Health inspection·March 15, 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 interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents, hazards, and supervision. CNA A, CNA B, and CNA C failed to follow the plan of care which required a 2 person assist to transfer Resident #1 with the Hoyer Lift on 11/26/23. Resident #1 was transferred to a local hospital and an x-ray confirmed a proximal tibia and fibula fracture (break, in the shinbone just below the knee). The failure resulted in actual harm to Resident #1 on 11/28/2023. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. The failure placed residents at the facility who require the Hoyer lift at risk for pain or serious injuries. Findings included: Record review of Resident #1's Face Sheet, dated 03/14/2024, revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), chronic pain (frequent), and presence of left artificial knee joint (knee replacement). Record review of Resident #1's quarterly MDS assessment, dated 02/08/2024, revealed Resident #1 had a BIMS score of 07, which indicated severe cognitive impairment, and lower extremity impairment on both sides and was dependent on chair to bed transfer. Record review of Resident #1's quarterly Mobility Assessment, dated 11/09/2023 revealed Resident #1 required a sling lift / Hoyer lift. Record review of Resident #1's Care Plan, last reviewed on 02/08/2024, revealed Resident #1 was dependent on 2 staff using the Reliant 450 sling lift / Hoyer lift for all transfers. Record review of facility's Provider Investigation Report revealed on 11/26/2023 at approximately 6:00 pm, CNA A, CNA B, and CNA C transferred Resident #1 from her wheelchair to her bed without using Page 1 of 3 676020 676020 03/15/2024 Menard Manor 100 Gay St Menard, TX 76859

F 0689 the Hoyer lift. Level of Harm - Actual harm Record review of progress notes dated 11/27/2023 at 8:09 am revealed Resident #1 complained of right knee pain. The doctor was notified, and x-ray was ordered. Residents Affected - Few Record review of the radiology report, dated 11/27/2023, revealed a proximal tibia and fibula fracture. Record review of progress notes dated 11/27/2023 at 1:40 pm, revealed a doctor order to immobilize the right knee and refer Resident #1 to the orthopedic surgeon to be seen on 11/28/2023. Record review of progress notes dated 11/28/2023 at 11:36 am, the doctor sent Resident #1 to the local hospital for assessment instead of sending her to the orthopedic surgeon upon assessment. Resident #1 returned to the facility with an immobilizer brace on her right knee. Record review of the local hospital Emergency Department Discharge summary dated [DATE] revealed Resident #1 had a fracture of the tibia and fibula of right knee. Knee immobilizer placed and returned to nursing facility. Injury was non-surgical as Resident #1 was not weight bearing. In an interview on 3/14/2024 at 2:00 pm, Resident #1 stated her knee was completely well now. Resident #1 said that was the only time the Hoyer lift had not been used during transfers. In an interview on 03/15/2024 at 9:54 am, the DON said the three CNAs took Resident #1 to her room, CNA A bear hugged (a tough tight embrace) resident and stood her up as CNA B held the handles of the wheelchair and CNA C held her legs. When they pivoted Resident #1's right foot got caught on her wheelchair and twisted when they laid her down on the bed. The CNA's said the reason they did not use the Hoyer lift was they were trying to get everyone laid down as they were running late. The CNA's denied they had transferred Resident #1 without using the Hoyer lift in the past. The DON said corrective action was taken for CNA A, CNA B, and CNA C for not following Resident #1's care plan on how to properly transfer a resident. The CNAs had to complete a competency checkoff on use of the Hoyer lift. In-services were completed on how to move a resident from the bed to the wheelchair and instructions for safe bed mobility. In an interview on 03/15/2024 at 1:30 pm, CNA B said they got in a hurry and decided to transfer Resident #1 without the Hoyer lift. She stated she held the legs of Resident #1. CNA B denied she had transferred a resident that required the Hoyer lift without using it in the past. In an interview on 03/15/2024 at 1:35 pm, CNA A said they were in a hurry as it was time for their shift to end, and they decided to transfer Resident #1 without using the Hoyer lift. He said he bear hugged Resident #1 and stood her up while CNA B held the handles of the wheelchair. He said they pivoted slowly and sat the resident on the bed. CNA C said something about her foot, but he (CNA A) couldn't see it. CNA A said he had never transferred a resident without the use of a Hoyer lift that required it before. CNA C was not available for an interview., Record review of CNA C's written statement, dated 11/29/2023 stated CNA A bear hugged Resident #1 and CNA C held onto the handles of the wheelchair. 676020 Page 2 of 3 676020 03/15/2024 Menard Manor 100 Gay St Menard, TX 76859

F 0689 Level of Harm - Actual harm Record review of CNA A, CNA B, and CNA C employee files revealed a correction action record dated 11/29/2023 and signed by the employee. Competency check offs for use of the Hoyer lift were completed on 11/30/2023. In-service training for moving a patient from bed to a wheelchair and caregiver guide and instructions for safe bed mobility were completed on 11/30/2023. Residents Affected - Few Record review of the facility policy [Facility name] Safe Mechanical Lifting Policy and Procedure, dated as revised 08/02/2016, revealed the following [in part]: Policy: It is the policy of [facility name] to ensure resident and employee safety when transferring residents with a mechanical lift. 676020 Page 3 of 3