Health inspection·June 5, 2023

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 that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 5 residents reviewed for accidents. (Residents #1) The facility failed to ensure CNA A and CNA B performed a safe mechanical lift transfer for Resident #1. This failure could place residents at risk of injury from accident and hazards. Findings included: Record review of the face sheet dated 06/05/23 revealed Resident #1 was [AGE] years old and admitted on [DATE] with diagnoses including heart disease, difficulty walking, and muscle wasting. Record review of the quarterly MDS dated [DATE] revealed Resident #1 was usually understood and usually understood others. The MDS revealed Resident #1 had a BIMS of 4 which indicated severe cognitive impairment. The MDS indicated Resident #1 required extensive to total assistance with ADLs. Record review of the care plan last revised on 04/20/23 revealed Resident #1 was at moderate risk for falls due to confusion, gait/balance problems, incontinence, psychoactive drug use, and awareness of safety needs. There was an intervention for the use of 2 staff members and a mechanical lift for safe transfers. Record review of a Complete In-Service Training Report with Personnel Attending dated 05/24/23 and titled Hoyer Lift Transfers indicated, .2 staff in room at all times .Ensure lift & pad are in good working order . The in-service was for all staff. The in-service was not signed by CNA A or CNA B. During an observation on 06/05/23 at 1:45 p.m., CNA A used a mechanical lift to transfer Resident #1 from the wheelchair to the resident's bed. CNA B assisted with the transfer. After lifting Resident #1 from the wheelchair, CNA A moved the legs of the base of the lift from a wide position to a narrow position. CNA A then moved the lift across the room approximately 4-5 feet to the bed with the legs in the narrow position. The resident was then lowered into the bed with the legs in the narrow position. During an interview on 06/05/23 at 2:04 p.m., . Resident #1 said there were times when only one staff member had transferred him using the mechanical lift. Page 1 of 2 675241 675241 06/05/2023 Avir at Jefferson 1307 Martin Luther King Dr Jefferson, TX 75657

F 0689 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/05/23 at 2:59 p.m., CNA A said during the mechanical lift transfer of Resident #1, she did close the base of the legs after lifting the resident from the wheelchair. She said she did not open the legs back up during the transfer. She said the mechanical lift was secure and all the way under the bed. She said she did not know the legs were to be kept in the wide position during transfers. She said there were always two staff members present during mechanical lifts. Residents Affected - Few During an interview on 06/05/2023 at 3:23 p.m., the DON said when a resident was transferred from a wheelchair with a mechanical lift it should have been open around the wheelchair. She said you have to close the legs of the lift so that it will fit under the beds in the facility. She said she always left the base open, but she could see it either way as long as it was stable. She said she had never seen any lifts being done with just one person. She said they have even come to get her to be the second person. She said she would expect there to be two or more staff members during a mechanical lift transfer. During an interview on 06/05/203 at 3:42 p.m., CNA B said she did assist with the mechanical lift transfer of Resident #1. She said she knew the legs on the base of the mechanical lift should not be closed during a transfer. She said they should always be left open to keep the lift stable. She said they were closed on 06/05/23 because CNA A was the one controlling the lift. During an interview on 06/05/23 at 4:04 p.m., the Administrator said he would expect staff to transfer residents safely and the follow the facility's policy. He said he disagreed that the transfer of Resident #1 was an unsafe transfer because the facility policy did not require that the base be open in the wide position . He said the FDA (Food and Drug Administration) was only making a recommendation. He said Resident #1 had a low BIMS and might not be able to give factual information. He said he did expect two staff members to be present during a mechanical lift transfer and everyone knew that was their policy. Review of a Lifting Machine, Using a Mechanical facility policy dated July 2017 indicated, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift. It is not a substitute for manufacturer's training or instructions . The policy did not indicate how the base of the lift should be positioned during transfers. Review of Best Practices for Using Patient Lifts by the U.S. Food and Drug Administration, www.fda.gov was accessed on 06/05/23 indicated on slide 7, .keep the base (legs) of the patient lift at maximum open position . Review of How to Properly Operate a Hoyer Lift dated 4/10/2019 at https://medical-stretchers.com/articles/how-to-properly-use-a-wheelchair-n104 and was accessed on 06/05/23 indicated, A Hoyer Lift is a device that is designed to easily transfer or lift a person with minimal physical effort. There are many safety tips and precautions one needs to follow while operating a Hoyer lift .When using the lift you should always ensure that the base is open to ensure that the equipment remains stable during the lift . 675241 Page 2 of 2