**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of four sample residents received adequate supervision and services to prevent an accident/hazard. Resident #1 had diagnoses of dementia, bilateral knee contractures and chronic pain. She required extensive assistance with a mechanical lift to transfer. The facility had mechanical ceiling lifts in resident rooms and tub rooms. Resident #1 had a brain injury due to a fall from a ceiling lift on 5/27/23 at approximately 11:00 a.m. According to the facility investigation, Resident #1 had fractures of the right and left femur (thigh bone), C1 and C2 fractures (neck), right clavicle fracture and a subdural hematoma (bleeding in head between brain and outermost covering) due to the fall. She passed away at the hospital. The facility investigation documented the resident was a two person transfer with a ceiling lift, and the nurse aide was transferring the resident with the ceiling lift by herself. The investigation revealed one of the sling loops came off the lift hook causing the resident to fall. Findings include: I. Facility policy and procedure The Transferring, Lifting, Repositioning policy, revised 5/31/23, was received from the director of nursing (DON) on 7/13/23 at 12:07 p.m. The policy documented in pertinent part, Upon admission or change of condition, residents will be evaluated for their ability to transfer safely. Mechanical lift transfers may be completed by one or two staff in accordance with facility protocol. No staff member is to use a mechanical lift device until properly educated on its use. Utilize the Mechanical Lift (sling) for: Anyone requiring maximum assistance of one person for lifting or transfers; Anyone requiring 2 people to transfer or lift; Anyone unable to bear weight for at least 4 seconds (so they can't safely stand/pivot); Anyone who is unpredictable with the amount of assistance they require (if their knees tend to 'give out' , if they resist when trying to transfer or lift, or if they are uncooperative at times); Any situation where it is unclear if the resident can be transferred safely with the assistance of one person; or anytime a resident is on the floor and needs to be lifted to a chair or bed. Residents will be re-evaluated throughout their stay for any possible changes to their transfer status, which will be communicated to nursing and therapy staff. See sling color chart for (lift manufacturer) slings. II. Resident status Resident #1, over [AGE] years old, was admitted on [DATE] and readmitted on [DATE] and discharged to the hospital 5/27/23. According to the July 2023 computerized physician orders (CPO) diagnoses included right and left knee contractures, dorsalgia (back pain) and osteoarthritis. The 5/19/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and unable to complete a brief interview for mental status score (BIMS). She had short term memory loss and moderate difficulty making daily life decisions. She required extensive two person assistance with transfers, and extensive one person assistance with bed mobility, toileting, dressing, and personal hygiene. She had not had any falls since her last assessment. III. Facility investigation The facility investigation was received on 7/12/23 at 12:10 p.m. from the nursing home administrator (NHA). The investigation documented: A form titled Occurrence summary, dated 5/27/23, in the investigation file documented Resident #1 was being transferred from bed to wheelchair with the ceiling lift by nurse aide (NA) #1 who was working as the bath aide. The resident sustained a fall to the floor with neurological changes and complaints of left leg pain.The resident landed on the floor mat with her upper body on the floor. The resident was sent to the hospital and diagnosed with fractures to both femurs, C1 and C2 vertebrae of the neck, right clavicle fracture and subdural hematoma. NA #1 reported that she had been using two hands to operate the ceiling lift remote, as it was not functioning properly. A loop on the sling slipped off the lift and the resident fell out of the sling. The investigation documented the NA transferred the resident without two people using the ceiling lift, and the resident's care plan said she was a two person transfer. The charge nurse, registered nurse (RN) #2, contacted the on-call nurse manager, the staff development coordinator (SDC). The SDC came into the facility at 11:53 a.m. and began interviewing the staff involved. The investigation documented the director of nursing (DON) and nursing home administrator (NHA) were notified on 5/27/23, and the SDC finished the investigation on 5/27/23 at 5:00 p.m. Interviews in the investigation file documented the following: Nurse aide (NA) #1 documented she had just finished Resident #1's bath. She said in the tub room she had to hold the wire at the base of the remote for the ceiling lift to work. She took the resident to her room. She used the ceiling lift in the resident's room to transfer the resident. NA #1 said she had to hold the cord at the base of the remote in a certain way for the buttons to function on the ceiling lift. She connected the loops of the sling