Health inspection·July 10, 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 interview, and record review, the facility failed to ensure a resident's environment remained as free of accident hazards for (Resident #1) one resident reviewed for transfers. The staff failed to ensure Resident #1 was transferred without a Hoyer lift, resulting in an anterior right shoulder dislocation with associated comminuted fracture. This failure put the residents at risk for falls and injury. Review of Resident #1's face sheet, dated 07/10/2023, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses of hypertension, anemia, kidney disease, and dementia. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 04 indicating a severe cognitive impairment. Further review of the MDS revealed a bed mobility of extensive assistance with two plus person set up, and a transfer of total dependence with two plus persons set up. Review of Resident #1's care plan, undated, revealed a focus Resident #1 has an ADL self-care performance deficit, with a goal to maintain current level of function in ADLS, and intervention for transfers revealing Resident #1 required total dependence by 2 staff using Hoyer lift for all CNA transfers to move between surfaces as necessary. Review of Resident #1's ADL plan of care in the ADL flowsheet, dated 06/08/2023, revealed transfers: total dependence x 2 person assist (using Hoyer lift). Review of Resident #1's progress notes, dated 06/23/2023, revealed Resident #1 noted her arm was hurting a little bit on 23:15 (11:15 p.m.) staff assessed and treated Resident #1. Further review revealed a stat order for mobile x-ray to be performed. The progress notes revealed the x-ray report indicated Resident #1 has a dislocation of right anterior shoulder, the doctor was notified, and orders were obtained to give Resident #1 Tramadol 100 mg. Resident #1 was sent to the hospital for further treatment. Review of Resident #1's medical records, dated 06/28/2023, revealed an x-ray to the shoulder, result 1. Acute anterior right shoulder dislocation with associated comminuted fracture through the surgical neck and greater tuberosity. Review of the facility reported incident investigation's interviews, dated 06/26/2023, revealed CNA A's statement in that she was working with CNA B on Resident #1, CNA B arrived to assist CNA A to Page 1 of 4 676026 676026 07/10/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0689 Level of Harm - Actual harm Residents Affected - Few get Resident #1 out of the chair, CNA B did not state she needed a Hoyer lift. CNA A stated this was her first time working at the facility, and she was following CNA B's lead as CNA B stated she was working there for a while. Review of the facility reported incident investigation's interviews, dated 06/26/2023, revealed CNA B's statement, on 06/23/2023 CNA B and CNA A assisted Resident #1 to her bed, stating they slid her on the bed. CNA B revealed that she did not know Resident #1 required a Hoyer lift. CNA B stated, I hate this happened to Resident #1 we were only trying to help transfer her back into bed. Interview on 07/10/2023 at 09:40 a.m., the DON revealed CNA A and CNA B were agency staff. The DON revealed during the facility's investigation CNA B admitted she transferred Resident #1 without a Hoyer lift. The DON revealed all agency staff are oriented to the facility with an agency staff checklist. The DON revealed agency staff are oriented by the off going CNA including a tour of the facility and are walked to assigned hall and briefly review any concerns or appointments with residents. The DON stated the outgoing CNA was to orient the agency CNA to the ADL flowsheet. DON added there is more than likely a chance that the injury occurred during the transfer, as the CNA admitted that they did not use a Hoyer lift and the resident afterwards complained of pain. DON added that CNA A and CNA B were called to the facility to complete in-services after the incident, they did not show, this is one of the reasons why they were listed as DNR (do not return) to the agency company. Interview on 07/10/2023 at 10:11 a.m., the ADM revealed CNA B did a transfer without a Hoyer lift, the ADM revealed that during the investigation the Hoyer lift was in Resident #1's room, ADL flowsheets instructing Resident #1 was a 2 plus person assist with a Hoyer lift, and CNA A and CNA B have both been oriented to the facility. The ADM revealed CNA A and CNA B are in do not return DNR to the facility status. Interview on 07/10/2023 at 10:37 a.m., CNA C stated that there is an agency book that is located at the nurse's station for agency staff to sign, this is used to familiarize the agency staff to our residents and their needs, all agency staff must sign and the CNA that is that is informing the agency staff must report and acknowledge agency staff have been informed. CNA C stated she is aware that Hoyer transfer are always needing 2 or more staff members and should never be done alone. CNA C stated that the ADL books for residents are located at every hallway, it is in a binder on the wall. Interview on 07/10/2023 at 10:43 a.m., LVN A stated Resident #1 needs a Hoyer lift requiring 2 plus persons. LVN A stated she was not here at the time of the incident with Resident #1. LVN A stated that agency staff are to check in and sign the agency checklist, the outgoing CNA will do a standard walkaround with incoming CNAs to give information on residents that staff are assigned to, they are to discuss continuation of care, whether it would be showers, check and change, meals, and how residents are to be transferred. LVN A stated that all staff, including agency, are informed to ask any and all