Health inspection·May 28, 2024

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 record review, interview, observation, review of a facility investigation, and facility policy review, the facility failed to ensure residents were properly transferred by mechanical lift. This affected two residents (#22 and #44) of three residents reviewed for transfers. The facility census was 53. Actual Harm occurred on 05/05/24 when two State Tested Nursing Assistants (STNA's) were transferring Resident #22, who had severely impaired cognition and was dependent on staff for transfers, via mechanical lift to her wheelchair and failed to operate the mechanical lift properly, resulting in Resident #22 falling and sustaining a spiral femur fracture requiring surgery and hospitalization. The resident was assessed to exhibit severe pain with leg movement following the incident and signs/symptoms of pain/distress throughout the morning of 05/06/24 before being transferred to the hospital. Findings included: 1. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including localized edema, anxiety disorder, Alzheimer's Disease, and polyosteoarthritis. Additional diagnoses added in May 2024 included fracture of unspecified part of neck of left femur, history of falling, altered mental status, pain in left hip, fall from other furniture initial encounter, other acute post-procedural pain, and anemia. Review of a care plan revised on 06/23/21 revealed Resident #22 had an activity of daily living (ADL) self-care performance and mobility deficit related to weakness, right artificial hip, anxiety, lower back pain, and severe cognitive impairment with a goal of participating in self-care to optimum level as evidenced by clean, odor free and dressed daily. Interventions included transfers with a hoyer lift and two staff to get out of bed in the morning and a sit to stand with two person assist for all other transfers. Review of a nursing note dated 05/05/24 at 4:56 P.M. by Licensed Practical Nurse (LPN) #201 revealed at 4:00 P.M. a State Tested Nurse Aide (STNA) came to this nurse to report the hoyer lift had started to tip while transferring resident, STNAs were able to lower resident to the floor slowly while securing the lift. Resident was given a head-to-toe assessment with no injuries noted, then placed into wheelchair, STNAs were given an in-service on hoyer lift safety during transfers for the fall intervention. Review of a nursing note dated 05/06/24 at 6:19 A.M. by Registered Nurse (RN) #221 revealed Resident #22 was showing signs of severe pain when her left leg was moved, with the on-call providers paged twice and no response. After 6:00 A.M. the facility nurse practitioner was notified with orders for Page 1 of 4 366300 366300 05/28/2024 Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709

F 0689 x-ray of left hip, left femur, left knee, and left lower leg. Level of Harm - Actual harm Review of a nursing note dated 05/06/24 at 10:35 A.M. by LPN #215 revealed Resident #22 was awake in bed with signs and symptoms of pain/distress this morning, nurse instructed STNAs not to move resident and leave her in bed, an x-ray was ordered, results were received and report to the provider and the Director of Nursing (DON). Transportation was arranged and Resident #22 was sent to the emergency department for evaluation and treatment. DON called Resident #22's representative to notify them. Residents Affected - Few Review of a discharge Minimum Data Set (MDS) assessment completed on 05/06/24 revealed Resident #22 had severely impaired cognition, required maximum assistance for upper body dressing, lower body dressing, putting on footwear, personal hygiene, and bed mobility, was dependent on staff for transfers, always incontinent of bladder, and frequently incontinent of bowel. Review of a nursing note dated 05/06/24 at 2:54 P.M. by LPN #215 revealed she spoke with the hospital emergency department nurse and received an update, Resident #22 would be admitted for the femur fracture and was waiting on a trauma consult. Review of a nursing note dated 05/06/24 at 2:57 P.M. by DON revealed she made contact with Resident #22's responsible party after playing phone tag all morning to inform her Resident #22 was sent to the hospital with a fracture for evaluation and treatment. Review of a nursing note dated 05/07/24 at 6:44 P.M. revealed an unspecified RN spoke with Resident #22's responsible