**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #56) reviewed for pressure ulcers, the facility failed to provide care according to professional standards to prevent the development of a pressure ulcer. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included failure to thrive, chronic kidney disease stage 4, and Alzheimer's disease. A pressure sore risk assessment dated [DATE] identified Resident #56 was bedfast, completely immobile, nutrition was probably inadequate, and friction & sheer was a potential problem. The assessment identified Resident #56 was at significant risk to develop a pressure sore. The annual MDS assessment dated [DATE] identified Resident #56 had moderately impaired cognition, required extensive assistance of 2 staff with bed mobility, dressing and toilet use, was incontinent of bowel and bladder, and was free of pressure ulcers. The care plan dated 12/21/18 identified Resident #56 was at risk to fall related to cognition, impaired mobility and vision impairment. Interventions included to provide current seating system, which includes a tilt in space wheelchair with pressure relief cushion, bilateral leg rests and pelvic positioning belt to increase safety and comfort. Additionally, transfer the resident via a hoyer lift, and provide needed assistance or supervision with mobility and toileting if needed. The care plan identified Resident #56 was noncompliant with daily care needs. Interventions included to discuss objections, reasons, fears, ideas, inform resident about risks of non-compliance, offer alternatives, give positive feedback, accept resident's right to refuse and show respect for decisions. Review of the January 2019 documentation survey report v2, (31 days or 93 shifts), for turning and repositioning, 37 shifts lacked documentation that Resident #56 was turned/repositioned, and 23 shifts lacked documentation that Resident #56 was assisted with bed mobility. Review of the February 2019 documentation survey report v2, (6 days or 18 shifts), for turning and repositioning, 6 shifts lacked documentation that Resident #56 was turned/repositioned, and 5 shifts lacked documentation that Resident #56 was assisted with bed mobility. A wound assessment, (weekly), dated 2/7/19 identified Resident #56 was identified with a new left buttock stage II pressure ulcer that measured 2.0cm by 1.0cm by 0.1cm. Minimal bleeding was noted, and Triad was applied. A facility acquired pressure ulcer investigation tool dated 2/8/19 identified Resident #56 developed a facility acquired pressure ulcer on the coccyx. Additionally although a turning and repositioning program was in place, it was not done because Resident #56 is non-compliant and refuses. Further, a low air loss mattress was added on 2/8/19. The root cause analysis of the pressure sore development was identified as a general decline, poor oral food and fluid intake and decreased albumin level. A nurse's note dated 2/11/19 identified Triad was applied to Resident #56's open area on the left buttocks, and the resident would be seen by the wound nurse tomorrow. A wound assessment, (weekly), dated 2/12/19 identified Resident #56's left buttock stage II pressure ulcer measured 3.5cm by 2.2cm by 0.1cm. Moderate sero sanguineous drainage and the peri skin is dry and intact. Additionally, the treatment was changed to Calcium Alginate Ag, and the note clarified that the area is on the coccyx, not the left buttock as previously documented. Review of the wound physician visit report dated 2/12/19 identified Resident #56 had an acute stage 2 pressure ulcer and initial measurements were 3.5cm by 2.2cm by 0.1 cm with 50% epithelialization with moderate sero-sanguineous drainage, and the peri-wound is dry and intact. Recommendations included Calcium Alginate Ag followed by a dry clean dressing, pressure off loading in bed and frequent incontinent care. A physician's order dated 2/13/19 directed to cleanse the wound on the coccyx with wound cleanser, pat dry, apply Calcium Alginate Ag and cover with a dry clean dressing daily. Additionally, provide the resident with pressure off loading to the coccyx every shift. A wound assessment, (weekly), dated 2/19/19 identified Resident #56's coccyx had deteriorated to an unstageable pressure ulcer that measured 3.0cm by 4.5cm by 0.2cm with 75% slough present. Subsequent to physician notification, a new treatment with Santyl was ordered. Review of facility documentation identified the resident's weight on 3/5/19 was 115.6 pounds. A wound physician report dated 2/19/19 identified an acute unstageable pressure