**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to properly transfer 1 of 4 residents reviewed for mechanical lift transfers (Resident #1). Staff transferred Resident #1 into the shower without the use of a mechanical lift and a second staff person assisting directly with the transfer as directed in her Care Plan. This resulted in a fall with a fractured femur. The facility reported a census of 39 residents. Findings include: A Minimum Data Set, dated [DATE], documented that Resident #1's diagnoses included osteoarthritis, right knee pain, weakness, and unspecified hearing loss. A Brief Interview for Mental Status (BIMS) revealed a score of 10 out of 15, which indicated the resident had moderate cognitive impairment. The resident was dependent on staff for transfers. An untitled undated CNA Assignment Sheet directed staff that Resident #1 was a transfer assist of 2 staff using a mechanical lift (Hoyer). A Progress Note dated 12/30/24 at 1:32 p.m., documented that, the nurse was called to the whirlpool room and found Resident #1 laying on her right side on the floor. A Certified Nurse Aide (CNA) was sitting next to Resident #1. Water was noted on the floor. This resident was assessed for pain and injuries. A large skin tear was noted on Resident #1's left shin. The area was cleaned and Steri-strips were applied. A dressing was applied over this. Resident #1 complained of pain to her upper leg and knee area. It was very difficult for this resident to move her leg. An order was obtained to send Resident #1 to the emergency room (ER) for evaluation. Ambulance was called and daughter-in-law was notified. Resident #1's vital signs (VS) were: temperature 97.9 Fahrenheit, pulse 102 beats per minute, respirations 20 breaths per minute, and blood pressure was 148/84. Resident #1's oxygen saturation was 94% on room air. A Progress Note dated 12/30/24 at 2:30 p.m., documented that a call was placed to Resident #1's daughter-in-law regarding the fall this a.m. in the whirlpool room. Staff B (LPN), reported to the daughter-in-law that the resident was being pivot transferred with 1 staff member and not the mechanical lift when the fall occurred. Staff B told the daughter-in-law that the facility would have to report this fall to the state and that the employee who improperly transferred the resident at the time of the fall was suspended immediately until the investigation was complete. A Progress Note dated 12/30/24 at 5:24 p.m., documented that the nurse received a call from the ER. The family was not wanting any interventions at this time. The provider splinted Resident #1's leg and a urinary catheter was placed. Resident received pain medication at 5:15 p.m., and would need to get comfort care medication orders for her the following day. The resident was being brought back to the facility at this time. A Progress Note dated 12/30/24 at 8:19 p.m., documented that Resident #1's right leg was still wrapped. Staff at the hospital had stated the resident was trying to take it off. A Progress Note 12/31/24 at 12:56 a.m., documented that Resident #1 was resting quietly in bed. Resident does moan and yell out in pain when being repositioned. PRN (as needed) pain medication was given. A Progress Note dated 12/31/24 at 5:43 a.m., documented that Resident #1 was yelling that she needed to have a bowel movement. This nurse and a medication aide got Resident #1 on to a bed pan. Resident #1 was yelling and screaming loudly in pain. PRN pain medication was given. This resident was on the bed pan for about 10 minutes and she never went. Gave drinks of water. A Progress Note dated 12/31/24 at 9:06 a.m., documented that this resident was yelling to get up. Reassurance was offered but not effective. Resident #1 was very restless and taking her gown off. Call was placed to the daughter-in-law to report resident's confusion and as to why she cannot get up currently was due to extreme pain. Pain pill was given. A Progress Note dated 12/31/24 at 12:42 p.m., documented that a fax was sent to the provider asking for comfort medications. A Progress Note dated 12/31/24 at 4:37 p.m., documented that the daughter-in-law wanted a referral to Hospice. All necessary paperwork for admission was faxed to Hospice. A Progress Note dated 1/1/25 at 9:29 p.m., documented that at 8:30 p.m., Resident #1 was without a heartbeat and was not breathing. It documented that the funeral home arrived at 10:00 p.m., and her body was released. ED (Emergency Department) Provider Notes with a date of service of 12/30/24 at 11:16 a.m., documentation included the following for Resident #1: A [AGE] year-old female presented to the ED via EMS (Emergency Medical Services) ground (ambulance) for evaluation of a fall. This patient had a fall onto her right knee earlier on this day. Patient had a history of right knee pain however it appeared more swollen and was acutely tender to the patient at this time. Patient was able to wiggle her toes however did have a large amount of pain in her right lower extremity. Patient was extremely hard of hearing and was minimally conversant secondary to the hearing difficulties. It documented that this resident was in acute distress. It documented her right upper leg had swelling, edema and deformity. It documented her right knee