**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the policy titled Safe Elder Handling-Transfers, the facility failed to ensure that one of 25 residents (R) (R100) was safely transferred using a mechanical lift. Actual harm occurred on 1/20/2024, when R100 fell from a mechanical lift during transfer from bed to chair and sustained one left rib fracture and two right rib fractures. There were 25 residents that required transfer assistance with a mechanical lift. Findings included: Review of the facility policy titled Safe Elder Handling-Transfer, revised 8/28/2023 documented the policy is to ensure elders are handled and transferred safely to prevent risk for injury and provide a safe, secure, and comfortable environment. Policy Explanation: All elders require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Compliance Guidelines: Number 3. Mechanical lifting equipment or other approved transferring aids will be used based on the elders' needs to prevent manual lifting except in medical emergencies. Review of the clinical record revealed R100 was admitted to the facility on [DATE]. Diagnoses included cerebral vascular accident (CVA) with left hemiplegia, aphasia, diabetes, dementia, obesity, and depression. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. Section GG revealed R100 had impairment in bother upper and lower extremities and was dependent on staff for all transfers. Review of the Progress Note dated 1/20/2024 at12:29 pm documented Nurse at Nurses Station was alerted that resident was lying on floor in bedroom beside the mechanical lift. The nurse went into residents' room and observed resident lying on floor with a complaint of pain to right side of the head, neck, and hip areas. Review of the Progress Note dated 1/20/2024 at 1:06 pm documented the Nurse at the desk was alerted that resident was on floor post mechanical transfer with two CNA's. Resident complained of back and right hip pain. Review of the Progress Note dated 1/20/2024 at 1:57 pm revealed resident was transferred to a local hospital related to post fall observation and treatment. The facility staff updated the responsible party. Review of the hospital medical records dated 1/20/2024 revealed multiple radiologic studies were completed status post polytrauma, blunt trauma from fall; Computerized Tomography (CT) of left elbow, CT of the chest/abdomen/pelvis; CT of the brain and spine; and two views (internal and external) x-ray of right shoulder. All testing revealed no injuries. Review of the Progress Note dated 1/25/2024 at 3:51 pm documented a new order from the Physician for right lateral rib series due to pain to rule out fracture. Review of the Progress Note dated 1/25/2024 at 5:56 pm documented that an x-ray was ordered for R100, and the results revealed that R100 was positive for a fracture to the eighth and nineth rib. It was further documented that the Physician Assistant (PA) and spouse were notified. Review of the Radiology Results Report dated 1/25/2024 revealed a test of the right ribs noted acute fractures of the eighth and nineth lateral ribs. Review of the Radiology Results Report dated 1/26/2024 revealed a test of the left ribs noted non-displaced fracture of the 11th rib. Interview on 4/5/2024 at 9:22 am, R100 stated that two staff members were helping him transfer to a chair using a mechanical lift, and he fell out of the sling and landed on the floor. He stated he immediately felt pain after the fall and was transferred to a local emergency room (ER), where he had several tests to see if he had any injuries. He stated the ER doctor told him he had not sustained any fractures or injuries. Further interview revealed over the next few days post fall, R100 experienced abdominal pain, and additional testing was ordered. He stated the results revealed he had some fractured ribs. Interview on 4/5/2024 at 10:38 am, the Director of Nursing (DON) confirmed that R100 had a fall on 1/20/2024, while being transferred with the mechanical lift. She stated that the mechanical lift had silver hooks to which the mechanical sling connects. Upon investigation, it was determined that Certified Nursing Assistant (CNA) CNA BB did not properly attach the sling to the mechanical lift, causing R100 to fall from the sling, when lifted. She stated the resident was sent to ER for evaluation and all tests were negative for fractures. During further interview, the DON stated on 1/25/2024, R100 complained of pain in the abdomen, and additional diagnostic testing was completed. The results from the 1/25/2024 tests revealed R100 had fractured the eighth and nineth right ribs and the 11th left rib. The DON revealed that CNA BB resigned without notice on 1/22/2024. Interview on 4/6/2024 at 9:07 am, CNA AA stated she had received training on the use of mechanical lifts as part of her annual training in-services throughout the year. CNA AA confirmed she work on 1/20/2024 and stated R100 required assistance transferring from the bed to a chair for his lunch meal. She stated she asked CNA BB to help her, as two staff were required for all mechanical lifts. She stated she secured the mechanical sling on her side, and CNA BB secured her side of the sling to the hooks on the lift. CNA AA stated she lifted R100 up with the lift and began the transfer. She stated as resident was lifted from the bed and moving towards the chair, the sling became disconnected from the hook on the side of the lift CNA BB was on, causing the resident to fall to the floor. She stated the incident happened so fast