**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure safe assistance was provided for one resident (#2) to prevent an accident during a hoyer lift transfer. The deficient practice could result in further incidents of staff providing unsafe assistance, resulting in harm to residents. Findings include: Resident #2 was admitted to the facility on [DATE], with diagnoses including unspecified open wound of right foot, multiple fractures of pelvis with stable disruption of pelvic ring, hypothyroidism, epilepsy, and disorder of bone density and structure. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 15, indicating Resident #2 was cognitively intact. A care plan dated December 11, 2024, revealed the resident has an activity of daily living (ADL) self care deficit and requires mechanical hoyer lift for transfers. Review of the physician orders revealed no evidence of orders for monitoring a change of condition for Resident #2 on March 9, 2025. Review of a physician order dated March 10, 2025, documented at 11:45 AM, indicated for an x-ray of the right femur / of the right knee. Review of a physician order dated March 12, 2025, documented at 1:45 PM, indicated to send the resident to the emergency room (ER) for further evaluation of the right knee. Review of a Health Status progress note dated March 10, 2025, revealed new pain and possible injury to the resident's right leg as of yesterday, discussed with the medical doctor. Right femur and right knee x-rays were ordered and will be done the following day per the staff member with the mobile x-ray company. A documented Change of Condition Evaluation effective March 10, 2025, signed on March 17, 2025, by a Registered Nurse (RN / Staff #26), revealed the change in condition was that, patient injured on 03/9 while being transferred with hoyer. Additionally, the resident was having difficulty with mobility due to new onset of right femur pain. The pain was indicated as acute, and a pain scale level of 8, on the right lower femur. The note indicated that the medical provider was notified on March 10, 2025, at 11:00 AM, and an x-ray was ordered. A Medical Practitioner Note dated March 11, 2025, revealed Resident #2 was seen because of an injury to her right lower extremity. The resident was being transferred in a hoyer lift on March 9, 2025, and developed extreme pain in the right knee. The note indicated that the resident was evaluated by the nurse who noted that the straps on the hoyer lift were not the right ones for the resident. The assessment indicated a contusion to the right knee, and that x-rays pending to rule out fracture. A mobile x-ray report dated March 11, 2025, revealed slight distal cortical disruption with findings consistent with distal femur facture. A Medical Practitioner Note dated March 12, 2025, revealed the right femur x-ray shows cortical fracture and the resident is sent to the ER. Hospital records revealed a progress note dated March 13, 2025, indicating the resident had transferred from the ER to hospital admission and presents with concerns of right knee pain suffered during a hoyer lift transfer. A right knee x-ray report indicated an, oblique fracture involving the distal aspect of the right femur. A hospital discharge summary note dated March 14, 2025, indicated the resident was treated non-operatively for a closed fracture of the right distal femur, and to wear a knee extension brace on the right leg at all times. A facility Reportable Event Record dated March 18, 2025, revealed that on March 9, 2025, two Certified Nursing Assistants (CNAs), Staff #51 and Staff #30, were transferring Resident #2 from her wheelchair to her bed using a hoyer lift. When they started lifting her, the resident said that her leg was still strapped to the wheelchair. The CNAs lowered her back down to the chair, unstrapped her leg, then transferred the resident to the bed. During the transfer, the resident complained of pain in her leg due to the placement of the sling. The CNAs got another CNA (Staff #18) to help get the resident back to bed. Staff #18 came to the room and brought a different sling. The nurse was notified that the resident was in pain within 5 minutes. The nurse administered Tylenol. On March 10, 2025, the physician was notified and an x-ray was ordered. The x-ray was completed on March 11, 2025, indicating findings consistent with distal femur fracture. The resident was sent to the ER, and was transferred to a different hospital for further assessment. No surgical intervention were completed, and the resident returned to the facility on March 14, 2025. Interventions implemented after the incident included, staff were provided transfer education and proper sling sizing and placement; and that staff involved in the incident received additional education and demonstrated proper lift mechanics. A Witness Statement signed March 13, 2025, by a CNA (Staff #51) revealed that on March 9, 2025, at 1:30 PM, Resident #2 needed