**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, facility document review, Resident #14's emergency department medical records, and the facility's policy titled Person Centered Care Plans the facility failed to ensure staff implemented the care plan for transfers with a mechanical lift for Resident #14. Specifically, on 04/11/2023 Certified Nursing Assistant (CNA) #1 and CNA #2 failed to implement Resident #14's care planned intervention for transfers with mechanical lift, which resulted in the resident having arm pain while being transferred without the use of the mechanical lift and being lowered to the floor. The incident resulted in a left humerus fracture and numerous rib fractures. This deficient practice affected Resident #14, one of three residents reviewed for falls. Findings included: A review of a facility policy titled, Person Centered Care Plans, effective 08/15/2018, indicated, .STANDARD . the facility develops a comprehensive person centered plan of care for each resident/guest that includes measurable objectives and timetables to meet a resident/guest(s) medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment and based upon the resident/guest(s) goals and preferences . PROCESS .I. Assessment and Person Centered Care Plan Process . f) Upon completion of baseline care plan or comprehensive care plan and when reviewed quarterly/significant change, the MDSC [Minimum Data Set Coordinator] will ensure care plan intervention(s) are entered into Care Guide ADLs [Activities of Daily Living]/Intervention in the electronic medical record that are considered outside of routine care. This will provide the CNA with individualized information needed to meet the resident's care needs . A review of Resident #14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/07/2023, indicated the resident was admitted to the facility on [DATE]. The resident had active diagnoses that included Cerebrovascular Accident (transient ischemic attack or a stroke), Dislocation of Right Internal Hip Prosthesis, and Anxiety Disorder. Further review revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. The MDS indicated the resident had no delirium or behaviors. Per the MDS Resident #14 required total staff assistance for transfers and toilet use. A review of Resident #14's Care Plan, with a start date of 07/02/2021, revealed the resident had the potential for falls related to impaired mobility. An intervention, initiated on 09/01/2022, indicated the resident transferred with two-person assistance using a mechanical lift. A review of the Verification of Investigation document signed by the Administrator on 04/19/2023, revealed on 04/11/2023 at approximately 6:30 AM, CNA #1 and CNA #2 transferred Resident #14 with two-persons' assistance when the resident's care plan indicated the use of a mechanical lift was required. Further review revealed, CNA #1 acknowledged she and CNA #2 transferred the resident with two-person assistance and did not use a mechanical lift. CNA #1 reported the staff lowered the resident to the floor when the resident complained of pain and then lifted the resident from the floor with a mechanical lift pad to transfer the resident to the wheelchair. CNA #2 reported he did not know how the resident should transfer and was following the direction of CNA #1. The investigation included an interview with Resident #14 who reported that he/she told CNA #1 and CNA #2 that he/she could not transfer without the use of the mechanical lift. The resident stated the CNAs told him/her, We are going to transfer you the fast way. The resident said that while they were transferring him/her there was a pop in his/her arm and a sharp pain. When the resident's arm started hurting the CNAs lowered the resident to the floor. The CNAs then put a mechanical lift pad under him/her and lifted him/her into the chair without the mechanical lift. During a follow up interview, CNA #2 confirmed Resident #14 told the CNAs that they required a mechanical lift before they transferred the resident, but CNA #2 did not see anything wrong with just transferring them. CNA #2 reported the CNAs manually lifted the resident off the floor by lifting the mechanical lift pad underneath him/her. The ALLEGATON DISPOSITION section of the Verification of Investigation revealed, . All information provided points to [Resident #14's] fracture occurring during the improper transfer . A review of the hospital emergency department Radiology Results, dated 04/11/2023 at 3:26 PM, revealed Resident #14 sustained a fracture of the left humeral neck, subluxation [a partial dislocation] of the humeral head with a small humeral head impaction fracture, and numerous minimally angulated posterior rib fractures. During an interview on 08/20/2023 at 10:49 AM, Resident #14 stated they had a fall once at approximately 6:50 AM when the resident wanted to transfer to the wheelchair for an early appointment with an outside provider. Resident #14 stated they informed CNA #1 from the night shift that they transferred via mechanical lift, but CNA #1 said they would transfer the resident quickly and did not use the mechanical lift. Resident #14 said the CNAs transferred him/her under his/her arms. Resident #14 stated they fell during the transfer and screamed in pain. Resident #14 stated CNA #1 and the second CNA rolled the resident on the floor to place a mechanical lift pad under the resident and lifted the resident to the wheelchair manually and did not use the mechanical lift. The resident stated it was determined there was a shoulder fracture and rib fractures. During an interview on 08/23/2023 at 4:14 PM, Licensed Practical Nurse (LPN) #3 stated the resident had always used the mechanical lift to transfer, and it was on their care plan. During an interview on 08/23/2023 at 2:51 PM, the Administrator indicated the transfer status for a resident was shown on the CNA care plan in the CNA charting system. The staff referenced that before every shift and as needed during the shift. The Administrator stated CNA #1 and CNA #2 should have known Resident #14's transfer