The facility identified a census of 18 residents, with 8 residents included in the sample. Four residents were sampled for accidents. Based on observation, record review, and interview, the facility failed to ensure that a Hoyer lift (a mechanical device used to assist in transferring a resident) full body sling strap (a fabric device used to help suspend and attach to the Hoyer lift when transferring a resident) was fully inserted and clasped into the hook on the lift arm of the Hoyer lift. As a result, Resident (R) 5 slipped from the sling and was lowered to the floor, which resulted in a fractured left ischial tuberosity (the curved bone that makes up the bottom of the pelvis). Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of multiple sclerosis (MS - a progressive disease of the nerve fibers of the brain and spinal cord), dementia with behavioral disturbances (a progressive mental disorder characterized by failing memory, confusion with behaviors of verbal and physical aggression), and mononeuropathy of the lower limb (damage to of nerves outside of the brain and spinal cord in the lower limb). The Annual Minimum Data Set (MDS) dated 09/28/21 documented R5 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. She required extensive to total dependence of one to two staff for her activities of daily living (ADLs). She required total dependence of two staff for transfers. She had functional limited range of motion (ROM) impairment on both sides of her upper and lower extremities. She required the use of a wheelchair for mobility and had no history of falls since prior assessment. The Quarterly MDS dated 12/29/21 documented a BIMS score of 11, which indicated a moderately impaired cognition. She required extensive to total dependence of one to two staff for ADLs. She required total dependence on two staff for transfers. She had functional limitation ROM impairment of one side on her upper extremity and in both lower extremities. She required the use of a wheelchair for mobility and had no falls since the prior assessment. The ADLs Care Area Assessment (CAA) dated 10/06/21 documented R5 needed assistance with most ADLS and noted she had an unsteady transitional balance. Staff used a full body lift for transfers. R5 had very poor core strength and was unable to sit on a toilet. She had MS that had progressed to where she was unable to stand or walk. She was minimally able to use her upper body to help with cares, but required assistance. She participated with an exercise program that included ROM. R5 was at risk for further ADL decline, falls, contractures, and skin breakdown. The Falls CAA dated 10/06/21 documented R5 had an unsteady transitional balance. She had a Morse fall risk assessment on 09/21/21 with a score of 15, which indicated a low risk for falls. She had not walked for several years related to progression of MS. R5 transferred with a full body lift with the assistance of two and used a wheelchair for mobility. The Care Needs Care Plan for R5 documented a new intervention dated 02/28/22 to use a full body lift with assist of two for transfers. R5 always used a wheelchair for all mobility and required foot pedals. Staff were to assist R5 with wheelchair mobility. Transfers should be done using a Hoyer lift with the assistance of two. R5 was non-weight bearing to her left lower extremity. A Nurse Progress Note by Licensed Nurse (LN) H on 02/26/22 at 06:30 AM documented two Certified Nurse Aides (CNAs) were getting the resident up for her shower using the Hoyer lift. One of the upper straps of the lift sling slipped off during transfer. R5 slipped out of the sling and staff lowered her to the floor. R5 landed softly on her bottom and did not hit her head, per witness reports. LN H went to the room and assessed the resident. R5 reported slight pain to her left lower leg with no redness noted, though a reddened area was noted to her mid/upper back at that time. R5 was alert and oriented to person and place and could not rate her pain to the lower left leg. R5 denied any other pain at that time. Staff obtained vital signs which were within normal limits. R5 had equal grips, and her pupils were reactive. No other injuries were noted. Staff assisted R5 to the shower chair with the Hoyer lift with the assistance of two CNAs and the nurse. Staff sent a fax to the clinic to notify the provider. Staff notified R5's representative who had no questions/concerns. A Nursing Note dated 02/28/22 at 08:18 AM documented R5 continued to complain of pain to the left leg with movement. Staff requested and received an order for an x-ray of the left hip and left knee. A Radiology Report dated 02/28/22 at 09:13 AM documented the following impression: Suspect left inferior pubis ramus (a part of the pelvis) or posterior acetabular wall (the back part of your hip) fracture. Consider a computerized tomography scan (CT-a series of x-ray images taken from different angles around a body part) to confirm. A CT scan of the pelvis result dated 02/28/22 at 3:29 PM documented an impression of an acute left ischial tuberosity fracture. A Nursing Note dated 02/28/22 at 04:16 PM documented R5 returned to the facility with new orders for non-weight bearing status on the left lower extremity. The order directed staff may use the Hoyer lift if there was no undue stress/pressure on the