**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility neglected to provide necessary care and services to prevent falls and a fall-related injury and ensure appropriate post-fall monitoring and evaluation, for 1 of 4 residents reviewed for fall risk, of a total sample of 8 residents, (#4); and failed to maintain effective processes to educate staff and offer adequate supervision to meet the needs of all residents at risk for falls. The facility's failure to appropriately monitor residents with cognitive and/or physical impairments resulted in actual harm for resident #4, and placed all residents who required increased supervision at risk for injury. Resident #4, a physically and cognitively impaired resident, received blood thinner medication and had a history of repeated falls. On 12/22/24, the Certified Nursing Assistant (CNA) assigned to supervise residents in the fall prevention program in the activity room left the residents unattended, and resident #4 fell from her wheelchair to the floor. Ten days later, another CNA left the resident alone in the activity room and she had another unwitnessed fall from the wheelchair. Assigned nurses neither initiated neurological checks nor notified with the physician until almost 12 hours after the fall when staff discovered the resident had a bruise and a golf ball sized hematoma on her forehead. The resident suffered pain and anxiety, and required transfer to the hospital for diagnostic testing to rule out a brain bleed. Findings: Cross reference F689. Review of the medical record revealed resident #4, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, stroke, lack of coordination, repeated falls, generalized muscle weakness, unsteadiness on her feet, right knee contracture, anxiety disorder, paranoid schizophrenia, and Alzheimer's disease. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 10/16/24 revealed resident #4 had a Brief Interview for Mental Status score of 6/15 which indicated she had severe cognitive impairment. She had fluctuating inattention which changed in severity and continuous disorganized thinking. Resident #4 had functional limitation in range of motion with impairment of one leg and used a wheelchair for mobility. She required substantial or maximal assistance for mobility and transfers and did not walk. The MDS assessment showed resident #4 received a high-risk drug, an anticoagulant or blood thinner, in the look back period. Resident #4's medical record revealed a care plan for fall risk, initiated on 2/07/23, which indicated she was unable to ambulate or transfer independently and had fall risk factors including decreased mobility, weakness, psychiatric medications, and cognitive deficits. The goal was resident #4 would not sustain a major fall-related injury by utilizing fall precautions as evidenced by observation and documentation. Interventions included participation in the fall risk program, remind to ask for help but recognize that the resident might not remember to ask, and escort to activity programs. A care plan for impaired mobility, initiated on 2/22/24, revealed resident #4 required ongoing assistance with mobility. The goal was she she would be out of bed daily in her wheelchair and transfer with assistance from one staff member. Review of a care plan for cognition, initiated on 2/22/24, revealed the resident's confusion and a language barrier affected her comprehension. Interventions included provide a safe and structured environment. On 2/14/25 at 12:24 PM, and 2:10 PM, the Director of Nursing (DON) explained the facility initiated a fall prevention program to provide enhanced or increased monitoring for residents at risk for falls. The DON stated either activities assistants or CNAs who were assigned to the floor monitored these residents in the activity room. She verified resident #4 was at high risk for falls and needed to participate in the fall prevention program. The DON reviewed resident #4's fall on 12/22/24 at 1:45 PM. She stated resident #4 was one of the residents in the fall prevention program. She explained the resident was found on the floor and the assigned CNA verified she was not in the activity room at the time. The DON said, We were doing 1-hour rotations for fall prevention and all CNAs shared the responsibility. She stepped out to give a resident a shower on instruction of a nurse. She stated the facility educated CNAs and nurses regarding endorsing the supervision task to another staff member before leaving the room. Review of an Education/In-Service Attendance Record dated 12/22/25 and titled 1 to 1 Supervision revealed the Administrator educated staff on the expectations for one-to-one supervision of residents. The program description read, When on 1:1 supervision as assigned, you cannot leave the resident(s) you are supervising unless coverage is there to relieve you. If you need