to the bar of the lift. She began to lift the resident but the right lower loop was not connected. She lowered the resident back down and reconnected the right lower loop. The NA said after reconnecting the loop she started the lift again and stated she started struggling with the remote control. She said the cord appeared to be not connected to the remote. The NA said she was focused on holding the remote correctly at the top so the buttons would work on the lift's remote. She said both hands were on the remote in order for the lift to work correctly. Resident #1 was suspended over the floor mat which was still in place adjacent to her bed. NA #1 said it appeared the right lower loop on the sling disconnected again from the lift hook. The resident fell, landing on her bedside mat diagonally, with her head on the floor, both legs were under the bed and the right knee hit the vertical post under the bed and the left leg followed. She said she did not have her resident information sheet (RIS). She knelt next to the resident, held the resident's head and tried to find a pulse. She began yelling for help and pushed the call light. Two certified nurse aides (CNAs) came within two minutes and ran for the nurse. She said RN #3 and RN #1 responded within five minutes. RN #1 documented a CNA came and told her she needed a nurse. RN #1 said she and RN #3 ran to the room and observed Resident #1 lying diagonally on the floor mat. NA #1 was holding the resident's head. NA #1 told RN #1 that she was transferring the resident when one of the loops came off. The NA said she tried to protect the resident's head as she fell. RN #1 said she could only hear a faint heartbeat at her chest. She said RN #3 obtained a pulse in the 50s on the resident's wrist (normal pulse for this resident was 54 to 72 beats per minute). RN #1 said she did not see any lumps or bumps on the resident's head but the resident's pupils were sluggish to react and unequal. She was unsure if this was the resident's normal baseline. RN #1 said she called for the charge nurse. The charge nurse, RN #2, arrived at the room. RN #1 documented she focused on stabilizing the cervical (neck) spine while RN #2 inspected the resident's lower extremities for passive range of motion. RN #1 said Resident #1 was not initially responsive to verbal or tactile stimulation, but her eyes were open. Resident #1 became more alert with the exam of her lower extremities. RN #2 left the room to call the family. RN #2 returned and said the family wanted to discuss with each other whether to send the resident to the hospital. RN #1 said that RN #2 observed the resident's left foot was rotated inward. The right leg appeared normal. RN #2 left the room again to inform the family of a possible fracture to the left leg. RN #1 said the resident's power of attorney (POA) arrived and asked the resident how she was doing, the resident responded she was not doing well. The resident said her left leg hurt. RN #1 said emergency medical services (EMS) arrived a few minutes later and the resident was transferred to the hospital. RN #3 documented at approximately 10:50 a.m. she heard a CNA yelling down the hall they needed a nurse. She said she and RN #1 ran to Resident #1's room. The resident was lying on the floor on her fall mat on her right side. Her legs were hitting the bottom of the bed. The bath aide (NA) #1 was with the resident. NA #1 said she was transferring the resident with the ceiling lift from the bed to the wheelchair, had trouble with the remote and one of the straps on the sling came undone from the lift. RN #3 said Resident #1 appeared to be having a hard time breathing and was not responding, just staring off into space. RN #3 said she did not know if the resident hit her head on the floor or the fall mat next to her bed. She said she ran to get the vital sign equipment, RN #1 stayed with the resident and RN #2 went to call the family. RN #3 said Resident #1's blood pressure and respiratory rate were elevated. She said RN #1 listened to the resident's chest, but had a hard time hearing her heartbeat. RN #3 said she was able to locate a pulse on the resident's wrist and it was in the 50s. RN #3 said RN #2 arrived. RN #3 said she turned the resident's oxygen up from one liter per minute (LPM) to four liters per minute to keep the resident's oxygen saturation above 90%. She said RN #2 assessed the resident's eyes and said her pupils were sluggish and the right more dilated than the left. RN #3 said the resident continued to appear to have difficulty breathing. She said RN #2 left to call the family and she monitored the vital signs while RN #1 stabilized the resident's neck. RN #3 said the resident became more alert and started to answer questions but not at her baseline. She said the resident was still staring off in space. RN #3 said RN #2 had spoken to the family and they would discuss what they wanted to do. RN #3 said she, RN #2, RN #1 and NA #1 transferred the resident to the bed to be more comfortable. RN #3 said the resident was more comfortable in bed and appeared to be breathing easier and began to answer questions. RN #3 said the