**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of Resident Identifier (RI) #154's medical record and review of the facility's investigation file, Employee Identifier (EI) #8 and EI #9, Certified Nursing Assistants (CNAs) failed to follow RI #154's plan of care/care guide when RI #154 was transferred from the wheelchair to the bed on 03/09/21. RI #154 is care planned for a two person assist with transfers using the Hoyer lift. On 03/09/21 on the 3 PM - 11 PM shift, RI #154 was transferred by being picked up under the arms and placed on the side of the bed. Once on the bed, RI #154 slid to the floor. RI #154 was transferred to the ER (Emergency Room) for evaluation. An X-ray from the hospital showed acute fractures of RI #154's left and right distal femurs. This deficient practice affected RI #154, one of 37 sampled residents whose plans of care were reviewed. Findings include: RI #154 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Muscle Weakness (Generalized) and Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting Unspecified Side. RI #154's care plan titled I require assistance with ADLs (Activities of Daily Living) such as . transfers . related to DX (diagnoses): muscle weakness, other lack of coordination . impaired mobility . with an initiated date of 05/04/18, had an intervention of . *I use a lift for transfers x (times) 2 person assist/med (medium) sling . This care plan intervention was initiated on 11/26/18. RI #154's most recent Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 01/27/21, assessed RI #154 as scoring a 14 on the Brief Interview for Mental Status Score, indicating RI #154 was cognitively intact. This assessment also indicated RI #154 had range of motion impairment on both sides of the lower extremities. A review of RI #154's Lift Transfer Evaluation dated 02/01/21, revealed RI #154 could not transfer, bear weight on a least one leg, turn or pivot and required support for maintaining balance. RI #154 was also assessed as Total Lift Required, with Two Team Members required and used the medium size sling. A review of RI #154's care guide dated 3/2021 revealed RI #154 was marked as a Fall Risk and was to be transferred with a lift with the assist of two individuals. RI #154's Progress Notes (Nurses Notes), dated 03/09/21 at 4:58 PM, revealed the following: Patient was being assisted to bed, from (his/her) wheelchair and started sliding, (he/she) went to the floor . This note was made by EI #2, Registered Nurse (RN) Unit Manager/Assistant Director of Nursing (ADON). RI #154's Physician's Orders, dated 03/09/21, documented: Transfer to ER (Emergency Room) for evaluation p (after) fall . The local hospital documentation indicated RI #154 was admitted to the hospital on [DATE] at 5:20 PM with an admit diagnosis of Bilateral Hip Pain D/T (due to) Fall. RI #154's HISTORY OF PRESENT ILLNESS indicated .Chief Complaint: FALL and PELVIS INJURY. RIGHT and LEFT HIP INJURY . The injury occurred just prior to arrival. Occurred at a nursing home. Fell: . (EMS [Emergency Medical Services] States patient was dropped while being transferred from the chair to the bed by caregivers. patient was in pain and lower extremity was in different directions) . PHYSICAL EXAM . Extremities: Bony tenderness present. shortened right lower extremity). PROGRESS AND PROCEDURES . 18:53 (6:53 PM) 03/09/21 . will admit to orthopedic service . CLINICAL IMPRESSION Closed oblique, subtrochanteric, intercondylar fracture of the distal, shaft of the right and left femur . Contained within the facility's investigation file was a document dated 03/15/21, which revealed an interview was conducted by EI #1, the Administrator with RI #154's sponsor. The interview revealed RI #154 reported to the sponsor he/she had been picked up without the lift being used and was dropped on the floor. On 04/21/21 at 3:29 PM, a telephone interview was conducted with EI #8, the CNA assigned to care for RI #154 on 03/09/21 on the 3 PM - 11 PM shift. EI #8 said 03/09/21 had been her first day caring for RI #154. The surveyor asked EI #8, if she as a CNA had never cared for a resident before, where would she go to find out the type care the resident should receive. EI #8 said on the resident care plan. When asked if she looked at RI #154's care plan before she and EI #9, another CNA, attempted to transfer RI #154, EI #8 said no. EI #8 said she did not know where the care plans were kept. The surveyor asked EI #8 did she ask anyone where RI #154's care plans were. EI #8 said no. EI #8 said usually if the resident is a Hoyer lift they will have a Hoyer pad (sling) under them. EI #8 said RI #154 did not have one under him/her when he/she was in the wheelchair. EI #8 said that is why she and EI #9 assumed RI #154 was not a lift person. The