injury obscured full thickness skin and tissue loss and measured 3.0 cm x 4.5 cm x 0.2 cm deep. Observation of Resident #56 on 4/1/19 at 11:55 AM identified the resident positioned in bed on his/her back. Interview and review of facility documentation with the MDS Coordinator, (RN #2), on 4/3/19 at 1:15 PM identified that she was responsible for the development of the resident's care plan and was unable to find a current care plan that addressed preventative measures for skin prior to the development of the stage pressure ulcer on 2/7/19. RN #2 indicated she had resolved the previous at risk skin integrity care plan on 12/18/18 but indicated she should have only eliminated part of the care plan, not the entire skin care plan, and that there was no longer a current care plan for skin integrity until following the development of Resident #56's pressure ulcer on 2/7/19. Subsequently, a care plan was developed on 2/13/19 related to skin integrity. Interview and review of facility documentation with the wound nurse, (RN #3) on 4/3/19 at 1:39 PM identified although the physician was notified of Resident #56's pressure ulcer on 2/7/19 according to the weekly wound assessment, there was no physician's order for the Triad paste. RN #3 indicated an order should have been obtained. Additionally, RN #3 identified that Resident #56's off-loading of the coccyx began on 2/13/19 when the physician wrote the order. Intermittent observations of Resident #56 on 4/4/19 at 9:28 AM to 12:15 PM identified the following: The alternating pressure mattress was set to (Static 325) and was not alternating. Resident #56 was lying on his/her back with pillows on either side, and the head of the bed was elevated. Subsequent observations at 9:47 AM and 10:11 AM identified the resident had not changed position and/or the mattress settings was at Static 325. Observation at 10:40 AM identified a nurse aide was noted in the room with the resident, and at 11:14 AM Resident #56 remained on his/her back, the head of the bed was noted to be lower with pillows on either side of the resident, and the bed setting unchanged. Observation at 12:15 PM identified Resident #56 remained in the same position with no change in the bed setting. Interview and review of facility documentation with the DNS on 4/4/19 at 10:40 AM identified that although there was intermittent documentation that Resident #56 was provided with turning and re-positioning, the DNS was unable to provide evidence that staff provided consistent turning and re-positioning prior to the development of the pressure ulcer on 2/7/19. The DNS identified that the nurse aides should be documenting that the resident was turned and re-positioned every shift per the facility policy. Additionally, the DNS was unable to provide evidence that staff provided Resident #56 education on the need for turning and positioning, and/or that the resident had documented occurrences of refusals. Interview, observation and review of facility documentation on 4/4/19 at 12:20 PM with LPN #1 identified that she was unaware of the settings for the air mattress, but indicated it has been set that way since the resident received the mattress. LPN #1 identified that according to the physician's order, the resident was supposed to be off loaded from his/her coccyx. LPN #1 identified that she was unaware that the resident had not been repositioned off his/her back since 9:28 AM (almost 3 hours earlier) but the resident may have refused as he/she often refuses care. Another nurse aide entered the room and repositioned the resident onto his/her right side. Interview with the resident's assigned nurse aide, (NA #4) on 4/4/19 at 12:23 PM identified that Resident #56 had been cooperative with care and the only thing he/she refused during the shift was mouth care. NA #4 did not identify why the resident had not been re-positioned off his/her back and identified that nurse aides are not allowed to touch the air mattress settings. Interview and review of facility documentation on 4/4/19 at 3:02 PM with MD #1 identified that he was not sure if there needed to be physician directed settings for the air mattress, but that the wound nurse and wound physician would make that determination. Additionally, if there was a physician's order to provide off-loading to the coccyx, although the resident could not be off loaded at all times, MD #1 would expect the facility to follow the orders. Review of the manufacturer's operation manual for the air mattress identified that it is recommended that the patient be repositioned periodically while using the