that she could not break the residents fall. During further interview, she stated she stayed with R100, while CNA BB went to get the nurse. Resident was transferred to the ER for evaluation. After the incident, the mechanical lift and the sling were inspected, and there were no indications the mechanical lift malfunctioned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Care Planning - Interdisciplinary Team the facility failed to follow the care plan for one resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a fracture of the C1 (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. Additionally, the facility failed to develop a care plan for one Resident (R#94) for the use of a travel pillow for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team reviewed on 3/1/18 noted: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS [Minimum Date Set]); 2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team. The policy did not include additional information regarding the development and implementation of resident care plans. 1. Review of the clinical record for R#49 revealed that the resident had the following diagnoses of atrial fibrillation, heart failure, hypertension, hyperlipidemia, Alzheimer's disease, non-Alzheimer's dementia, blindness (left eye) and depression. Review of the Annual MDS, for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing requiring two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of the Fall care plan for R#49 last reviewed on 1/24/19 revealed the resident was a fall risk and required extensive to total assistance for Activities of Daily Living (ADLs). Pertinent interventions in place at the time of the resident's fall on 12/15/18 included the following: to assist with all ADLs, total transfer assist with Hoyer lift, floor mat at bedside, assist rails x 2; Broda chair when out of bed for comfort and positioning; and to keep bed in low position. Review of the Behavior care plan for R#49 last reviewed on 1/24/19 revealed that R#49 had behaviors - at risk for complications/side effects r/t (related to) use of antipsychotic and other mood stabilizing medication use. The interventions documented that if resistive/combative behavior was noted, leave R#49 alone and return when safe to do so/provide additional assist as needed. Review of a handwritten statement dated 12/21/18 written by CNA FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towel and shirt. She punch at me and hit the right bedrail. I let her head down and lifted the right bedrail up and begin peri care. I turned her (R#49) to her left side to clean her bottom. She continue swinging her right arm backward towards me and pushing back. I felt that I could not clean her well, so I place her on her back. I went to pull right bedrail back down (meaning put the siderail in place) and R#49 grabbed it and begin shaking and punching it. I left it up (meaning that the siderail was not in place) and walked to the doorway and called for help. While I was standing in the doorway I heard a bang and when I turned around R#49 was laying on her back on the floor. I went towards her and yelled for the nurse. Signed by CNA FF. (sic) During an interview at the nurses' station on 1/30/19 at 11:55 a.m. with Registered Nurse Charge Nurse AA on 12/15/18, revealed that CNA FF told Registered Nurse AA that R#49 was combative so she (CNA FF) went to the resident's door to ask for help and when she turned back around the resident was on the floor. CN AA said that even if CNA FF felt like she had to go get someone, she should have made sure the bed was lowered as indicated in R#49's plan of care. During an interview at the nurses' station on 1/30/19 at 3:20 p.m. with CNA EE, CNA EE revealed that it usually required two staff to care for R#49. When asked about steps to take when the resident became combative during care, CNA EE said staff were supposed to wait until she calms down and then try to give care later. Telephone interview on 1/30/19 at 4:43 p.m. with CNA FF revealed on 12/15/18 the CNA FF was providing care to R#49 when the resident became aggressive. CNA FF said the resident and she played tug of war with the face towel while CNA FF washed the resident's upper extremities. According CNA FF, R#49 was striking out at the CNA FF and also punched the side rail with her right fist. Continued interview with CNA FF revealed that she did not re-approach the resident as indicated in her care plan and did not use the call light to seek help from other staff. During a follow-up interview at the nurses' station on 1/31/19 at 9:58 a.m. with Registered Nurse Charge Nurse AA revealed that the she thinks the resident's care plan called for one person for receiving care in bed and two people if resident is combative. Cross Reference F689 2. Review of the clinical record for R#94 revealed an admission date of 5/5/10 with diagnoses of arthritis, depression and non-Alzheimer's dementia. Review of the Annual Minimum Data Set (MDS) assessment for R#94 dated 1/8/19 revealed R#94 was severely cognitively impaired and required extensive to total assistance of one to two staff persons for all activities of daily living (ADLs). During this assessment period, R#94 received occupational therapy (OT), passive range of motion (PROM), and splint/brace assistance. Review of the Task tab printed from the electronic record for R#94 on 1/31/19 revealed Restorative staff was to provide R#94 with Passive Range of Motion (PROM) to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used for proper