assistance with changing. The CNA got assistance from a second CNA for a hoyer lift transfer. During the transfer, the resident complained about pain in the inner thigh from the sling straps because of the type of sling being a crossed strap sling. While the resident was being lifted, the resident noticed a strap on her leg and told the CNAs to remove the strap. The resident was lowered back down, and the resident was complaining of pain. Another coworker came to assist. The resident was changed and then offered a different sling, and was then transferred back into the wheelchair. A Witness Statement signed March 14, 2025, by a CNA (Staff #18) revealed on March 9, 2025, during the incident, the CNA was in a different room providing care to another resident. Staff #30 came to the room and asked for assistance with Resident #2. When Staff #18 arrived to the room, Resident #2 was in bed and needed transferred back to her wheelchair. During and after, resident became very upset (yelling and screaming). Staff #18 tried to calm her. After the resident was transferred back in the wheelchair, the resident stated that one of the CNAs forgot to unstrap her leg, and during the lift it pulled on her leg. Staff #18 apologized that it had happened to her, and then left the room to care for other residents. A Witness Statement signed March 18, 2025, by a CNA (Staff #30) revealed on March 9, 2025, at 2:00 PM, Resident #2 was in the wheelchair, and Staff #30 was asked by another CNA (Staff #51) to assist with the transfer. Staff #51 had put the hoyer sling under the resident. The sling was attached to the hoyer. The staff attempted to raise the resident from the wheelchair with the mechanical lift, and then heard the resident yell, and the resident was lowered back down. Another CNA (Staff #18) was called for help, and then Staff #30 was called to another room to provide care. A Witness Statement, undated, and signed by a Licensed Vocational Nurse (LVN / Staff #60), revealed on March 9, 2025, after 2:00 PM, staff approached this nurse reporting that the resident was requesting Tylenol. The nurse went to the resident's room and the resident was sitting in her wheelchair. There were two CNAs in the room, and one reported that, the sling had slipped in transfer. The nurse asked the resident if she wanted a Tylenol. The resident stated, Yes, for my leg. The resident was given Tylenol at 2:26 PM. No visual injuries were noted at this time. At supper time, this nurse asked the resident if the Tylenol helped, and the resident stated that yes, it's better. The resident had no further complaints the rest of the shift. A Witness Statement signed March 15, 2025, by an RN (Staff #26) revealed on March 10, 2025, at 8:00 AM, Resident #2 stated that over the weekend, her right leg became injured after two CNAs used the wrong hoyer sling and that since then, the resident had a lot of pain with movement in her right leg. Resident #2 required frequent pain medication to stay comfortable. That morning, the resident's daughter came to see the resident and stated that the resident's, leg appeared slightly bent and that this was abnormal because her leg has a rod in it and is normally straight. The doctor was notified, and x-rays were ordered. An In-Service Training Report, dated March 18, 2025, revealed a one-on-one training occurred with a CNA (Staff #30) on the subject of mechanical lift. An observation was conducted on March 24, 2025, at 12:45 PM, of Resident #2 sitting in her wheelchair in her room. The resident had her right leg propped on an elevating leg rest, and on the resident's right leg was a leg immobilizing brace. An interview was conducted at this time with Resident #2. The resident stated that she was injured during an incident, had a leg fracture, and now has to wear a leg brace. She stated that the incident occurred during a hoyer transfer, when two CNAs who did not really know her used the wrong hoyer sling, that was for, a much bigger person. The resident stated that she screamed during the transfer; and that, the strap for the hoyer sling was at the wrong place, and was much lower down on her leg than it should have been. She stated that during the transfer, my leg was down. She stated, it was the strap that caused the break in her leg. Additionally, she stated that afterward, Staff #18 came into the room and told the two CNAs that he would take over. She stated she has not seen the two CNAs again since the incident. A telephonic interview was conducted with an LVN (Staff #60) on March 24, 2025, at 1:07 PM. The LVN stated that one of the CNAs had come to her and said that the hoyer lift sling had slipped; and that, Resident #2 was requesting pain medication because her leg was hurting. She stated that the CNAs were not specific in what went wrong with the hoyer transfer. When she went to the resident's room, the resident was sitting up in her wheelchair with a hoyer sling underneath her. She stated the