**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were transferred per plan of care with the right amount of assistance for 2 of 6 residents reviewed for accidents. One resident sustained a fractured right shoulder (Resident 98) and another resident sustained injury to an existing wound requiring invasive wound vacuum therapy. (Resident 26) The Immediate Jeopardy began on 6/7/22 when the facility failed to ensure a resident was safely transferred by qualified staff which resulted in the resident experiencing immediate pain and was sent to the hospital where it was discovered the resident sustained right shoulder fracture (Resident 98). On 7/17/22 a resident sustained a fall which resulted in profuse bleeding from an existing wound. The resident then required wound vacuum treatment to heal the opened wound. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 7/22/22 at 2:00 p.m. The Immediate Jeopardy was removed on 7/23/22 at 4:40 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm but potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an interview on 7/19/22 at 11:30 A.M., Resident 98 indicated in the early evening of 6/7/22, Certified Nursing Aide (CNA) 1 and CNA 2 were attempting to reposition her in the bed but could not locate the handled pull sheet that was used to reposition her. They attempted to pull her up in bed by getting behind her as she layed in bed, putting their arms under her shoulders, and pulling her up toward the head of the bed. There was a pop in her right shoulder and immediate pain. She was sent to the hospital where she was told she had a fracture in her shoulder area. Her movement was restricted and she had pain in her shoulder and right arm and had to go back to the doctor at some point to see if a sling was all she needed for her fracture. During an interview on 7/21/22 at 11:15 A.M., CNA 1 indicated on the evening of 6/7/22 she and CNA 2 were attempting to reposition the resident higher in the bed. The resident was usually moved in bed by a pull sheet with handles due to her larger size and osteoporosis, but they were unable to access the handles on the pull sheet. They pulled the resident up in the bed by reaching under her arms and pulling her. There was a popping sound from her right shoulder and they reported the incident to the nurse. During an interview on 7/22/22 at 10:15 A.M., Licensed Practical Nurse 1 indicated on 6/7/22 CNA 1 and CNA 2 reported to her they were attempting to reposition Resident 98 in her bed and were not able to access the slip sheet handles, so they pulled her by the arms and there was a pop in the resident's right shoulder. The resident required a slip sheet with handles for bed mobility due to her larger size and osteoporosis. On 7/20/22 at 11:10 A.M., Resident 98's clinical record was reviewed. The diagnoses included, but were not limited to, morbid severe obesity, anxiety disorder, and osteoporosis (a medical condition in which the bones become fragile and brittle) with current pathological fracture, unspecified site. The Annual MDS (Minimum Data Set) assessment, dated 3/25/22, indicated the resident was cognitively intact and required extensive assistance of 2 people for bed mobility. A nursing progress note, dated 6/7/22 at 5:14 P.M., indicated, Aides were repositioning resident when her right shoulder popped really loudly and resident was not able to move extremity .pain rated as an eight. DON [Director of Nursing] and NP [Nurse Practitioner] on call notified. Resident sent to [hospital name] for eval [evaluation] and treatment . A Nurse Practitioner's progress note, dated 6/16/22 at 9:59 P.M., indicated, .the patient reported that facility staff were trying to move her up in the bed by picking her up by the shoulders when she heard a loud pop and felt immediate pain in the right shoulder .active medical problems .fracture of humerus: upper end of left humerus, subsequent encounter for fracture with routine healing .past medical history .fracture of upper end of left humerus, subsequent encounter for fracture with routine healing . A radiology record, dated 6/7/22 at 5:29 P.M., indicated, .severely comminuted (a fracture that produces multiple bone splinters) displaced fracture of the right humeral neck in the right humeral head . An Inpatient Discharge summary, dated [DATE] at 11:51 A.M., indicated, .severe comminuted displaced fracture of the right proximal humerus .non-operative treatment recommended at this time with pain control and sling .follow-up . On 7/22/22 at 11:00 A.M., the care plans were reviewed. A care plan, with a start date of 4/19/21 and edit date of 7/21/22 indicated, .requires assistance for bed mobility .assist resident in proper transfer, bed mobility . 