Health inspection·October 20, 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 the resident environment remained free of accident hazards for 1 of 5 residents (Resident #1) reviewed for quality of care in that: CNA A failed to operate the Hoyer lift with 2 staff per facility policy when transferring Resident #1 from the chair to the bed. Resident #1 sustained a fracture of the right lower tibia / fibia. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: Record review of Resident #1's face sheet dated 4/30/2022 indicated Resident #1, was a [AGE] year-old female admitted on [DATE]. She had diagnoses of Malignant neoplasm of the brain (cancer of the brain), seizure disorder, hypothyroidism (deficiency of the thyroid hormone), hemiplegia of the right side (loss of movement of the right side of the body), Anemia (low red blood cells), and Unspecified protein calorie malnutrition (lack of protein within the body). Record review of Resident#1s Annual MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 99, which indicated she was not able to complete the interview, staff interview within the same MDS indicated Resident #1 had Severely impaired cognition. Section G Functional status of the MDS reflected Resident # 1 required 2 person assist Ambulation/Transfers, bathing, hygiene, dressing and grooming. Record review of Resident #1's care plan dated 1/26/2021 reflected Resident #1 required ADL assistance that included a transfer status of Hoyer (mechanical lift) lift with assistance of 2 staff. Record review of Resident #1s care plan dated 10/09/23 reflected Resident #1 had a bone fracture of right tibia/fibula (lower leg). Interventions were included for pain relief related to fracture. Antibiotics were administered for infection prevention related to swelling and fracture of right lower leg. Support was given to right lower leg with the use of an immobilizer. Nursing was to continue to monitor right lower leg and report changes in condition to medical doctor. Record review of a incident report dated 10/08/2023 at 06:05am by RN A, indicated, Resident #1 was sent to the emergency room for right lower leg that had a large dark purple/blue bruise with a large fluid filled blister near the center of the bruise with several smaller fluid filled blisters scattered across the bruised area. Page 1 of 3 676047 676047 10/20/2023 Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059

F 0689 Record review of a progress note dated 10/08/2023 at 11:45 am by RN A indicated, the facility was notified by the hospital that Resident #1 had a tibia/fibula (lower leg) fracture. Level of Harm - Actual harm Residents Affected - Few Record review of a progress note dated 10/08/2023 at 3:08pm by RN A indicated, Resident #1 returned from the ER with a brace to her right lower leg. Resident #1 was given tramadol for pain and instructed to follow up with orthopedic specialist. In an observation on 10/20/23 at 1:00pm of Resident #1 revealed she was in bed laying with eyes open and did not respond to interview questions. A leg brace was observed in place to right lower leg. In an interview with CNA B on 10/20/23 at 2:35PM revealed, to use the Hoyer lift to transfer any resident there must always be two nursing staff present during the transfer. CNA B admitted he did transfer Resident #1 by himself on 10/7/23 at 6pm. He stated at the time of Resident #1's transfer there was no other staff on the unit. He stated he could have asked a nurse to assist him. CNA B stated he was not sure why he did not ask the nurse to assist him with the Hoyer lift. CNA B stated he has been a CNA for 36 years but had only worked at this facility 3 days. He stated He was trained on the use of the Hoyer lift during orientation on 10/5/23. CNA B stated that Resident #1 did not complain of pain and did not make any facial grimaces to indicate pain during the transfer. He denied that he bumped or injured Resident#1's leg during the transfer. CNA B stated he was trained during orientation on the Hoyer Lift Policy. In an interview with the ADM on 10/20/23 at 3:00pm, she stated Resident #1 used a Hoyer lift for transfers. She stated it was the policy of the facility that if any staff who were caught using a Hoyer lift improperly were to be terminated. The ADM stated CNA B admitted he transferred Resident #1 by himself using the Hoyer lift. The ADM reported although the facility investigation could not prove exactly when the injury occurred to Resident #1's leg, the incident investigation on 10/08/23 was able to identify the need for education for staff on an area required improvement. All staff were educated on Using a Hoyer lift on 10/9/23. All staff were educated specifically that 2 Nursing staff must be used when a resident was transferred with a Hoyer lift. In an interview with the DON on 10/20/23 at 3:15pm, revealed he was called to the facility on [DATE] upon discovery of the incident with Resident #1 and immediately began his investigation. He stated that once he learned of the improper transfer CNA B was placed on suspension. It was the facility's policy to terminate staff who improperly use the Hoyer lift. The DON stated CNA B denied resident hitting leg on lift. The DON stated he immediately in serviced all staff on ANE and Using the Hoyer and lift. Upon completion of investigation, it was the facility's decision to terminate CNA B due to failure of following the Hoyer lift policy. Record review of CNA B's employee file revealed, he was trained on Hoyer lift policy on 10/5/23 including At least two (2) nursing assistants are needed to safely move a resident with a mechanical. CNA B was suspended on 10/8/23 and terminated on 10/9/23. Records review of an in-service dated 10/8/23 and sign-in sheets regarding Lifting machine, using a mechanical policy and procedure dated 07/2017 conducted by DON, reflected the nursing staff members had been in-serviced on this process. Records review of in-service dated 10/9/23 and sign-in sheets regarding Lifting machine, using a mechanical policy and procedure dated 07/2017 conducted by DON, reflected that all staff members had been in-serviced on this process. 676047 Page 2 of 3 676047 10/20/2023 Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059

F 0689 Level of Harm - Actual harm Record review of the facility policy Titled Lifting machine, using a mechanical dated 07/2017 general guideline #1 revealed, at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Residents Affected - Few 676047 Page 3 of 3