mattress. Adjust the mattress' internal pressure according to the patient's weight by using the weigh button on the control panel. Care givers should always perform a hand check by placing their hands underneath the patient's pelvis area to check if there is sufficient air support to ensure the patient is not bottoming out. The weight range is from 100 to 325 pounds. Alternating mode has a cycle time of 10 minutes and the mattress is to be set to 325 pounds during transfers. Review of the pressure ulcer policy identified turning and re-positioning is done at a minimum of every 2 hours. Review of the turning and re-repositioning schedule in bed identified the schedule is designed to maintain skin integrity while in bed, nursing assistants are responsible for tuning and repositioning the resident per the schedule, the staff nurse is responsible for oversight and monitoring and positioning residents on pressure ulcers should be avoided. Although Resident #56 was assessed to be at significant risk to develop a pressure ulcer, required extensive assistance of 2 staff with bed mobility, had a documented general decline, poor oral food/fluid intake, decreased albumin level, and a history of refusing turning and re-positioning, the facility failed to ensure staff provided consistent turning and re-positioning, and/or failed to provide Resident #56 education on the risks of non-compliance with turning and re-positioning, and/or failed to offer alternatives and/or failed to document the residents refusals with turning and re-positioning, and/or failed to notify of the physician of the refusals. Additionally, on 2/7/19 when Resident #56 was identified with a new stage II pressure ulcer, the facility failed to obtain an order for treatment to the area until 2/13/19, 6 days later. Further, when an air mattress was ordered on 2/8/19, the facility failed to ensure staff were knowledgeable regarding the air mattress and/or followed the manufacturer's recommendations for the settings. Although Resident #56 weighed 115.6 lbs., intermittent observations on 4/4/19 at 9:28 AM to 12:15 PM identified the mattress was set to static 325, and Resident #56 was not re-positioned off his/her back for almost 3 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #44 and Resident #58) reviewed for accidents, the facility failed to ensure interventions and adequate supervision to prevent falls with a resulting femur fracture, and/or failed to investigate the resident's concern regarding his/her leg getting caught during a Hoyer transfer and/or failed to provide staff with re-education to ensure safe Hoyer transfers which resulted in a hip fracture. The findings include: Resident #44's diagnosis included anxiety, depression, and psychosis. The quarterly MDS assessment dated [DATE] identified Resident #44 had moderately impaired cognition, required extensive assistance with bed mobility, transfers and toilet use, required limited assistance with walking in room, utilized a walker and wheelchair, and had a history of falls. a. A reportable event form dated 2/25/18 at 2:00 PM identified Resident #44 had an unwitnessed fall while self-transferring from the wheelchair to the bathroom. Resident #44 sustained no injury. The facility intervention directed to conduct a bowel and bladder diary for 72 hours to re-evaluate elimination patters to establish prompted toileting plan. Interview with the DNS on 4/4/19 at 11:45 AM identified that although the bowel and bladder intervention was placed on the care plan, the diary was never initiated. b. A reportable event form dated 3/10/18 at 5:15 PM identified Resident #44 had an unwitnessed fall when he/she lost his/her balance walking between the recliner chair and the bed. Resident #44 sustained no injury. The investigation identified that the nurse aide did not follow the care card, and the room was identified to be cluttered. Additionally, although Resident #44 had moderately impaired cognition, corrective action included to reinforce teaching the resident to call for assistance. Interview with the DNS on 4/4/19 at 11:45 AM identified that the intervention to address the fall placed on the care plan on 3/12/19 was to conduct a bowel and bladder diary for 72 hours to develop prompted toileting based upon elimination patterns. The DNS identified that the bowel and bladder diary was incomplete, and that the facility did not evaluate the information to determine an outcome and/or make a determination on toileting patterns. c. A reportable event form dated 3/26/18 at 3:20 PM identified Resident #44 had an unwitnessed