**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, witness statements, and interviews the facility failed to provide adequate assistance with transfers for 1 (Resident #3) resident who required a two person assist for transfers and had a documented history of falls. The failed practice resulted in past non-compliance. The findings are: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/27/23 documented resident required 2-person assistance with transfer. a. The Care Plan initiated on 12/13/22 documented, .Falls: Increased risk for falls related to cognitive loss, history of falls, very poor safety awareness, and potential med side effects. Resident is unable to use call light to call for assistance due to cognitive impairments. 3/21/2021 Fall, 5/22/2021 Fall, 5/25/2021 Fall, 8/19/2021 Fall, Unavoidable falls 11/2/2021, Fall 4/8/2022, Fall 6/29/2023, Fall .Transfers x2 [times two] assist Wheelchair for general mobility-Mobile via staff push .ADL [Activities of Daily Living] status/Pain: Requires extensive to total assistance with ADL's related to cognitive loss. Dx. [Diagnosis] Dementia and Alzheimer's. Resident is edentulous 9/14/2021 Decline in ADL function noted related to weakness associated with pneumonia .Provide assistance to extent necessary with ADLs (Bathing, dressing, grooming, toileting needs/pericare, hygiene, etc.) Requires extensive to total assistance x2 with ADL tasks .Resident has a current diagnosis of Dementia and Alzheimer's Disease . b. Closet Care Plan in Resident #3's room with a print date of 06/26/23 documented, .Transfer, Extensive assistance, two persons physical assist . c. A Nursing I & A (Incident and Accident) Note dated 06/29/23 at 1804 (6:04 PM) showed, called to room by CNA [Certified Nursing Assistant), resident lying on floor on left side, no s/s [signs/symptoms] of pain noted, no injuries noted. ROM [Range of Motion] WNL [Within Normal Limits] for resident no injuries noted, resident assisted back to bed by staff x2. d. A timeline of documentation provided by the facility for 07/18/23 showed: 12:00 PM - CNA transferred resident from bed to wheelchair X 1 assist 1:30 PM - CNA transferred resident from wheelchair to bed x 1 assist 3:00 to 3:30 PM - CNA changed resident and provided peri care X 1 assist 3:40 PM - the ADON (Assistant Director of Nursing) assessed resident and ROM WNL 6:25 PM - LPN (Licensed Practical Nurse) assessed leg and did not document and findings and reported her findings to oncoming nurse 6:45 PM - CNA x 2 assist provided care and notified LPN of swelling of leg and bruising, and looked broken 7:20 PM - LPN observed right leg turned out while patella and upper thigh turned inward. Notified APRN (Advanced Practice Registered Nurse) via Telemed. Orders received to send to ER (Emergency Room). e. On 7/18/23 Physician ordered, Send to ER [Emergency Room] for eval [evaluation] and tx [treatment] pain in R [Right] leg. f. 07/18/23 ER documentation, .Comminuted, Angulated, and impacted distal femoral metaphyseal .She is non ambulatory and her bone quality is not good. Because of these 2 factors I think it is unwise to consider internal fixation. I am not sure the screws would hold for 1 and the other is that she is non ambulatory and has a flexion contracture . g. The following Witness statements were obtained regarding the events that occurred with Resident #3: -Witness statement dated 07/19/23 completed by Certified Nursing Assistant (CNA) #9 documented, During Monday 7/17/23, I [employee name] gave [Resident name] a shower and all that was noticed was an old yellow bruise on her right lower thigh. I then informed the charge nurse on the hall. -Witness statement dated 07/19/23 completed by CNA #5 documented, As of Monday, when we transferred [Resident #3] back to bed, we asked charge nurse please take a look at her knee and inner knee cause of bruising. The color of bruising was yellowish for I know this past weekend we worked which was Sat [Saturday], Sun [Sunday], and Mon [Monday] she would guard her knee and would favor it not putting any weight on it. When transferring [Resident #3], we use 2 [two] people transfer and a gait belt. She doesn't pivot or turn or stand by herself or with help. -Witness statement dated 07/19/23 completed by CNA #6 documented, I, [employee name] worked the 400 hall on 7/17/23. At that point [Resident #3] had a light-colored bruise on the inside of her leg and slight swelling of her knee. I noticed when she was rolled to be changed, she would grab her right knee and seemed to be in pain. My sister, [CNA #5] and I informed the nurse. When we transfer [Resident #3] we use a gait belt and two people. -Witness statement dated 07/19/23 completed by Licensed Practical Nurse (LPN) #1 documented, 7/17/23 CNA's brought to my attention resident had bruising to her R [right] thigh and they thought her knee was hurting her. I told CNA's I would assess it after her shower and if it needed to by x-rayed I would get one. After shower complete and resident was put to bed this nurse went down an assessed residents leg. Bruising noted to inner R [right] thigh. Bruise appeared to be a few days old. I did