to leave and no coverage, notify nurse. When on 1:1 you are responsible for that resident. Reconciliation of the attendance sheet with the facility's employee list revealed signatures for a total of 13 staff members including 4 of 11 Registered Nurses (RNs), 2 of 7 Licensed Practical Nurses (LPN) and 7 of 27 CNAs. On 2/14/25 at 10:25 AM, Activities Assistant P was seated in the activity room with four residents. She explained none of the residents required one-to-one supervision, but she watched over them while they were in the room. On 2/15/25 at 9:34 AM, Activities Assistant Q stated she was assigned to the activity room every Saturday from about 9:30 AM until lunchtime. She explained not all residents in the room were at risk for falls, and indicated only one of the six residents present was a fall risk. Although resident #4 was in the room, Activities Assistant Q pointed to another resident and when asked, denied resident #4 was the person at risk for falls. On 2/15/25 at 2:07 PM, the Administrator verified as the facility's Risk Manager, his duties included implementing interventions and processes to prevent recurrence of incidents and ensure the safety of residents. He confirmed resident #4 fell in the activity room on 12/22/24 when the assigned CNA left the residents unattended, and as a result, he initiated education on expectations for the fall prevention program to ensure the residents received the required level of supervision. The Administrator was informed only 13 of 45 nursing staff received the in-service, and no activities staff were included even though they were assigned to monitor residents in the activity room. He acknowledged the in-service did not reach an adequate number of staff and it was apparent that education did not continue after the day he initiated it. On 2/14/25 at 12:24 PM, the DON verified resident #4 had another unwitnessed fall in the activity room on 1/01/25 at 10:30 PM. She explained the resident was with a CNA who was charting in the activity room, and the CNA left her unattended to respond to a call light. The DON stated at the time the assigned nurse assessed her, the resident had no injuries, but the following day staff discovered a hematoma on her forehead. She confirmed the assigned night shift nurse did not perform neurological checks and the developing hematoma went unnoticed. According to the Agency for Healthcare Research and Quality (AHRQ), there is an increased risk of intracranial hemorrhage (bleeding in the brain) in elderly patients on anticoagulant therapy. The AHRQ indicates important clinical communications include documentation of the incident, outcome, and initial and ongoing observations, and an updated care plan in the medical record; and the medical provider should be notified at the time of the incident. Since there may be late manifestations of head injury even after 24 hours, it is necessary to perform neurological checks or neurochecks for 72 hours to evaluate and monitor residents after falls. Neurochecks include monitoring of vital signs, pupil size and reaction to light, reflexes, movement, and level of consciousness (retrieved on 2/24/25 from www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html). On 2/15/25 at 10:03 AM, the DON stated her expectation was nurses would adhere to accepted standards of practice and conduct post-fall neurochecks immediately after the incident, every 15 minutes for one hour, then every 30 minutes, with increasing intervals up to 72 hours, or until discontinued by the physician. Review of an Interdisciplinary Team (IDT) progress note dated 1/02/25 revealed on 1/01/25, resident #4 was agitated and attempted to get out of bed. The note indicated staff intervened for safety reasons, assisted her to her wheelchair, and brought her to the unit's common are for observation. The document revealed a while later, resident #4 was found on the floor. The assigned nurse called the Advance Practice Registered Nurse (APRN) to report the fall and then gave shift change report regarding the incident to the oncoming night shift nurse. The IDT note showed no actions taken related to closely monitoring the resident's status during the night shift, additional attempts to notify the provider, and obtaining appropriate orders. The document revealed the provider arrived at the facility the following morning to round and assessed resident #4 at that time. The physician instructed staff to send the resident to the hospital for evaluation due to her fall and head injury with the risk factor of receiving blood thinner medication. On 2/14/24 at 10:42 AM, resident #4's daughter stated her mother fell in the activity room a little over a month ago. She explained it was a scary incident as her mother was on blood thinners and hit her head when she fell. She recalled her mother's face was badly bruised for a while, but fortunately