fall and was found on the floor in the bathroom. Resident #44 sustained no injury. Interview with the DNS on 4/4/19 at 11:45 AM identified that the intervention to address the fall was to toilet the resident on last rounds on the 7:00 AM to 3:00 PM shift. Although written on the reportable event form, the interventions was not placed on the care plan, and staff were not aware of the intervention. d. A reportable event form dated 3/30/18 at 3:20 PM identified Resident #44 had an unwitnessed fall, and found next to his/her roommate's bed. Resident #44 sustained a skin tear to the left forearm and small abrasion. The care plan update included to provide the resident a visual reminder to call for assistance. e. A reportable event form dated 3/31/18 at 11:23 AM identified Resident #44 had an unwitnessed fall and sustained no injury. The care plan was updated to include encouraging the resident to attend activities and encourage call bell use. f. A reportable event form dated 4/18/18 at 11:00 AM identified Resident #44 had an unwitnessed fall and sustained no injury. Interview with the DNS on 4/4/19 at 11:45 AM identified the care plan was updated to include using a visual reminder to call for assistance. The DNS identified that the previous sign, must have been missing so the facility repeated the intervention. g. A reportable event form dated 7/13/18 at 2:15 PM identified Resident #44 had an unwitnessed fall, and was found at the bottom of the recliner by a nurse aide. Resident #44 stated he/she was trying to get up and go to the bathroom. Resident #44 sustained bruises to the left leg, lateral and posterior calf. The intervention included to place Dycem in the recliner chair, and check the resident every 15 minutes. The supervisor's investigation identified that every 15 minute safety checks and alarms were in place. The alarm, however, was placed at an angle where it did not catch the resident's movement. NA #4's statement identified that Resident #44's motion alarm was on. Interview with the DNS on 4/4/19 at 11:45 AM identified the record failed to reflect when the resident had the motion alarm placed, and/or that the motion alarm was identified on the plan of care, and/or that the resident was on 15 minute checks. h. A reportable event form dated 7/19/18 at 5:20 AM identified Resident #44 had an unwitnessed fall and sustained no injury. The report identified the motion sensor did not alarm at the time of the fall, and the care plan was updated to include ensuring placement and function of the motion sensor. i. A reportable event form dated 7/22/18 at 1:45 PM identified Resident #44 had an unwitnessed fall when he/she attempted a self-transfer and sustained pain to the right shoulder and a purpura opened on the left forearm. Interview with the DNS on 4/4/19 at 11:45 AM identified that the care plan was updated to conduct a 72 hour bowel and bladder diary to establish elimination patterns to develop a prompted toileting plan. The DNS identified that the bowel and bladder diary was incomplete, and that the facility did not evaluate the information to determine an outcome and/or make a determination on toileting patterns. j. A reportable event form dated 8/3/18 at 4:00 PM identified Resident #44 had an unwitnessed fall when he/she lost his/her balance and was found on the floor. The care plan was updated to include mounting the motion sensor on the wall, and 15 minute checks were continued. k. A reportable event form dated 8/12/18 at 7:45 PM identified Resident #44 had an unwitnessed fall when he/she attempted a self-transfer from the recliner to bed without the use of the walker. Resident #44 hit the back of his/her head on the bedside table, ice was applied and the care card was updated to include putting the resident back to bed early after 7:00 PM. The investigation identified that although the care plan directed the use of a motion sensor, the motion sensor was off. Interview with the DNS on 4/4/19 at 11:45 AM identified that he/she believed that the staff had forgotten to turn the alarm back on. l. A reportable event form dated 8/25/18 at 3:02 PM identified Resident #44 had an unwitnessed fall and was found on the floor. Interview with the DNS on 4/4/19 at 11:45 AM identified that the intervention from 3/26/18 to toilet the resident on last rounds during the 7:00 AM to 3:00 PM shift was never placed on the care plan. Additionally, the DNS identified that the alarm was again in the off position when the resident fell and, according to the nurse aide statement dated 8/26/18, he/she had forgotten to recheck if the