Health inspection·June 7, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents. NA E failed to use an assistive device used for lifting and transfers on 4/30/24 when transferring Resident #1, resulting in Resident #1 experiencing pain to her Right ankle and requiring an x-ray. This failure could place residents at risk of injuries and a decline in quality of life. Findings include: Record review of Resident #1's Face Sheet dated 6/6/2024, revealed a [AGE] year old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of muscle wasting, Diabetes Mellitus 2 , cognitive communicative disorder ,recurrent depression, history of fracture right femur(primary leg bone), hyperlipidemia(high cholesterol), and dementia without behaviors. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 11 indicating cognitively intact. MDS reflected Resident #1 required 1 to 2 person transfers with lift. Record review of Resident #1's care plan dated 5/14/2024 revealed Resident #1 required assist of 1 or 2 staff members to transfer with a Total Lift(a lifting machine for transferring people). Record review of Resident #1's nursing progress notes dated 5/1/2024 revealed Resident #1 had complained of pain to her right foot and right ankle. There were no signs and symptoms of swelling or bruising at that time. Resident stated pain was 10/10. She was administered Tramadol 50 mg 2 tabs for pain. An x-ray was ordered to her right ankle and right foot. Record review of Resident #1's x-ray results dated 5/1/2024 of right ankle revealed no fracture. During an observation and interview on 6/6/2024 at 11:30 am revealed Resident #1 was lying in bed awake alert. Interview with Resident #1 resulted in her explaining NA E told her it was time to get up. Resident #1 told NA E to use the lift. Resident #1 stated NA E told her I can get you up quicker by myself and I won't hurt you. Resident #1 said NA E sat her up on side of bed and placed a gait belt on her then stood her up to transfer her to her wheelchair. Resident #1 stated she heard and felt her right ankle pop and she stated it hurt. Resident #1 stated she had an xray of her right foot and there was no fracture but it hurt for several days after. Page 1 of 2 676425 676425 06/07/2024 The Enclave 18803 Hardy Oak San Antonio, TX 78258

F 0689 Telephone attempts x2 were unsuccessful to NA E for interviews during investigation. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/7/2024 at 2:33 pm Agency NA D stated staff were to transfer Resident #1 with a Total Lift when transferring her out of bed to the wheelchair or to shower chair. She further revealed the information for the Total Lift usage was in Resident #1's [NAME] (computer resource for residents needs and requirements) and staff had access. Residents Affected - Few During an interview on 6/7/2024 at 2:40 pm NA C stated staff were to transfer Resident #1 with a Total Lift when transferring out of bed to wheelchair or to shower chair. She further revealed the information for the Total Lift usage was in Resident #1's [NAME] and staff had access. During an interview on 6/7/2024 at 2:45 pm RN B revealed Resident #1 had in her [NAME]/Care plan to use Total Lift when transfers occured. May use 1 or 2 staff. During an interview on 6/7/2024 at 4:17 pm the DON revealed NA E was terminated due to her admitting Resident #1 told her to use Total Lift and she still transferred Resident #1 by herself without the Total Lift. She further revealed NA E told her it was faster. DON stated Resident #1 had reported on 4/30/24 the 2pm-10 pm aide (NA E) had transferred her without using the Total lift and hurt her right ankle . She said Resident #1 had asked NA E to use the Total Lift and NA E said she won't hurt you and transferred her without the Total Lift. X rays were done and there was no fracture to her right ankle or foot. DON said she felt that NA E should have listened to the resident or checked the residents [NAME]. She felt all other staff asked the nurse or looked in the residents [NAME] on how to transfer residents. She further revealed NA E was trained and in serviced on using safe transfer equipment and the safety of the resident. Record review of NA E's HR file education competency records revealed a competency titled Orientation checklist; Safe Lift/Movement: Transfers/Gait Belt: Use, Level of Care Needs, Wheelchair positioning and Mechanical Lifts: signed by NA on 10/3/2023 as being completed. Record review of NA E's education competency records further revealed competency titled Fall Prevention and Accident and Restraint Free Environment was signed by NA on 10/3/2023 as being completed. Record review of facility CNA/Caregiver Competency Checklist dated 4/9/2024 revealed NA E met competency for Accessing the [NAME] to review level of care and safety needs at beginning of shift and as needed, Reviewing [NAME] for safety needs, Mechanical Lift Device: signed by NA E on 4/9/2024 as met. A Hoyer Lift competency checklist was signed by NA E on 4/9/2024 as met. 676425 Page 2 of 2