distal end of the left thigh area appeared deformed. RN #2 left to call the family again. RN #3 said the family arrived and the resident told them she was not doing well and had pain in her left leg. The resident was transported to the hospital via EMS per the family's request. RN #2 documented the resident had fallen from the ceiling lift. She was lying diagonally on the floor mat with her legs under the bed. She had a pillow under her head. RN #2 said Resident #1 was diaphoretic (sweating heavily). She was less alert than her baseline. RN #2 said her oxygen saturation level was low and it had been difficult to obtain vital signs. She said her legs appeared bent, without obvious injuries. She said her right pupil was larger than the left and she had a change in cognition. RN #2 said she had no bumps on her head. RN #2 said Resident #1 said ouch a few times during the assessment but could not state the location of her pain. RN #2 said she left to call the family due to the advance directive medical orders for scope of treatment (MOST) form documenting comfort care was desired. She said the family would discuss what they wanted to do. RN #2 said upon further assessment of Resident #1, the left thigh area had a bump and was visibly deformed. She left to call the family again. RN #2 said the family came to the facility. The resident was sent to the hospital. The investigation documented the resident passed away on 5/28/23 at 1:40 a.m. in the hospital. It further documented the hospital records listed the immediate cause of death was heart block; other significant conditions which contributed to the death included C1 and C2 fracture, right and left femur fractures. The facility findings in the investigation documented: The resident fell while using a mechanical lift and sustained an injury. Safety interventions and facility's policies and procedures were not followed. The fall was due to human error but may be secondarily due to equipment malfunction. Resident #1 required two people to transfer with the lift due to pain. The resident was transferred with one person and the nurse aide did not have a RIS with her to indicate how the resident transferred. NA #1 was working as the bath aide that day and the bath sheet did not contain the resident's transfer status. The facility documented they changed the policy after this to print out an RIS for the bath aide each day for all the halls. The maintenance department was notified of the issue with the ceiling lift in Resident #1's room and in the tub room. NA #1 was suspended on 5/27/23 and the facility terminated her employment on 6/1/23. The facility documented NA #1 had not followed facility policy, she did not have a second person with her for a ceiling transfer, and the resident was not secured properly in the lift. NA #1 reported that she had trouble with the lift remote, however this had not been reported to the charge nurse or maintenance. The termination further documented the NA had transferred the resident three previous times without seeking assistance. The SDC documented she tested the ceiling lift in the tub room and in Resident #1's room that morning and the lifts only worked intermittently. The lift in the resident's room appeared to have a connection issue at the cord and remote which was what NA #1 had described. The lift in the tub room and the buttons on the controls failed intermittently with weight to the sling. She documented the ceiling lift belt that extended down to the bar which held the sling was observed to be frayed. The facility documented their plan was to provide education both verbal and written to NA #1. The NA was suspended and sent home pending the investigation. It documented the NA did not follow proper transfer techniques and did not tag out faulty equipment. The facility documented it intended to conduct education for all staff on ceiling lifts and education on maintenance. The investigation documented immediate transfer training was started 5/27/23, with education on not using equipment that was not functioning properly and notifying the maintenance department. On 5/27/23 the education, titled Transfer Safety Education, was based on the previous facility policy that allowed ceiling lift transfers to be done by one or two people. The education included steps for a safe transfer with a one or two person assist, including proper sling placement and ensuring the sling straps were secured properly and evenly. The education documented to never use a piece of equipment that was not functioning properly. Notify the maintenance department via a maintenance request that a repair was required as soon as possible. Always transfer resident as indicated on the RIS. The RIS should be carried by all CNAs each shift. On 5/28/23, the education titled Transfer Safety Education was revised. It documented two people were needed to assist a resident with a ceiling lift transfer. The first person would operate the lift controls and assist with resident positioning. The second person would manage the resident's extremities for safety, manage oxygen or catheter tubing as needed and assist with positioning. On 5/30/23 a Transfer