**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 out of 3 residents reviewed for falls with injuries (Resident #1). Resident #1 experienced a fall from a full-body mechanical lift that resulted in a left arm injury. The facility failed to inspect a sling prior to transferring a resident with a mechanical lift which resulted in one strap breaking causing the resident to fall approximately 41 inches to the ground. While in the hospital, three months after the fall, an X-Ray revealed a fracture to her left proximal humerus (break in the upper part of the left bone of the arm near the shoulder). Findings include: Resident #1 ' s Minimum Data Set (MDS) assessment dated [DATE] documented diagnoses of anemia (low iron in the blood), anxiety, depression, heart failure, hypertension(high blood pressure), diabetes mellitus, post traumatic stress disorder, and below the knee amputation to the left leg. The MDS included a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. The MDS indicated Resident #1 required total dependence of 2 persons with transfers and did not walk. The Care Plan with a target date of 1/18/24 reflected that Resident #1 had a risk for falls related to impaired mobility and episodes of decreased alertness. The care plan interventions included the following: Be sure that my call light is within reach and encourage me to use it for assistance as needed. Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that I am wearing appropriate footwear when I am mobilizing in my wheelchair. I have been provided with an extra long reacher. I have fallen out of my wheelchair trying to get something from under my bed. Please encourage me to use it and please make sure it is where I can reach it. Please do not leave me in my wheelchair in my room. I have fallen out of it trying to reach for things. If I want to be in my room, please assist me to bed. Resident #1 ' s Fall Risk Evaluations on 6/6/23 documented a score of 8 (A score greater than 10 or more represents high risk for falls). The Incident Report (IR) Note on 10/2/23 at 8:20 AM documented that someone summoned Staff E, Licensed Practical Nurse (LPN), to Resident #1 ' s room because she fell from the mechanical lift. Resident #1 landed on her buttocks and laid back against the lift. Resident #1 rested her head on the lift with her left arm up on the mechanical lift leg, and her right arm at her side. Resident #1 placed her right leg over the bed frame with her left prosthetic pushed against the bed frame. Resident #1 answered questions by yelling WHAT. The note described Resident #1 ' s left lower arm just below the elbow as light blue in color. Resident #1 moaned and cried out when moving her left arm. Resident #1 rated her pain a 7 (7 out of 10 on a numerical pain scale indicated severe pain) to the left arm. The Investigative Report dated 10/2/23 completed by the DON (Director of Nursing) with Staff A, CNA (certified nursing assistant), and Staff B, CNA showed the CNA ' s reported that they connected the loops of the mechanical lift sling to the mechanical lift. Staff A and Staff B reported Resident #1 did not look crooked in the mechanical lift sling. As Staff A operated the mechanical lift buttons, Staff B got the wheelchair from approximately 10 feet away. They reported Resident #1 ' s bottom fell to the floor first, approximately 41 inches. They immediately called for the nurse. They denied hearing anything when the black loop on the sling snapped. Staff E, LPN, assessed Resident #1 and someone called the DON to assess the situation. The DON assisted Staff E and Staff F, RN (Registered Nurse), to remove the lift from behind Resident #1. They completed range of motion (ROM) to Resident #1 ' s four extremities noting pain to the left arm with bruising. Resident #1 had a history of pain to left arm prior to the accident. When they notified the Primary Care Physician (PCP), they ordered an x-ray of the left arm. The facility examined the sling and found no abnormalities, except the bottom black loop. A Progress Note dated 10/2/23 at 11:45 AM revealed the facility sent Resident #1 to the emergency room for x-rays of the left arm and shoulder. The Hospital Diagnostic Radiology report dated 10/2/23 revealed x-rays completed to Resident #1 ' s right humerus and right forearm. The impression of the report showed no right humerus or right forearm fracture. A Hospital Diagnostic Radiology Report dated 1/3/24 at 8:16 PM documented an x-ray of the left humerus was taken due to pain. The findings revealed a proximal humerus fracture at the level of the neck with callus formation. The impression documented a left proximal humerus subacute fracture with correlation for recent traumatic injury. The impression further documented an underlying pathologic lesion was not excluded. The impression suggested short term follow up radiograph to assure appropriate healing. An Emergency Department (ED) Nursing Progress Noted date 1/3/23 at 8:58 PM documented the ED received a call from Staff C, LPN who requested the left arm x-ray report. The ED note