party and the surgeon stated the surgery went well, Resident #22 had a rod placed to support fractured left femur, would likely be in the hospital for two to three more days, and would be non-weight-bearing for eight weeks. Review of a nursing note dated 05/10/24 at 7:55 P.M. revealed Resident #22 re-admitted to the facility. Review of a written statement from STNA #237 dated 05/05/24 revealed while transferring Resident #22, the hoyer lift fell over and they made sure she didn't get hurt. Review of a written statement dated 05/05/24 by STNA #230 revealed while moving Resident #22 from the bed to the chair with a lift, the legs came apart and flipped. STNA #230 stated she caught Resident #22 while STNA #237 lowered the hoyer to the floor. Review of an additional statement from STNA #237 dated 05/05/24 revealed she was guiding the hoyer pad with Resident #22 in it while getting the wheelchair ready while STNA #230 was operating the hoyer lift, when they turned the lift around, it started to tip, both STNAs grabbed Resident #22 and lowered her to the floor. The legs of the hoyer lift were open. Review of an additional statement from STNA #230 dated 05/05/24 revealed she was operating the hoyer lift and when she pulled it away from the bed and started to turn it, the hoyer started tipping over. The other STNA grabbed Resident #22 to catch her from falling to the floor, the legs of the hoyer were open and they were careful with the transfer. Review of an interview from STNA #237 dated 05/06/24 revealed she and STNA #230 tried to transfer Resident #22 from the bed to her wheelchair when the hoyer lift began to tip. STNA #237 and #230 366300 Page 2 of 4 366300 05/28/2024 Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709

F 0689 caught Resident #22 and lowered her to the floor before she fell. STNA #237 stated she felt as though STNA #230 was always in too much of a hurry and rushed the residents. Level of Harm - Actual harm Residents Affected - Few Review of an interview from STNA #230 dated 05/06/24 revealed she and STNA #237 were trying to transfer Resident #22 from the bed to the wheelchair when the hoyer lift started to tip over. STNA #230 stated she and STNA #237 grabbed Resident #22, caught her, then lowered her to the floor so she would not fall. STNA #230 stated Resident #22 did not cry out in pain but did appear to be scared. Review of an interview from LPN #201 dated 05/06/24 revealed STNAs reported to him at 4:00 P.M. Resident #22 was in the hoyer lift when it tipped, STNAs told him they caught Resident #22 and lowered her to the floor. A head-to-toe assessment was completed including vital signs and range of motion with no signs or symptoms of injury or distress. LPN #201 stated he gave the STNAs an in-service on hoyer safety usage as the intervention because he felt they used the hoyer improperly. Review of a hospital note dated 05/07/24 revealed Resident #22 presented from the facility after an incident in the hoyer lift where she ended up on the ground and was found to have a distal left femur spiral fracture. Resident #22 was admitted under trauma service, with an orthopedic consult for surgery to complete an open reduction total fixation of left femur on 05/07/24. Review of a care plan dated 05/14/24 revealed Resident #22 had a hip fracture related to fall, non-ambulatory status, fall 05/06/24 with spiral fracture during transfer and underwent surgical intervention of left retrograde femoral rodding on 05/07/24. Review of a MDS assessment completed on 05/17/24 revealed Resident #22 had severely impaired cognition, was dependent on staff for upper body dressing, lower body dressing, putting on footwear, personal hygiene, bed mobility, and transfers, and was always incontinent of bowel and bladder. Interview on 05/23/24 at 3:00 P.M. with STNA #230 revealed she was not actually using the hoyer, but guiding Resident #22 in the hoyer sling to her wheelchair. STNA #230 stated while transferring Resident #22, STNA #237 was operating the hoyer lift when she turned it around and it started to tip. STNA #230 stated she did not know why the lift had started to tip because she was focused on Resident #22 but when she noticed the hoyer began to tip, she attempted to get the wheelchair closer, but was not able to, so she went to the ground on her knees to catch Resident #22. Resident #22's back landed on STNA #230's chest, but Resident #22's coccyx and