she did not suffer a brain bleed. The resident's daughter stated hospital staff emphasized that her mother needed to got to the hospital for evaluation after any falls with possible head injuries. She stated the facility informed her the CNA who was with her mother got up and left her alone in the activity room. On 2/14/25 at 3:52 PM, RN M stated resident #4 was at high risk for falls and often required increased supervision from staff to ensure her safety. She explained there were several other residents who were at high risk for falls and providing adequate supervision for them all was challenging. RN M recalled on 1/01/25, resident #4 was agitated and staff brought her to the nurses' station to monitor her. RN M stated she was occupied with another resident who needed to be transferred to the hospital and she told the three CNAs on the unit that someone needed to watch resident #4. She recalled when she finished with the other resident, she heard a moan from the activity room, and discovered resident #4 on the floor. RN M said, They weren't paying attention to me. I don't know why she was abandoned in the activity room. I felt like it was insubordination by the CNAs as several times I told them to sit with her. She explained the resident did not appear to have any injuries and she handed over her care to the oncoming night shift nurse. RN M confirmed she did not initiate neurochecks even though the fall was unwitnessed and it was unknown if the resident hit her head. She explained the resident was on her back and appeared to have slid to the floor. RN M acknowledged the resident's use of a blood thinner increased her risk for a serious brain bleed related to a head injury. She stated she called the APRN and left a message but never received a call back, and she did not attempt to notify or obtain orders from another provider. On 2/14/25 at 1:36 PM, in a telephone interview, LPN K recalled she received shift change report from RN M on 1/01/25 regarding resident #4's fall, and was told the post-fall assessment was negative and she did not seem to have hit her head. LPN K stated RN M informed her the APRN had not yet returned her call. She remembered when she arrived for her shift, all staff were arguing about who was supposed to have been supervising the resident. She stated a CNA sat with resident #4 until she started falling asleep in the wheelchair and staff then put her to bed. LPN K stated the resident slept throughout the night and she did not see her until the next morning when the day shift CNA got her out of bed and brought her out of her room. LPN K said, I looked at her and noticed discoloration to the side of her head. I said she doesn't look right. She confirmed she had not followed up with the APRN during her shift nor perform neurochecks since RN M had not initiated them. LPN K acknowledged if a resident had an unwitnessed fall, neurochecks should be done because there might be a head injury. She explained residents on blood thinners who had an unwitnessed fall should be sent to the hospital for testing. On 2/15/25 at 11:43 AM, the DON verified although resident #4 was a known fall risk, she had two unwitnessed falls over a 10-day period when CNAs left her unattended in the activity room. However, she stated she felt the resident was adequately supervised on both occasions as she did not have a care plan for one-to-one supervision. She acknowledged the first fall occurred when the assigned CNA left the group of residents in the fall prevention program and the second fall occurred after a CNA ignored a nurse's explicit instruction to remain with resident #4. The DON confirmed resident #4's physician was not informed of the second fall for almost 12 hours, and the resident remained in the facility without being appropriately monitored by nurses, but she reiterated, I would not say it was neglect. Review of the facility's policy and procedures for the Abuse Prevention Program, revised in August 2006, revealed residents had the right to be free from abuse and neglect. The policy listed components for the prevention of neglect that included staff training, identification of occurrences and patterns of potential abuse or neglect, conducting ongoing review and analyses of incidents, and implementing changes to prevent future occurrences. Review of the Facility assessment dated [DATE] revealed the facility was able to meet the needs of residents with common diseases, conditions, and physical and cognitive disabilities such as impaired cognition, anxiety disorder, behavior that required intervention, Alzheimer's disease, muscle weakness, and a history of falling. The Facility Assessment revealed staff would provide person-centered care by identifying hazards and risks and preventing abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide adequate supervision to prevent falls and