2. On 7/18/22 at 3:00 P.M., Resident 26's clinical record was reviewed. The diagnoses included, but were not limited to: lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), postmastectomy lymphedema syndrome (a problem that may occur after cancer surgery when lymph nodes are removed), dyspnea (fainting), difficulty in walking, weakness, edema (swelling), pain, anxiety disorder, postviral fatigue syndrome (a disease characterized by profound fatigue, sleep abnormalities, pain, and other symptoms that are made worse by exertion.), and paroxysmal atrial fibrillation (a condition when a rapid, erratic heart rate begins suddenly and then stops on its own). A Quarterly MDS assessment, dated 5/2/22, indicated the resident had moderately impaired cognition and required the extensive assistance of 2 staff members with transfers. A fall event, dated 7/18/22 at 1:57 A.M., indicated the resident sustained a fall while being transferred from her wheelchair. The CNA (Certified Nurse Aide) informed the nurse the resident slipped off of the bed during transfer. The nurse observed the resident sitting on the floor beside her bed. The resident complained of pain to her right arm. Bleeding was observed from an existing wound on her right breast during the assessment. The RN and CNA assisted the resident back into bed and the nurse changed the dressing. The Progress Notes indicated the following: -On 7/18/22 at 2:03 A.M., CNA informed the nurse the resident had slipped off of the bed during transfer. Nurse observed resident sitting on the floor beside her bed. Resident was able to move legs and left arm without discomfort, but did state that her right arm was sore. Bleeding was observed from an existing wound on the right breast during an assessment. The nurse and CNA assisted patient onto the bed. The nurse changed the dressing. -On 7/18/22 at 6:47 A.M., RN 1 monitored the residents vitals and weight. -On 7/18/22 at 6:49 A.M., RN 1 gave medication and no adverse side effects were noted. -On 7/18/22 at 12:35 P.M., RN 2 indicated the resident did not have any pain or discomfort. -On 7/18/22 at 2:09 P.M., the DON (Director of Nursing) indicated the resident fell to the floor while being transferred from wheelchair to the bed by a CNA. The resident landed with only the top half of her body on the bed during initial transfer and the CNA attempted to better position the resident in the bed causing resident to fall to the floor. IDT (interdisciplinary team) recommended to educate staff to use slide board during transfers. -On 7/18/22 at 2:09 P.M., the DON indicated a scab to the right upper chest wound dislodged during the fall and the area continued to bleed. A pressure dressing in place was saturated four times. A new order was received to send the resident to the emergency room for evaluation and treatment. During an interview on 7/20/22 at 11:00 A.M., Resident 26 indicated she sustained a fall, on 7/17/22, which resulted in an injury to an existing upper chest wound. During an observation, at that time, the resident pulled down the neck of her blouse to reveal a pressure dressing in place to her right auxiliary (armpit) region. She had lymphedema to her right arm and was observed with a compression wrap on her right arm. She indicated the wound profusely bled and the facility sent her to the emergency department for treatment. The wound opening had immediately caused her a significant amount of pain and bleeding. She requested RN 1 to put a pillow underneath her armpit before she was pulled up off of the floor, however, the staff did not put anything to prevent her wound from further injury. On 7/22/22 at 10:50 A.M., Resident 26's clinical record was reviewed. The progress notes included, but were not limited to: -On 7/18/22 at 3:05 P.M., the resident was sent out of the facility by ambulance and transported to the hospital. -On 7/18/22 at 11:48 P.M., the resident arrived back to the facility. -On 7/22/22 at 12:38 P.M., the wound doctor assessed the resident and ordered a wound VAC(Vacuum-assisted closure of a wound is a type of therapy. The vacuum pump pulls fluid and infection from the wound. This helps pull the edges of the wound together. It also helps the wound heal by promoting the growth of new tissue.) for the right chest wound. -On 7/22/22 at 12:55 P.M., the resident continued to be upset about the fall incident and was worse when her emergency contact was in the facility. A hospital health and physical, dated 7/18/22 at 4:15 P.M., indicated the resident presented to the emergency department with an open right armpit wound secondary to injury that occurred last night. The patient fell from her bed onto the floor after having her right arm pulled with significant force. Nursing home nurses attempted to pack the wound and control the bleeding temporarily, though she had continued bleeding profusely throughout the day. The patient had a chronic right auxiliary wound that required a wound VAC which was removed 4 weeks ago. The scab was busted open in the fall and had been bleeding profusely. The wound was repacked at the hospital before the resident discharged back to the facility. The resident's current July, 2022, physician's orders indicated on 7/18/22, the resident was