legs hit the floor. STNA #230 stated it was hard to tell how hard the impact to the ground was because it happened so quick and there was no way to ease the hoyer lift when it tips over. STNA #230 stated Resident #22 fell, and was not lowered to the ground. Interview on 05/23/24 at 4:07 P.M. with STNA #250 and STNA #257 revealed the legs of hoyer lifts do not open unless the remote was used to open the legs. Interview on 05/23/24 at 4:43 P.M. with the Maintenance Director revealed the hoyer lifts were electric and operated by a remote. The Maintenance Director stated if everything on the inspection checklist was operating correctly, there was no way the hoyer lift legs could open up without someone pressing the button. Interview on 05/23/24 at 5:12 P.M. with DON confirmed the conflicting statements as noted above in the facility fall investigation and interviews. 366300 Page 3 of 4 366300 05/28/2024 Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709

F 0689 Level of Harm - Actual harm Residents Affected - Few 2. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, Alzheimer's disease, and osteoporosis. Review of a care plan dated 09/26/22 revealed Resident #44 had an ADL self-care performance and mobility deficit related to anxiety, chronic pain, cognitive impairment, hypertension, osteoporosis, atrial fibrillation, spinal stenosis, non-ambulatory, needs assistance with ADL's, and muscle weakness. Interventions included use a hoyer lift for all transfers and the assistance of two staff members. Review of a MDS assessment dated [DATE] revealed Resident #44 had severely impaired cognition and was dependent on staff for transfers. Review of an order dated 01/06/22 revealed Resident #44 required a hoyer lift with assistance of two staff for all transfers. Observation on 05/23/24 at 3:59 P.M. revealed STNA #250 and #257 assisting Resident #44 with a hoyer lift transfer from her bed to her standard wheelchair. Resident #44 was resting in bed with a hoyer pad under her. STNA #250 and STNA #257 began connecting the hoyer lift to the sling using the red loops, instructed Resident #44 to cross her arms, then STNA #257 began lifting Resident #44 by operating the hoyer lift. Once Resident #44 was lifted from the bed, the hoyer legs were closed then the staff began to move the hoyer lift. While STNA #257 operated the lift, STNA #250 helped to guide Resident #44 towards her wheelchair. Once Resident #44 was hovering over the wheelchair, STNA grabbed the wheelchair and tilted it backwards onto its back wheels with the front wheels completely off the ground and held the wheelchair in place until Resident #44 was lowered into the seat. STNA #250 then lowered the front wheels of the wheelchair down then began to disconnect Resident #44 from the lift. Interview on 05/23/24 at 4:54 P.M. with STNA #250 revealed she positioned Resident #44's wheelchair by tilting it back on the back wheels. STNA #250 stated Resident #44 is the only resident who transfers by hoyer into a standard wheelchair and an agency aide taught her to tilt the wheelchair back to make it easier to position Resident #44 in the chair. STNA #250 stated she had not considered the risks of the wheelchair slipping and falling. Review of hoyer lift bi-monthly inspections dated 12/11/23, 02/13/24, 04/18/24, and 05/08/24 revealed all lifts in the facility were in proper working condition. Review of Resident Council Minutes from 04/11/24 revealed a resident had concerns related to a young, female staff member attempting to transfer him to his bedside commode with a front-wheeled walker. The resident stated he had to educate the staff member on what a bedside commode was, what a sit-to-stand lift was, and how to operate it. Resident stated other aides eventually came to help with the situation so he was able to transfers safely but he was concerned about training because the interaction made him uncomfortable. Review of a Fall policy dated 01/24/23 revealed a fall was any unintentional change in position where the resident ended up on the floor, ground, or other lower level. Review of a policy titled Lifting Machine, Using a Mechanical dated 09/2022 revealed lift design and operation vary across manufacturers, staff must demonstrate competency using the specific machines or devices utilized in the facility. This deficiency represents non-compliance investigated under Complaint Number OH00153814. 366300 Page 4 of 4