resident asked for pain medication and the nurse administered it. A telephonic interview was conducted with a CNA (Staff #30) on March 24, 2025, at 1:57 PM who stated that herself and the agency CNA, whom she could not recall the name, assisted Resident #2 with putting on a hoyer sling -- because the resident did not have a sling under her initially while she was sitting in the wheelchair. Staff #30 stated that when they used the hoyer lift to raise the resident up, the resident started screaming, and then they lowered the resident back down to the wheelchair. She stated that Resident #2 was indicating her right knee was hurting her and kept putting her hands toward her knee. She stated that the resident usually has a blue strap around her right foot to the wheelchair, and that this strap was still attached. She stated that then she got the other CNA (Staff #18), and then notified the nurse (Staff #60). She stated that Staff #18 and the agency CNA then transferred the resident back to the bed while Staff #30 had to go answer call lights. She stated that as a result of this incident, that she received training and reviewed the whole hoyer transfer process, and had to sign a paper. A telephonic interview was conducted with a CNA (Staff #51) on March 24, 2025, at 2:03 PM, who confirmed that she was an agency CNA contracted to work at the facility. The CNA stated that she was not assigned to Resident #2 on the day of the hoyer transfer incident, but that she was answering a request to transfer Resident #2 from the wheelchair to the bed to provide care. Staff #51 stated that she thought the resident required a hoyer lift to transfer and went to get another staff member. She stated that she requested assistance from Staff #30; and that, the resident did not have a hoyer sling under her in the wheelchair, and that Staff #30 went to get a hoyer sling. Staff #51 stated that she believed from observing the way that the resident was sitting in the wheelchair, that the type of sling that should have been used was a sling that was whole. However, Staff #51 stated that the sling that Staff #60 brought was a different type, it was a sling that, you have to slide in the back of the resident and then cross between the legs. She stated that she was not sure what type of sling to use, but she knew Staff #30 had worked with the resident before, so they put the sling on the resident. Staff #51 stated that then, the two CNAs lifted the resident up in the hoyer lift and the resident still had a strap on her right foot. She stated that this strap was on her foot to hold the resident's foot on the wheelchair legrest to keep it from sliding off. She stated that when using the hoyer, that they had the resident lifted almost to the bed and then had to lower the resident back down. Staff #51 stated that Staff #30 should have removed the foot strap before the transfer because it was on her side, however Staff #51 stated that she unstrapped the resident's foot quickly as soon as she noticed. Then, she stated that Staff #18 walked into the room and helped to, take over the situation, and the resident was then assisted to the bed. Then, the nurse was notified and within 5 minutes assessed the resident. Staff #51 stated that the hoyer sling should never have been missing from the chair originally; and that, there were no other hoyer slings that herself or Staff #30 could find. A telephonic interview was conducted with Resident #2's daughter on March 24, 2025, at 2:29 PM. The resident's daughter stated that her understanding of the incident was one agency staff member and one, not too experienced staff member were using a hoyer to transfer the resident. The resident's daughter stated that, we are trying to set up a meeting where the facility is going to reconstruct the incident to figure out what angle could have caused the injury. She stated that staff at the facility have used phrases such as, the sling slipped to describe what happened during the incident. Additionally, she stated the facility staff have informed her that they will no longer have agency staff care for Resident #2 while she is using the hoyer. An additional telephonic interview was conducted with a CNA (Staff #18) on March 24, 2024, at 2:38 PM who stated that he was in a different room at the time of the hoyer transfer incident involving Resident #2. He stated that he witnessed the aftermath when he walked into the resident's room and saw that the two CNAs that were in the room with Resident #2 were not able to calm her down. Staff #18 stated that the resident was, clearly in pain and distress. Staff #18 stated that there was nothing he could do, except diffuse the situation and try to calm Resident #2 down. He stated that it was clear that at some point during the transfer that the two CNAs assisting had made mistakes, so he asked what had happened. He stated that he was told that one of the CNAs did not position the sling correctly and additionally, that