**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and review of policy, the facility failed to ensure 2 residents (#45 and #22) did not sustain injuries related to preventable accidents. The facility census was 62. The deficient practice increased the risk for pain, injury and rehospitalization. Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included cognitive social or emotional deficit following cerebral infarction, dementia without behavioral, psychotic or mood disturbance and tachycardia. An activity of daily living (ADL) self care performance deficit care plan was initiated on 08/27/19 related to activity intolerance, contracture of right hand and bilateral foot drop, muscle weakness, knee contractures and total assistance with ADLs. The goal was for the resident to maintain her current level of function. Intervention included assisting 2 staff with full mechanical lift. The quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored 5 on the Brief Interview for Mental Status, indicating severe cognitive impairment. She required extensive to total 2-person physical assistance for most ADLs including transfers. An event note dated 05/31/23 included that at 2:50 p.m. a loud noise was heard from the resident's room. The note indicated that the resident was observed on the floor after being transferred from the Hoyer lift to her bed. According to the note, the sling was wet from a shower the resident had prior, and the Certified Nursing Assistant (CNA) was operating the Hoyer by herself with no one helping or supervising. The note included that after obtaining help to get the resident off the floor, blood was noted behind the resident's head and her head was bleeding. The note revealed the Director of Nursing (DON) and the doctor were notified and came into the resident's room to assess her. The note included that 911 and the resident's family were called. Upon re-entering the resident's room, the resident's oxygen saturation reading was at 90% and her heart rate was 177. The resident was placed on 4 liters of oxygen and at 3:05 p.m. emergency services arrived and the resident was transported to the hospital. The note indicated that the resident never lost consciousness. On 06/01/23 a health status note included that the resident had been admitted to the intensive care unit (ICU) for a head injury. Review of the hospital History and Physical dated 06/01/23 revealed the resident had been admitted to the trauma ICU in guarded condition. Per the assessment, the resident had a small right falx subdural hematoma, a small right subarachnoid hemorrhage, and a prominent soft tissue hematoma posterior to the left proximal tibia and fibula, measuring approximately 6.4 x 3.2 x 8.4 centimeters. During an interview conducted on 06/06/23 at 10:25 a.m. a Certified Nursing Assistant (CNA/staff #39) stated that she had worked in the facility for about 3 months. She stated that she had to complete computer classes and some lifting tests, to check for proper body alignment, before she could work on the floor. She stated that she did not complete skills training or check-off. She stated that she did not have training on how to use a Hoyer lift and that she did not know which sling to use for which resident. Further she stated that she just used the one in the resident's room. She stated that she would not transfer a resident by herself, but that she could not say anything for anyone else. She stated that she had not ever dropped a resident during a Hoyer transfer. At 10:37 a.m. on 06/06/23 an interview was conducted with resident #45's roommate (resident #2). She stated that she saw the resident fall from the Hoyer on 05/31/23. She stated that the CNA (staff #4) was using the Hoyer lift by herself. She said that staff #4 crossed the sling between the resident's legs before she transferred her, but somehow one of the loops slid off the hook. She stated that the first thing staff #4 did was to look at the sling. She stated that resident #45 had just come out of the shower and had been brought into the room. She stated that the sling was wet, but that both sides were hooked. She stated that resident #45 just slipped right out of it, landed on her bottom and then hit her head. She stated that she thought there were supposed to be two aides transferring the resident in the Hoyer. An interview was conducted on 06/06/23 at 11:00 a.m. with a CNA (staff #4). She stated that if they are short handed they always need to get someone to help them and work as a team. She stated that she has transferred residents by herself using a Hoyer because there was no one to help her. She stated that it was facility policy to always have two people. On 05/31/23, she stated that she was transferring resident #45 by herself. She stated that she was using a grayish, criss cross sling that crosses between the resident's legs and hooks up to the Hoyer. Regarding the incident with resident #45 she stated that she put the sling under the resident and showered her. After the shower, as she was transferring the resident back into her bed, she stated that one of the loops on the sling unpopped and the resident fell onto the floor. She stated that the resident fell on her butt then hit her head. She stated that she went to get the nurse while the resident was on the floor and after the nurse assessed her, the two of them put the resident back into bed. She stated that the doctor was in the facility at the time, so the resident was sent out right away. During the interview staff #4 demonstrated how the loop on the sling had slipped off the hook by indicating the loop had not been fully secured into the base of the hook, but was resting on top of it. She stated that the resident, sling and the Hoyer were wet and the loop had just slipped off. She stated that after the incident she met with the Director of Nursing (DON/staff #74) who told her that it was her fault because she did not have another person in the room with her when the resident fell. She stated that it was decided that she would always have two people to do a Hoyer transfer. On 06/06/23 at approximately 3:30 p.m. an interview was conducted with the DON (staff #74). She stated that her expectation was that two members of staff would assist with Hoyer lift transfers and that it did not meet her expectations for staff #4 to have transferred resident #45 by herself. The Transfer With a Mechanical Lift, Long-Term