head positioning. Review of the comprehensive care plans for R#94 last reviewed on 1/12/19 revealed that there was not a plan of care developed to address proper neck/head positioning. Review of the Occupational Therapy (OT) Discharge Summary for R#94 dated 1/11/19 revealed one of the discharge recommendations was to continue to use cervical travel pillow when in bed and in Broda chair. Review of an Interdisciplinary Communication Memo for R#94 dated 1/11/19 completed by OT BB documented the following: Continue to use cervical travel pillow when in bed and Broda chair to maintain appropriate head positioning. Observation of R#94 in her room on 1/28/19 at 10:55 a.m. revealed that R#94 was lying in her bed with the head of the bed (HOB) elevated approximately 30 degrees. R#94 had a travel neck pillow around the back of her neck and the resident's head was bent forward and to the right near her shoulder with the resident's chin touching her chest as she slept. Interview at the nurses' station on 1/30/19 at 12:06 p.m. with Registered Nurse Charge Nurse AA revealed that R#94 used the travel neck pillow for positioning and for comfort. Interview on 1/30/19 at 3:50 p.m. with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator revealed that R#94 had used the travel neck pillow for quite some time (over a year) at the daughter's request because she felt her mother was comfortable with its use. The MDS Coordinator confirmed that a care plan should have been developed to address the use of the resident's travel neck pillow. Cross Reference F688

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Fall Policy the facility failed to provide supervision during a bed bath to prevent an avoidable fall for one Resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a fracture of the C1 (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. The sample size was 26 residents. Findings include: Review of the facility's policy titled, Fall Policy reviewed 3/1/18 revealed The facility will identify each resident who is at risk for falls and will plan appropriate care and implement interventions to assist in fall prevention. The facility will attempt to decrease falls with injury by providing an environment that is free from potential hazards. Review of the clinical record for R#49 revealed an admission date of 1/13/17 with diagnoses that included, but not limited to, atrial fibrillation, heart failure, hypertension, Alzheimer's disease, non-Alzheimer's dementia and depression. Review of the Annual Minimum Data Set (MDS), for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing and required two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of a handwritten statement dated 12/21/18 written by Certified Nursing Assistant (CNA) FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towel and shirt. She punch at me and hit the right bedrail. I let her head down and lifted the right bedrail up and begin peri care. I turned her (R#49) to her left side to clean her bottom. She continue swinging her right arm backward towards me and pushing back. I felt that I could not clean her well, so I place her on her back. I went to pull right bedrail back down (meaning put the siderail in place) and R#49 grabbed it and begin shaking and punching it. I left it up (meaning that the siderail was not in place) and walked to the doorway and called for help. While I was standing in the doorway I heard a bang and when I turned around R#49 was laying on her back on the floor. I went towards her and yelled for the nurse. Signed by CNA FF. (sic) Review of a Fall Report dated 12/15/18 completed by Registered Nurse Charge Nurse (CN) AA documented the following: CN AA (Registered Nurse Charge Nurse AA) was summoned to R#49's room and that the resident was noted lying on the floor on the right side of her bed .range of motion done, patient assessed and placed back on the bed. According to the report, the fall resulted in a laceration to the top of the resident's scalp. There were no other injuries noted. Predisposing Physiological Factors affecting the fall were noted as confused, drowsy, incontinent, recent change in condition, impaired memory and recent change in medications/New. Review of the section titled Witnesses revealed there were No Witnesses found. According to the report, the resident's Physician and family were notified of the fall. There was no other information included in the report. Record review of the Health Status Notes for R#49 dated 12/15/18 documented by Registered Nurse Charge Nurse AA revealed the following documentation in pertinent part: summoned to resident's room by caregiver, resident noted lying on the floor with a laceration to forehead extending to top of head with a small amount of bleeding. Patient assessed, and range of motion done and placed back to bed. Vital signs stable. Small amount of bleeding noted, able to control the bleeding. Neuro checks completed and intact .spoke to Nurse Practitioner who gave orders to send to ER (Emergency room). Spoke with patient's son and niece who agreed for her (R#49) to be sent out. Review of a History and Physical (H&P) Hospital Final Report from the acute care hospital dated 12/15/18 documented that R#49 was a [AGE] year old female with severe dementia, who presents from nursing home after ground level fall (do not know many details of how fall happened, attempting to contact nursing home and family) .Non-contrast head CT (computed tomography) scan revealed left parietal and occipital hemorrhage which appeared to