ROM [Range of Motion] on leg. Full ROM R knee and foot. Resident showed no signs of discomfort with ROM. R knee was slightly longer than the left. I did not order x-ray because resident ROM was WNL [Within Normal Limits]. I also was aware resident had a recent fall which possibly caused the bruising. -Witness statement dated 07/19/23 completed by LPN #3 documented, I came on shift on 7/18/23 at 7am and Resident was up in chair in the common area in Med A station. Resident had no distress noted during that time. Resident showed no signs of pain or discomfort. I gave report and ended my shift at 1400 [2:00pm] to ADON (Assistant Director of Nursing). Nothing reported to me from staff during my shift. -Witness statement dated 07/19/23 completed by Certified Nursing Assistant (CNA) #1 documented, I went and got [Resident name] up at around noon yesterday for lunch. I did transfer by myself from her bed to her wheelchair. I have worked with her before, but I didn't look at her care plan before providing care. -Witness statement dated 07/19/23 completed by CNA #2 documented, Tuesday the 19th approximately 1:30pm I put [Resident name] to bed. I pulled her wheelchair as close to the bed as possible and I proceeded to place my arms around her in a bear hug position and set her on the bed and I performed peri care on her and put a clean brief on her and position her bed and put floor mat down. -Witness statement dated July completed by CNA #7 documented, I came in around 3:00pm and started around 3:30pm to change 400 hall. I started in [Resident #3] room. When I removed the covers off her I saw that she had a purple/blackish and yellow bruise on her thigh (right thigh). That her right leg was bent as well. I reported to the charge nurse which was the DON [Director of Nursing] and ADON [Assistant Director of nursing] [name]. I let them know about the bruise and her leg looking bent in bed. I continued to change her. She didn't try to push my hands away or showed any movement like she didn't want to be changed. I went in there again around 5:45pm to feed [Resident #3] dinner. I later did another round about 7:00pm [Resident #3] needed to be changed again so I had another CNA go in the room with me to get her changed. When I went to change her the last time I saw her leg still looking deformed and the bruise, so I let [nurse name] know. She was the next nurse who came in. -Witness statement dated 07/19/23 completed by ADON (Assistant Director of Nursing) Documented, This nurse was approached by a CNA stating resident has a bruise and asked nurse to assess. Upon entering the room, resident was lying in bed with eyes closed, respirations even and unlabored. Nurse assessed area reported. Brusing noted to inner thigh, yellow in color. Area cool to touch, no edema noted, ROM completed an WNL. No signs of pain or discomfort noted with ambulation. Results reported to DON. This nurse was notified by CNA at approximately 1530 [3:30pm] and resident was assessed at approximately 1540 [3:40pm]. -Witness statement dated 07/18/23 completed by DON (Director of Nursing) documented, CNA notified this nurse and ADON that resident had a bruise to her R [right] upper thigh, indicating area by rubbing her own R thigh. ADON immediately called the tx [treatment] nurse asking if she had noticed any bruising. She informed him that she was not aware of any bruising, but resident did have a fall on 6/29/23. ADON assessed the resident at this time and reported back to me that she had a yellowing old bruise to R upper thigh. He stated he performed ROM and resident did not express/indicate pain or discomfort. He also reported no noted edema, redness, or warmth. -Witness statement dated 07/18/23 completed by CNA #8 documented, On July 18th, 2023, at 6:45pm I went and help with care on [resident name] with [CNA #7]. When I went in, she was in a fetal position. After care, I went to my nurse [LPN#2 name] and ask did she get report about [Resident #3] and that her leg looks broke. When we were doing cares, I saw swelling and a bruise on inner thigh. After reporting it to the nurse she came to look, and she was not informed about [Resident #3] leg. Looking at the bruise one part was yellow and the other part was dark purple. -Witness statement dated 07/19/23 completed by LPN #2 documented, As I was passing medicine to my residents the CNA asked me if I could come look at another resident because her leg looked weird. I finished my med pass and went to the resident's room at 1525 [6:25pm]. When I arrived to the resident's room, I noticed a bruise on the resident's leg. The bruise on the resident's leg was red and fingerprint marks were implanted in her leg. The aide told me that she couldn't straighten her leg and tried to show me. I told her to not try to straighten her leg I did not report the incident because the CNA's told me that it was already reported to the ADON and DON before they left for the day. When I took the keys for 400/600 hall nothing was reported to me about the resident's leg. I reported the incident to the oncoming nurse when she arrived. I did not document what I seen in the resident log. -Witness statement