Care policy, revised May 22, 2023, included the facility will ensure that two associates should be present during the transfer of residents who require a mechanical lift, and at least one of the two associates must be over the age of 18. -Resident #22 admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral, psychotic or mood disturbance, anxiety and type 2 diabetes mellitus. An Occupational Therapy (OT) Evaluation & Plan of Treatment dated 08/12/22 included that the resident had a history of wounds and currently required maximal assistance for wheelchair positioning. According to the evaluation, formal assessment of strength was unable to be completed due to cognitive deficits and language barrier. Per the evaluation, range of motion was spastic in nature, with limitations in bilateral lower extremities and upper extremities and resident was resistant to movement. Further, the resident's neck was in a forward flexed position and her spine was kyphotic in nature. The recommendation included a Tilt in space recliner chair for optimal positioning and ease of transfers, self-feeding and overall improvement of quality of life. An ADL deficit care plan revised on 03/01/23 related to impaired balance and limited mobility due to osteoarthritis had a goal to maintain current level of function without decline in ADLs. Interventions included assistance of one to two staff for transfers. A Rehabilitation Services Multidisciplinary Screening Tool dated 05/15/23 revealed the resident had no functional level changes and that she was not appropriate for skilled therapy intervention at that time. The quarterly MDS assessment dated [DATE] did not include a brief interview for mental status. According to the assessment, the resident displayed no behaviors and she was totally dependent upon staff for ADLs with 1-person physical assistance required for bed mobility and 2+ physical assistance required for transfers. An incident report dated 06/04/23 at 1:34 p.m. included that a CNA found the resident slid down in her wheelchair with her leg bent and twisted in the wheelchair stabilizer/padding. Per the note, the CNA lifted the resident up in the wheelchair and transferred her to bed. According to the note, later in the shift the resident's sister told staff the leg was red and swollen. Nursing called the medical doctor (MD) and received an order to elevate and ice. A health status note dated 06/04/23 at 5:55 p.m. revealed the resident had edema to her left lower leg. The note indicated that the resident was placed in her bed to elevate and monitor and that the resident had no complaint of pain to the extremity, only her right hip. On 06/05/23 at 6:57 a.m. a health status note included that the resident had a swollen left leg. Per the note, the on-call was called and orders were received for two view x-rays of the tibia/fibula STAT. According to the note, a complete blood count with differential and a complete metabolic panel were also ordered STAT. Additional orders included to elevate the leg above the waist and to ice. At 10:50 a.m. on 06/05/23 a communication note included that the resident's family was notified that the resident had just been transferred to the hospital for evaluation and treatment, and that updates would be provided as information was available. On 06/05/23 at 1:17 p.m. an event note included the CNA who cared for the resident on 06/04/23 reported that the resident had slid down in her wheelchair, the CAN also reported that the resident's leg was bent and twisted in the wheelchair leg rest/support cushion. Per the note, the CNA then assisted the resident up into her wheelchair and back into bed. She stated the resident did not seem to be in pain at the time of the incident. An interview was conducted on 06/16/23 at 9:10 a.m. with a CNA (staff #43). She stated that on 06/04/23 she was just coming back from lunch and saw the resident sitting in her chair in the dining room, just getting done eating. She stated that she noticed that the resident was sliding down out of her chair, so she pulled her up. She stated that she stood behind the chair, put her arms under the resident's armpits and pulled her up as she normally would. She stated that the resident's feet looked fine before she pulled her up in the chair. She stated that the resident's feet did not touch the foot pedals because her legs were contracted up. She stated that the resident could not straighten out her legs at all. She stated that the resident's wheelchair was standard, with the sitting position as normally would be. She stated that she did not know whether the resident's leg or foot had been caught and she did not know what or when it happened because the resident did not make any noise when she was pulled up. She stated that it could have happened when she put the resident back into bed. She stated that depending upon the CNA, the resident may or may not be a 2-person assist. She stated that the resident usually makes noises whenever any type of care is provided. She stated that the resident did not make any noise to indicate she had been hurt when the resident was pulled up in the chair or when she was helped back into bed. At 10:26 a.m. on 06/16/23 a phone call was made to the resident's family member. She stated that when she visited the resident on 06/03/23, the resident was ok. On Sunday, 06/04/23, she stated that she went in around 3:00 p.m. to see the resident. She stated that the resident was in bed and that staff told her the resident had laid down after lunch. She stated that she asked the staff to help the resident get out of bed so that she could eat her dinner. She stated that the resident was crying, and found that the resident's left leg was really swollen. She stated that she asked the resident if she had fallen and the resident told her no. She stated that she reported the swelling to the CNA and the nurse. She stated that the swelling was about 3-4 inches above the resident's ankle, in the middle of her leg and that it was really red and swollen and it looked like it would explode. She stated that she told the nurse that she wanted to have the leg x-rayed and that the nurse told her to wait until the following day when the doctor could see her. She stated that the following day, the resident was sent to the hospital for x-rays and the results were 2 fractures in the left lower leg. She stated that the resident had to have surgery and the