**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and procedures, resident and staff interviews, the facility failed to ensure staff followed policies and procedures and established plan of care to ensure prompt evaluation and safe transfer after a fall for 1 (Resident #31) of 4 residents reviewed for falls. The findings included: The facility policy Incident and Reportable Event Management reviewed 9/14/23 documented, The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable incidents . Avoidable accident means that an accident occurred because the facility failed to . Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident . Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force . Incident/Injury. The Licensed nurse should evaluate the resident and render first aide if needed. The nurse evaluation should be completed prior to moving a resident who has fallen to determine presence of injury . Review of the clinical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included a left above the knee amputation and left hemiplegia and left hemiparesis (weakness or inability to move the arm and leg on one side of the body). The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 5/7/24 documented Resident #31's cognitive skills for daily decision making were intact with a Brief Interview for Mental Status score of 14. The MDS noted the resident was dependent for chair/bed-to chair transfer (Helper does all of the effort. Resident does none of the effort to complete the activity). The CNA [NAME] specified for transferring, The resident is dependent and requires [Brand name] mechanical lift with 2 staff assistance for transfers. Review of the nursing progress notes showed on 7/6/24 Resident #31 complained of new onset of left arm pain. The Advanced Practice Registered Nurse was notified and ordered an X-ray of the left arm. The X-ray result showed an acute left humeral fracture. Review of the facility's investigation revealed the X-ray obtained on 7/6/24 showed Suspect incomplete fracture in proximal shaft of the left humerus with rather severe osteoporosis [weak, brittle bones] The investigation noted Certified Nursing Assistant (CNA) Staff N said on 7/5/24 when she went to assist Resident #31 into bed, the resident was leaning to the side and bent over forward. She said while repositioning the resident in the chair, he began to slide forward out of the chair so she lowered him to the floor. CNA Staff N stated the resident's left arm did not hit the chair or the floor and he was seated upright in front of the wheelchair. Resident #31 did not complain of any pain at the time. She said she got CNA Staff J and they lifted the resident from the floor onto the bed. Staff N said she put her arms under the resident's lower extremities and Staff J put his arm around the resident's upper body and they lifted him into the bed. CNA Staff J reported that Staff N asked him to help transfer Resident #31 into bed. When he entered the room the resident was sitting on the floor in front of his wheelchair. He put one arm under the resident's right arm and the other arm around the resident's left arm as the resident told him that his left arm was paralyzed from a stroke. Staff N put her arms around the resident's lower extremities and they lifted him into bed. Staff J reported the resident did not complain of any pain or discomfort to his left arm before, during, or after the transfer. The investigation noted on 7/6/24 Resident #31 complained of pain to his left arm and told the nurse he thought something happened to his arm when he was transferred into bed on 7/5/24 without the full body mechanical lift. On 7/8/24 the primary provider assessed and diagnosed Resident #31 with a fragility fracture of the left humerus related to severe osteoporosis and ordered to continue current pain medication regime as resident reported effectiveness. On 7/9/24 Resident #31 was assessed by an orthopedic doctor. An X-ray of the resident's left arm showed a fracture in the area of the humeral neck. The X-ray noted diffuse demineralization (losing bone minerals which can cause the bones to become brittle). The facility's investigation noted the resident was inconsistent in reports of events. Staff assigned to resident reported that resident was lowered to the floor while they were repositioning him in his wheelchair. Staff reported that resident was seated on the floor in front of the wheelchair. They performed a two person transfer from the floor to the bed. On 7/22/24 at 12:05 p.m., in an interview Resident #31 said he uses a mechanical lift for transfers. He said, I remember what happened when they dropped me. It was a female and a male CNA. I was in my wheelchair and they were lifting me, the girl had my foot and he had me around the waist under my arms and just as we got close to the bed they dropped me and down I went to the floor. I don't know why they didn't use the lift with me. My left arm hurts, they said it is broken. On 7/22/24 at 12:18 p.m., in an interview Restorative CNA Staff M, said Resident # 31 required a mechanical lift for all transfers with a special sling since his