Health inspection·February 6, 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** Based on review of the medical record, staff, family and resident interviews, and policy review, the facility failed to safely transfer Resident #42 resulting in a fall. This affected one (#42) of four residents reviewed for falls. The facility census was 80. Findings include Review of the medical record revealed Resident #42 had an admission date of 12/20/23 and a readmission date of 01/13/24. Diagnoses included acute kidney failure, discitis lumbar area, type two diabetes mellitus, radiculopathy lumbar region, low back pain, and chronic kidney disease stage three. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 required substantial/maximal assistance for toileting hygiene, bed mobility, and transfers. The resident had no prior falls. Review of a fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of the care plan dated 01/06/24 for Resident #42 revealed the resident required moderate/maximal assistance of one to two staff for transfers. The resident was at risk for falls related to debility, unsteady gait with weakness, poor safety awareness, and a history of polio when younger. Interventions included to anticipate and meet resident needs, be sure the call light was within reach, prompt response to all requests for assistance, educate family/caregivers about safety reminders and what to do if a fall occurs, and encourage the resident to participate in activities that promote exercise, physical ability for strengthening and improved mobility. Review of a nurse's note dated 01/27/24 at 1:15 P.M. revealed the resident had a witnessed fall in his room today with a nursing assistant during transfer. The nursing assistant reported the resident's knees buckled while using the walker. The nursing assistant pulled a chair behind the resident and attempted to have the resident sit in the chair. The resident sat on the edge of the chair and slid down to the floor on his knees. The resident's family member was present in the room. An assessment was completed and no new injuries found. The resident's skin was intact. Vital signs were within normal limits. A neurological assessment was completed and was within normal limits for the resident. The resident denied any complaints at this time. A Hoyer lift was used to put resident back in bed with the assistance of three staff. The physician was notified with no new orders. Interview on 02/01/24 at 11:26 A.M. with Resident #42 revealed he was sitting in a regular chair using his peddling bike and wanted to go back to bed. Resident #42 revealed Nursing Assistant (NA) Page 1 of 2 365997 365997 02/06/2024 Parkvue Health Care Center 3800 Boardwalk Blvd Sandusky, OH 44870

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #192 assisted him up from the chair by grabbing onto his pajama bottoms. Resident #42 revealed he was using his walker and NA #192 was following behind him with a regular chair. Resident #42 revealed he told NA #192 he felt weak. Resident #42 revealed NA #192 told him to sit down. Resident #42 revealed he went to sit down and fell on his knees on the floor because the chair was not close enough. Resident #42 revealed NA #192 was not using a gait belt on him. Resident #42 revealed his family member was present when the fall happened. Interview on 02/01/24 at 11:50 A.M. with NA #192 revealed she was a nurse aide in training. NA #192 revealed she was transferring Resident #42 using his walker but his knees were giving out. NA #192 revealed she was following the resident with a high-top chair. NA #192 revealed she did not have a gait belt on the resident and she should of used a gait belt. NA #192 revealed she told the resident to sit down in the chair but she could not get the chair underneath the resident far enough. NA #192 revealed the resident slipped off the edge of the chair and fell on the floor. Interview on 02/01/24 at 1:35 P.M. with Registered Nurse (RN) #203 revealed a nursing assistant alerted her Resident #42 had fell. RN #203 revealed she assessed the resident with no injuries and the Hoyer lift was used to put the resident back in bed. RN #203 revealed the nursing assistant stated she grabbed the chair for the resident but he sat too close to the edge of the chair and went down on his knees. RN #203 revealed the nursing assistant had not used a gait belt and should have been using a gait belt to transfer the resident. Interview on 02/01/24 at 5:05 P.M. with Family Member (FM) #142 revealed the resident was sitting in a chair and asked to go back to bed. FM #142 revealed the resident was not able to stand up so NA #192 took a hold of the resident's pajama bottoms and pulled the resident up. FM #142 revealed NA #192 was not using a gait belt on the resident. FM #142 revealed the resident tried to take two steps with his walker. NA #192 was following behind the resident with a regular chair (not a wheelchair). FM #142 revealed the resident told NA #192 his legs were giving out and he needed to sit down. FM #142 revealed NA #192 told the resident to sit down. FM #142 revealed NA #192 had not placed the chair close enough to the resident. The resident went to sit down and slid off the edge of the chair onto his knees on the floor. FM #142 revealed staff used a hoist to get the resident back up and into bed. Interview on 02/05/24 at 11:40 A.M. with Assistant Director of Nursing (ADON) #332 revealed the resident fell while using his walker when a nursing assistant had not gotten a chair far enough under the resident to sit down. ADON #332 revealed she was not aware the nursing assistant was following the resident with a regular chair. ADON #332 revealed the nursing assistant should have followed with a wheelchair and should have used a gait belt. ADON #332 revealed she was going to complete some re-education with the nursing assistants and ensure each resident had a gait belt in their room. Review of the policy, Safe Resident Handling and Transfers Guidelines, last revised 02/10/23, revealed the facility would provide a safe and secure environment while handling and transferring residents safely to prevent risk for injury to residents and staff. The resident's mobility would be evaluated and assessed upon admission and reviewed quarterly. Transferring/handling aides would be based on the resident's needs or condition. Further review of the policy revealed a gait belt was a sturdy transfer belt that was used with residents at least partially ambulatory for transfer or walking assistance to prevent falls and caregiver back injury. This deficiency represents non-compliance investigated under Complaint Number OH00150649. 365997 Page 2 of 2