Health inspection·January 9, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 free of accident and hazards for 2 of 7 residents (Residents #1 and #2) reviewed for accident hazards. CNA B and CNA C failed to ensure Resident #2's Hoyer lift (an assistive lift device that allows for transfer using electrical power) transfer was performed correctly. CNA D did not lock Resident #1's bed during incontinent care. These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life. Findings included: 1. Record review of the face sheet dated 1/9/24 indicated Resident #2 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure and COPD (chronic obstructive pulmonary disease - group of lung diseases that block airflow and make it difficult to breathe). Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, rarely made herself understood and rarely understood others. The MDS indicated Resident #2 cognitive skills for decision making was severely impaired and she had both long-term and short-term memory problems. The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 was completely dependent on staff for toileting, oral hygiene, eating, bathing, dressing, and personal hygiene. The MDS indicated Resident #2 was completely dependent on staff for rolling side to side and all transfers. The MDS indicated Resident #2 had no impairment to the upper and lower extremities. The MDS indicated Resident #2 was always incontinent of bowel and bladder. Record review of the care plan dated on 10/19/23 indicated Resident #2 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with transfers as needed. The care plan also indicated Resident #2 was at risk for falls due to factors including decreased activity, confusion, and poor safety awareness. During an observation on 1/9/24 at 1:20 p.m., CNA B and CNA C began to transfer Resident #2 from her wheelchair to her bed using a Hoyer lift. Resident #2 was initially combative with the CNAs, swinging her arms at them as they worked to attach the Hoyer sling to the Hoyer lift. After hooking the sling to the Hoyer lift, without locking the brakes (on the wheels) of the Hoyer lift, CNA B and CNA Page 1 of 3 675812 675812 01/09/2024 Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some C lifted Resident #2 from her wheelchair. They (CNA B and CNA C) then guided the Hoyer lift to Resident #2's bed. Without locking the brakes of the Hoyer lift, they (CNA B and CNA C) lowered Resident #2 into the bed. During an interview on 1/9/24 at 1:34 p.m., CNA B said she should have ensured the brakes were locked on the Hoyer lift wheels before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA B said she just forgot to double check and ensure the lift brakes (on the wheels of the Hoyer) were locked during the transfer. CNA B said the lift could have slid when they lifted/lowered Resident #2 and fallen over, especially since she (Resident #2) could be combative. CNA B said Resident #2 could have fallen out of the lift and gotten hurt. During an interview on 1/9/24 at 1:37 p.m., CNA C said she should have ensured the brakes (on the wheels of the Hoyer) were locked on the Hoyer lift before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA C said she was just busy and forgot to ensure the Hoyer lift brakes were locked. CNA C said the lift could have tipped over and Resident #2 could have fallen into the floor. 2.Record review of the face sheet dated 1/9/24 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, high blood pressure and heart disease. Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, usually made herself understood and usually understood others. The MDS indicated Resident #1 had mild cognitive impairment (BIMS of 9). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 required substantial/maximal assistance with personal hygiene, putting on/taking off footwear, dressing, and bathing. The MDS indicated Resident #1 required substantial/maximal assistance with rolling left to right and tub/shower transfer. The MDS indicated she required partial/moderate assistance with sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS indicated she required partial/moderate assistance with toileting and oral hygiene. The MDS indicated Resident #1 required setup or clean-up assistance with eating. The MDS indicated Resident #1 required extensive assistance of 2 persons to complete bed mobility, transfers, bathing and toilet use. The MDS indicated she had no impairment to the upper and lower extremities. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder. Record review of the care plan dated on 12/25/23 indicated Resident #1 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with turning/repositioning while in bed, and staff will assist bathroom. The care plan also indicated Resident #1 was at risk for falls due to factors including decreased mobility. During an observation on 1/9/24 at 1:00 p.m., CNA D provided incontinent care to Resident #1. CNA D did not check the brakes on the wheels of the bed before she started the incontinent care. During the incontinent care, CNA D moved the bed away from the wall and went to the left side of the bed (the side that was against the wall). CNA D did not lock the brakes on the wheels of the bed. CNA D then rolled Resident #1 to her (Resident #1's) right side (the side not against the wall). CNA D completed the care, returned the bed to the original position and did not lock the brakes on the wheels of the bed. During an interview on 1/9/24 at 1:10 p.m., CNA D said she should have locked Resident #1's bed before starting the incontinent care, after she moved the bed, and after returning the bed to its original position. CNA D said Resident #1 could have fallen out the bed and sustained an injury. 675812 Page 2 of 3 675812 01/09/2024 Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/9/24 at 1:40 p.m., LVN A said the CNAs should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. LVN A said CNA D should have double checked to ensure Resident #1's bed was locked before care was started. LVN A said Resident #1's bed should have been locked, before Resident #1 was repositioned in the bed and after CNA D completed Resident #1's care. LVN A said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels) were locked when a resident was repositioned in the bed) were safety issues. LVN A said Resident #2 could have been dropped from the Hoyer lift and Resident #1 could have fallen out of the bed. During an interview on 1/9/24 at 1:57 p.m., the ADON said the CNA B and CNA C should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. The ADON said CNA D should have ensured Resident #1's bed was locked before care was started, before Resident #1 was repositioned and after the care was completed. The ADON said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels of the bed) were locked when a resident was repositioned in the bed) were posed a risk of injury. She said the system in place to ensure staff performed Hoyer lift transfers safely was the annual skills check off which included Hoyer lift transfers and ensuring brakes were locked on beds before repositioning a resident. The ADON said going forward a system would be put in place to perform spot checks on CNAs to ensure they were safely repositioning and transferring residents. During an interview on 1/9/24 at 3:00 p.m., the Administrator said he expected staff to take appropriate measures to ensure residents safety during Hoyer lift transfers and incontinent care. The Administrator said leaving the bed unlocked and the Hoyer lift unlocked while a resident was lifted/lowered were not practices that would ensure resident safety. During an interview on 1/9/24 at 2:30 p.m., the ADON said the facility did not have a policy and procedure specifically related to ensuring bed brakes (on the wheels of the bed) were locked. Record review of the facility policy and procedure titled Lifting and movement of Resident-safe, dated December of 2017 stated, Policy: In order to protect the safety and well-being of staff and residents and to promote quality care, this home uses appropriate techniques and devices to lift and move residents . The policy and procedure did not specifically address the use of bed brakes (on the wheels of the bed or mechanical lift brakes (on the wheels of the mechanical lift). Record review of the facility policy and procedure titled Mechanical Lift, dated December of 2017 reveled it did not specifically address the use of mechanical lift brakes . 675812 Page 3 of 3