ordered a sliding board with the assistance of 2 staff members with transferring. On 7/19/22, the resident was ordered an amoxicillin and azithromycin (antibiotic medications) for her upper chest wound. On 7/25/22, the resident was ordered a wound VAC to her right chest. An ADL (activities of daily living) care plan, dated 1/24/22 and current through 10/20/22, included an intervention for the resident to be transferred with a gaitbelt and a sliding board with the assistance of 2 staff members. This intervention was not implemented until after Resident 26's fall on 7/17/22. Weekly wound assessment dated [DATE] at 12:23 P.M., indicated the resident's right chest wound size measured 0.6 centimeters in length, by 0.4 centimeters in width, by 0.1 centimeters in depth. The wound's health status was improving. Weekly wound assessment dated [DATE] at 8:50 P.M., indicated the resident's right chest wound size measured 2.7 centimeters in length, by 2 centimeters in width, by 2.4 centimeters in depth. The wound's health status was declining. During an interview on 7/21/22 at 4:03 P.M., CNA 3 indicated she did not get a report sheet, nor report, when she got to the facility; only her assignment for her evening shift. She had an hour left in her shift when the resident asked for help getting out of her wheelchair and into her bed for the night. The CNA asked the resident how she transferred and the resident told her that she could stand and pivot. The resident instructed the aide to count to 3, pulled up on her pants, and slid her from her wheelchair to her bed. The CNA attempted to self transfer the resident and when she counted to 3, the resident did not fully stand, so her bottom came back down into the wheelchair. Together they attempted to get her transferred a second time, and this was when the resident ended up with half of her bottom in the bed and half on the wheelchair seat. The resident began to slide down, so she assisted her to the floor. The CNA went to get RN 1 for help, and upon entry, the RN indicated they could not use the full body dependent mechanical lift since it did not go all the way to the floor. RN 1 indicated they needed to manually lift the resident up off of the floor by pulling underneath the resident's shoulders. At that time, the resident requested the RN place a pillow under her arm due to her wound. No pillow was provided. CNA 3 immediately saw blood on the resident's shirt and it was obvious it was coming from a bandage which she was not aware of the resident having a wound. The aide obtained a clean gown, cleaned her up, and made sure the resident was not hurting. During an interview on 7/22/22 at 10:30 A.M., RN 1 indicated she was working the night when the resident had the fall. CNA 3 came and told her the resident had fallen. When she came into the room, the resident was sitting on her bottom and facing the foot of the bed. RN 1 did not know the full body dependent mechanical lift went all the way down to the ground, so she told the aide to put her foot in front of the resident's feet for traction, lift up under her arms, and push up on her bottom. The RN stood on the resident's right side and the CNA was on the left. Since the bed was in low position, they just slid her over to her bed. The resident initially complained of pain in her right arm while on floor, but did not complain of pain until later in the shift until it was discovered she was bleeding. The nurse repacked the wound, and then a few hours later, the wound was still bleeding. During an interview on 7/22/22 at 10:45 A.M., the resident indicated the wound doctor had assessed her wound and she would need a wound VAC. She indicated she was frustrated she needed to have the wound VAC and the treatment would set her progress back a couple of months. During an interview on 7/22/22 at 10:54 A.M., the resident's wound doctor indicated the resident required a wound VAC due to the fall incident. During an interview on 7/22/22 at 1:37 P.M., the Director of Nursing indicated the wound doctor ordered a wound VAC for the resident which should arrive on Monday, 7/25/22. The facility would utilize wet-to-dry dressing changes until the wound VAC arrived. She indicated therapy ordered the slide board. The facility did not have a policy in regard to resident transfers. During an interview on 7/25/22 at 12:26 P.M., Resident 26 was observed with wound VAC in place on her right chest. The resident indicated she was very depressed with the wound VAC. She demonstrated she could not raise her right arm above her shoulders and the presence of the wound VAC set her progress back at least two months, which was very frustrating to her. The Immediate Jeopardy, that began on 6/7/22, was removed on 7/23/22 when the facility educated and trained staff on the proper assistance levels for resident transfers, ensured policies and procedures were followed, and ensured monitoring was in place, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. 3.1-45(a)(2)