14/24 at approximately 8:30 P.M. the aide transferred Resident #10 from chair to bed using a gait belt and resident's right leg got caught under her knee. When STNA #115 straightened the resident's leg out the aide heard a pop. Resident #10 did not show any signs of pain immediately following the transfer. Further review of the statement revealed on 01/14/24 at approximately 11:00 P.M. STNA #115 noted the resident's right knee was swollen and bruised and she reported her concerns to the nurse. Review of the statement revealed STNA #115 had not used a Hoyer lift to transfer Resident #10 on 01/14/24. Interview on 02/07/24 at 11:30 A.M. with the Director of Nursing (DON) confirmed Resident #10 should have been transferred using a Hoyer lift per the resident's care plan. DON confirmed STNA #115 had not used a Hoyer lift to transfer Resident #10 on 01/14/24 and the aide had received disciplinary Page 1 of 2 365799 365799 02/08/2024 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0684 action regarding the improper transfer. Level of Harm - Minimal harm or potential for actual harm Interview by telephone on 02/07/24 at 3:02 P. M. with STNA #115 confirmed she transferred Resident #10 on 01/14/24 using gait belt instead of using a Hoyer lift. STNA #115 further confirmed she noticed bruising and swelling to the resident's right lower extremity a couple hours after the transfer on 01/14/24. Residents Affected - Few Review of the facility policy titled Care Plan dated January 2023 revealed the facility Interdisciplinary Team (IDT) would ensure staff complied with the resident's plan of care which included approaches that met the resident's needs including care and services to be delivered. This deficiency represents non-compliance investigated under Complaint Number OH00150490. 365799 Page 2 of 2