Health inspection·November 21, 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, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents. CNA B failed to have assistance from another staff member when she transferred Resident #1, who required 2-person assist with transfers, via a mechanical lift resulting in Resident #1 sustaining a shoulder fracture. This failure placed residents at risk for accidents and injuries. Findings included: Review of Resident #1's face sheet, dated 11/21/23, revealed the resident was a [AGE] year-old female, who admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis of the left dominant side, contracture (deformity and rigidity of joint), muscle wasting and atrophy, and history of stroke. Review of Resident #1's MDS assessment, dated 10/28/23, reflected the resident's severe cognitive impairment with a BIMS score of 5 and she required total assistance of two-person assistance for transfers. Review of Resident #1's care plan, dated 08/15/23, revealed: [Resident #1] has ADL Self Care Performance Deficit r/t immobility secondary to CVA, contracture, hemiplegia (paralysis). Will remain free of complications related to immobility, including contractures, thrombus formation (formation of blood clots), skin-breakdown, fall related injury through the next review date. Will be safe through the review. TRANSFER: Requires x2 staff participation with transfers. may use Hoyer lift. Interview on 11/21/23 at 9:06 AM with the Interim DON revealed when using the Hoyer lift, facility policy stated two people were to assist when completing transfers with the mechanical lift. The Interim DON stated CNA B did not wait for assistance from staff to use the Hoyer lift. Instead, CNA B used the lift incorrectly by using the Hoyer lift alone resulting in Resident #1's fall to the floor from her wheelchair. The Interim DON stated that CNA B was suspended pending investigation. However, CNA B called HR during her suspension and resigned. CNA B's training record revealed she was trained on Hoyer lifts during her orientation. Therefore, CNA B was aware of the correct Hoyer lift procedure prior to this Hoyer lift transfer. The Interim DON revealed staff failed to have another person present when completing the transfer with the mechanical lift per policy and procedure which resulted Page 1 of 2 455576 455576 11/21/2023 Richland Hills Rehabilitation and Healthcare Cente 3109 Kings CT Fort Worth, TX 76118

F 0689 in a fracture (per stat x-rays and further confirmed via ER visit) to Resident # 1's shoulder. Level of Harm - Actual harm Interview on 11/21/23 at 9:21 AM with the ADON revealed that the Hoyer-lift policy reflected 2 people should always operate the Hoyer lift. The ADON stated that one person cannot operate the Hoyer lift. The ADON also said when new staff are oriented, they are provided training on the Hoyer lift. The facility provided a check-off list for the Hoyer lift that was to be completed by the aides that were training the new aides. The ADON also stated that if the new aides were uncomfortable with the process, they were instructed to let management know. When Resident #1 complained to LVN A that her shoulder hurt, LVN A called and received an order for an x-ray. When the x-ray confirmed her shoulder was a fracture, they sent her to the ER for further treatment. The ADON began re-education that day of ANE, falls, Hoyer lifts, and accidents. It was confirmed through record review CNA B did receive Hoyer lift training prior to starting her shifts after orientation. Residents Affected - Few Interview on 11/21/23 at 10:03 AM revealed that LVN A was working at the time of Resident #1's injury. LVN A stated she was in the middle of med pass and saw two aides pass her and enter Resident #1's room. LVN A stated CNA C came and asked for assistance because Resident #1 was on the floor. LVN A revealed that she assessed the resident and provided care. She also confirmed that she was not asked for assistance by CNA B before the incident. She stated that she knew Resident #1 was a two person assist due to her diagnoses as did CNA B. Resident #1 was in pain, so LVN A received an order for the stat x-ray. Resident #1 was sent to the ER after the shoulder x-ray revealed a fracture. Record Review confirmed the fracture both from the stat x-ray and hospital records. LVN A revealed the facility policy reflected that Hoyer lifts require a two person assist to prevent injury. LVN A also confirmed that residents who are a two-person assist are at risk for injury when only one person assists the resident. Interview on 11/21/23 at 1:18 PM via cell phone revealed CNA B was hired on 10/26/23. CNA B revealed in her orientation she was trained to use the Hoyer lift with a 2-person assist. CNA B verbalized that Resident #1 needed assistance getting from her bed to the wheelchair. CNA B stated she did not ask her nurse for help. She stated that she asked one CNA for assistance. However, she did not wait for her to finish showering her resident, and she used the Hoyer lift alone instead of waiting for assistance because she wanted to complete dressing her residents for the day. CNA B placed Resident #1 in the wheelchair using the lift. Resident #1 fell to the floor from her wheelchair and CNA B went and got assistance. Resident #1 complained of shoulder pain, so an x-ray was obtained that revealed a fracture. Resident #1 was sent to the hospital where the shoulder fracture was confirmed and an ortho appointment was suggested. CNA B was aware her failure was not waiting for assistance from a second staff member to assist with the Hoyer lift resulting in injury to Resident #1. Review of the facility's current Nursing Clinical policy, Subject: Hoyer lift, revised May 2007 reflected: Policy: It is the policy of this facility that the Hoyer Lift will be utilized for resident transfers only. It will not be used to transport resident to another location. Assistance of two personnel will be used with Hoyer Lift 455576 Page 2 of 2