surveyor asked EI #8 when she was in orientation was she told the CNAs are supposed to look at the residents' care guide to see the type care (use of the lift) a resident was to receive. EI #8 said she did not receive any of that information in orientation. A review of EI #8's personnel file indicated the CNA began her employment with the facility on 02/03/21. On 02/03/21, EI #8 signed a TEAM MEMBER ORIENTATION GUIDE RECEIPT AND ACKNOWLEDGEMENT FORM indicating the facility's Safe Lift Program had been discussed with her, signed a Team Member Acknowledgement of Diversicare's Lift Program Policy and Procedure, and signed that she had been informed of the facility's SAFE -WORKING PRACTICE AGREEMENT which indicated 1. It is your responsibility to know your job responsibilities and how to perform these tasks safely. If you need direction or assistance you must notify you supervisor immediately. 2. All employees must know and observe all safety rules and safe practice policies, which are in place at the facility to create a safe working environment. 3. You must . use the mechanical lifting devices for those residents who have been assessed as unable or unwilling to assist in movement . On 04/22/21 at 11:45 AM, a telephone interview was conducted with EI #9, the CNA assisting EI #8 to transfer RI #154 to bed on 03/09/21 on the 3 PM - 11 PM shift. EI #9 said it had been a long time since he last cared for RI #154. The surveyor asked EI #9 when he cared for RI #154, how did he transfer RI #154. EI #9 said when he cared for RI #154 he/she was always in the bed. When asked where the CNA would go to find out how a resident was to be transferred, EI #9 said you would go to the report sheet (care guide) right next to where the CNA assignment sheets were kept. The surveyor asked EI #9 how RI #154 was transferred from the wheelchair to the bed on that shift. EI #9 said he and EI #8 did a pivot and stand. EI #9 said they placed their arms under RI #154's arms and sat RI #154 on the side of the bed. The surveyor asked why RI #154 was not transferred to bed with a Hoyer lift when he/she was cared planned for that. EI #9 said they were just told to put RI #154 to bed by the charge nurse. EI #9 said the nurse never told them to use a lift. When asked who was ultimately responsible for knowing the type care the resident is to be provided, EI #9 said whoever was assigned to care for the resident. On 04/21/21 at 3:08 PM, the surveyor conducted a telephone interview with EI #10, the LPN (Licensed Practical Nurse) assigned to care for RI #154 on 03/09/21 on the 3 PM - 11 PM shift. The surveyor asked EI #10 how would anyone caring for the resident know the type care the resident was to receive. EI #10 said by looking at the residents care guide. EI #10 said the resident's care guide was kept in the assignment book at the nurses' station. EI #10 said the CNAs have access to the assignment book. EI #10 said the CNAs caring for RI #154 that evening never asked her anything about RI #154's care guide. EI #10 said if the resident used a lift it should be two people assisting with the transfer. The surveyor asked EI #10 if RI #154 was care planned to have a lift for transfer with two people helping and that was not done, was RI #154's plan of care followed that evening. EI #10 said no. On 04/22/21 at 3:26 PM, the surveyor conducted an interview with the Unit Manager/Assistant Director of Nursing, EI #2. The surveyor asked EI #2 how RI #154 was care planned to be transferred in and out of bed. EI #2 said with a lift and the assist of two staff to transfers. When asked how the CNA caring for RI #154 would know RI #154 was to be transferred with a lift with the assist of two people, EI #2 said all residents have a care guide at the nurses' station and it was available to all nursing staff. EI #2 said EI #8 and EI #9 did not follow RI #154's care guide which resulted in the tragic fall. EI #2 said when EI #8 and EI #9 signed the Safe Working Practice Agreement they were agreeing to the fact that it was their responsibility to know their job requirement to perform all work tasks safely. EI #2 said when they both came out of RI #154's room she asked them did they know where the residents care guides were, and they were able to tell her they knew that the information about the lift was in the care guides. On 04/22/21 at 3:57 PM, the surveyor conducted an interview with EI #1, the Administrator. EI #1 said he was made aware of the fall involving RI #154 immediately after it happened. EI #1 said the finding from the investigation done by the facility revealed the aides did not follow the care guide, which resulted in a fall with injuries. The surveyor asked EI #1 what did the facility put in place to ensure an incident like this one would not recur. EI #2 said the facility reviewed all the patients care plans, lift transfer evaluations and care guides for accuracy. EI #1 said staff were re-educated on the lift transfer program and the need to follow the residents care guide. EI #1 said the facility also established a tool to monitor and ensure compliance with the lift transfer program and the tool was being used to monitor compliance. EI #1 said the facility was monitoring how staff transferred the residents (return demonstrations). EI #1 said five residents were being monitored per unit per week, for four weeks, then every other week for four weeks. On 04/23/21 at 8:35 AM, the surveyor conducted a telephone interview with RI #154. RI #154 said when EI #8 and EI #9 got her up from the wheelchair and put him/her on the bed he/she fell on the floor. RI #154 said she told them to use the lift, but they did not listen to him/her. On 04/23/21 at 9:10 AM, the surveyor conducted a telephone interview with EI #11, the former DON. EI #11 said when new employees are orientated they are told the facility is a no manual lift facility, meaning if the resident cannot stand or pivot they have to be lifted using a Hoyer lift. EI #11 said each resident is evaluated by the nurse on admission, when there is a change and at least quarterly on their need for a lift and the type lift to be used. EI #11 said this is communicated to the CNAs in the residents' care guide. EI #11 said the care guides are kept at each nurses' station in front of the assignment book. EI #11 said the CNAs have access to the residents' care guide and are to look at the care guides every shift. EI #11 said even if the CNA is familiar with the resident they are to look at the care guide every day because something may have changed. EI #11 said when the facility completed their investigation it was found out EI #8 and EI #9 did not follow RI #154's care guide. ************************* .The surveyors determined current facility compliance by: 1) Review and verification of the facility's Action Plan as outlined in general terms below: STEP 1 What immediate interventions were initiated for resident identified? CNAs failed to comply with Care Plan to transfer resident as total lift for transfers, resulting in a fall, which required the resident to be transferred to the hospital. CNAs were placed on administrative leave pending the results of the investigation. Ad Hoc QAPI (Quality Assurance and Process Improvement) meeting was held on 3/10/2021 to discuss the root cause analysis for the incident. The root cause was found to be staff failed to follow the care plan and care guide for transfer . STEP 2 What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? All resident lift transfer evaluations were reviewed . for accuracy on 3/10/2021. No issues/discrepancies were identified. All resident care plans were reviewed . for correct transfer status and updated as needed on 3/10/2021. All resident care guides were reviewed . to ensure correct transfer status on 3/10/2021. No issues/discrepancies were identified. STEP 3 What system changes were made or modified? What systemic education was completed to enhance knowledge development of team members? Nursing staff were educated . on the lift transfer program to include following the resident care plan and following the resident care guide, Education to be completed by 3/31/2021. Lift transfer competencies with return demonstration will be performed on nursing staff by 3/31/2021. Education on transfers completed on hire and at least annually. STEP 4 Continued Quality Assurance audits implemented to ensure enhanced system compliance? Monitoring plan? Lift Monitoring Audit Tool will be done . on up to 5 residents per unit per week for 4 weeks (through April 9); then every other week for 4 weeks (through May 7) to monitor/ensure compliance with the lift transfer program. Any discrepancies will result in immediate correction, reeducation, and/or disciplinary action. Results of the monitoring tool will be reviewed by QAPI for continued compliance with changes made as necessary. 2) Review of the facility's Progressive Disciplinary Forms indicating both EI #8 and EI #9 were terminated as of 03/16/21 due to a serious violation of safety rules. 3) Various interviews with current staff verifying they have received education and were aware of policies in place regarding care plans, care guides, and resident transfers. 4) Observations during survey of staff using appropriate transfer methods in accordance with resident care plans and care guides. ************************* This deficiency was cited as a result of the investigation of complaint/report number AL00041331.