Training inservice reviewed safety and the current lift transfer policy. Nurse managers would complete routine audits to observe staff transfer residents with ceiling for lifts, daily for two weeks, weekly for four weeks, monthly for three months and quarterly for four quarters. The investigation documented the evening charge nurse on 5/28/23 completed an audit of the facility ceiling lifts. The investigation documented the maintenance department assessed the lift in the affected resident's room on 5/30/23. The only issue noted was an issue with the battery that did not interfere with safety. A ceiling audit lift done by maintenance on 5/31/23 indicated the lift in Resident #1's room was no longer in use. Additionally, 56 other lifts were removed or tagged out to not use due to, for example, issues with the emergency stop switches, hand controls or remotes not working properly, cracks in chassis (load bearing portion of lift) and wheels, worn straps and battery issues (see below). -Although 56 lifts were removed or tagged, six residents who required the ceiling lifts were changed to a mechanical hoyer lift. The facility investigation documented they had updated their Transfer and Lift policy on 5/28/23, from one to two person assist with lifts based on the resident status to two person assist with all lifts. The facility charge nurses and nurse managers completed random audits of staff transferring residents with a mechanical lift. The random audits by the nurse managers and charge nurses were reviewed. The facility had completed 47 random observations of lift transfers with the nursing staff since the fall on 5/27/23. One person required more education, which was immediately completed. The facility investigation concluded the cause of the fall from the lift was due to the NA not having second person with her for the transfer, not carrying the resident information sheet with her, verifying placement of the sling loops on the ceiling lift, the ceiling lift remote not functioning and the ceiling lift not being tagged and removed from service when the NA first noticed the issue with the remote. IV. Observations and interviews CNAs #1 and #3 were interviewed on 7/12/23 at 10:40 a.m. during an observation of transferring Resident #2 with a ceiling lift. CNA #1 said she heard Resident #1 fell during a ceiling lift transfer due to the sling not being properly connected and the remote was not working correctly. CNA #1 and CNA #3 said in the past the CNAs could use the ceiling lift with one or two people to transfer. They said after the resident had the fall from the lift, the staff had to use two people. CNA #3 said they were in-serviced about a month ago to use two people for the lifts. The two CNAs began to roll Resident #2 and place a sling under Resident #2 to transfer him with the ceiling lift. The resident was then lifted by the ceiling lift with CNA #1 controlling the lift and CNA #3 guiding the resident from the bed to the wheelchair. CNA #1 said a resident's transfer status was listed on the RIS (resident information sheet) the CNAs carried in their pockets. She said the charge nurse updated them with a new admission or change in condition for a resident. CNA #1 said the RIS was a list of basic things the resident needed like how they transferred, whether to use a lift and how many staff were needed to assist the resident. CNA #2 was interviewed with CNA #3 on 7/12/23 at 10:51 a.m. while transferring Resident #3 with the ceiling lift from bed to wheelchair. CNA #4 entered the room after a few minutes and introduced herself as the CNA team lead. CNA #2 controlled the lift and CNA #3 guided the resident to the wheelchair. CNA #2 said she had training on the lifts about two months ago due to a resident who fell out of a sling from a lift. She said the training consisted of a demonstration of the lift and placement of sling loops. She said she did not have to demonstrate how to use the lift and there was no quiz or other follow up from the inservice. She said the staff were educated that all residents who used a lift required two staff members to assist. CNA #2 said in the past, some residents could be transferred with the lift and one staff member to assist. CNA #2 said the RIS sheet told the staff how to transfer the resident. She said each resident had their own sling in their room. CNA #2 said she checked the lifts to make sure there was no red warning light on. She said some of the other lifts had red lights on but those had not been used since Resident #1 fell. Resident rooms on the second floor were observed on 7/12/23 at 3:59 p.m. Rooms 2109, 2209, 2217, 2509 and 2409 had signs on the ceiling lift to not use them. Resident #1's room, the ceiling lift was removed. V. Record review and interviews The NHA was interviewed on 7/12/23 at 12:10 p.m. She said the maintenance supervisor (MS) was new and had started on 6/1/23. She said the regional maintenance director (RMD) had completed an audit of all ceiling lifts for any malfunctioning or repairs needed on 5/31/23.The NHA provided a copy of the maintenance audit of the ceiling lifts and personnel file for NA #1 on 7/12/23 at 