pelvis and further ordered a consult with orthopedics (bone specialists) on 03/01/22. The Investigation Report documented on 02/26/22 at 06:30 AM, CNA M and CNA N transferred R5 from her bed to her shower chair. R5 had MS, was non-weight bearing, and always used a Hoyer lift for transfers. The CNA's lifted R5 from the bed in the sling and moved the lift away from the bed towards the wheelchair. CNA N pushed the lift and CNA M guided the sling. At that time, the left top strap of the sling slipped off, which caused the resident to fall/slide out of the sling. CNA M supported R5's upper body and prevented her head from hitting the floor while CNA N supported R5's lower extremities and lowered R5 as best they could. The legs of the lift had not been opened yet to straddle the wheelchair and R5 was lowered down onto the legs of the lift. R5 reported slight pain to her left lower leg upon assessment. The assessment revealed a reddened area to R5's mid/upper back. A Witness Statement from CNA M dated 02/26/22 documented R5 slipped out of the sling and was lowered to the floor by staff. CNA M wrote one of the hooks on the Hoyer lift came off. A Witness Statement from CNA N dated 02/26/22 documented the incident occurred in the middle of R5's room. CNA N stated staff transferred R5 and one of the slings straps came off (left top strap) of the hook. The resident slid out of the sling and staff held R5's head and lowered her to the floor. The facility provided a Post-Accident Interventions and Actions report which recorded the sling was not adequately rested in the sling cradle. On 03/21/22 at 09:22 AM R5 stated she was doing okay. She only had occasional pain when being transferred in the lift. On 03/22/22 at 07:15 AM R5 sat in her high-back wheelchair and had the Hoyer lift sling underneath her. Her wheelchair was at the dining table and staff assisted R5 to eat breakfast. On 03/23/22 CNA M and CNA N were unavailable for interview. On 03/23/22 at 11:04 AM CNA O stated there should always be two people assisting when doing transfers with the Hoyer lift. Both staff members should make sure that the sling straps are hooked onto the tabs/hooks. One of the staff members stays with the resident in the sling while the other staff member operated the lift. Staff members received training and were checked off on lift use when hired and annually. CNA O stated she knew there had been an incident with R5, but she was not working at that time. The facility obtained a new sling for R5. CNA O stated she was responsible for the cleaning and checking the lifts weekly to ensure they worked properly. On 03/23/22 at 10:46 AM LN G stated before the Hoyer lift could be used for a resident, the resident had to be assessed by therapy. Staff members were required to do skills training upon being hired and annually for use of the lifts. Any lift transfer required the assistance of two staff members. LN G would expect the CNA's to immediately report if a sling or lift was not operating properly. On 03/23/22 at 10:39 AM Administrative Nurse D stated new slings were ordered for R5 and she was using a different one than when the incident on 02/26/22 occurred. She stated she would expect when staff members transferred any resident in a lift that two people would assist the resident. Staff were checked off on lift use upon being hired as well as annually. On 03/23/22 at 10:40 AM Administrative Staff A stated that after an investigation it was hard to determine what the cause of the incident was other than that the staff members did not ensure that the sling strap was securely attached to the lift arm before the resident was moved. The facility policy Safe Patient Handling last reviewed February 2020 documented: Purpose- to provide caregivers with guidelines to assess and make decisions about the lifting and transferring methods required for residents weighing over 15.9 kilograms (35 pounds). Assistive devices-when using a mechanical lift, follow guidelines- staff will complete the lift training on hire, yearly, and as needed. This is to ensure that all staff is continuing to lift and use the lift properly. The facility failed to ensure the safe transfer of R5 with the use of a Hoyer lift and sling when staff members failed to ensure the sling strap was securely latched/attached to the lift arm hook/clasp. This deficient practice resulted in an avoidable accident when R5 slipped out of a mechanical lift sling, which resulted in a fracture to R5's left ischial tuberosity. On 03/02/22 the facility completed the following corrective actions: Staff were educated on being aware of the sling and resting it in the cradle and to double check all sling areas that was attached to the lift. Education that was done was as follows: Hoyer type lift competency checklist; All slings and lifts were inspected weekly; All staff to inspect the lift and slings at each use; All staff watched the instructional video for the lift. The facility ordered four new slings to test which ones gave the most security to the sling in the cradle. The facility reviewed the incident at the Quality Assurance Performance Improvement (QAPI) meeting. Education and any issues with the lift/staff/education/condition will be reviewed quarterly for three quarters and then annual thereafter. The deficient practice was cited at past non-compliance.