**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of the facility documents the facility failed to follow the care plan/ Nursing [NAME] related to two staff assistance for transfers for one resident (R) #67 of two residents reviewed. Actual harm was identified when R#67 sustained a left arm fracture from an improper transfer. Findings include: Record review revealed that R#67 was admitted to the facility on [DATE], current diagnosis includes but not limited to contracture of the muscle, lack of coordination, osteoarthritis, abnormal posture, and proximal left humerus fracture. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing [NAME] dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. A phone interview was conducted on 2/27/19 at 12:45 p.m. with Certified Nursing Assistant (CNA) EE, regarding the incident with R#67. The CNA revealed the resident refused to use the lift to get up. She asked the resident if she could she stand and pivot to the wheel chair and the resident said yes. The CNA revealed the resident was sitting on the side of the bed and had both her feet on the floor. The resident was assisted to a standing position and pivot to the wheel chair and the resident's left arm went up. The CNA revealed she felt pressure from the resident and eased her in the wheel chair. The CNA revealed she notified her charge nurse and called the supervisor. The CNA revealed she did not ask for assistance from another staff person. CNA revealed she is aware of the residents [NAME] (guide on how to take care of the residents) and did not look at the resident's [NAME] prior to the transfer. The CNA revealed she does not have a reason of why she did not look at the [NAME]. An Interview was conducted on 02/27/19 at 11:46 a.m. the Assistant Director of Nursing (ADON) regarding R#67 transfers. The ADON revealed that R#67 is care plan transfer with two people or two people and a lifting device. The ADON revealed that each resident has a [NAME] hanging at the end of the resident bed on a clip board that gives the CNA guidance on how to care for the residents. Refer to F689

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and family interviews, and review of the facility documents the facility failed to ensure a safe and secure environment related to accidents, for one of two residents (R) reviewed for falls. Actual harm was identified on 1/11/19 when R#67 was transferred improperly by one Certified Nursing Assistants (CNA) when the resident required assistance of two staff resulting in a fracture to the left arm. Findings included: Record review revealed that R#67 was admitted to the facility on [DATE], current diagnosis includes but not limited to contracture of the muscle, lack of coordination, osteoarthritis, abnormal posture. On 1/16/19 diagnosis of acute displaced fracture of greater tuberosity of left humor was added to R#67 diagnoses list. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer and toilet use. The resident was assessed as total dependence for care. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 revealed impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing [NAME] dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. Review of the progress note dated 1/11/19 at 10:40 a.m. revealed: Writer was notified by Certified Nursing Assistant (CNA) during transferring of resident from bed to wheel chair, resident knees gave out and was going down. CNA broke fall by supporting her arm under resident left armpit and ease her into wheel chair. ROM (range of motion) performed. Able to move RT (right) arm. HEX (history) old FX (fracture) to LT (left) shoulder and muscle weakness. C/O (complained of) discomfort to LT shoulder. NP (Nurse Practitioner) notified and ordered X - Ray LT shoulder. Review of the Physician orders dated 1/11/19 at 10:35 a.m. stated x-ray of left shoulder for pain. Review of the x-ray of the left shoulder dated 1/11/19 revealed: no acute fracture or other acute abnormality Review of the progress note dated 1/13/19 at 05:08 it is documented in part c/o (complain of) pain in the left shoulder, medicated for pain x 1. There is no evidence that the nurse assessed the resident's left shoulder. Review of an Progress Note dated 1/15/19 at 02:24 it was documented in part by an Licensed Practical Nurse; Resident was assessed, to observe left upper arm and shoulder swollen and purple color discoloration. .An interview was conducted on 2/27/19 at 11:46 a.m. with the Assistant Director of Nursing (ADON) revealed the sister of R#67 called the ADON from the resident's eye appointment on 1/15/19 and requested that the ADON look at Resident # 67 arm because the resident was still complaining of pain and the resident had swelling and bruising. The ADON revealed on 1/16/19 she assessed R#67 and the left arm was swollen and bruising and called the Physician. The Physician gave an order to x-ray the left clavicle, left shoulder and left humerus. The x-ray was completed on 1/16/19 and the results of the x-ray revealed a fracture of the left humerus. An Encounter note written by a Physician dated 1/22/19 documented R#67 was seen for a proximal humerus fracture that occurred while she was in care at the (Name) home. She was not using the lift but was being lowered to the floor and a pop was felt. She was initially told that her arm was not broken, but subsequently a fracture was determined to be present. The onset date of 1/11/19, lowered to the floor, CNA said she heard a snap. She is right-hand dominant. She also has limited hand functions and a moderate amount of pain. An interview was conducted on 2/27/19 12:01 p.m. with Registered Nurse Supervisor DD regarding the incident with R#67. Supervisor DD stated when she arrived at the floor, she assessed the resident. The resident verbalized pain and there was no swelling at the time of her assessment. The Supervisor asked the CNA why she was transferring the resident alone and the CNA responded she was helping another CNA, and this was not her assigned resident. Supervisor DD revealed the CNA should have had another staff person to assist her with the transfer. Supervisor DD revealed the CNA should have checked the resident's [NAME] (guide on how to take care of the residents) prior to the transfer. Supervisor BB revealed that the [NAME] was located at the end of each residents' bed on a clip board. The CNA's are in-serviced on using the [NAME] as a resource. An interview was conducted on 2/27/19 at 12:30 p.m. with R#67 and her sister/Responsible Party (RP). Resident #67 family revealed on 1/16/19 she met R#67 at the eye doctor and when R#67 arrived she was crying. The resident expressed that she was in pain and her left arm hurt. The family member looked under R#67 clothes and seen that the arm was swollen and black and blue. The RP called the facility and spoke with the Assistant Director of Nursing (ADON) and asked her to assess the resident's arm. The next day when she arrived at the facility, she was informed by the ADON that R#67 had a fracture of the arm. The RP made an appointment for the resident to be seen by and orthopedic physician on 1/17/19. A phone interview was conducted on 2/27/19 at 12:45 p.m. with Certified Nursing Assistant (CNA) EE, regarding the incident with R#67. The CNA revealed the resident refused to use the lift to get up. She asked the resident if she could stand and pivot to the wheel chair and the resident said yes. The CNA revealed the resident was sitting on the side of the bed and had both her feet on the floor the CNA stood in front of the resident. The CNA revealed she placed her left arm under the resident's right armpit and her right arm went under the residents left arm pit. The resident was assisted to a standing position and pivot to the wheel chair and the resident's left arm went up the CNA revealed she felt pressure from the resident and eased her in the wheel chair. The CNA revealed she notified her charge nurse and called the supervisor. The CNA revealed she did not ask for assistant from another staff person. CNA revealed she is aware of the residents [NAME] (guide on how to take care of the residents) and did not look at the resident's [NAME] prior to the transfer. The CNA revealed she does not have a reason of why she did not look at the [NAME]. Review of the Radiology report dated 1/16/19 revealed Impression: Acute displaced proximal humeral fracture. Review of the orthopedics History and Physical report dated 1/17/19 revealed the following, R#67 seen today for a left proximal humerus fracture. She has moderate amount of pain. An interview was conducted on 2/28/19 at 11:40 a.m. with the Director of Staff Development regarding if CNA EE received any in-service training for using the [NAME]. The Staff Development Director revealed in-services are done but she has no documentation to support that CNA EE was in-service on using the [NAME].