3:43 p.m. The NHA said the maintenance audit was done on 5/31/23 by the RMD. She said the facility was built in 2007 and many of the ceiling lifts in resident rooms and tub rooms were installed at that time. She said some were installed later according to the audit done by the RMD and dates on the lifts. The untitled, undated, unsigned resident room ceiling lift audit completed on 5/31/23 by the RMD according to the NHA, revealed the following information: Twenty-nine rooms listed as room number 0. The lifts were dated 2004, 2005 and 2007. Repairs needed included one or more of the following for each lift: emergency stop switch issue, maintenance light was on, see damage report, cracked chassis, batteries and hand control issues, new strap needed on lift, new strap switch plate needed, new switch board and chassis needed. It was unclear where these lifts were located. Twenty-five rooms, with specific room numbers listed, dated 2004 and 2007, documented emergency stop switch issues, hand control issues, battery concerns, cracked chassis and maintenance lights that were on. Six of these rooms were highlighted in the audit. The audit did not indicate what the highlighting meant. These six rooms were observed during the survey with signs on the lifts to not use them (see above). The residents in these six rooms required a lift, and the hoyer lift was used. Resident #1's room number was not listed on the audit (the lift may have had one of the lifts listed as room 0.) Resident #2 and Resident #3's rooms were listed on the audit as no repairs needed. The RMD was interviewed with the NHA on 7/13/23 at 10:48 a.m. The RMD said he could not locate any previous maintenance records for the ceiling lifts. He said he had been in contact with the manufacturer and had signed a contract to have the manufacturer come out and inspect the lifts. He said it would be next month in August but he did not have a date yet. The NHA said the staff knew to let the maintenance supervisor know if there were any issues with the lifts. She said the facility had started a new process for maintenance requests. The NHA said she did not remember when, she thought maybe in June 2023. The new process involved having a maintenance book on each floor where the staff could write their concerns and the maintenance supervisor would review when he was in and sign off the request. The RMD said the rooms listed as 0 on the 5/31/23 ceiling lift audit were lifts he removed from rooms. He said he did not keep track of which ones were removed from which rooms. He said the highlighted rooms on the audit that had maintenance issues were six rooms where the resident needed a lift and the staff should use a portable mechanical lift and not the ceiling lift. He said a sign had been placed on the ceiling lift to prevent use. The RMD said the rest of the resident rooms with ceiling lift issues were residents who did not use the lifts. The NHA or RMD did not have a process to track if a resident's transfer status in those rooms changed and they needed to use the lift to ensure the staff did not use the ceiling lifts. The RMD said he had checked the lifts with his assistant on 5/31/23 for maintenance lights, issues with the switches for the emergency stops, cracked chassis housing, worn straps, hand control issues and battery issues. He said the lifts would be inspected again by him next quarter. The RMD said he assessed the four tub lifts on 5/31/23 and the lifts were working appropriately. The maintenance supervisor (MS) was interviewed with the NHA on 7/13/23 at 11:57 a.m. The MS said he had the position at the facility on 6/1/23. He was the only maintenance person for the facility but he could call the regional maintenance director (RMD) if he needed to. The MS said if the staff had a maintenance issue, they logged in a maintenance book on each floor. He said he checked the maintenance books when he came in each day. The MS said the staff had sometimes left him sticky notes on his door, sent him an email or called him if there was a maintenance issue rather than writing it in the maintenance book. He did not have a preferred method for the staff to communicate with him. The NHA said the facility had started the new process of writing maintenance requests in books on each floor a month or two ago, but she could not remember. She said she was unhappy with an outside company who the facility used for maintenance tracking and the facility had switched to this new process. The facility general orientation sheet documented NA #1 had been given information and facility's policies about resident handling, transfers and body mechanics. On 7/26/23 at 3:40 p.m., during the survey, the nurse consultant (NC) provided a computer printout that documented NA #1 had nursing orientation on 3/18/23 that included a skills assessment on mechanical lifts. The staff development coordinator (SDC) was interviewed on 7/13/23 at 11:40 a.m. She said she was the nurse manager on call on 5/27/23 and had come into the facility to investigate what happened on 5/27/23. She said the event with Resident #1 was an accident. She said she had spoken to the staff on 