be hemorrhagic conversion of ischemic stroke given fairly localized to PCA territory (neurosurgery in agreement). Patient also found to have a C1 fracture for which she was placed in a C-spine collar. Further review of this H&P revealed that the Assessment/Plan documents . found to have a left parietal and occipital ICH (intracranial hemorrhage) which appears to stay fairly confined to the left PCA territory, suggesting hemorrhagic conversion of an ischemic stroke rather than traumatic ICH. She (R#49) was also found to have a C1 fracture which will require stabilization. On exam, she moves all extremities equally and spontaneously. Review of R#49's Task List Report (a list of tasks to be completed by the Certified Nursing Assistants (CNAs) printed on 1/31/19 revealed the tasks of completing personal hygiene, bathing, and bed mobility were initiated on 1/13/17 (the resident's date of admission). According to the report, R#49 required the total assistance of one-two persons for personal hygiene; she required the extensive assistance of one person for bathing; and she required the extensive assistance of one person for bed mobility. According to the Task Report, the resident's level of assistance during ADLs had not changed since the tasks were initiated on 1/13/17. Observation in the resident's room on 1/30/19 at 11:09 a.m. revealed the resident was in her bed sleeping and the head of bed (HOB) was elevated approximately 30-45 degrees. The bed was in a low position. R#49 wore a neck collar, and the floor mat was on the floor to the left side of the bed. Continued observations revealed a healed vertical scar down the middle of the resident's forehead spanning from the middle of her forehead and into her hairline. During an interview at the nurses' station on 1/30/19 at 11:55 a.m. with Registered Nurse CN AA revealed that on 12/15/18, when the nurse entered the resident's room after the fall, R#49 was on the floor and had a laceration to her forehead that was deep. R#49 was sent out to the emergency room for the laceration and once at the hospital, it was found that her injuries were more than that. Registered Nurse CN AA said she remembered CNA FF was in the resident's room providing care. CNA FF told Registered Nurse CN AA that R#49 was combative, so she came to the door to ask for help and when she turned back around the resident was on the floor. Registered Nurse CN AA said staff were trained to use the call light if a resident became combative. The nurse said staff should get help to come to the room because at that point they (residents) can't be left unsupervised. Registered Nurse CN AA continued that even if (CNA FF) felt like she had to go get someone, she should have made sure the bed was lowered. Interview at the nurses' station on 1/30/19 at 3:20 p.m. with CNA EE revealed that CNA EE did not usually work with R#49, but that she had assisted other CNA's who had were assigned to assist the resident. CNA EE said it usually required two staff to care for the resident because, she (R#49) fights. Continued interview with CNA EE revealed that when residents become combative staff were supposed to wait until she (the resident) calms down and then try to give care later. Go in with two people once she calms down. Telephone interview on 1/30/19 at 4:43 p.m. with CNA FF revealed on the day of the resident's fall, she entered the resident's room to provide care (bed bath). The resident was sitting in bed with the head of the bed (HOB) elevated approximately 60 degrees. CNA FF said she raised the bed in order to provide care and left the resident with the HOB elevated and in a sitting position in order to wash the resident's face and upper extremities. CNA FF said the bilateral side rails were lowered (meaning that they were in place). When CNA FF began to wash the resident's face, the resident became combative and was grabbing at the towel. CNA FF said they were playing tug of war with the towel. CNA FF said she was able to complete washing the resident's upper extremities and then began to put on the resident's shirt. At this point, CNA FF said the resident began to swing at her which prevented the CNA FF from being able to put the resident's arms in her shirt. CNA FF stated that at one point in an attempt to hit CNA FF, that R#49 punched the side rail. Once CNA FF completed the resident's upper body, she lowered the HOB and lifted the side rail towards the HOB (meaning that the side rails were not in place), so she could complete peri care for the resident. CNA FF stated she raised the side rail to complete peri care because it was easier to reach the resident with the side rail raised (meaning that the side rail was not in place). CNA FF turned the resident over on her left side while the resident was still being combative, and the resident was using her right hand to swing back at CNA FF and grabbing the towel. CNA FF said she continued to take the towel out of the resident's hand. Once on her left side, CNA FF realized that the resident had been incontinent of bowel. The resident continued to be combative and striking and CNA FF realized she needed help to complete the resident's care. At this point, CNA FF said she attempted to put the side rail back in place and attempted to lower the bed. Due to the resident's physical aggression, she was unable to do so, but CNA FF stated she believed the bed did lower some. CNA FF then went to the doorway of the resident's room to call for assistance from another staff member. CNA FF said she called for help three