had swelling and deformity with decreased range of motion. The ER provider documented they were unable to perform examination of right lower extremity secondary to large amount of pain for the patient. X-rays were done with diagnoses of hip dislocation, femur fractures, and patellar (kneecap) dislocation. Family elected to go with the hospice route instead of surgery. Patient was discharged back to the facility via ambulance and was given hydrocodone (narcotic medication) for uncontrolled pain every 4 hours. Manipulation was performed with mild improvement of the bone fragments being better aligned in her leg. A long leg splint was placed on her leg. An undated Internal Investigation, documented that at approximately 9:00 a.m. on 12/30/24, the Director of Nursing (DON) was called to the whirlpool room by Staff B. When the DON entered the room, Resident #1 was found on the ground with Staff A, CNA. Resident had on just her shirt. She was not wearing pants, socks, shoes and didn't have a gait belt on. There also was not a mechanical sling in her wheelchair. Resident had a large skin tear to her left shin that Staff B was concerned about. The area was cleansed and area was approximated easily. Steri-strips were applied and area was covered. Resident was noted to be in pain. Resident is extremely hard of hearing and was having difficulty explaining where it was hurting. She was grabbing at her right thigh/right upper leg. Resident was further assessed and no rotation or shortening was noted but right knee was noted with swelling and increased pain with touch/palpation. Staff B received an order to have resident evaluated in emergency room for evaluation and treatment. Staff A was called to the Administrator's office at 9:40 a.m. after the incident. When Staff A was questioned if she was aware that Resident #1 was a Hoyer transfer, she stated yes. When asked what happened she stated that she told Staff D, CNA, that she would just transfer Resident #1 real quick from the wheelchair to the whirlpool chair and she asked Staff D to pull down the residents' pants when she lifter her. Staff A stated she didn't know why she chose to transfer this way, but did state she (Resident #1) is just a tiny little thing and I thought I could just do it really quick. Staff A stated that when she was assisting this resident up she put her arms under the resident's arms and Staff A had just bought herself a new pair of Crocs shoes over the weekend, Staff A's foot slipped and she and the resident fell down to the ground together. Once it was determined that Resident #1 had sustained a fracture, Staff A was notified her position with the facility was ending due to improper transfer and not following the Care Plan per regulations. Staff A stated she wasn't going to lie about it, it was her fault and she felt terrible. Staff D was asked about the incident and Staff D stated that this was her 2nd day on the floor after her training. Staff D asked Staff A for assist to get Resident #1 into the whirlpool. Staff D and Staff A took Resident #1 into the whirlpool room and Staff A stated she would transfer Resident #1 herself. Staff A wanted Staff D to pull down Resident #1's pants when Staff A stood Resident #1 up. Staff D questioned Staff A regarding transfer status and Staff A told Staff D that they were currently working on getting her to a different transfer status, so it was ok. On 1/12/25 at 2:40 p.m., the DON stated that it was a terrible situation. The DON stated that Staff A knew that the resident required a mechanical lift with 2 staff for all transfers. She stated she just thought she could pick her up and put her in the chair. The DON stated they suspended Staff A right away and then waited to hear if there was an injury. When that was confirmed they let her go. The DON stated that Staff D told Staff A that Resident #1 was to be a mechanical lift, however Staff A insisted on transferring Resident #1 without a mechanical lift and Staff A told Staff D that the facility was working on getting this resident to transfer without the mechanical lift. When asked how the CNAs know the transfer status for each resident, the DON stated that there is a CNA sheet that each CNA carries. It is updated frequently. The DON stated the facility was not trialing getting Resident #1 to a different transfer status. On 1/13/25 at 2:50 p.m., the DON stated that Staff A should have chosen the right transfer method for Resident #1. She stated that unfortunately it was around 9:00 a.m. in the morning and that was break time. The DON stated that the initial documentation of this incident in the Progress Notes was put in at the wrong time. It was documented in the afternoon but should have shown the incident occurred in the morning. On 1/13/25 at 1:56 p.m., Staff B stated she was at the nurses' station when Staff D told her Resident #1 had fallen. Staff B stated Resident #1 was on the floor in the whirlpool room and Staff A was sitting on the floor next to Resident #1. Staff B first noticed there was blood on the floor and Resident #1 had a skin tear on her left shin. Resident #1's right knee looked kind of swollen, Resident #1 was saying that her right knee was hurting, she was having some pain in the right knee. Staff B stated staff were getting ready