documented Staff C reported Resident #1 had a fall in October and x-rays were ordered but the x-rays were done on the right arm instead of the left arm. On 10/2/23 the DON filled out a Food and Drug Administration (FDA) Form 3500 (used for mandatory reporting of medical device adverse events by manufacturers, user facilities and importers) stating that the company sling rated for 1000 pounds failed. The form documented the mechanical lift sling failed when the black leg loop split while the staff were transferring Resident #1. According to the form, Resident #1 fell to the floor, falling approximately 41 inches. No major injury determined from the fall at the time of the incident. During interview on 1/8/24 at 3:34 PM, Staff E reported that she worked on 10/2/23 and got called to Resident #1 ' s room by the CNA ' s. Staff E reported she observed Resident #1 on the floor but could not remember exactly how Resident #1 laid. Staff E reported feeling confident Resident #1 went for x-rays. Staff E reported two CNA ' s utilized the hoyer lift. Staff E described the break as a clean snap on the hoyer lift sling from the hook on the hoyer lift. Staff E reported she couldn ' t remember the CNA staff members during the incident. Staff E reported she didn ' t remember the intervention put in place or any education provided regarding the hoyer lift after the incident. During interview on 1/9/24 at 12:15 PM, Staff D, Environmental Services, reported she audited the hoyer lift slings quarterly to check and make sure they have no rip/tears and if they did she removed the slings from use. Staff D reported completing an audit on 10/5/23. The facility put four new slings in place on 11/28/23. Staff D explained she writes the serial number off of the slings so when she does the audits she can check off that the sling is good. Staff D reported she also checks the slings that are in the residents wheelchairs. They replace the slings yearly. Staff D reported she took the gray looped slings out of commission due to there not being any residents at the facility that is under 100lbs. Staff D made a list of what color sling each resident must use. Staff D reported that she didn ' t do anything with educating the staff regarding lifts and slings, as the DON did that. On 1/9/24 at 2:40 PM, observed the mechanical lift sling used to transfer Resident #1 on 10/2/23. The sling did not have a tag or serial number. As the sling did not have any identification, there was no way to verify when the facility purchased the sling or put it into use in the facility. In addition, the observation revealed the torn left lower black loop, a frayed green loop, and the sling ' s green color looked faded. On 1/9/24 at 3:30 PM, the DON reported on 10/2/23, the day of the fall, someone called her to Resident #1 ' s room. The DON reported she witnessed Resident #1 laying on the floor with her head resting on the lift bar, her right foot resting in a gap on the bed, her left arm tucked between her body, and the lift. The staff assisted Resident #1 into bed from her wheelchair as she just finished her shower. The DON reported when Staff A and B transferred Resident #1, strap on the hoyer lift sling broke. The DON described Staff A and Staff B as very nervous as these types of things should not happen. The DON reported when the left loop of the hoyer sling snapped it caused Resident #1 to lean to the left side and slide out of the hoyer lift sling onto her buttocks. The DON reported the loop had a straight tear in it. The DON reported the sling didn ' t have evidence of any wear or tear. The staff members are good about turning in slings to Staff D and if they have concerns, then Staff D will reorder new hoyer lift slings. The Corporation instructed her to fill out an FDA report since they had faulty medical equipment. The report triggered the hoyer lift/sling company. The DON reported phone calls and email communication with the lift/sling company. She added that she took pictures and sent them to the lift/sling company. The DON reported she did not feel there was a breakdown in the facility process. The DON reported that staff are aware to check the hoyer lift slings each time with use and also when they are laundered. The DON reported the facility replaced four new hoyer lift slings in October or November 2023. The DON reported that she did training regarding the hoyer lifts during the facility skills fair. She added that she did spot checking and gave real time education to the staff. The DON reported when she is out and about, she didn ' t hesitate to give education in the rooms when needed. The DON reported she provided training using the electronic health record (EHR) and main dashboard as needed. She reported after another resident ' s fall she provided education to the staff about having two staff members with all transfers, having the wheelchair close by, properly placing the wheelchair, and not lifting the hoyer lift high. The DON explained they trained the staff how to use the hoyer lifts on orientation. The Nursing Assistant Skill