status by reviewing the documentation and known because the resident informed them; the resident told them to get the lift, and they should have reviewed the documentation to verify it and to ensure that was the accurate way to transfer the resident. The Administrator stated they should have transferred the resident via mechanical lift, as that was indicated on the CNA care plan. This deficient practice was cited as a result of complaint/intake #AL00043925. During the survey, no current failed practice related to F656-Develop/Implement Comprehensive Care Plan was identified; thus, past non-compliance was cited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, facility document review, Resident #14's emergency department medical records, the facility's policies titled Lifting Devices and Incidents and Accidents, and a report submitted by the facility to the Alabama Department of Public Health Online Incident Reporting System the facility failed to ensure Resident #14 was transferred from his/her bed to their wheelchair with a mechanical lift in accordance with the resident's plan of care and facility policies which resulted in an accident. Specifically, on 04/11/2023 Certified Nursing Assistant (CNA) #1 and CNA #2 failed to transfer Resident #14 in accordance with the plan of care and the resident's voiced need to be transferred by the mechanical lift, also known as a Hoyer lift. While being transferred, Resident #14 complained of having arm pain and the staff lowered him/her to the floor. The facility further failed to ensure CNA #1 and/or CNA #2 reported the incident per facility policy to the nursing staff before the resident was transferred from the floor to the wheelchair resulting in the resident being moved unnecessarily before the resident's condition was assessed. The incident resulted in a left humerus fracture and numerous rib fractures. This deficient practice affected for one (Resident #14) of five resident reviewed for accidents. Findings included: A review of a facility policy titled, Lifting Device, effective 05/16/2014, revealed, . PURPOSE . A lifting device may be used to assist in lifting and repositioning residents per plan of care . A review of a facility policy titled, Incidents and Accidents, effective 11/10/2014, revealed, .PURPOSE . The resident/guest environment remains as free of accident hazards as possible, however, when an accident occurs, prompt response and reporting occurs . PROCESS . I. Handling Accident Occurrences .a) The resident/guest should not be moved unnecessarily until condition has been accessed . A review of Resident #14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/07/2023, indicated the resident was admitted to the facility on [DATE]. The resident had active diagnoses that included Cerebrovascular Accident (transient ischemic attack or a stroke), Dislocation of Right Internal Hip Prosthesis, and Anxiety Disorder. Further review revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. The MDS indicated the resident had no delirium or behaviors. The resident required total staff assistance for transfers and toilet use. The MDS indicated Resident #14 did not walk. A review of Resident #14's Care Plan, with a start date of 07/02/2021, revealed the resident had the potential for falls related to impaired mobility. An intervention, initiated on 09/01/2022, indicated the resident transferred with two-person assistance using a mechanical lift. On 04/12/2023 the facility submitted an initial report to the State Survey Agency via the Alabama Department of Public Health Online Incident Reporting System. This report indicated Resident #14 was transferred by CNA #1 and CNA #2 with two-persons' assistance when the resident's plan of care dictated that he/she should be transferred with use of a Hoyer lift. The CNA's reported they did not know his/her transfer orders. On 04/12/2023 after the resident returned to the facility, Resident #14 reported he/she informed the CNAs of his/her transfer status prior to them attempting the transfer and they transferred him/her anyways. A review of the Verification of Investigation document signed by the Administrator on 04/19/2023, revealed on 04/11/2023 at approximately 6:30 AM, CNA #1 and CNA #2 transferred Resident #14 with two-persons' assistance when the resident's care plan indicated the use of a mechanical lift was required. Further review revealed, CNA #1 acknowledged she and CNA #2 transferred the resident and did not use a mechanical lift. CNA #1 reported the staff lowered the resident to the floor when the resident complained of pain and then lifted the resident from the floor with a mechanical lift pad to transfer the resident to the wheelchair. CNA #2 reported he did not know how the resident should transfer and was following the direction of CNA #1. Further review of the facility investigation revealed the charge nurse, Licensed Practical Nurse (LPN) #3, reported she did not know about the incident until Resident #14 was in the wheelchair. Resident #14 reported that he/she told CNA #1 and CNA #2 that he/she could not transfer without the use of the mechanical lift. The resident stated the CNAs told him/her, We are going to transfer you the fast way. The resident said that during the transfer there was a pop in his/her arm and a sharp pain. When the resident's arm started hurting the CNAs lowered the resident to the floor. The CNAs then put a mechanical lift pad under him/her and lifted him/her into the chair without the mechanical lift. CNA #2 later confirmed Resident #14 told the CNAs that he/she required a mechanical lift before they transferred the resident, but CNA #2 did not see anything wrong with just transferring them. CNA #2 reported the CNAs manually lifted the resident off the floor by lifting the mechanical lift pad underneath him/her. The ALLEGATON DISPOSITION section of the Verification of Investigation revealed, .Both [Resident #14] and [CNA #2] reported that [Resident #14] informed the staff members of [his/her] hoyer lift transfer orders. They then chose to transfer [him/her] that way despite [his/her] information . All information provided points to [Resident #14's] fracture occurring during the improper transfer . A review of LPN #3's written statement dated 04/11/2023 indicated Resident #14 reported to her that two CNAs hurriedly tried to transfer him/her from the bed to the wheelchair without using the Hoyer lift resulting in him/her falling and popping his/her left shoulder. The statement also indicated that Resident #14 reported while he/she was on the floor the CNAs placed a pad underneath him/her and lifted him/her from the floor to the wheelchair causing lots of pain. A review of the hospital emergency department Radiology Results, dated 04/11/2023 at 3:26 PM, revealed Resident #14 sustained a fracture of the left humeral neck, subluxation [a partial dislocation] of the humeral head with a small humeral head impaction fracture, and numerous minimally angulated posterior rib fractures. According to the Departmental Notes, dated 04/12/2023 at 2:03 AM, the resident returned from the hospital on [DATE] at 11:44 PM with a sling on their left arm. During an interview on 08/20/2023 at 10:49 AM, Resident #14 stated they had a fall once at approximately 6:50 AM when the resident wanted to transfer to the wheelchair for an early appointment with an outside provider. Resident #14 stated he/she informed CNA #1 from the night shift that they transferred via mechanical lift, but CNA #1 said they would transfer the resident quickly. Resident #14 said the CNA did not use the mechanical lift. Resident #14 stated they fell during the transfer and screamed in pain. Resident #14 stated CNA #1 and the second CNA rolled him/her while on the floor to place a mechanical lift pad under him/her and then lifted him/her to the wheelchair manually without the use of the mechanical lift. The resident stated it was determined there was a shoulder fracture and rib fractures. Resident #14 said he/she did not know why the CNAs did not use the mechanical lift. During a follow-up interview on 08/23/2023 at 3:36 PM, Resident #14 stated they told CNA #1 she needed to get a lift to transfer him/her because the resident could not stand and walk. The resident stated CNA #1 said, they were going to do it the quick way, and lifted the resident without the mechanical lift. During an interview on 08/21/2023 at 7:36 AM, LPN #3 stated she was the charge nurse on the night shift on 04/10/2023. LPN #3 stated she was charting at the end of her shift the morning of 04/11/2023 when CNA #4 from the day shift reported the resident was crying and did not want to go to their appointment because of pain. LPN #3 stated she went to the resident's room to assess his/her pain, but the resident refused to allow a full assessment. LPN #3 stated she called her supervisor, Registered Nurse (RN) #5, and returned to the resident's room with her phone on speaker so RN #5 could speak to the resident about going to the appointment. LPN #3 stated the resident described the incident and how the CNAs had transferred the resident to their wheelchair by hand and did not use the mechanical lift, and the resident had a fall. LPN #3 stated she then ran to attempt to catch CNA #1 and CNA #2, but they had already left the building and did not answer text messages or phone calls. During a follow-up interview on 08/23/2023 at 4:14 PM, LPN #3 stated the resident had always used the mechanical lift to transfer, and it was on their care plan. She stated it was not appropriate to transfer a resident from the floor by manually lifting them with a mechanical lift pad; a mechanical lift should be used. During an interview on 08/22/2023 at 2:48 PM, Registered Nurse (RN) #5 stated she was the supervisor the morning of 04/11/2023. She stated Resident #14 transferred using a mechanical lift and had for approximately the past year because the resident was so heavy and could not stand. During an interview on 08/22/2023 at 7:31 AM, CNA #4 stated she worked with Resident #14 on the day shift on 04/11/2023, and the resident complained of arm pain. CNA #4 stated she did not know anything had happened to the resident and reported the pain to LPN #3. She stated Resident #14 used a mechanical lift to transfer, and CNA #1 and CNA #2 should have checked the resident's care plan and transferred the resident properly. CNA #4 stated it was unacceptable to lift any resident under their arms if the resident was assessed to need a mechanical lift. During an interview on 08/23/2023 at 2:51 PM, the Administrator stated CNA #1 and CNA #2 should have known Resident #14's transfer status by reviewing the documentation on the CNA care plan. When the resident informed the CNAs to get the lift, they should have reviewed the documentation to verify it and to ensure that was the accurate way to transfer the resident. The Administrator stated they should have transferred the resident via mechanical lift, as that was what was indicated on the CNA care plan. During an interview on 08/24/2023 at 3:41 PM, the Administrator was asked why the facility substantiated neglect at the conclusion of the investigation. The Administrator read the Allegation Disposition section on the Verification of Investigation form. The Administrator stated, due to the information collected during the investigation, the allegation of abuse, neglect will be indicated for the resident and both CNAs involved. Both Resident #14 and CNA #2 reported that Resident #14 informed the staff members of his/her Hoyer lift transfer orders. They then chose to transfer him/her that way despite his/her information. Resident #14's arm began hurting during said transfer and Resident #14 was found to have a fracture that afternoon. All information provided points to Resident #14's fracture occurring during the improper transfer and his/her injury being a result of the CNAs neglect to follow his/her proper care orders. This deficient practice was cited as a result of complaint/intake #AL00043925. During the survey, no current failed practice related to F689-Free of Accident Hazards/Supervision/Devices was identified; thus, past non-compliance was cited.