dated 07/19/23 completed by LPN #4 documented, This nurse clocked into work on 7/18/23 at 1839 [6:39pm]. This nurse reported to assigned halls to take report and count cart with day shift nurse. Day shift nurse was called by this nurse at 1843 [6:43pm]. She stated she was in a room with a resident. While waiting for day shift nurse, CNA reported [Resident#3]: her right leg looked really weird and I think it could be hurting her. CNA also reported a bruise to the right inner thigh. Upon inquiring CNA about falls or injuries, CNA denied knowledge and stated she reported findings to DON and ADON prior to night shift. In the middle of CNA report day shift nurse arrived and reported abnormality and bruise to leg and asked that I follow up on it. This nurse proceeds to count and get report from day shift nurse. I tended to a different resident to administer comfort care meds then proceeded to 400 hall with med cart. CNA reminded me to check on [Resident #3], Upon inspection, a blue/black/purplish bruise was noted to inside of right thigh. Right leg was noted to be visibly abnormally placed and positioned. Right foot was noted to be turned outward while patella and upper thigh noted to be turned inward. Upon assessment, I was unable to abduct or adduct RLE [Right Lower Extremity] nor was I able to assess ROM in any direction of the leg, hip, knee, or ankle. Upon attempt, the resident cried out in pain. Assessment stopped and APN [Advanced Practice Nurse] notified as I saw no new orders or interventions for this resident and was told the incident had been reported. APN denied knowledge. Telemed visit conducted, new orders received to send to ER [Emergency Room] for eval and treat r/t [related to] pain and decreased mobility of right leg. APN notification at 1920 [7:20pm]. DON notified of findings and orders at 1927 [7:27pm]. DON stated it had been reported to her and ADON. DON stated ADON assessed resident and there were no abnormal findings. Medic One called for transport at 1928 [7:28pm]. Once Medic One arrived, I was questioned about the origin of possible injury and bruise. I denied knowledge of origin. Medic stated, I have to call this in. She has a broken leg and finger tip bruising to her thigh, without unknown cause. I voiced understanding and attempted to notify DON at 1959 [7:59pm] with no answer. I then notified Admin per chain of command at 2000 [8:00pm]. DON returned my call at 2002 [8:02pm] and was notified of transport and Medic One's Observations/statement. Resident left the facility with Medic One at 1958 [7:58pm]. Son [name] notified at 1942 [7:42pm]. h. On 07/21/23 at 1:32 pm, the Surveyor asked CNA #3, Where is the residents transfer assistance level documented so that you know how the resident is transferred? CNA #3 stated, In the closet care plan. The surveyor asked CNA #3, If a resident is a two person assist for transfers is it ok for one CNA to transfer that resident? CNA #3 stated, No. They surveyor asked CNA #3, Why? CNA #3 stated, Because there is a risk for falls and there is a reason the resident is a two person assist. Mostly for safety reasons. i. On 07/21/23 at 1:35 pm, the Surveyor asked CNA #4, Where is the residents transfer assistance level documented so that you know how the resident is transferred? CNA #4 stated, In their closet care plan. The surveyor asked CNA #4, If a resident is a two person assist for transfers is it ok for one CNA to transfer that resident? CNA #4 stated, No. Not at all The surveyor asked CNA #4, Why? CNA #4 stated, Because you can drop them, hurt them and it's not practical at all. j. On 07/21/23 at 1:42 pm, the Surveyor asked Director of Nursing (DON), Where is the residents transfer assistance level documented so that you know how the resident is transferred? DON stated, In their closet care plan and care plan. The surveyor asked DON, If a resident is a two person assist for transfers is it ok for one CNA to transfer that resident? DON stated, No. They surveyor asked DON, Why? DON stated, It is unsafe, and it is against their plan of care. k. On 07/21/23 at 1:38 pm, the Nurse Consultant provided a copy of the DMS-762. The DMS 762 documented, .Facility has determined per investigation and witness statements that yellow/green bruising to right thigh is R/T [related to] fall on 6/29/23. Based on hospital findings of resident's bone density we can prove that the leg was not broken from the inappropriate transfer vs [versus] the previous injury of the fall that worsened over time. We do not know that the transfer broke her leg. We do know we had an inappropriate transfer x2 [times two] but cannot confirm the fracture was due to the inappropriate transfer . l. On 07/21/23 at 12:23 pm, the Nurse Consultant provided a policy labeled, Safe Lifting and Movement of Residents. The policy documented, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency) . The facility submitted an action plan that was completed prior to the survey entrance to include, staff providing return demonstration of resident transfers, closet care plans reviewed, updated and transfer status highlighted for quick view, and transfers will be monitored.