alarm was on before leaving the shift on 8/25/18. m. A reportable event form dated 9/27/18 at 2:15 PM identified Resident #44 was witnessed lowering him/herself to the floor. The care plan was updated to offer toileting every hour when awake. The investigation identified that the resident had a tabs alarm and that the resident was identified as disconnecting the alarm. Interview with the DNS on 4/4/19 at 11:45 AM identified she was unaware the resident had a tabs alarm. Additionally, the DNS could not identify documentation of the tabs alarm in the clinical record. n. A reportable event form dated 11/20/18 at 1:45 PM identified Resident #44 had an unwitnessed fall and was found sitting on the bathroom floor. Resident #44 stated he/she slipped when he/she tried to stand up from the toilet. No injury was sustained. Interview with the DNS on 4/4/19 at 11:45 AM identified the care plan was updated to include remaining within eyesight or visualization of the resident in the bathroom after meals. The DNS identified that residents who have alarms and/or are at high risk should not be left alone in the bathroom without staff. o. A reportable event form dated 11/28/18 at 2:00 PM identified Resident #44 had an unwitnessed fall and was found on the floor in the bathroom. The resident was noted to have bitten his/her right inner lip. The care plan intervention to remain with the resident when he/she was in the bathroom was repeated. A statement by NA #5 dated 11/28/18 identified she put the resident on the toilet and left the room. Interview with the DNS on 4/4/19 at 11:45 AM identified NA #5 did not remain with the resident and was in the hallway at the time the resident fell. p. A reportable event form dated 12/6/18 at 10:30 AM identified Resident #44 was witnessed sliding out of the recliner chair onto the floor. Resident #44 was attempting to self-transfer. The care plan was updated to assist the resident back to bed after breakfast. Interview with the DNS on 4/4/19 at 11:45 AM identified although the care plan directed to utilize a motion sensor, it was not in place at the time of the fall because she had done a facility wide alarm reduction project. The DNS identified that the resident no longer had a motion sensor at the time, but could not identify the date of the alarm removal. q. A reportable event form dated 1/16/19 at 6:30 AM identified Resident #44 had an unwitnessed fall and was found on the floor, lying on his/her right side under the bedside table against the wall next, with his/her head on the legs of the bedside table. The care plan was updated to include keeping the bed in low position. The resident had a full range of motion in all four extremities with some discomfort of the left hip. A left hip x-ray at the facility on 1/16/19 identified a left subcapital femur fracture with minimal displacement and angular deformity. The resident was sent to the hospital and underwent surgery to repair the femur fracture. A statement by NA #6 dated 1/16/19 identified Resident #44 was a little bit agitated/restless when he/she rang and wanted to get up but was not steady so NA #6 provided the resident a bed pan and removed it when the resident was done. NA #6 indicated the resident was unstable to walk. The documentation failed to reflect that NA #6 notified the charge nurse that Resident #44 was agitated/restless and/or not steady to walk. Interview with the DNS on 4/4/19 at 11:45 AM identified between 2/16/18 through 1/16/19, 11 months, Resident #44 had a total of 17 falls, and on 1/16/19 fell and sustained a left hip fracture. Additionally, the clinical record failed to reflect when the resident's motion sensor was removed. Additionally, the DNS identified that the resident had changed rooms since the left hip fracture and no longer had an alarm in the room. Although it was requested, the facility failed to provide documentation that 15 minute checks were consistently completed. Although Resident #44 had moderately impaired cognition, poor safety awareness and 16 falls between 2/16/18 through 1/15/19, the facility failed to ensure interventions were implemented correctly and consistently, failed to communicate care plan interventions to staff, and failed to provide adequate supervision to prevent the resident from repeated falls. Subsequently, on 1/16/19, despite being agitated/restless and unsteady, Resident #44 was left in bed without the benefit of supervision and had an unwitnessed fall and sustained a left subcapital femur fracture with minimal displacement and angular deformity which required surgical intervention. 