to put Resident #1 into a whirlpool (chair), Resident #1's top half was dressed. Staff A was transferring Resident #1 from the wheelchair to the whirlpool chair. Staff B stated that the whirlpool chair is on a track and it kind of rolls into the whirlpool. The brakes were locked on the whirlpool chair. Staff B stated that it was probably right at 9 a.m. or a little after. Staff B acknowledged her documentation was dated 12/30/24 at 1:32 p.m., and that was wrong as it happened earlier that morning. Staff B stated that Resident #1 was grimacing and holding that leg. Staff B was putting a dressing on Resident #1's skin tear and Resident #1 was grimacing and saying ooo. Staff B stated Staff A and Staff D should have done a 2 person transfer with a mechanical lift. Staff B stated they have bath slings that are used specifically for the whirlpool. Staff B stated she was upset and asked why, and the CNA told her she thought they were going to change Resident #1 to an easy stand transfer. Staff B stated when she walked into the shower room, she asked where is your Hoyer (mechanical lift) and Staff A said she's not sure why she did it that way, she was rushed, she really didn't have a good reason why. She felt terrible, obviously. Staff B stated that Staff D was just learning and fresh off of orientation. Staff B stated that Staff D actually questioned Staff A why they weren't using a Hoyer. Staff B did not know what Staff A told Staff D in response. Staff B stated that after they got Resident #1 safely back to her bed, Staff B asked Staff D where Staff A went and Staff D didn't know. Staff B found out later that Staff A had gone on break. Staff B stated that Resident #1 came back from the ER on comfort medications. Staff B stated that she found out Resident #1 had a broken right femur right above her knee. It was just a terrible situation. On 1/15/25 at 11:37 a.m., the Licensed Nursing Home Administrator (LNHA), stated that on the day of the incident, the DON came into the LNHA's office and said that Staff A had just transferred Resident #1 in the whirlpool room, Staff A fell down as her foot had slipped and Resident #1 landed on top of her. The DON said Resident #1's leg might be broken. The LNHA stated she immediately asked how could that have happened with the mechanical lift? The DON told the LNHA that Staff A had not used the mechanical lift. The LNHA then told the DON that they needed to call her into the office right away and suspend her for not following the Care Plan. Staff A then went into the LNHA's office and stated her foot slipped, she fell and Resident #1 landed on top of her. Staff A said she knew it was really bad that she didn't use the mechanical lift and said it was completely her fault. The LNHA stated that at this point, the DON had already told the LNHA that Staff D had questioned Staff A about using the mechanical lift. The LNHA then asked Staff A, and Staff A confirmed that Staff D did ask her about the mechanical lift. Staff A said she told Staff D they were trying to change the transfer method for Resident #1. Staff A said she didn't know why she said that nor why she decided to transfer Resident #1 that way. The LNHA then talked with Staff D. Staff D stated she had asked Staff A for help to get Resident #1 into the whirlpool tub. Staff D said Staff A told her she was going to stand Resident #1 up and wanted Staff D to pull Resident #1's pants down after Staff A stood Resident #1 up from the wheelchair and before sitting Resident #1 back down into the whirlpool chair. Staff D said she showed Staff A the CNA sheet that directed Resident #1 was to be transferred by 2 staff using a mechanical lift. Staff D said that Staff A said the facility was trialing a different transfer method with Resident #1. Staff D reported that Staff A picked Resident #1 up and fell backwards with her. On 1/15/25 at 1:47 p.m., Staff C, CNA, stated that she worked the day of Resident #1's fall incident. She stated they transfer Resident #1 the way the CNA Care Plan reads. She stated Resident #1 was to be transferred with a mechanical lift, so they used the mechanical lift to transfer Resident #1. On 1/14/25 at 4:06 p.m., Staff A stated that on 12/30/24 before 9:00 a.m., they were kind of late getting people out to breakfast that day. It was just kind of a crazy day. The nurses were asking where the other residents were who were not out at breakfast. Residents are supposed to be out by 9:00 a.m. Staff A thought there were at least 2 or 3 residents left to get up. Staff A stated they didn't have a late start getting residents up, they just had to answer call lights and things like that in between. Sometimes the call lights are going off more than other days. On this day the call lights were going off more. Staff A stated they had enough staff working. Staff A stated it was Resident #1's shower day. Staff A said that Resident #1 seemed normal to her. Staff A had asked Staff D to pull down the residents britches. Staff A stated with that transfer it was her that had a hold of Resident #1. Staff A said that Resident #1 did not have a gait belt on. When Staff A went to transfer Resident #1, Staff A's foot slipped and Staff A started to fall down. Staff A tried to pull Resident #1 on top of her, so Resident #1 would land