fall-related injury for 1 of 4 residents reviewed for fall risk, of a total sample of 8 residents, (#4). The facility's failure to appropriately monitor residents with cognitive and/or physical impairments resulted in actual harm for resident #4, and placed all residents who required increased supervision at risk for injury. Resident #4, a physically and cognitively impaired resident, received blood thinner medication and had a history of repeated falls. On 12/22/24, the Certified Nursing Assistant (CNA) assigned to supervise residents in the fall prevention program in the activity room left the residents unattended, and resident #4 fell from her wheelchair to the floor. Ten days later, another CNA left the resident alone in the activity room and she had another unwitnessed fall from the wheelchair. Assigned nurses neither initiated neurological checks nor notified the physician until almost 12 hours after the fall when staff discovered the resident had a bruise and a golf ball sized hematoma on her forehead. The resident suffered pain and anxiety, and required transfer to the hospital for diagnostic testing to rule out a brain bleed. Findings: Cross reference F600. Review of the medical record revealed resident #4, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, stroke, lack of coordination, repeated falls, generalized muscle weakness, unsteadiness on her feet, right knee contracture, anxiety disorder, paranoid schizophrenia, and Alzheimer's disease. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 10/16/24 revealed resident #4 had a Brief Interview for Mental Status score of 6/15 which indicated she had severe cognitive impairment. The document indicated she had fluctuating inattention which changed in severity, and continuously present disorganized thinking. The resident had functional limitation in range of motion with impairment of one leg, used a wheelchair for mobility, and required substantial or maximal assistance for self-care and mobility. The MDS assessment showed resident #4 received a high-risk drug, an anticoagulant or blood thinner, in the look back period. A Fall Risk Screen dated 9/16/24 revealed a score of 16 which indicated resident #4 was at high risk for falls. Resident #4's medical record revealed a care plan for fall risk, initiated on 2/07/23, indicated she was unable to ambulate or transfer independently and had fall risk factors including decreased mobility, weakness, psychiatric medications, and cognitive deficits. The care plan revealed she fell at least four times between July and December 2024. The document was updated on 12/18/24 to reflect a fall without injury when she attempted to go to the bathroom. A revision dated 12/23/24 revealed the resident slid from her wheelchair onto the floor and did not sustain any injuries. The goal was resident #4 would not sustain a major fall-related injury by utilizing fall precautions as evidenced by observation and documentation. Interventions included participation in the fall risk program, non-slip pad for the wheelchair seat, remind to ask for help but recognize that the resident might not remember to ask, and escort to activity programs. A care plan for impaired mobility, initiated on 2/22/24, revealed resident #4 required ongoing assistance with mobility. The goal was she she would be out of bed daily in her wheelchair and transfer with assistance from one staff member. Review of a care plan for cognition, initiated on 2/22/24, revealed the resident's confusion and a language barrier affected her comprehension. Interventions included provide a safe and structured environment. Review of an incident report dated 12/22/24 at 1:45 PM revealed resident #4 fell to the floor from her wheelchair in the activity room. The document indicated she was uninjured and staff assisted her back to the wheelchair. Review of staff statements obtained during the incident investigation revealed resident #4 was one of a group of residents in the facility's activity room. The residents were supposed to be under direct supervision of an assigned CNA, who explained she left the residents in the room to attend to another resident who needed a shower. Statements from both Registered Nurses (RNs) on schedule revealed resident #4 was found on the floor with her coloring book nearby. A Post Fall Evaluation dated 1/01/25 at 11:30 PM, revealed ten days later, resident #4 fell in the facility's activity room at 10:30 PM. The document indicated the unwitnessed fall occurred because she was unattended in activity room. RN M's documentation revealed she instructed CNAs three times to not leave the resident unattended. She wrote, Resident left unattended in activity room, while I was giving report to [Emergency Medical Services]to send another resident to the hospital due to critical abnormal labs. The document indicated a hematoma was noted on resident #4's head the following day, on 1/02/25. Review of resident #4's Physician Orders revealed on 12/02/24, her physician prescribed Warfarin Sodium 6 milligrams once daily at 5:00 PM. There was an order dated 1/02/25 to transfer her to the hospital for ecchymosis or bruising and a hematoma on her forehead after a fall. Warfarin is an anticoagulant or blood thinner drug that reduces the formation of blood clots and can cause major or fatal bleeding. The manufacturer's instructions to providers indicate the use of Warfarin for geriatric patients, particularly those with cognitive issues, requires more frequent monitoring for bleeding in any situation or with any physical condition where added risk of hemorrhage is present (retrieved on 2/19/25 from www.drugs.com/pro/warfarin.html). A hematoma is a raised, bruised area resulting from a collection of clotted blood due to an injury or trauma (retrieved on 2/19/25 from www.my.clevelandclinic.org/health/diseases/15235-bruises). Falls can cause very serious head injuries, especially if the person is taking blood thinners. Older persons who fall and hit their heads should see a physician immediately to ensure they do not have a brain injury (retrieved on 2/20/25 from www.cdc.gov/falls/data-research/facts-stats/). Review of the Resident Transfer Form dated 1/02/25 revealed resident #4's diagnoses at the time of her transfer to the hospital were fall, blood thinners, and dementia. The document showed the resident had an injury to the left side of her forehead. Resident #4's hospital record revealed a computed tomography (CT) scan of her head, done on 1/02/25, found no hemorrhage or skull fractures, but showed soft tissue swelling in the left frontal scalp. On 2/14/24 at 10:42 AM, resident #4's daughter stated her mother fell in the activity room a little over a month ago. She explained it was a scary incident as her mother was on blood thinners and hit her head when she fell. She recalled her mother's face was badly bruised for a while. The resident's daughter said, Thanks to God she didn't have a serious injury inside her head. At the hospital they told me since she was on [Warfarin], she should get checked out there after a fall. She stated the facility informed her the CNA who was with her mother got up and left her alone in the activity room. On 2/14/25 at 3:52 PM, RN M described resident #4 is a well-known fall risk who needed staff supervision, sometimes one-to-one, to ensure she did not crawl out of bed or slide out of her wheelchair. She recalled the resident was agitated on the night of 1/01/25, so she asked CNAs to keep her in a common area and monitor her closely. RN M stated while she attended to another resident in a crisis situation, she repeatedly looked towards the nurses' station where resident #4 sat in her wheelchair, and repeatedly instructed the CNAs to ensure someone stayed with her. RN M stated a little later she was in the hallway and heard a moan from the activity room. She explained she discovered the resident on the floor, parallel to her wheelchair, and there was no CNA present in the room. RN M stated she assessed resident #4 and noted no injuries, so staff returned her to the wheelchair. She stated there were no new fall prevention interventions for this resident, and residents at risk for falls were placed in the activity room with CNAs rotating through the room to watch them. She explained the facility did not always have enough staff to monitor residents who needed more supervision. On 2/15/25 at 9:14 AM, the Director of Rehabilitation (Rehab) confirmed resident #4 had cognitive issues and required close monitoring to promote her safety. She reviewed an Occupational Therapy Evaluation completed on 11/22/24 which indicated the resident was at risk for falls due to impaired safety awareness and decision-making. The Director of Rehab explained resident #4 was not able to stand and transfer without moderate assistance from one person, and if she was not inclined to cooperate, it might be necessary for two people to assist for safety reasons. The Director of Rehab said, She is impulsive and thinks she can do stuff. She stated the interdisciplinary team spoke about a reacher after the fall in January 2025 as a possible intervention to prevent falls. She explained due to the resident's poor cognition, she probably would not use a reacher effectively. She verified falls were a leading cause of injuries for the elderly, and stated some falls could be prevented if residents could be educated and followed commands. The Director of Rehab acknowledged supervision was the most important approach to keep resident #4 and other cognitively impaired residents safe. On 2/14/25 at 12:24 PM and 1:30 PM, the Director of Nursing (DON) discussed resident #4's recent falls in the activity room. She explained on 12/22/24, the resident slid from her wheelchair when she reached to pick up coloring items that fell to the floor. She stated the care plan was revised to include a a non-slip pad for her wheelchair to prevent her from sliding. However, the DON acknowledged the exact circumstances of the fall were unknown as it was unwitnessed. She verified the resident fell when the CNA assigned to ensure the safety of residents in the fall prevention program left the room. Although resident #4's fall occurred when she was not supervised, the care plan was not updated to reflect her need for supervision, and the DON maintained a non-slip pad was an appropriate intervention for that circumstance. The DON stated after the resident's fall on 1/01/25, she asked the therapy department to re-evaluate her for wheelchair positioning and a reacher device. She confirmed the resident's fall occurred after a CNA again left her alone in the activity room. The DON verified although the CNA should not have left the resident unattended, and nursing documentation revealed she needed close monitoring, the care plan was not revised to show she required increased supervision. She reiterated the interventions related to assessing the resident for proper positioning in the wheelchair and use of a reacher were appropriate Review of the facility's Falls-Clinical Protocols, revised in March 2018, revealed the physician would identify medical conditions affecting fall risk including cognitive impairment and musculoskeletal abnormalities, and note the risk for significant complications of falls such as an increased risk for bleeding in residents who took anticoagulants. The document indicated staff and the physician would attempt to identify underlying causes, develop pertinent interventions to try to prevent subsequent falls, and monitor the effectiveness of the approaches.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility staff failed to promote safety during transfers with a mechanical sit-to-stand lift to prevent an accident with major injury for 1 of 3 residents reviewed for incident investigation, of a total sample of 8 residents, (#1). The failure to ensure a mechanical lift had functional and back up batteries prior to performing a transfer, and failure to take appropriate care based on potential hazards during a manual transfer resulted in actual harm. Resident #1 sustained a right shoulder dislocation, required transfer to a higher level of care, and suffered a decline in his functional range of motion. Findings: Review of the medical record noted resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] after a hospitalization. His diagnoses included hemiplegia or paralysis affecting his right dominant side, difficulty speaking, lack of coordination, and dislocation of the shoulder joint. The Annual Minimum Data Set (MDS) assessment with assessment reference date of [DATE] revealed he had a Brief Interview for Mental Status score of 15 out of 15, which indicated his cognition was intact. The MDS assessment showed the resident had difficulty communicating some words or finishing his thoughts, but he was able to if prompted or given time. The document indicated the resident required extensive physical assistance from two persons for bed mobility, transfers, toilet use, dressing, and personal hygiene. The MDS assessment revealed resident #1 had functional limitation in range of motion of one arm. Review of resident #1's medical record revealed physician orders dated [DATE] for an X-ray of the right shoulder for a diagnosis of pain, and to send the resident to the hospital related to a dislocated right shoulder. An Accident/incident note dated [DATE] at 8:16 AM, documented by Licensed Practical Nurse (LPN) A, read, Resident complains of pain to the right shoulder related to being suspended in the sit to stand above his wheelchair. [As needed] pain medication has been given as ordered.Family and doctor have been notified and [an immediate] order for a X-ray to the right shoulder is in place. Review of the resident's radiology report revealed the date of exam was [DATE]. The document was signed by the radiologist on [DATE] at 11:59 AM and read, Humeral head impaction fracture: to his right shoulder and indicated there was a dislocation of the joint. Review of the hospital After Visit Summary dated [DATE] indicated the reason for the resident's visit was shoulder pain. The document revealed his diagnoses were anterior dislocation of the right shoulder and acute pain of the right shoulder. A nursing progress note dated [DATE] at 7:38 AM read, Monitoring resident related to dislocated Right shoulder. Resident denies pain or discomfort at this time. Review of the physician's progress note with date of encounter of [DATE] at 12:30 PM, revealed the resident had shoulder pain that had been occurring for days, had been worsening, and was aggravated by movement. The document read, There is a sling in place to the right shoulder.Shoulder dislocation.Manually manipulated back in to place in ED [Emergency Department]. Review of the facility's Risk Management Tracking Tool revealed an entry on [DATE] for resident #1 regarding an incident that occurred on [DATE]. The document indicated staff used a mechanical lift to transfer the resident out of bed and into his wheelchair, but during the transfer, the lift stopped functioning. The document revealed the resident was suspended over his wheelchair and became anxious and tried to turn around, so staff assisted him out of the lift and completed the transfer into his wheelchair by slipping his arms out of the lift's support straps. The Risk Management Tracking Tool indicated the resident later complained of right shoulder pain, so the physician was notified, and the facility obtained orders for an X-ray and pain medication. The X-ray result showed a right shoulder dislocation, and the physician gave an order to send resident #1 to the Emergency Department for further evaluation. On [DATE] at 2:00 PM, the Registered Nurse (RN) / Interim Unit Manager (UM) stated she was out of town when resident #1's incident with injury occurred on [DATE]. She recalled when she returned, she heard about an issue with the sit-to-stand mechanical lift. She recalled she was informed the lift would not go down because the battery might have died, and ultimately the transfer caused resident #1's shoulder dislocation. The RN / Interim UM stated the sit-to-stand lift had an emergency release, but she was not sure if staff attempted to use it. On [DATE] at 3:49 PM, Certified Nursing Assistant (CNA) B recalled the day she transferred resident #1 from his bed to his wheelchair with a sit-to-stand mechanical lift and the lift got stuck and would not go down. CNA B stated the resident was suspended in the sling above the wheelchair. She explained they replaced the battery but the lift still did not work and the emergency switch would not function. She said, Since the resident was suspended, we had to act fast. CNA B explained LPN A, who had been assisting her with the transfer, removed resident #1's arms from the sling and allowed him to slump down into the wheelchair. CNA B stated they did not have enough room to lower the resident slowly and gently into the wheelchair beneath him, and he complained of arm pain when the transfer was completed. On [DATE] at 4:26 PM, in a telephone interview, LPN A recalled resident #1 was on her assignment on [DATE]. She stated she was at her medication cart when CNA B informed her that the sit-to-stand lift was not working. LPN A stated after she instructed CNA B to get another battery, she left the medication cart and went into the resident's room. LPN A explained when she arrived at the room, she observed resident #1 suspended from the sit-to-stand lift. She stated she attempted to lower the resident, but neither the battery functioned nor the emergency switch worked. She recalled CNA B wanted her to release the sling straps on both sides of the resident and they positioned him in the wheelchair. LPN A stated resident #1 did not complain of pain at that time, but when he complained later on, she notified the physician and obtained an order for an X-ray. She confirmed the X-ray showed the resident had a dislocation of the right shoulder and he was sent out to the ED for further evaluation. On [DATE] at 4:50 PM, the Executive Director confirmed staff were trained on the facility's protocols for use of mechanical lifts and they were expected to always utilize two people for all mechanical lift transfers, to lower residents with the emergency button if the lift stopped working, and to ensure batteries were placed on the charger after use on the 3:00 PM to 11:00 PM shift, and remained there overnight. On [DATE] at 5:45 PM, the Maintenance Director stated the facility had a total of three mechanical lifts, two full body lifts and one sit-to-stand lift. He explained the facility leased the mechanical lifts and the leasing company serviced the equipment annually. The Maintenance Director stated he was made aware of the incident regarding the sit-to-stand lift after the fact. He stated he checked the lift and noted the problem was a dead battery. The Maintenance Director explained he placed a new battery and the sit-to-stand lift functioned. He stated the facility had four battery charging stations and when he evaluated all the batteries, he discovered one battery would not remain charged, so he took it out of service. The Maintenance Director had no documentation to verify his actions after the incident, and explained he assumed the Director of Nursing would have documented since there was no problem with the lift itself. When asked about the emergency switch, the Maintenance Director said, If the lift had a dead battery, nothing will work. He verified the facility did not replace the sit-to-stand lift as he only placed a new battery. Review of the User Manual for the sit-to-stand lift revealed documentation under the heading Warning and Caution read, Please note that a lifted patient cannot be lowered down when battery is out of power. On [DATE] at 6:15 PM, the Executive Director shared an incident report dated [DATE], prepared by Licensed Practical Nurse (LPN) A, that showed at 7:40 AM, Certified Nursing Assistant (CNA) B notified her that resident #1 was stuck in the sit-to-stand lift. The CNA reported the resident was suspended over his wheelchair because the lift's battery was dead, as were all the other replacement batteries. The incident report noted LPN A assisted in removal of the resident's arm from the support strap, complained of pain to the arm and a follow up X-ray showed he had a dislocated shoulder. The Executive Director explained findings from an interview with CNA B indicated the sit-to-stand lift's battery was not charged and she called the nurse to help her get the resident into his wheelchair. The Executive Director stated CNA B said the battery seemed to be out, the lift was stuck, and the resident was calling out to be lowered from the lift. When asked if CNA B was transferring the resident by herself when the lift stopped working, the Executive Director said, It does not show whether someone was there or not there. The facility had no other witness statements included in the documents presented by the Executive Director. There was no evidence that the resident and his roommate were interviewed after the incident, although they were both alert, oriented, and without cognitive impairment. On [DATE] at 8:42 AM, in a telephone interview, the resident's son explained his father's right side and vocal cords were paralyzed. He recalled that on [DATE], the facility called at 8:20 AM and a staff member informed him,there was a bit of accident, but Dad's fine. The son stated he was told his father would receive Tylenol for pain. He recalled his father called later and complained of pain and asked, What shall I do? The son stated the facility called again at 2:30 PM, approximately six hours after the incident, to notify him that his father was on the way to the hospital Emergency Department (ED) because an X-ray showed an issue. He said, It was not the first, second, or third time that the [sit-to-stand] lift had not worked. He stated it took the facility seven hours from the time of the incident to send his father to the hospital. The son verbalized the roommate told him his father was in the corner of his room crying and saying he was in pain. He explained resident #1 was paralyzed on his right side, so he assumed the pain must have been excruciating if he was crying. He recalled, The surgeon said it was one of the worse dislocations he had seen. On [DATE] at 10:00 AM, 10:53 AM, and 1:43 PM, the incident was discussed with the Executive Director. He described the incident as human error and a one-time event. However, he validated facility staff should follow all procedures and regulations. On [DATE] at 3:04 PM, resident #1 was seated in his motorized wheelchair in his room. In a soft voice, he described the events of [DATE]. The resident explained the nurse and the CNA got him out of bed with the sit-to-stand lift, but as the lift lowered him to the wheelchair it stopped because the battery was dead. He recalled staff tried four different batteries while he was suspended in the lift sling, but all the batteries were dead. Resident #1 recalled the nurse tried to lower him to the wheelchair, but .did it wrong. She held my left shoulder and my right arm bumped into the wheelchair, and my shoulder popped. He recalled his arm hurt and he realized his shoulder was dislocated. The resident stated his memory was vague, but he thought he waited at least three to four hours after the incident before he was sent out to the hospital. Review of the medical record showed no documentation to indicate what time the resident was transferred to the hospital on [DATE]. Review of the resident's Plan of Treatment for Rehabilitation with start of care on [DATE] and onset date of [DATE], revealed his primary diagnosis was dislocation of the right shoulder joint and pain in the right shoulder. The document read, resident referred following a recent change in status due to [right] shoulder dislocation.suffered [right] shoulder dislocation following incident at SNF [Skilled Nursing Facility]. The document indicated an X-ray done on [DATE] identified a fracture of the head of the right humerus which caused right shoulder pain and .impacting burden of care during transfers with caregivers. The facility's policy Reporting Accidents and Incidents indicated Each resident receives adequate supervision and assistance devices to prevent accidents.