2 Resident #58's diagnoses included diabetes mellitus and Multiple Sclerosis. Physician's orders dated 11/2018 directed to administer Gabapentin 600mg every 8 hours, Carbamazepine 400mg twice a day and Oxycodone 5mg every 6 hours as needed for pain. A quarterly MDS assessment dated [DATE] identified Resident #58 had intact cognition, and required total assistance with transfers, toilet use and bathing and had no pain. The corresponding care plan identified a problem with self-care deficit related to MS. Interventions included to provide assistance with care utilizing two staff members and to transfer the resident with a mechanical lift with the assistance to two staff members. A nurse's notes dated 11/17/18 at 9:48 PM identified Resident #58 was complaining of left upper leg pain upon movement. Additionally, the resident stated it (left upper leg) may have been injured during a transfer with Hoyer lift earlier in the day. Physician's order dated 11/18/18 directed to apply a muscle rub to the resident's left thigh (4) times a day and as needed for pain until resolved. A nurse's notes dated 11/18/18 at 7:23 PM identified Resident #58 was complaining of left upper leg pain upon movement and a muscle rub was applied with little effect. A review of the Supervisor/24 hour Resident Status Communication Summary Report dated 11/17, 11/18, 11/19, 11/20, and 11/22/18 identified Resident #58 complained of left upper leg discomfort. Additionally, the Supervisor/24 hour Resident Status Communication Summary Report dated 11/23/18 identified Resident #58 continued to complained of left leg pain and a request was made for the APRN to come and evaluate the resident. An APRN note dated 11/19/18 identified Resident #58's chief complaint was her/his follow up for a vitamin D level. The APRN note also identified Resident #58 complained of left upper leg pain upon movement and indicated his/her left upper leg was caught on the Hoyer lift when he/she was transferred on 11/17/18, and an order was obtained for a muscle rub as needed to area. Review of the November 2018 MAR dated 11/18/18 through 11/30/18 identified muscle rub was applied 4 times a day with the exception of 11/19/18 at 1:00 PM and 11/24/18 at 9:00 PM. The MAR dated 11/22/18 identified Resident #58 received oxycodone (pain medication) at 12:01 PM for pain. A nurse's note dated 11/24/18 at 1:26 PM identified Resident #58 received Tylenol 650mg for complaint of pain. A nurse's note dated 11/24/18 at 7:00 PM identified Resident #58 continues to complain of left femur pain. Tylenol and muscle rub give as needed and a new order for an X-ray was obtained. A radiology report dated 11/24/18 identified Resident #58's left hip x-ray identified a slightly separated comminuted intertrochanteric/sub-trochanteric fracture. A nurse's note dated 11/25/18 at 9:44 AM identified Resident #58 stated that his/her left foot was caught during a Hoyer transfer to bed a few days ago, or it may have occurred 2 ½ weeks ago. Additionally, Resident #58 reported that it happened again yesterday morning (11/24/18). Resident #58 states he/she has pain 10/10 with movement. A reportable event form dated 11/25/18 at 9:00 AM identified Resident #58 reported yesterday (11/24/18) his/her foot was caught on the bottom of the Hoyer lift during a transfer. The report further identified statements from NA #2 and NA #3 that identified during a transfer on 11/24/18 (day shift) Resident #58's foot became stuck under the Hoyer lift. The facility investigation dated 11/25/18 identified NA #3 indicated that while she was assisting NA #2 with the Hoyer lift for Resident #58 from the power chair to the bed, the resident's foot dropped in between the front pedal of the power chair, and the base of the Hoyer lift. Resident #58 said my foot at which time NA #2 and NA #3 stopped the transfer, and attempted to correct the problem. NA #3 indicated after the incident, Resident #58 never said anything else about her/his leg. Further review of the facility investigation dated 11/25/18 identified that on 11/24/18 during a transfer of Resident #58, NA #2 indicated she and NA #3 began to lift Resident #58 up via a Hoyer lift when the resident's foot got stuck under the Hoyer lift. NA #2 and NA #3 stopped the transfer, lowered the Hoyer lift and dislodged Resident #58's foot. NA #2 further indicated she and NA #3 did not inform the nursing staff of what had happened because Resident #58 seem fine after the incident. Interview with Resident #58 on 4/3/19 at 11:38 AM identified he/she sustained an injury during a Hoyer lift transfer on the