left leg is amputated. On 7/23/24 at 12:00 p.m., in a second interview Resident #31 said, I fractured my arm because the staff did not use a lift with me. I was in my wheelchair. They tried to transfer me to bed without the lift and they dropped me. The guy had me under the arms around my chest, I guess he didn't know I can't use my left arm at all, it does not work. They dropped me and then they picked me up and tossed me into the bed. The girl had my right leg, and down I went on the floor. They did not use the mechanical lift; I don't know why. I did not have pain right then and there because I don't always have feeling in the left arm. But the next day it really hurt. On 7/24/24 at 8:39 a.m., in an interview CNA Staff L said she was not working on 7/5/24 when the incident with Resident #31 occurred. She said a day or so after the incident Resident #31 was yelling loudly that his arm hurts so she reported it to the nurse. On 7/24/24 at 9:41 a.m., in an interview the Director of Nursing (DON) said she was notified Resident #31 complained of pain to left arm. He told the nurse he believes something happened when he was put into bed the other night. The resident said it had happened the other night when the CNA's transferred him. He went to the orthopedic physician, and they did another x-ray that showed a fracture of the left humeral neck. When she spoke with Resident #31, he confirmed he was on the floor and they lifted him into bed. I asked and he kept saying they dropped me, they dropped me. He said he was in the wheelchair and was leaning to the right. He confirmed he was lowered to the floor and picked back up. The DON said they did not know when the fracture happened, and the provider documented a pathological fracture (fracture caused by weakness of the bone structure). She said the policy specifies to notify the nurse when a resident falls or is lowered to the floor. Staff N did not notify the nurse when she lowered the resident to the floor. The resident said the pain started later in the night and he did not tell anyone until morning. He said he felt the injury was from the transfer. CNA Staff J said he had his arm over the resident's left arm, in a bear hug to get him into bed. She concluded it could have happened during the transfer. Resident #31 directly said the pain occurred after the fall and the likelihood was the fracture did happen during the transfer. The DON said, They did not call the nurse and they did not use the lift but I can't say how the fracture happened. I can't say exactly, there are different factors. I can't connect the two occurrences, the lowering to the floor and bear hug to lift him in the bed as the cause of the fracture. On 7/24/24 at 11:12 a.m., a phone call was placed to CNA Staff J. He did not answer and did not return the call. On 7/24/24 at 11:14 a.m., in a telephone interview CNA Staff N said on the night of 7/5/24, Resident #31 was in the wheelchair. She was trying to get the sling behind him which was hard to do. He could not grip the chair and started to slide out of the wheelchair. She could not stop him so she lowered him to the floor, next to the bed. She got CNA Staff J to come and help her. She grabbed the resident's buttocks and the right leg. CNA Staff J grabbed the top of the resident. Staff J had his arms wrapped around the resident like a hug. She verified they manually lifted and transferred the resident from the floor to the bed and did not use the mechanical lift as specified in the care plan and the [NAME]. She also verified she did not notify the nurse of the resident's fall since he did not complain of pain at that time. On 7/24/24 at 11:47 a.m., in a telephone interview Registered Nurse (RN) Weekend Supervisor Staff M said, first thing in the morning about 8:00 or 8:30 a.m., on 7/6/24 the nurse became aware the resident had pain. She went to speak with him. Resident #31 complained of pain to the left shoulder rated seven out of 10. Resident #31 told her he thought it happened the night before when they transferred him. He said the CNAs lifted him without the mechanical lift. He did not tell anyone about the incident but told the CNA and the nurse his arm was hurting. He got a pain pill. Staff M said when the X-ray revealed a fracture she notified the Director of Nursing. She spoke with CNA Staff J who said Resident #31 was sitting on the floor, slumped and leaning forward when he went in to help CNA Staff N. They lifted the resident off the floor and put him to bed. He did not know if the resident had fallen. On 7/24/24 at 5:38 p.m., in an interview the DON said if a resident is on the floor, the process is to notify the nurse who will assess for any injury, potential fracture, get a gait belt to transfer. She said it is not always feasible to use the lift to get a resident off the floor. It depends on the situation, such as the position of the resident, weight bearing status. If therapy is present they would assist with the transfer and determine if the lift is needed. She said the main error was that CNA Staff N did not notify the nurse immediately. The nurse should have assessed the resident.