Mt. Olympus Rehabilitation Center

jeopardy to resident health or safety

tabs at the shoulders and some about mid-thigh that were used to help lift the patient. CNA 1 stated that the straps for the transfer sling appeared like they were intact and did not have any wear or tear. CNA 1 stated that the transfer sling that resident 3 came into the facility with was not a Hoyer lift sling, it was a transfer sling. CNA 1 stated that she had used those types of transfer slings in the past with the Hoyer lift and has not had any issues with them. CNA 1 stated that the facility did have these types of slings available in the facility that they have gotten from other facility transfers.On [DATE] at 5:25 PM, a telephone interview was conducted with CNA 2. CNA 2 stated that resident 3 came to the facility on a gurney and that she was responsible for the section that resident 3 was going to be in. CNA 2 stated that they knew from the report that resident 3 would require the Hoyer lift due to her size. CNA 2 stated that if a resident came to the facility with a sling underneath them, then she would use it. CNA 2 stated that resident 3 had a sling underneath her that was not unfamiliar as the facility used the same type of sling. CNA 2 stated that the sling was made from a plastic like material and that it was tarp-like. CNA 2 stated that the sling had multiple straps on the sides and two straps on each corner. CNA 2 stated they used the sling underneath resident 3 because it was familiar to them and they did not usually get admissions in the evening. CNA 2 stated she was familiar with the sling and knew it was a Hoyer sling. CNA 2 stated they looked at the straps and she told CNA 1 there was an option to use multiple straps and they did that. CNA 2 stated she personally had only used the blue ones that were tarp-like just like the one that resident 3 was on and she had never used a mesh one. CNA 2 stated that they figured because it was tarp-like that it would be good to use. CNA 2 stated that CNA 1 brought in the Hoyer lift that also weighed residents. CNA 2 stated that they put resident 3 on the Hoyer lift with four straps on each side and got a weight of 325 pounds. CNA 2 stated that she bent down to move the bed control and resident 3's oxygen tubing when the sling straps snapped and resident 3 fell on top of the Hoyer lift. CNA 2 stated that she fell over the two metal legs of the Hoyer lift and one of the legs was behind resident 3's neck and the other was on resident 3's coccyx area. CNA 2 stated that a nurse came in and they pulled resident 3 off the Hoyer lift legs to lay her flat on the floor and began CPR. CNA 2 stated that EMS arrived and they took over CPR. CNA 2 stated that EMS found that resident 3 was a DNR and CPR was stopped and pronounced deceased . CNA 2 stated that police officers arrived at the facility and they turned the room into a crime scene and asked her and CNA 1 how they had hooked up the straps on the Hoyer lift.On [DATE] at 9:21 AM, an interview was conducted with CNA 5. CNA 5 stated that she had been employed at the facility for about 9 years. CNA 5 stated that Hoyer slings were kept downstairs in the laundry room. CNA 5 stated that she had not received any hands-on training regarding the use of Hoyer lifts and Hoyer slings. CNA 5 stated that there were about five residents in the facility that currently used Hoyer lifts. On [DATE] at 9:22 am, an interview was conducted with CNA 6. CNA 6 stated that she had training on the Hoyer lift but it had been a couple years. [NAME] stated that she had worked at the facility for 40 years. CNA 6 stated there might have been another training since that she had missed but she was unsure. On [DATE] at 9:36 AM, an interview was conducted with CNA 7. CNA 7 stated that he had training a couple days ago on the Hoyer lift policies. On [DATE] at 10:22 AM, an interview was conducted with CNA

• CNA 8 stated the last hands on Hoyer lift training was about a month ago. CNA 8 stated when the facility

got new Hoyer slings the staff had to visualize the new slings and sign off that they saw them.

Facility ID: