Garland Nursing And Rehabilitation

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated that the therapy staff recently performed inservices for sliding boards. Review of the facility Accident and incidents policy dated 2017 revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instruction. 1. At least (2) nursing assistants are needed to safely move a resident with a mechanical lift.

Review of the Lifting Machine, Using a Mechanical policy dated 2001 revealed, The facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. Review of the Care Planning - Interdisciplinary Team policy dated 2024 revealed The interdisciplinary team is responsible for the development of the resident care plans.g. other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. Review of the facility Fall Risk Management policy dated 2018 revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A Facility Transfer Policy specific to transfers and transfer techniques was requested but not provided. The facility took the following actions to correct the non-compliance on 11/11/2025: 1. Physician G, Director of Nurses H, and Resident #1's Responsible Party were notified of the fall on 11/07/2025. Documented in the incident report and confirmed with interview. 2.

CNA A was suspended on 11/11/2025. Confirmed with interview. 3. Resident #1 was transferred to the emergency room (ER) on 11/07/2025 and returned on 11/12/2025. Confirmed with hospital records and interview. 4. In-services were conducted by the Administrator E and DON H and will continue to be conducted until every staff member has received the in-service at the start of their shift: a. Appropriate Transfer for all residents dated 11/11/2025. 33 Care staff check for all resident transfers. Demonstrations were given and staff returned demonstrations. b. Abuse and Neglect dated 11/11/2025. 43 Care staff check for Abuse and Neglect training. c. Gait Belts and Transfers for all residents dated 11/13/2025. 30 Care staff check for Gait Belts and Transfers. d. Lifting Machine Using a Mechanical dated 11/13/2025. 29 Care Staff check for Mechanical Lift Competency. e. Use of Sliding Board Transfers dated 11/12/2025. 10 Therapy Staff check off for not leaving sliding boards in resident rooms unattended. 5. Residents were audited to ensure the MDS matches the residents' current transfer status. 6. Resident rooms were audited for sliding boards. All sliding boards were removed until therapy can educate and check off the CNA's and communicate which residents are appropriate for sliding board transfers. 7. CNA's and Charge Nurses checked off with the Hoyer lift competency to ensure understanding and proper transfers. 8. Competency Checkoffs with direct care staff on how to check the Kardex (Nursing Documentation System) and proper transfers performed 5 times a week x4 weeks to ensure competency. Interviews on 11/13/2025 with CNA A, Administrator E, Therapy Director F, Therapy Assistant B, CNA C, DON H, CNA I, CNA J, ADON K, DON L, LVN M, CNA N, CNA O revealed they understood the policies regarding mechanical lifts, sliding boards, and the use of a Hoyer lift. They stated they recently performed inservices for Mechanical lifts, sliding boards, and the use of a Hoyer lift. On 11/13/2025 at 10:30 AM and 11:09 AM CNA J and CNA N were observed transferring Resident #2 and Resident #3 with a mechanical lift using good technique.

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