Health inspection·March 10, 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 observation, interview, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. CNA A failed to ensure Resident #1 was properly transferred by two persons using a Hoyer Lift to prevent accidents. CNA B failed to ensure Resident #1 remained free from accidents while operating the Hoyer Lift. This failure could place the residents at risk of injury. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admission date 01/21/2019, Diagnoses: Alzheimer's disease (progressive memory impairment), Encounter for prophylactic measures (measures designed to prevent an adverse event, disease or its dissemination), Muscle wasting and atrophy (decrease in size and wasting of muscle), multiple sites, 2019-nCoV acute respiratory disease(History of), Rash and other nonspecific skin eruption, Other specified local infections of the skin and subcutaneous tissue (deepest layer of skin), Rash and other nonspecific skin eruption, Unspecified lack of coordination, Pseudobulbar affect (sudden and uncontrolled laughing or crying), Other lack of coordination, Other abnormalities of gait and mobility, Pain, Muscle weakness (generalized), Full incontinence of feces, Edema (swelling caused by too much fluid), Anorexia (eating disorder by restriction of food intake), Abnormal weight loss, Personal history of colonic polyps (small clump of cells in lining of colon), Other specified depressive episodes (extreme prolonged sadness), Other seborrheic keratosis (noncancerous skin growth). Record review of Resident #1's electronic health record revealed the most recent Care Plan dated 12/19/23, revised on 2/13/24, on page 2 of 26 stated Ambulation/Transfers amount of assist: Total dependent x 2 assist. Record review of Resident #1's progress notes by LVN A dated 12/25/23 at 11:10 am revealed Resident was being transferred in Hoyer mechanical lift to Geriatric chair (large padded chair with wheeled base), while transferring resident the lift came off the ground on 2 wheels and caused a bruise to her right cheek area. Resident doesn't answer questions appropriately, medicated with PRN pain med and ice pack applied immediately. Page 1 of 3 455555 455555 03/10/2024 Avir at Graham 1224 Corvadura St Graham, TX 76450

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record Review of CNA A Oral Written Warning dated 12/25/23 revealed Staff will always assist (total assist x2) when using a Hoyer lift. Interview on 3/10/24 at 3:32pm with CNA A revealed she had been trained on transfers and Hoyer Lifts at hire and a few times since. CNA A stated she knew it was a two person to transfer with a Hoyer lift and it is not safe for residents or staff [to transfer a resident by Hoyer with one staff member]. The other staff and CNA A transferred Resident #1's roommate together with Hoyer and the other staff member left the room and CNA A transferred Resident #1 with the Hoyer alone. CNA A further revealed she does not know what happened with the lift , but she knows to use two people but was waiting thinking the other staff would come back and he did not. The other staff did not come back until after the accident happened. CNA A revealed someone came because the resident screamed. Interview on 3/10/24 at 11:18am with CNA D revealed she has never seen staff use a Hoyer by themselves because it is a two-person assist. Interview on 3/10/24 at 11:43 am with RN A revealed that staff have done Hoyer lift and transfer training and competency checks. It is required two-person assist. RN A stated she always told staff to come get her if needed. Interview on 3/10/24 at 12:00 pm with ADON revealed CNA A had been trained on Hoyer Lifts and she stated to ADON during interview that she got in a hurry and did not wait. ADON revealed CNA A knew to come get staff and has gotten ADON before. ADON stated CNA A was written up and retrained and is getting random audits of her care all the time to make sure she is following the procedures and has no more chances [final warning]. Interview on 3/10/24 at 5:55 pm with ADM revealed she found out about the aide (CNA A) that used the Hoyer lift on her own and she (CNA A) kept apologizing that she got into a hurry and was trying to get a lot done at once. ADM revealed CNA A had help and she could have waited and made a bad decision. ADM stated CNA A had been trained prior to the incident and after again and written up. Observation on 3/9/24 at 12:58 pm of Resident #1's transfer from the Geriatric chair to the bed with CNA B and CNA D revealed CNA B moved the lift towards Resident #1 as CNA D readied the sling under Resident #1 (CNA D was looking at the sling under resident with back to CNA B and Hoyer). The front arm of the Hoyer in front of Resident #1 moved towards resident, and the cradle that holds the sling tapped the residents' forehead. Resident #1 squinted her eyes and CNA D told CNA B to slow down and grabbed the cradle to prevent it from swinging into resident again. CNA D instructed CNA B where to place the Hoyer for a better angle. CNA B said, I know as she continued along her current positioning and movement of the Hoyer Lift with Resident in it. CNA D moved the Geriatric Chair out of way as she hurriedly gained her momentum to give support under Resident #1 during transfer from chair to bed. Interview on 3/9/24 at 12:58 pm with CNA B revealed she had been trained on Hoyer lifts and signed off on for competency. Interview on 3/9/24 at 12:58 pm with CNA D revealed she had been trained on Hoyer lifts and signed off on for competency. Interview on 3/09/24 at 3:30pm with CNA D revealed she is sorry about the incident with her coworker, CNA B, as she is usually good and knows what she is doing but gets talkative and was nervous with 455555 Page 2 of 3 455555 03/10/2024 Avir at Graham 1224 Corvadura St Graham, TX 76450

F 0689 state surveyor here. CNA D stated she reported the incident. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's progress note dated 3/9/24 revealed while cnas [CNA B] and [CNA D] were transferring resident using the hoyer lift, one of the metal hooks on the lift came into contact with the RIGHT temple on resident. This LVN [ADON] and RN B performed assessment on said resident. No non verbal SXS of pain or discomfort. slight pink color to RIGHT TEMPLE, No other physical changes noted to resident temple. Residents Affected - Few Record review of Inservice for Transfers and Number of Assistance Required dated 12/25/23 revealed Minimum assistance needed with each type of transfer: gait belt-1; mechanical lift (hoyer) -2; sliding board-1; stand by assist -1. Record review of Inservice for Following Care Plan and Hoyer Safety dated 12/25/23 revealed To [CNA A]: You must follow the care plan exactly to ensure the safety of residents. Hoyer lifts always require at least 2 people. Record review of Safe Lifting and Movement of Residents policy dated 3/31/23 revealed 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 12. Safe lifting and movement of residents is a part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies;. 455555 Page 3 of 3