they, forgot to unstrap her leg from the wheelchair legrest. He stated that because the resident has dropfoot on her right foot and had a fused right knee, that she requires a strap to keep her foot from sliding off of the leg rest, and that during the hoyer transfer incident, this strap had not been unstrapped by the CNAs, keeping the resident's foot secured to the leg rest as the resident was being raised in the hoyer lift. He stated that Resident #2, has fear now and, now she's scared of everybody. An interview was conducted with the Director of Nursing (DON / Staff #9) on March 24, 2025, at 4:37 PM, who stated that her expectation for staff to keep residents free from accidents is to follow best practice and the facility policy. She stated for hoyer transfers, there should be two staff members assisting; and that, staff check with the therapy department if they are not sure how to assist a resident with a transfer. The interview continued, and the DON stated that her understanding of the hoyer lift incident with Resident #2 was that a staff CNA and an agency CNA were going to transfer Resident #2 back to bed from her wheelchair. The staff put the sling on the resident, and when the staff lifted the resident, she yelled, and they lowered her back down to her wheelchair. The staff then got additional help from another CNA. The DON stated that statements had been taken from staff, and that nobody had informed her that anything was done incorrectly during the transfer. The DON stated that, we had a stat x-ray in the building, and resident was sent to the ER was diagnosed with a fracture in her femur above the knee. She stated that there was supplemental training done with all staff on hoyer transfers and that each resident's sling will be left in their room. An interview was conducted with an RN (Staff #26) on March 25, 2025, at 8:31 AM. Staff #26 stated that he was not in the facility on the day that the incident occurred with Resident #2 and the hoyer transfer, but was the resident's nurse the following day on March 10, 2025. The RN stated that the night nurse told him there had been an injury the day before, that, maybe there was a wrong sling that was used and caused the resident's leg to hurt. On March 25, 2025, the regional Director of Operations (DO / Staff #89) signed a statement that the facility had no other policies for accidents or incidents other than the policy titled Incident Log. Review of the facility policy titled, Incident Log, dated June 2020, revealed the purpose is to provide a system for the facility to track incidents and analyze trends to identify root cause and improve the quality of care provided to residents. The facility will log incident reports as they occur. In the event of an incident, a licensed nurse or the individual who first witnesses the incident will complete an Incident/Accident Report Form and ensure the following is included: resident name, day and shift which the incident occurred, type, injury, location, severity, and medication/treatment error. Review of the facility procedure titled How to Use a Hoyer Lift, dated October 2013, revealed the U-Sling is a type of hoyer sling that wraps around the thigh and crosses between the legs of the consumer. Review of the facility procedure titled Patient Lifts Safety Guide, undated, revealed that before using a patient lift, check the patient's weight and physical condition to make sure you have the correct lift and sling for the patient's condition. Assess patient's size, weight, and hip measurement. Choose the size of sling based on manufacturer's recommendation for patient's measurement. Choosing correct sling size is critical for safe patient transfer. If the sling is too large, the patient may slip out. If the sling is too small, the patient may fall out or the sling may worsen a patient's condition. Using the wrong type of sling may cause serious injury. Some factors that may affect sling choice between the U-sling and the full-body hammock style sling are patient's size and weight, pressure sensitivity, need for padding, and patient's preferred or medically appropriate position. Review of the manufacturer's instructions for the utilized facility Lift equipment, revised October 24, 2024, revealed the procedure for using the U-Sling included the note that if the patient's legs are extremely rigid, it may work better to bring the left sling leg under the right thigh and the right sling leg under the left thigh instead of threading between the patient's legs. The top of the sling must reach just above the patient's shoulders and the base of the sling should be 2 inches below their tailbone. If you have gone under both legs with the sling legs for a rigid patient, bring the loops straight up along the outside of the legs and hook on the longest loop. Crossing the leg straps is the most common procedure, however caregivers must assess the condition of the patient to determine what method is appropriate.