questions about residents. LVN A stated that all staff should be aware to not do transfers alone, LVN A states she always tells her staff to call whenever needed, and she will always be available if there is need for assistance, and to always use a Hoyer lift for all residents. Observation on 07/10/2023 at 10:57 a.m., revealed location of agency staff checklist for facility at nurses station, and further observations on each hallway revealed ADL flowseet binder for residents in all hallways. Further observation reveled Resident #1's ADL plan of care in the ADL flowsheet, dated 06/08/2023, revealed transfers: total dependence x 2 person assist (using Hoyer lift). Observation on 07/10/2023 at 11:28 a.m., was made on CNA D and CNA E for a resident transfer using 676026 Page 2 of 4 676026 07/10/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0689 a Hoyer lift. The Hoyer lift was in good working condition. CNA D and CNA E followed procedure for a two person assist for using a Hoyer lift. Observations confirmed a successful transfer. Level of Harm - Actual harm Residents Affected - Few Interview on 07/10/2023 at 11:39 a.m., CNA D and CNA E stated that they are familiar with which residents require a Hoyer lift but they always have to confirm with the ADL sheet for residents, if staff are not aware, or if they are new, there is an ADL flowsheet folder located in every hallway for all residents. CNA D and CNA E displayed knowledge of location, and identified area for ADL Flowsheet, staff added that Hoyer transfers are always completed with 2 plus persons, no matter what, CNA D stated that there are many risks, such as dropping a resident or hurting a resident during a transfer. CNA E added that if a Hoyer lift is not used, this can hurt the resident and even hurt the employee, such as hurting their back by lifting. CNA D and CNA E both stated that all agency staff are to acknowledge and sign the agency staff checklist, and the outgoing CNA is required to orient the incoming CNA with resident rounds on the hallway. CNA D added that this is how we communicate to staff what needs to be done and how procedures are to be done. Observation on 07/10/2023 at 01:38 p.m., was made on CNA F and CNA G for a resident transfer using a Hoyer lift. The Hoyer lift was in good working condition. CNA D and CNA E followed procedure for a two person assist for using a Hoyer lift. Observations confirmed a successful transfer. Interview on 07/10/2023 at 2:07 p.m., CNA F stated that all Hoyer transfer are done by two staff, CNA F added there are no exceptions, and If you are alone do no attempt a transfer by yourself and to always ask for help, CNA F stated you can ask another CNA or a nurse to help. CNA F stated that regular staff are familiar with residents and their needs, but we must always check the ADL sheet for residents which is located in a binder on every hallway for our residents. CNA F added that the sheet has all the information for a resident, such as how to transfer, feeding information, showers days, and any preference of the residents. CNA F stated she recalls informing CNA A on how to transfer Resident #1 as she was the staff leaving, CNA F added she informed CNA A of where the Hoyer lift was located at, and did a demonstration how to use it, she added that she informed CNA A on all the residents in the hallway, informing CNA A on the details needed to care for the residents. Attempted interview on 07/10/2023 at 2:33 p.m. to CNA B, the line was answered, after introduction there was no response from the receiving end, the call then ended in the receiver's side. At 2:35 p.m. a second attempt was made to call CNA B, there was no answer, an option was given to leave a voice message and a message was left for a return phone call. Attempted interview on 07/10/2023 at 2:37 p.m. to CNA A, there was no answer, an option was given to leave a voice message and a message was left for a return phone call. At 2:40 p.m. a second attempt was made to call CNA A, there was no answer, an option was given to leave a voice message and a second message was left for a return phone call. Review of the facility reported incident investigations correspondence with agency, dated 06/28/2023, revealed CNA A status was do not return, description failure to follow plan of care/ADL flowsheet for elder. Review of the facility reported incident investigations correspondence with agency, dated 06/28/2023, revealed CNA B status was do not return, description failure to follow plan of care/ADL flowsheet for elder. Review of the facility's agency staff checklist, dated 05/18/2022, revealed CNA B signed and 676026 Page 3 of 4 676026 07/10/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0689 Level of Harm - Actual harm Residents Affected - Few acknowledge to: screen at kiosk at front door, sign in at front nurses station and report to front charge nurse, PCC (point click care) log in info, front charge nurse will escort to assigned call and introduce to offgoing CNA, off going CNA will orient agency CNA to facility including a brief tour of facility (show agency location of both nurses stations, activity room, dining room, bathrooms, supply rooms, linen carts and linen room break room), offgoing CNA is to walk assigned hall with agency and briefly review any concerns or appointments with elders, offgoing CNA is to orient agency CNA to ADL flowsheet and activity calendar. Further verbiage states to turn in the form to charge nurse at end of shift. Review of facility's policy lifting machine, using a mechanical, revised July 2017, revealed general guidance 1. At least two nursing assistants are needed to safely move a resident with a mechanical lift. 676026 Page 4 of 4