evening shift on 11/17/18. Resident #58 further indicated that during the transfer the 2 staff members had his/her legs split, each leg on either side of the middle bar (states they should have had my legs together on one side) and when they spun him/her around his/her left leg got caught and twisted on the bar and pulled on his/her hip. Interview with RN #5 and review of facility documentation and Resident #58's clinical record on 4/3/19 at 1:08 PM identified she initiated a reportable event form on 11/25/18 because the resident reported his/her foot had been caught and hurt the day before (11/24/18) during a transfer. RN #5 also indicated she was unable to explain why she was unaware that an incident had occurred earlier in the week (11/17/2018) despite it being documented on the supervisor communication summary report. Interview with NA #2 on 4/3/19 at 1:25 PM identified that during a transfer with a Hoyer lift on 11/24/18, Resident #58's foot got stuck under the bottom of the hoyer Lift and the resident yelled stop. NA #2 further indicated the license staff was made aware that Resident #58 complained of left upper leg pain during the previous week and that she (NA #2) had heard that something happened to the resident on the evening shift the week before. Interview and review of Resident #58's clinical record and facility documentation with the DNS on 4/4/19 at 10:24 AM she indicated that she was unaware that an incident/accident occurred on 11/17/18 and was unable to provide documentation that an incident report and/or an investigation was completed for the 11/17/18 accident. Interview with the Nursing Supervisor, (RN #4) on 4/4/19 at 1:04 PM identified when she became aware that Resident #58 was injured during a transfer (as reported by the resident) she should have initiated a reportable event form and an investigation. RN #4 indicated she should have reported the resident's injury to DNS on 11/17/18 when she became aware of the injury. Interview and review of facility documentation with the ICN/Staff Development nurse (RN #3) on 4/4/19 at 8:37 AM identified facility staff were provided training on 12/1/18 related to the safe transferring (utilizing a hoyer/mechanical lift) of Resident #58 subsequent to the resident's injury and licensed staff was directed to observe the resident's transfer to ensure safety. Interview with APRN #1 on 4/4/19 identified she became aware of Resident #58's complaint of pain (due to a transfer) during morning report on Monday morning 11/19/18. APRN #1 indicated that staff had asked her to look in on Resident #58 for his/her complaint of left hip pain. APRN #1 indicated that on 11/19/18, the resident reported to her that the staff caught his/her leg (twisted up) on the Hoyer lift. APRN #1further indicated that she conducted an assessment on Resident #58 which identified some pain but no visible bruising. Interview and review of the radiology report dated 11/24/18 with MD #3 on 4/4/19 at 11:25 AM indicated Resident #58's comminuted intertrochanteric/subtrochanteric fracture was an acute (new) fracture. MD #3 further indicated that the type of fracture occurs from a rotational/bending type force, not spontaneous and that something happened to the extremity. Interview with RN #4 on 4/4/19 at 1:04 PM indicated that although the resident informed her that he/she had pain in the left upper leg and the pain occurred due to a hoyer lift transfer RN #4 did not follow the facility policy for initiating a reportable event form and investigation because she thought it had occurred on the previous shift and that the day nurse had completed the paper work. Review of the hoyer (mechanical) lift policy procedure identified the hoyer lift will be used to transfer residents who are unable to assist with transfers and that the goal is to safely and comfortably transfer residents and to prevent resident's injuries. The facility failed to protect Resident #58 from injury when they did not investigate the resident's concern regarding his/her leg getting caught during a hoyer transfer on 11/17/18, and subsequently, failed to provide staff with re-education to ensure safe hoyer transfers to prevent injuries. Additionally, on 11/25/18 at 9:44 AM, Resident #58 stated that again, during a hoyer transfer, his/her left foot was caught in the hoyer (11/24/18) and indicated he/she has pain 10/10 with movement. Subsequently, Resident #58 was diagnosed with a comminuted (a comminuted fracture is a break or splinter of the bone into more than two fragments) intertrochanteric/subtrochanteric fracture of the left hip.