Mechanical Lift Quarterly Audit revised January 2006 lacked direction regarding checking the slings before each use, making sure the sling is appropriate for residents, and when not to lock the brakes when utilizing the mechanical lift. On 1/9/24 at 4:42 PM, Staff B reported she entered the room after Staff A gave Resident #1 a bath. Resident #1 laid in bed, Staff A and B connected her to the hoyer lift to transfer her to the wheelchair. Staff B reported she hooked up the right side of the sling to the hoyer lift. She denied seeing any issues with the straps when she connected them. Staff B reported that she went around the bed to get the wheelchair as Staff A lifted Resident #1 up in the hoyer lift, when the strap broke, and Resident #1 fell on the floor. Staff B did not see the other side of the sling. Staff B reported if she had issues with the hoyer sling that she would give it to Staff D or to the DON. She received education every year. Everyone is always willing to help and answer any questions. Staff B reported the facility had let the staff know when a new resident is admitted , what sling they needed. On 1/10/24 at 9:15 AM Staff A reported they placed the sling under Resident #1. As the Resident #1 already had the sling in her room, Staff A didn ' t check the hoyer sling before she placed it under her. Staff A learned black is back and green is groin at the college she had attended. Staff A hooked up the top with the black loop and the bottom with the black loop. Staff A explained the bottom loop should have been on the green loop. Staff A reported that they crossed the legs of the sling. While lifting Resident #1 up in the lift, Staff B went to get the wheelchair. Staff A described Staff B ' s location as about 3 feet away. As she turned Resident #1 in the lift to place her in the wheelchair, the bottom left strap on the sling broke and Resident #1 fell to the floor. When she fell, she hit her head on the lift. When she first started at the facility she had a checklist regarding the lifts/slings and the CNA ' s showed her how to use the lifts/slings. Staff A reported that after the fall, the DON talked to her about the fall. The DON re-enacted the fall with her. On 1/10/24 at 9:42 AM the mechanical lift company ' s Safety Program Coordinator reported they could not determine the age of the sling, as no one at the facility could read the tag. She reported she received pictures of the sling from the facility and from the pictures she could tell the sling was not brand new, was used, and due to the color coming out of the green she knew they washed it, but she could not determine the age. She reported when a sling breaks it usually comes down to inspecting the sling before each use. She reported the company sends a Care Insert Page with each purchase of a sling that directs the facility to inspect the sling before each use for wear, tear, and frays. On 1/10/24 at 11:40 AM during a follow-up interview, Staff D reported the slings went to the laundry during the second and third shift. The laundry washed them and hung them to dry while inspecting them. Staff D reported that on 10/5/23 the facility had approximately 27 hoyer lift slings in the facility and at the time of the fall on 10/2/23 the facility did not have a formal audit done on the slings. Staff D reported she randomly went through the slings if needed and replaced them. Staff D reported that before she started her formal audits, the CNA ' s and laundry checked the slings. Staff D reported that after the fall on 10/2/23, she started doing formal audits of the slings and put a QAPI process in place. Staff D reported she recorded the serial numbers of the new slings and dated them in black permanent marker to help keep track of them when she put them out in 2023. On 1/10/24 at 11:40 AM observed a pile of ten slings next to Staff D ' s desk. Staff D reported the hoyer slings as questionable. Staff D showed the shower sling that had a tear near a handle. The laundry basket contained approximately 5 one-year old slings behind her that appeared in good condition. Staff D reported that she read the Hoyer lift company ' s recommendations and they recommended replacement after one year or if the sling or harness shows any sign of damage or wear. She explained the Administrator gave her recommendations. The Quality Assurance Report dated 11/9/23 indicated the first audit done on the slings. On 1/10/24 at 11:43 AM, the Hoyer Company ' s Representative reported one of their employees completed a wellness check on a Hoyer on 4/11/23. They described a wellness check as evaluating and testing the machine. She described herself as the person in charge of the safety and inspection program for the company. She reported that the facility didn ' t participate in the program. She reported the program did cost, but is optional. She reported an employee completed a wellness check on 11/9/22 that consisted of four stands and four lifts. She explained she did not have specific notes on any inservice or training provided to the facility recently. She reported