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of Resident Identifier (RI) #154's medical record, review of a facility policy titled Lift 4 Care - Safe 4 All Policy, and review of the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #8 and EI #9, Certified Nursing Assistants (CNAs), used a Hoyer lift, as determined necessary by RI #154's assessment, during a transfer on 03/09/21. During the 3:00 PM to 11:00 PM shift on 03/09/21, EI #8 and EI #9 failed to follow RI #154's plan of care when no Hoyer lift was used when RI #154 was transferred from his/her wheelchair to his/her bed. During the two person manual lift transfer, RI #154 slid from the side of the bed and fell to the floor. RI #154 was transferred to the local hospital to be evaluated after the fall. An X-ray from the hospital showed acute fractures of RI #154's left and right distal femurs which required surgical intervention. The facility concluded in their investigation, RI #154's injuries were caused by the transfer that occurred on 03/09/21, when RI #154 was not transferred using the Hoyer lift. This deficient practice affected RI #154, one of three sampled residents reviewed for accident hazards. Findings include: RI #154 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Muscle Weakness (Generalized) and Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting Unspecified Side. A review of a facility policy titled Lift 4 Care - Safe 4 All Policy, with a revision date of 04/16/20, revealed the following: Purpose: To provide residents with the safe assistance by mechanical lifts as indicated by their clinical evaluation and to eliminate unnecessary and possible unsafe manual lifting, transferring and repositioning by team members. Directives/Policies: . 3. The total lift will be used when residents are non-ambulatory and residents cannot bear weight or if they do not qualify for the sit-to-stand lift . 6. Individualized transfer plan is noted on the care guide sheet. RI #154's most recent Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 01/27/21, assessed RI #154 as scoring a 14 on the Brief Interview for Mental Status Score, indicating RI #154 was cognitively intact. This assessment also indicated RI #154 had impairment on both sides of the lower extremities. A review of RI #154's Lift Transfer Evaluation, dated 02/01/21, revealed RI #154 could not transfer, bear weight on a least one leg, turn or pivot and required support for maintaining balance. RI #154 was also assessed as needing to be transferred with a lift with two team members. RI #154's Progress Notes (Nurses Notes), dated 03/09/21 at 5:03 PM, revealed the following: Patient was being assisted to bed, from (his/her) wheelchair and started sliding, (he/she) went to the floor . RI #154's Physician's Orders, dated 03/09/21, documented: Transfer to ER (Emergency Room) for evaluation p (after) fall . RI #154's Clinical Report - Nurses Triage report , dated 03/09/21 at 5:20 PM, from the ER of the local hospital revealed the following: . Chief Complaint: FALL: . (Per EMS [Emergency Management System], pt (patient) was dropped out of a wheelchair onto the floor. Pt has shortening and rotation to right leg. pt c/o (complained of) pain to left leg. (pt sent to ER from Canteberry (Canterbury) Nursing home for being dropped onto the floor per EMS. Pt c/o pain to left leg. Pt has shortening and rotation to right leg . PHYSICAL ASSESSMENT . EXTREMITIES: Limited ROM (Range of Motion) present. (He/She) was unable to bear weight . (deformity to right leg, shortened) . RI #154's Clinical Report - Physician/Mid Levels, dated 03/09/21 at 5:20 PM, from the local hospital revealed the following: . HISTORY OF PRESENT ILLNESS Chief Complaint: FALL and PELVIS INJURY. RIGHT and LEFT HIP INJURY. The patient also has injury to right lower extremity (thigh, knee and leg) and left lower extremity (thigh, knee and leg). The injury occurred just prior to arrival. Occurred at a nursing home. Fell: The patient complains of severe pain. No blow to the head, neck pain, loss of consciousness or seizure. (EMS States patient was dropped while being transferred from the chair to the bed by caregivers. patient was in pain and lower extremity was in different directions) . PHYSICAL EXAM . Extremities: Bony tenderness present. (shortened right lower extremity). LABS, X-Rays, AND EKG (Electrocardiogram) X-Rays: Right Femur. Rt (Right) Femur X-ray: Intercondylar fracture of the distal right femur. Lt (left) Femur X-ray: Condylar fracture of the distal left femur. PROGRESS AND PROCEDURES . 18:53 (6:53 PM) 03/09/21 . will admit to orthopedic service . Disposition: . presenting medical condition was determined to be of emergent nature . CLINICAL IMPRESSION Closed oblique, subtrochanteric, intercondylar fracture of the distal, shaft of the right and left femur . RI #154's Radiology Report Details from the local hospital, dated 03/09/21, revealed the following: . Report Text . Clinical data: Fall. left lower extremity pain, right lower extremity pain, pelvic pain . 