BROWNWOOD, TX – CARE NURSING AND REHABILITATION CENTER

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Residents #6) of 7 residents reviewed for activities of daily living as evidenced by:

1) Resident #6 fell out of Hoyer lift due to strap breaking, receiving a fracture to right femur, when aides used a Hoyer sling that was brittle and not designated for resident.

This failure could place residents at risk of not being transferred correctly and could lead to a fall resulting in injury to resident.

In an interview on 2/14/20 at 10:22 a.m. Resident #6 (In-Hospital) stated she fell out of Hoyer sling, after strap broke on right lower extremity, resulting in a fracture to Right femur. Stated that she had always felt anxious when the Hoyer lift was used and stated she informed staff that a bed bath would be acceptable occasionally. Stated she never informed staff that she would not like to use Hoyer. Resident #6 stated she had not had an accurate weight due to scale having different readings, so she is unsure of her weight at this time. Resident #6 stated that when she fell out of sling she landed on the floor on her buttocks. Stated she is unsure how her Right lower extremity landed when she fell but stated that the staff had to lift her right leg to remove Hoyer lift from beneath it. Resident #6 stated that aides at facility had lifted her from her bed with Hoyer and transferred her to shower room (stated shower is two doors down hall from her room). Stated that after her shower aides had lifted her out of shower chair and was taking her back to her room and when they entered her room is when strap broke. Stated she was not aware of details after this occurred. Resident #6 stated that she was very anxious about recent incident and stated she had been informed in (MONTH) 2020 (by her oncologist) that the spots on her lungs had increased. Stated she is having trouble processing everything that had occurred over the last two months.

Observation on 2/14/20 at 3:08 p.m. of sling used on day of incident (2/11/20) revealed straps (nylon) areas dry and brittle, right lower extremity strap was torn in half, the left lower extremity strap was intact with investigator able to tear (in the same area as right lower extremity strap break) by hand. Sling was not frayed, and no tag was located on sling to indicate size of sling. Nylon area of upper extremity straps were more pliable than lower extremity straps.

In an interview on 2/14/20 at 3:30 p.m. Administrator stated that CNA’s are to check the condition of slings with every use and notify Central Supply if wear and tear, fraying or other issues are observed with slings. Administrator stated that laundry personnel were checking slings with each washing and training performed to contact Central supply with new concerns of slings. Stated that Central Supply had the duty to check slings periodically for wear and tear to slings since she is the one who orders them. Administrator stated that the last time new slings were purchased was 11/30/17 from facility appointed supply company. Administrator stated that on 2/11/20 (date of incident) maintenance was instructed to check all slings and Hoyer lifts. Administrator stated that a new check list was generated on 2/11/20 for Hoyer and Hoyer sling checks. Stated that maintenance and housekeeping supervisor will be checking slings monthly for arising wear and tear.