times and then heard a loud thump and turned around and saw the resident's feet on the floor. CNA FF went to the resident's side of the room and found the resident on the floor on her back with her head near the dividing wall between the resident's and her roommate's beds. R#49's legs were near the foot of her bed. CNA FF said she screamed out for help. Continued interview with CNA FF revealed that sometimes it required one and two staff members to provide care for R#49. When asked about methods of caring for residents who are exhibiting combative/resistive behaviors, CNA FF said options were: 1) re-approaching, 2) pushing call light, and 3) calling for help. CNA FF said she did not re-approach the resident and did not use the call light to seek help from other staff. CNA FF said the resident required a Hoyer lift for transfers and required staff assistance for bed mobility. According to CNA FF, R#49's level of assistance in bed mobility sometimes varied. Interview on 1/31/19 at 9:33 a.m. with CNA GG revealed R#49 usually required two person assist, but sometimes, it depends. CNA GG worked on 12/15/18, the day the resident fell from bed. CNA GG said she was on the other hall when the fall occurred but was told by CNA FF that the resident fell out of bed. CNA FF told CNA GG that she went to the resident's doorway to call her for assistance because the resident was being combative and fighting and while at the door CNA FF heard a thump and turned around and realized the resident fell out of bed. CNA GG said that when caring for combative residents, it was the staff's responsibility to make sure they (the residents) are safe before leaving their side to get help, or that staff should push call light to get assistance. During a follow-up interview on 1/31/19 at 9:58 a.m. with Registered Nurse CN AA, the nurse was asked what she saw when she walked into the resident's room. Registered Nurse CN AA said R#49 was face down on the floor and she could see a little blood on the floor. At that time, she turned the resident over and saw the laceration in the middle of her forehead. Registered Nurse CN AA said she thinks the bed was still in a high position and the side rail was up towards the HOB. Registered Nurse CN AA continued by stating she thinks that the resident's care plan called for one person for receiving care in bed and two people if resident is combative. Interview on 1/31/19 at 10:18 a.m. with Licensed Practical Nurse (LPN) HH revealed she was present along with Registered Nurse CN AA in R#49's room on 12/15/18, immediately after the fall. LPN HH said R#49's bed was in a high position and that the side rail was up towards the head of the bed (meaning the side rail was not in place). LPN HH revealed that she did not work on R#49's hall so she was not familiar with the kind of assistance the resident required; however, LPN HH said that when providing care for a combative resident that sometimes you need to get someone else or re-approach. Make sure the resident is safe and then ring call bell for assistance. An interview on 1/31/19 at 10:20 a.m. with the facility's Associate Medical Director (AMD) and the facility's Director of Nursing (DON) confirmed R#49's fall resulted in a C1 fracture. The AMD acknowledged that he was aware of the resident's combative behaviors and said the resident was very strong. During the interview, the DON said that when dealing with combative residents there should be two staff, and if a CNA realizes more assistance is needed, then they should get more help. The DON said it would have been a better choice for CNA FF to use the call light to ask for assistance, or to have lowered the bed and then seek help. She said that for R#49, one-two staff were required for care while in bed, it was at the CNA's discretion depending on the resident's behavior. Post survey telephone interview on 2/14/19 at 5:15 p.m., with the Administrator and Director of Nursing (DON) revealed that the Task List is a mini care plan that lists out Activities of Daily Living for CNA's for care planned individualized approaches. The DON revealed that if a resident has been assessed (such as for MDS) to require two plus person assist for baths then a two plus person assist bath should be provided. Further interview, at this same time, with the DON and Administrator revealed that during the facility's investigation of the fall they determined that CNA FF had left the bed in a high position and that the side rail was in the up position (meaning that the side rail was not in place at the time the resident fell out of bed). Continued interview with the DON revealed that what should have happened that did not happen was that CNA FF should have gotten additional assistance by using the call light or by yelling out, the CNA should have lowered the bed before leaving the resident, and that CNA FF should have ensured the safety of the resident. Post survey telephone interview on 2/14/19 at 6:25 p.m., with CNA FF clarified that that she was familiar with working with R#49, and that R#49 had exhibited behaviors like this before when she had provided care previously. CNA FF stated that previously she had been able to talk to the resident and redirect her but on 12/15/19 she was not able to re-direct the resident. CNA FF further revealed that she should have let the side rail down (put the side rail in place), and that she should have used the call button to call for help or even used her cell phone to call for help and that she should not have walked away from the resident.