2 views of the left femur demonstrates an acute fracture of the distal femoral metadiaphysis with mild apex medial angulation. There is advanced osteoarthritis of the most marked in the medical compartment . 2 views of the right femur demonstrates an acute comminuted fracture of the distal femoral diaphysis with one shaft width of anterior displacement of the distal fracture fragment and slight medial displacement of the distal fracture fragment. There is osteoarthritis of the knee . Impression: 1. Acute fracture of the distal right femur. 2. Acute fracture of the distal left femur. 3. Profound osteopenia . RI #154's Discharge Summary, with a discharge date of 04/17/21, revealed the following: . admission diagnoses: 1. Closed, displaced right distal femur fracture 2. Closed, displaced left distal femur fracture 3. Paraplegia secondary to stroke affecting bilateral lower extremities . Procedure performed: Open reduction internal fixation of bilateral distal femur fractures History of present illness: The patient is a [AGE] year-old (male/female) who sustained injury to bilateral lower extremities after (he/she) states 1 of the nursing aides (at) (his/her) nursing home dropped the patient while transferring (him/her) from the wheelchair to the bed. (He/She) had immediate pain that time presented to the emergency room. Radiographs were obtained demonstrating comminuted and displaced distal femur fractures bilaterally. Operative and non operative treatment options were discussed length.recommended operative management to stabilize the fractures to help with transfers secondary to reducing pain. Risks benefits alternatives were discussed (at) length (with) the patient (in) regards to operative management to include open reduction internal fixation. After discussion, the patient wished (to) proceed with surgical management. Hospital course: On March 9, 2021, the patient was admitted on the day of injury . On March 12, 2021, the patient was brought to the operating room where open reduction internal fixation with performed on bilateral distal femur fractures. Patient tolerated the procedure well and there were no complications intraoperatively. Postoperatively, they were transferred to the PACU (Post-Anesthesia Care Unit) in stable condition. During (his/her) hospital stay, the patient does not ambulate at baseline secondary to residual paralysis from stroke . Discharge condition: stable . Contained within the facility's investigation file was EI #8's written statement dated 03/06/21 (03/09/21), which documented: Today (RI #154) was sitting in (his/her) chair, (he/she) wanted to be put (to) bed there was no lift pad under (him/her) so (EI #9) and I had did a two man lift on (him/her) as we got (his/her) butt on the bed (he/she) began to slide that's when I heard (his/her) leg snap. (EI #9) went to inform the nurse while I stayed by (his/her) side . On 04/21/21 at 3:29 PM, a telephone interview was conducted with EI #8, the CNA assigned to care for RI #154 on 03/09/21 on the 3 PM - 11 PM shift. EI #8 said 03/09/21 had been her first day caring for RI #154. EI #8 said when she got to work that day RI #154 was up in his/her wheelchair. EI #8 said EI #9, another CNA, assisted her in putting RI #154 to bed. When asked how she and EI #9 put RI #154 in the bed, EI #8 said she and EI #9 did a two man lift. EI #8 said EI #9 got under one arm and she got under the other arm and they slid RI #154 from the wheelchair over to the bed. EI #8 said RI #154 began to slide and when RI #154 was sliding she (EI #8) heard RI #154's leg snap. The surveyor asked EI #8 which leg snapped. EI #8 said she could not remember. EI #8 said it was so traumatic when she heard the leg snap. The surveyor asked EI #8 why RI #154 was not transferred to bed with a Hoyer lift. EI #8 said no one told her RI #154 was to be transferred with a lift. EI #8 said usually if the resident is a Hoyer lift they will have a Hoyer pad under them. EI #8 said RI #154 did not have a Hoyer lift pad under him/her when he/she was in his/her wheelchair and that is why they assumed RI #154 was not a lift person. EI #8 said she never looked at RI #154's care plan to see how RI #154 was to be transferred before she and EI #9 attempted to transfer RI #154. EI #8 said she was never told RI #154 needed to be transferred with a lift with two people helping. Contained within the facility's investigation file was EI #9's written statement dated 03/09/21, which documented: I (EI #9) and (EI #8) were trying to two man lift (RI #154) to bed before she slip and fell and broke (his/her) leg . On 04/22/21 at 11:45 AM, a telephone interview was conducted with