**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a mechanical lift was used to complete a transfer according to the plan of care resulting in a fall, on-coming staff and the physician were informed of the fall, and thorough assessments were completed when the resident continued to complain of pain resulting in the delay in diagnosis and treatment of a fracture for 1 (Resident #73) of 1 resident who had a fall. These failed practices resulted in actual harm to Resident #73, who had a fall due to staff not using a mechanical lift during a transfer. The findings are: Resident #73 was admitted on [DATE] and had diagnoses of Nontraumatic Intracerebral Hemorrhage, Aphasia, Apraxia, Anxiety Disorder, Depression, Sleep Apnea, and Seizures. The Quarterly Minimum Data Set with an Assessment Reference Date of 04/05/2022 documented the resident was moderately impaired in daily decision making per a Staff Assessment for Mental Status required extensive assistance with two staff for bed mobility and transfers, and extensive assistance with one staff for dressing, toileting, and personal hygiene. a. The care plan documented, Focus I require extensive assist x [times] 2 staff with . transfers . Date Initiated: 2/22/22 . Interventions . I require assist x 2 staff and a mechanical lift with all transfers . Date initiated 2/22/22 . b. A document titled #2379 Fall documented, .[Resident #73] Incident Location: Resident's room . Nursing Description: CNAs [Certified Nursing Assistants] reported to this LPN [Licensed Practical Nurse] that as resident was put back in bed she began falling and was lowered to the floor by CNAs. She was then assisted to the bed prior to the LPN assessing the resident. She was c/o [complained of] right lower extremity pain at the time. She was pointing at her ankle and foot. Resident Description: I started falling and they lowered me to the floor . Description: Assessment done. Remind staff to be conscious of their ability to lift. Resident taken to hospital: N [No] . Injury Location: Right lower leg (front) . Predisposing Situation Factors: Incident during staff assist transfer to/from chair . Agencies/People Notified .Physician/Extender [Doctor] 03/08/2022 1513 [3:13 p.m.] Resident Representative [Husband] 03/08/2022 1513 . c. A Nurse's Note dated 03/06/2022 at 9:45 pm documented, .Previous shift stated resident had increased anxiety and pain since the tornado warning, resident screaming, inconsolable. Scheduled pain pill given and PRN [as needed] Flexeril. No change in resident, resident repositioned. Resident continues screaming. Called [doctor], ordered one-time extra dose of resident's prn pain medication, Tylenol with codeine. Resident lying in bed with head elevated. d. A Nursing Note dated 03/09/2022 at 6:23 pm for 03/07/22 at 08:30 am documented, Late entry: Note text: Called [Doctor] office approximately 0830 regarding resident who was calling out in pain rated 10/10. Left message explaining condition of resident and her requiring additional medication for pain and severe anxiety. [Doctor] returned my call approximately 15 minutes later and discussed status of the resident. [Doctor] could hear the resident yelling out while on the phone with me. [Doctor] ordered blood work, stat [immediate] medication which was ordered and additional PRN medication. [Husband] was notified and he came to the facility within 1-2 hours which helped relax his wife for a short period of time. Medication was dispensed and resident was closely monitored. e. An Incident note dated 03/08/2022 at 3:14 pm, documented, CNAs reported to this LPN that as resident was put back in bed she began falling and was lowered to the floor by the CNA's. She was then assisted to the bed by use of a Hoyer lift prior to this LPN assessing resident. She was c/o (complaining of) right lower extremity pain at the time. She was pointing towards her ankle and foot. Attempted to rub resident's lower extremity to reduce pain. Resident had stated it felt better at the time. f. An Activity Note 3/8/2022 at 3:48 p.m. documented, Note text: Order Received from [physician] to send Resident To ER to have Right Leg Pain Eval. g. An Injury of Unknown Origin Incident and Accident report date 03/08/2022 at 3:18 pm documented, .Resident had complaint of pain to right leg. Order obtained for x-ray of RLE [right lower extremity] where it was noted that there was a fracture of the right femur .Resident transferred to hospital for x-ray .swelling right knee front . h. The hospital Discharge Summary documented the resident was admitted on [DATE] and discharged on 3/15/2022. The diagnosis was right distal femur fracture. History of Present Illness: [Resident #73] is a [AGE] year old female patient . presented after She had a fall Sunday [3/6/2022] night at the nursing home, unable to rate her pain. She is unable to communicate fully due to prior stroke. Per her husband, during a tornado approaching on Sunday, 2 days prior to admission, she was being moved due to the inclement weather. After the storm had passed, they were trying to move her back to her bed in her room and apparently she slipped while placing her in a wheelchair injuring her right leg . Hospital Course: [Resident #73] admitted to the hospital for right shaft femur fracture . Ortho [orthopedics] was consulted for further recs [recommendations]. She has placed retrograde femoral nail on 3/11/2022 . i. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Resident Property and Exploitation of Residents in Long Term Care Facilities documented, .Date and Time of Discovery 3/8/2022 Time: 8:00 P.M . [Resident #73] was having continued pain in her right leg; she was sent to the ER [emergency room] for further evaluation. Upon x-ray it was noted resident had a right femur fracture and right fibula fracture. A report was completed for an injury of unknown origin . On 3/6/22 [Resident #73] was assisted to floor by staff. Resident assessed by nurse with no change noted to baseline. From the date of 3/6/22 to 3/8/22 no change was noted to her baseline with no bruising noted. Based on the facts and information gathered we are unable to identify when or how the injury occurred . Findings and Actions Taken . Inservice completed for abuse and neglect . j. On 04/11/2022 at 02:33 PM, the husband was asked about notifications during the representative interview. He stated, They did not tell me she fell. I found out when I visited the next day [03/07/22] and she was hurting, and I questioned her. I got it out of her that they dropped her. She understands everything but just can't articulate. They didn't do anything about it for two days. They questioned the nurse about it to come in and write a statement and I haven't seen that nurse since. He was asked if he had let the nurse know. He stated, Yeah I went out and asked the nurse about them dropping her on the floor. She said she didn't know anything about it. And I went the next day because she was still hurting, and that nurse said that maybe she needs to go to the hospital. k. On 4/12/2022 at 2:20 pm [Doctor] was asked if he was aware of the fall on 3/6/22. He stated, No I was not informed until 3/8/22. He was asked about her general condition. He stated, She has had a CVA, [Cerebrovascular Accident] and she gets frustrated easily because she's hard to understand. She's really sensitive to pain. I came over to see her when she came back because I wanted to see her wound. But I will say she has big legs, and it would be hard to be able to see if something was wrong with it or not, any deformity. l. On 04/12/2022 at 2:46 pm, CNA #3 was asked about what happened with the resident on 3/6/22. He stated, [Resident #73] was hollering more than usual. I didn't notice anything unusual with her leg, no swelling or redness. I just thought she hadn't had her pain medicine yet. He was asked, Did you report to the nurse? He stated, Yeah, we asked the nurse what was going on and she just said they had a storm last night and they thought that made her more anxious. m. On 04/12/2022 at 2:55 pm, CNA #4 was asked, Did you notice anything unusual about [Resident #73] on 3/7/22 when you worked? She stated, Well she's always been a screamer and that day she was screaming more than usual. She was asked, Did you notice anything unusual with her leg? She stated, No. She was asked, Did you report her increased screaming to the nurse? She stated, Yes. She was asked, What nurse? She stated, I don't remember.