there is a note that an employee did an inservice in February 2020. The facility taped that inservice and had fifteen staff members present. The Hoyer Company ' s Representative said according to the purchase history the facility purchased four large regular slings the year of 2023 (November 27). She added that the facility purchased several slings in October 2022. She reported she would send the 2022 and 2023 purchase history. The Hoyer Company Representative explained their recommendation is to replace the sling at the first sign of wear, tears, or after one year of use. She added the slings came with a six month warranty. The purchase history dated 10/21/22 listed the facility purchased fourteen slings (six medium, six large, and two extra large). On 1/10/24 at 12:50 PM Staff I reported completing the maintenance checks on the lifts bi-weekly and recorded it on a form called the Bi-Weekly Patient Lift Inspection Sheet. Staff I reported that they ordered parts through the website which is through the Hoyer lift company. They reported the last time they inspected the equipment as 12/20/23 and they planned to do it again that week. Staff I described the parts they usually ordered as more cosmetic things like the rubber green tabs for the hooks and the green/black tabs on the thumb buttons. Staff I reported that they constantly fell off even if he super glued the green tabs on the hooks due to the friction of the slings. Staff I reported that he never ran into any sharp areas. On 1/11/24 at 9:15 AM observed Staff L, CNA, and Staff M, CNA, transfer Resident #5 with a mechanical lift. They placed the mechanical lift sling under Resident #5 and connected it to the mechanical lift. Staff L put the black loop on top and the green loop on the bottom, with all four sling loops doubled looped. Staff M held Resident #5 ' s legs to help guide them to the wheelchair. Staff L turned the lift to sit Resident #5 in a wheelchair. Staff L locked the wheels on the mechanical lift while lowering the Resident #5 down into the wheelchair. Once in the wheelchair, Staff L and Staff M unhooked Resident #5 from the sling. Then Staff L unlocked the mechanical lift ' s wheels. On 1/11/24 at 10:10 AM observed Staff L and Staff N transfer Resident #6 with a mechanical lift. They placed the mechanical lift sling under Resident #6 and hooked the sling to the mechanical lift. The observation revealed all 4 loops on the black loops and doubled loops. Staff L lifted Resident #6 up in the mechanical lift sling and turned the mechanical lift towards the recliner. With Staff N next to Resident #6, they transferred them to the recliner. Staff L placed Resident #6 over the recliner and locked the wheels on the mechanical lift. Staff L lowered Resident #6 into the recliner. Once in the recliner they unhooked from the sling, and Staff L unlocked the mechanical lift wheels. On 1/11/24 at 10:15 AM Staff L reported that she had in-services on the hoyer lifts. Staff L reported that on the hoyer lifts the wheels are to be locked when raising and lowering the resident. Staff L also reported that if they had a problem with the sling that they took it to Staff D. On 1/11/24 at 10:15 AM Staff N reported that she watched an outside contracted educational video regarding the use of the hoyer lifts. Staff N said she last watched the video two years ago. Staff N also reported to lock the hoyer lift wheels, when raising and lowering the resident. Staff N added that if they found a problem with the sling that they would take it to Staff D. On 1/11/24 the observations completed on all mechanical lifts, revealed no sharp edges on the hooks and all in working order. The undated Company's Accessory Inspection Checklist instructed before operating the unit, ensure the accessory is not ripped, frayed or showing signs of wear: Check binding and loops for any fraying, wear, nicks or tears. Replace if fraying or wear is found. Check sling or harness body fabric for any rips, holes, fraying or weak spots. Hold sling up to a light, the sling must be replaced if any light shows through. Check all stitching of strap connections, for loose stitches. Check all binding stitching for loose stitches. Pull on all straps/loops in opposite directions and note if stitching becomes loose or comes apart. Remove from service if stitching tears. Check handles for loose stitches and tears. Remove from service if any found Check all straps where they attach to the sling hanger bars for wear. Remove from service if any fraying is found. The Company offered a 6 month warranty on slings and harnesses. They recommended replacing them after one year or if the sling or if the sling/harness shows any sign of damage or wear. On 1/10/24 at 2:22 PM, the Administrator provided the facility hoyer lift policy and reported the facility follows the manufacturers guidelines for each brand of lift. On 1/11/24 12:30 PM, the DON reported they expected the colors of the loops to match. The DON reported staff are informed based on resident positioning,Therapy alerts and provided demonstrations.