on her to break the fall. Resident #1 did land on Staff A but Resident #1's leg hit something. Staff A thought her leg hit the whirlpool chair or the wheelchair, she was not sure which one it was. Staff A stated she had gotten new Crocs shoes and hadn't worn them before at work. There was a puddle on the floor and Staff A slipped in it. Staff A said they were supposed to transfer Resident #1 with 2 staff and a mechanical lift. Staff A stated that she had not transferred Resident #1 before that day without using a mechanical lift. Staff A said she honestly didn't know why they didn't use a mechanical lift, they were just running behind that day. Staff A stated that Staff D didn't really say anything much, Staff D just kind of had a look on her face like she was worried because she was a brand-new CNA. Staff A said she noticed the look on Staff D's face in the whirlpool room before the fall, when Staff A asked Staff D to pull down Resident #1's britches. Staff A said she told Staff D to go get the nurse after the fall. Staff A said they did not talk about the fall, Staff D just left to get the nurse. Staff A stated she held Resident #1 on the floor. Resident #1 was on top of her and she was trying to hold Resident #1 as still as possible until the nurse got there. Staff A stated that Resident #1 apologized to her and she told Resident #1 to not apologize as it was her fault. Staff A stated that Resident #1 then kind of put her head on Staff A's shoulder and said it's okay. Staff A said that Resident #1 appeared to be in pain. Resident #1 kept saying her leg hurt her and was pointing toward her right leg. Staff A said that Staff B came into the whirlpool room and then the DON came in as well. They adjusted Resident #1's leg up because her legs were kind of sideways so they adjusted her legs straight out in front of her. Resident #1 responded when they positioned her legs. Resident #1 was moaning and was in pain. The 3 of us then got Resident #1 up off the floor with a gait belt, one on each side of her and the 3rd one holding her legs to minimize movement and sat Resident #1 back in her wheelchair. Staff A stated she was on one side of Resident #1, Staff B had Resident #1's other side and the DON held her legs. They then wheeled her down to her room and lifted Resident #1 with the mechanical lift into her bed. The nurse and someone else helped get Resident #1 in bed. Staff A stated she knew that she was supposed to follow the Care Plan and she knew that Resident #1 was a mechanical lift transfer with 2 staff. Staff A stated that she just thought Resident #1 doesn't weigh very much, she didn't know what she was thinking, it was stupid on her part. On 2/7/25 at 3:30 p.m., Staff D stated she asked Staff A to assist her with transferring Resident #1 with the mechanical lift into the whirlpool as on the CNA sheet it directed to use a mechanical lift with Resident #1 for all transfers. Staff D stated that it was a two person job to run the Hoyer mechanical lift. Staff D stated she was walking down the hall and she saw Staff A in a different residents room. Staff D asked Staff A that when she was done, would she come and help her and Staff A said yes. Staff D went on to the whirlpool room and then after about 2 minutes Staff A came in to the whirlpool room. Staff D had left the mechanical lift outside of the whirlpool room and was waiting for Staff A to come in and bring the mechanical lift in with her. Staff A came in to the whirlpool room without a mechanical lift. Staff A didn't say anything to Staff D at first. Staff D stated she thought they were going to put the shower sling under Resident #1 first, but then Staff A said that therapy was working with Resident #1 to do a pivot transfer instead of a mechanical lift. Staff D stated this made her feel uneasy. Staff D said that typically they transfer residents needing a mechanical lift out of bed with the whirlpool sling on their bath days. Staff A started transferring Resident #1 out of the wheelchair. Resident #1 was not wearing a gait belt. Staff D stated normally you would use a gait belt with a pivot transfer. Staff A asked Staff D to pull down Resident #1's pants. Staff A put her arms under Resident #1 and held on to her pants to pull Resident #1 up. Staff D didn't know if Staff A tripped over something but Staff A fell back. Staff D said that right as they fell Staff A said 'of course this would happen'. Staff D ran to get the nurse. Staff D stated Resident #1 still had her pants on, as soon as Resident #1 stood up Staff A fell back and had Resident #1 fall on top of her. Resident #1 kind of let out a yell when they fell and then she started crying because she hit her leg. An undated Safe Resident Handling/Transfers policy, directed the following: Policy: To ensure that residents are handled and transferred safely to prevent or minimize risk for injury. Procedure: 1. Nursing Staff (Nurses, CNA's, Nurse Aids in Training) will lift and transfer residents according to a resident's individual plan of care. Individual plan of care is determined by therapy and/or nursing department. 2. Mobility needs will be addressed on admission and reviewed quarterly and after a significant change in condition or based on direct care staff observations or recommendations.