5/27/23 about being more intentional with their work by paying more attention to what they were doing. She said it was not the process of the transfer that failed but it was a safety issue. She said she called and spoke to the DON on 5/27/23 about changing the facility's policy on one to two person assistance with the lifts to always having two people to help avoid further risks of errors with transfers. The SDC said she began to inservice the staff at the facility on 5/27/23 on transfer safety education. She said she thought maintenance did some audits of the lifts on 5/28/23. The SDC said she posted on 5/28/23 mandatory transfer training scheduled for 5/30/23, 5/31/23 and 6/1/23 in 30 minute blocks. The SDC said it was not that NA #1 did not know how to transfer the resident. She was trained before she went on the floor. She said the staff all know how to transfer the residents with the lifts. She said they just needed to be more mindful and purposeful with their work. The SDC said on 5/30/23 the facility changed their policy to always having two people to transfer a resident using a lift. She said during a transfer with ceiling lift, the second person's job was to guide the resident's legs and body while the first person operated the remote and lift. The SDC said the education on 5/30/23 through 6/1/23 consisted of a demonstration on the ceiling lift and portable hoyer lift. The SDC said all staff were trained when hired on tagging equipment and removing it from use if it was malfunctioning. The SDC said she did not know if all nursing staff had been through the education yet. She said she thought it was about 98% of the nurses and 83% of the CNAs. The SDC said she thought the business office was tracking the staff that still needed to be educated. The SDC said it was not a training issue, it was human error. The DON was interviewed with the NHA on 7/13/23 at 2:35 p.m. She said the facility had begun immediate training with the nursing staff on 5/27/23 regarding lift safety. She said additional education was provided again when the facility changed their policy to having two persons assist with all lifts 5/30/23. Additionally, in person demonstration of lift training was done over the next few days and the charge nurses began random audits of lift transfers and were still doing random transfers according to the facility's follow up plan (see above). The DON said when a resident was admitted the admitting nurse got a report from the hospital. The admitting nurse updated the RIS with the resident's needs including how they transferred. If the transfer status was unknown the resident was transferred with two people until they were assessed by the therapy department. She said the staff would use the mechanical lift if the resident could not bear 50 percent of the weight. The RMD was interviewed again on 7/26/23 at 1:55 p.m. He said some of the lifts were left in resident rooms even though they had maintenance issues after his audit on 5/31/23. He said those lifts were stuck and he could not remove them. The RMD said those rooms had a tag placed on them that indicated not to use them. The RMD was interviewed again on 7/26/23 at 3:40 p.m. He said the ceiling lift manufacturer would be coming to the facility on 7/31/23 to assess all the ceiling lifts for any further issues or parts needed. CNA #1 was interviewed again on 7/26/23 at 2:05 p.m. She said she did not recall any concerns with the lift for Resident #1 prior to the fall. CNA #1 said the staff used to type the maintenance concern on a tablet for the maintenance person. She said last month the facility transitioned to a maintenance request book on each nurses station. CNA #4 as interviewed on 7/26/23 at 2:07 p.m. She said she did not remember any concerns with the lift in Resident #1's room. LPN #1 was interviewed on 7/26/23 at 2:17 p.m. She said she did not remember any issues with Resident #1's lift prior to her fall. The DON was interviewed on 7/26/23 at 2:30 p.m. She said she did not think there were any other resident falls from using the lifts. She said she had been at the facility since it opened in 2007. RN #4 was interviewed on 7/26/23 at 2:50 p.m. She said she was not here the day Resident #1 fell from the lift. She said she heard the fall was due to user error. She said she heard the clip on the lift hook was not closed allowing the sling loop to slip out. She said if there was a concern with a lift, she would put a sign on it to not use it and use a different lift. RN #4 said a request for the maintenance department to look at the lift should be written in the maintenance request book. The DON was interviewed again on 7/26/23 at 3:40 p.m. She said the facility currently had 26 residents that required a mechanical lift. She said 46 of the facility ceiling lifts were functioning properly, 34 lifts had been removed from resident rooms due to maintenance issues, 15 rooms still had lifts in them that did not work and were tagged not to use and four lifts in the tub rooms were working properly. The DON said seven residents were using a Hoyer lift (floor lift) due to the ceiling lift in their room not functioning properly.