EI #9, the CNA assisting EI #8 to transfer RI #154 to bed on 03/09/21 on the 3 PM - 11 PM shift. EI #9 said when RI #154 was transferred from the wheelchair to the bed on his shift, he and EI #8 did a pivot and stand. EI #9 said he and EI #8 placed their arms under RI #154's arms and sat him/her on the side of the bed. EI #9 said as they got RI #154 on the bed RI #154 started slipping. EI #9 said as RI #154 started slipping RI #154's legs snapped and then RI #154 slid to the floor. EI #9 said as RI #154 starting sliding they tried to hold RI #154 to keep him/her on the bed but RI #154 just kept sliding. EI #9 said after RI #154 slipped he went to get the nurse and EI #8 stayed with RI #154. The surveyor asked EI #9 where would you go to find out how a resident is to be transferred. EI #9 said you would look at the resident's care guide. EI #9 said he looked for RI #154's care guide that evening but could not find it. EI #9 said when the nurse told them to put RI #154 to bed she never told them RI #154 needed to be transferred using a lift. When asked who is ultimately responsible for knowing the type care the resident is to be provided, EI #9 said who ever is assigned to care for the resident. Contained within the facility's investigation file was EI #10's written statement dated 03/09/21, which documented: (EI #8) stated that she was going to put (RI #154) to bed. This nurse told (EI #8) that she needed to wait for someone to help her put (RI #154) to bed that (RI #154) is a lift and it takes two people. (EI #8) states there is no sling under resident. This nurse told (EI #8) that a sling may not be under (RI #154) but resident is a lift and resident can't stand of do nothing. (EI #9) came to help (EI #8) put resident in bed. (EI #9) came out room and called nurse to come in room. This nurse asked (EI #9) what happened and (EI #9) stated (RI #154's) leg is broken. This nurse went in room resident was sitting on the floor with right leg bent back. This nurse went to get unit . manager and DON (Director of Nursing) to come to room. On 04/21/21 at 3:08 PM, the surveyor conducted a telephone interview with EI #10, the LPN (Licensed Practical Nurse) assigned to care for RI #154 on 03/09/21 on the 3 PM - 11 PM shift. The surveyor asked EI #10 what type care did RI #154 require. EI #10 said RI #154 was total care. When asked what happened concerning RI #154 on 03/09/21, EI #10 said RI #154 was up in his/her wheelchair and RI #154 was wanting to go to bed. EI #10 said the CNA (EI #8) assigned to RI #154 said she would go ahead and put RI #154 to bed. EI #10 said she told EI #8 RI #154 was a lift and she would need help putting RI #154 to bed. EI #10 said she then started her med pass. EI #10 said as she was preparing medications for the next resident (EI #9) came to the door of (RI #154's) room and waved for her to come to the room. EI #10 said she asked what was the problem and EI #9 said RI#154's leg was broke. EI #10 said she walked to RI #154's room and RI #154 was in the floor. EI #10 said she asked what happened and EI #9 said RI #154 flipped off the bed. The surveyor asked EI #10 how was RI #154 care planned to be transferred. EI #10 said with a lift. When asked how was RI #154 transferred from the wheelchair to the bed by the CNAs that evening EI #10 said she did not ask EI #8 and EI #9 how they tried to transfer RI #154. EI #10 said she assumed they did it under RI #154's arms because there was no lift in the room. When asked how would anyone caring for the resident know the type care the resident was to receive, EI #10 said by looking at the resident's care card. EI #10 said the care card is kept in the assignment book at the nurses station. On 04/22/21 at 3:26 PM, the surveyor conducted an interview with the Unit Manager/Assistant Director of Nursing, EI #2. EI #2 said RI #154 was dependent on staff for care and was not able to ambulate or stand. The surveyor asked EI #2 when was she made aware of RI #154 being observed on the floor of his/her room on 03/09/21. EI #2 said almost immediately after the occurrence EI #10 hurried to get her to come and assist her and to notify her of what was going on. EI #2 said when she entered RI #154's room she observed RI #154 on the floor between the two beds. EI #2 said RI #154's back was not leaning against the bed and RI #154's wheelchair was toward the foot of the bed away from RI #154's body. EI #2 said RI #154's body was about middle ways of RI #154's bed and RI #154 looked up at her and said his/her legs hurt. EI #2 said she told RI #154 she (EI #2) knew and she was getting him/her some help. EI #2 said RI #154's left leg was out straight with the left foot under the bed and RI #154's right leg was turned just above the knee and was lateral to RI #154's body. EI #2 said she went to call the Nurse Practitioner and was told to go ahead and send RI #154 to the nearest ER. EI #2 said she found out RI #154 had fractured both of his/her legs the next day. EI #2 said the results of the facility's investigation revealed RI #154 had fallen and fractured both legs. EI #2 said as a result of the fall both CNAs were terminated. When asked what was not done that contributed to the fall, EI #2 said the CNAs did not follow the patient care guide which resulted in the tragic fall. On 04/23/21 at 8:35 AM, the surveyor conducted a telephone interview with RI #154. The surveyor asked RI #154 what happened when the CNAs put him/her to bed on 03/09/21. RI #154 said the CNAs got him/her up and when they put him/her to bed he/she fell on the floor. When asked how he/she fell, RI #154 said EI #9 one of the people lifted his/her lower body and the little girl (EI #8) lifted him/her at the top. RI #154 said he/she told them they needed to use the lift but they did not listen to him/her. EI #154 said the CNAs normally transfer him/her by putting the sling under him/her and then transfer him/her with the Hoyer. RI #154 said he/she told them that but they did not listen to him/her. RI #154 said the CNAs did not do what they were supposed to. EI #154 said he/she told the CNAs before they started they had to have the Hoyer lift. On 04/23/21 at 9:10 AM, the surveyor conducted an interview with EI #11, the former DON. EI #11 said the facility was a no manual lift facility meaning if the resident could not stand or pivot they had to be lifted with a Hoyer lift. EI #11 said when doing the facility's investigation, the CNAs putting RI #154 to bed said they were doing a two man lift on RI #154 and when they sat RI #154 on the side of the bed RI #154 slipped off. EI #11 said when doing the facility's investigation it was revealed EI #8 and EI #9 did not follow RI #154's care guide. EI #11 said EI #8 and EI #9 were even told by the nurse (EI #10) RI #154 was a total lift. ************************* .The surveyors determined current facility compliance by: 1) Review and verification of the facility's Action Plan as outlined in general terms below: STEP 1 What immediate interventions were initiated for resident identified? CNAs failed to comply with Care Plan to transfer resident as total lift for transfers, resulting in a fall, which required the resident to be transferred to the hospital. CNAs were placed on administrative leave pending the results of the investigation. Ad Hoc QAPI (Quality Assurance and Process Improvement) meeting was held on 3/10/2021 to discuss the root cause analysis for the incident. The root cause was found to be staff failed to follow the care plan and care guide for transfer . STEP 2 What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? All resident lift transfer evaluations were reviewed . for accuracy on 3/10/2021. No issues/discrepancies were identified. All resident care plans were reviewed . for correct transfer status and updated as needed on 3/10/2021. All resident care guides were reviewed . to ensure correct transfer status on 3/10/2021. No issues/discrepancies were identified. STEP 3 What system changes were made or modified? What systemic education was completed to enhance knowledge development of team members? Nursing staff were educated . on the lift transfer program to include following the resident care plan and following the resident care guide, Education to be completed by 3/31/2021. Lift transfer competencies with return demonstration will be performed on nursing staff by 3/31/2021. Education on transfers completed on hire and at least annually. STEP 4 Continued Quality Assurance audits implemented to ensure enhanced system compliance? Monitoring plan? Lift Monitoring Audit Tool will be done . on up to 5 residents per unit per week for 4 weeks (through April 9); then every other week for 4 weeks (through May 7) to monitor/ensure compliance with the lift transfer program. Any discrepancies will result in immediate correction, reeducation, and/or disciplinary action. Results of the monitoring tool will be reviewed by QAPI for continued compliance with changes made as necessary. 2) Review of the facility's Progressive Disciplinary Forms indicating both EI #8 and EI #9 were terminated as of 03/16/21 due to a serious violation of safety rules. 3) Various interviews with current staff verifying they have received education and were aware of policies in place regarding care plans, care guides, and resident transfers. 4) Observations during survey of staff using appropriate transfer methods in accordance with resident care plans and care guides. ************************* This deficiency was cited as a result of the investigation of complaint/report number AL00041331.