surgeon placed 2 screws in the leg. She stated the resident was in the hospital for 4-5 days and that she did not want her to come back to this facility. On 06/16/23 at 11:16 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #12) who stated that the resident did not speak English, nodded yes or no and that pain evaluations were conducted based upon facial grimacing. She demonstrated that the resident normally kept her arms drawn into her body tightly, with her hands up into her neck and that the resident had always kept her knees drawn up, in a fetal-like position. She stated that the resident sat up in her wheelchair for meals and that she received assistance with feeding. She stated that the resident's feet did not normally hang down, so staff raised the foot rests up and placed a cushion onto the two bars that hold the foot rests. The LPN stated the cushion was pretty firm and that it had indentations for each of her legs. She demonstrated that the resident's legs were usually positioned in a 45 degree angle. She stated that the resident was a 2-person total assist for transfers and had no lower extremity strength. She stated she could not say how the resident slid down in her chair because of the cushion. She stated that on the afternoon of 06/04/23, the resident's legs were dangling down and there was no cushion. She stated that the resident was not crying. She stated that she asked the CNA to place the resident back into her bed so that she could see the resident's leg. She stated that she did see some edema in the leg, but it was not pitting. She stated there was no redness or discoloration. She said that when she palpated the resident's leg, the resident did not grimace or make any noise. She said she thought that maybe the swelling was from having her legs dangling. She stated that she called the CNA (staff #43) into the room and asked her if she knew anything about the resident's leg or whether anything had happened to the resident that day. She stated that staff #43 put her hands on her hips, looked at the resident's leg and said no, she did not know anything. She stated that later, she found out that staff #43 did know something about the resident's leg. Staff #12 stated that when she came in the following morning, the resident's leg was purple and very swollen. She stated that she and the night nurse reached out to the DON and the provider and she was directed to send the resident out for an x-ray. She stated that later that day, she received a call from a nurse at the hospital who told her that the bone in the residents left lower leg was shattered. She stated she called the DON and told her what the nurse had said and about a day later, an officer came and asked her questions about the resident's injury. She stated that it was at that point that staff #43 finally said something about what may have happened. She stated that this resident should never have been positioned by one person from behind because she was so contracted and frail. She stated that the resident actually required two persons to reposition her in the chair, each person holding her under an arm and knee. During an interview conducted on 06/16/23 at 12:14 p.m. the DON (staff #74) stated that resident #22 was not contracted. She stated that per the last OT evaluation, the resident range of motion was spastic in nature, and included limitations in bilateral lower and upper extremities. She stated that according to the assessment, the resident required maximal assistance with wheelchair positioning; and that maximal assistance meant that the person assisting was doing at least 50% of the work. She stated that the resident could help a little bit during repositioning, but that the staff member was doing most of the work. She stated that the resident was sitting in her old wheelchair on the date of the incident because she liked it better. She stated that one person could reposition her in the chair by pulling back on the blanket the resident sits on. However, she stated that if it had been her she would have gotten another person to assist her. She stated that staff #43 had told her that staff #43 thought the resident was going to fall out of her chair and that was why she got behind the chair and pulled the resident up quickly. Staff #74 stated that it was never appropriate to pull a resident up in her chair like that without looking at her feet prior. She stated that staff #43 told her that the resident was on the edge of her chair and that she quickly came and pulled her back, and then afterward she laid the resident back in bed and that she thought everything was fine. She stated that she told staff #43 that moving forward, she had to report any little missed fall because the resident's little bones could break, and that if anything happened out of the norm to let people know. She stated that she did not remember whether or not she educated the CNA on repositioning residents in their wheelchairs at that time, but that later she had an in-service where she talked about body mechanics and repositioning. She stated that she did not know the extent of resident #22's injury, only that the leg was fractured. She stated that staff #43 should have definitely mentioned that the resident had a near fall in the room and that she had hurriedly pulled her up in her chair. In addition, she stated that staff #43 had told her that the incident happened in the resident's room not the dining room. The Body Mechanics and Resident Care Activities policy, reviewed 09/12/22, included that associates will utilize correct body mechanics to prevent undue strain and possible injury to themselves or the residents with whom they care for. For repositioning in a chair, instructions included to not push on [the resident ' s] knees without friction reduction or manually lift the resident up in a chair. The Limited Lift Program (Safe Patient Handling) policy, revised 08/22/22, included the purpose was to establish protocols that will provide the safest possible methods to lift, transfer or reposition residents. The facility will assess the residents' need for assistance with transfers activities, mobility or repositioning utilizing a validated mobility assessment by either nursing or therapy. Associates will be responsible for utilizing mechanical lift devices, transferring devices, proper body mechanics to lift, transfer, and/or pivot non-ambulatory residents as indicated.