Health inspection·January 24, 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 received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. The PT failed to ensure Resident #1's body, to include her lower extremities, were positioned properly during a transfer using a sliding board, which is a rigid board used to bridge the gap between two surfaces to assist with transferring from one surface to another. During set-up of the transfer, the PT lowered the bed on or against the resident's foot causing a laceration that required 13 sutures. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Review of Resident #1's MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included paraplegia, scoliosis, pressure induced deep tissue damage of right hip, spinal cord injury at C7 (cervical vertebrae), and colostomy status. The MDS further reflected the resident had intact cognition, and she had lower extremity impairment to both sides. Review of Resident #1's care plan, revised on 12/01/23, reflected she had limited physical mobility related to paraplegia. Interventions included to provide supportive care, and assistance with mobility as needed. Review of the facility's provider investigation report, dated 12/20/23, reflected the following: The facility's investigation revealed that on 12/13/23, during a sliding board transfer, a paraplegic patient, who requires a two-person transfer, was being assisted by both a physical therapist (PT) and an occupational therapist (OT). The patient, seated in a wheelchair, was being prepared for transfer with appropriate precautions As the PT lowered the bed to ease the transfer a laceration to the patient's lower left extremity was discovered resulting in immediate medical attention and a hospital visit for suture treatment Review of Resident #1's progress notes, dated 12/13/23, reflected the following entries: .upon entering resident room resident R leg observed propped on side of mattress. [PT] was Page 1 of 3 676176 676176 01/24/2024 Crowley Nursing and Rehabilitation 920 E Fm 1187 Crowley, TX 76036

F 0689 Level of Harm - Actual harm Residents Affected - Few standing next to resident leg holding sheet over it and calling for help. Sheet, bed, floor and stool with blood on them. when asking what happened [PT] stated he was doing therapy and when bed was lowered resident leg was too close to it and the bed went down on it. Resident denies pain to leg D/T not having feeling in BLE. upon removing sheet from leg large open wound with significant bleeding noted. wound cleansed resident sent to [ER] 21:21 [11:21 PM] Resident returned from hospital, 13 sutures noted to [right] foot with edema noted elevated foot on pillow will continue to monitor Review of Resident #1's hospital records, dated 12/13/23, reflected the following: .Diagnoses Acute pain due to trauma Laceration of right lower leg .Instructions Suture removal in 10 days Daily dressing change with antibiotic ointment There were no further details on the size or appearance of the laceration in the hospital records. Interview on 01/24/24 at 10:35 AM with Resident #1's family revealed the resident could not be interviewed because she was undergoing surgery at the time, unrelated to the transfer incident. The family said Resident #1 told them therapy had lowered the bed on her foot. The family further stated the resident was not able to feel her cut because she was paralyzed to her lower extremities. The family said the laceration extended from one side of her ankle to the other. Interview on 01/24/24 at 9:56 AM with the PT revealed Resident #1 was a paraplegic who had no movement or feeling to her lower extremities. The resident was there for rehab therapy and they had been working on strengthening sliding board transfers, which they had successfully did several times in the past. The OT was assisting because Resident #1 did not have great balance and trunk control. As they were setting the resident up for the transfer, they were using a step stool for the resident's feet positioning. The step stool belonged to the resident that she used when she was home to help her with her transfers. They had made the necessary adjustments with the stool to make it safe for the resident when she discharged home. The PT positioned the wheelchair next to the bed and they were trying to place the sliding board underneath the resident. At that time the PT realized the bed appeared to be slightly higher and Resident #1's foot must have slipped off the stool, so as he began to lower the bed, it slid down the resident's leg and cut her. The PT then looked down and noticed blood and he applied pressure to the resident's leg, they called for assistance and 911 was called and the resident was sent out to the hospital for treatment. The PT further stated because the resident could not feel, she was not able to notice anything was wrong or that the bed had cut her. Once Resident #1 returned from the hospital, she continued to go to therapy. Interview on 01/24/24 at 10:16 AM with the OT revealed she was assisting the PT with Resident #1's transfer from her wheelchair to her bed. The OT was standing behind the resident as the PT 676176 Page 2 of 3 676176 01/24/2024 Crowley Nursing and Rehabilitation 920 E Fm 1187 Crowley, TX 76036

F 0689 Level of Harm - Actual harm Residents Affected - Few positioned the resident's feet on the stool. The PT placed the sliding board underneath the resident and as he was lowering the bed, the PT began to call for assistance. The OT stated because she was behind the resident, she was not able to see what happened or the extent of Resident #1's injury. Interview on 01/24/24 at 12:42 PM with the DOR revealed she was told by the PT and OT they were doing a sliding board transfer with Resident #1 and the bed was lowered on the resident's foot causing a laceration. The DOR said they had done many of the same transfers in the past, but it appeared the resident's foot fell off the stool this time as the therapist was lowering the bed. When she entered Resident #1's room and saw the PT had pressure to the injury site and they were waiting on EMS to arrive. The resident appeared to be in good spirits and in no distress at the time. The DOR further stated it appeared to be human error because all the safety precautions had been put in place. The DOR said after the incident they inspected the bed for anything sticking out and they concluded it was just the frame of the bed that cut the resident. Review of the facility's Two Person Transfers policy, revised October 2011, reflected the following: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to life perform two-person transfers 676176 Page 3 of 3