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Based on record review, interview, and observation the facility failed to provide care in a save setting by failing to provide an appropriate level of training to staff on the use of a Hoyer Lift (A mechanical lift used to transfer patients). This failed practice is likely to lead to increased risk of adverse events, direct physical and mental harm toward patients and increased length of stay.

Finding are:

A. Observation: On 01/25/22 at 3:07 pm during observation of patient room, a Hoyer lift was required to transfer a patient for discharge. The Hoyer lift was placed in the patient room and the S (Staff)#2 was looking for the battery for the Hoyer lift for approximately 20 minutes. The equipment was not readily available for use. The Patient was in their bed while looking for the battery. The patient was placed on the harness, S#14 (Medical Tech - a health care worker that provides basic patient care) was guiding S#15 (RN - Registered Nurse) on use of the Hoyer lift. Patient was then raised, and the Hoyer Lift got caught on a power cord under the bed as they were moving the patient. The patient was then moved, and as they were lowering the patient her feet got caught on a bar on the Hoyer lift and dropped approximately 2 feet. Patient appeared nervous and stated her husband had plenty of experience with the Hoyer lift and could assist them. The RN told the patient they are able to get her in the wheelchair. Then the wheelchair was moved and placed in an unsafe tilting position as her body was lowered in to the wheelchair. Patient was placed in the wheelchair, repositioned, and set for discharge.

B. On 01/25/22 at 3:33 pm during interview with S#14 confirmed that she was not provided any hands-on training on how to use the Hoyer lift, she received verbal training only on how to operate the lift. She also stated nurses are limited on use of the Hoyer lift and S#15 (RN) requested assistance with a patient that required the use of the Hoyer lift.

C. Record review of S#14 (tech) training record dated 01/13/2021 revealed that the tech received training on equipment, but the record was not clear that the tech was taught how to use the Hoyer lift specifically. The report states the use of mechanical lift training under the transfer devices section of the training report. For the tech it was signed off by her preceptor (the person training another) that she was validated by use of observation.

D. On 01/25/22 at 3:47 pm during interview with S#15 (RN) confirmed that she had been working at this facility for about two and a half months and was provided online learning modules but was not provided hands on training at this facility for use of the Hoyer lift.

E. Record review of S#15 (RN) training record revealed that the RN had received training in regard to patient lifts and was not specific to the Hoyer lift, on 11/6/2021 and was signed off by a staff member but the report does not indicate what method was used to train the RN or was the training a verbal training or a hand on training.

Based on observation and interview the facility failed to provide a COVID-19 (Respiratory infection) infection control screening process (Asking questions to evaluate if an individual has evidence of a disease) that includes a accurate temperature check for all individuals prior to entering the facility. This failed practice is likely to expose patients and staff in the facility to COVID-19.

Finding are:

A. On 01/25/2022 at 3:30 pm during observation of the facility's lobby revealed that one of two thermometers (devices used to take the temperature of individuals) used for the screening process was not taking accurate temperatures, the device was reading a low temperature when used.

B. On 01/25/2022 at 3:30 pm during interview with S (Staff)# 3 (Director of Quality) confirmed that one of two thermometers used for the screening process was not working properly.