**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and document review, the facility failed to ensure safe use of a mechanical lift per manufacturer's recommendations to transfer 1 of 11 residents (R1), who required a mechanical lift for transfers. This resulted in an immediate jeopardy (IJ) when R1 fell from a full body mechanical lift causing R1 to suffer fractures to her cervical spine (C1 and C6), nasal cavity, and left femur as well as lacerations to facial area requiring hospital admission. In addition, the facility failed to ensure a system for completed comprehensive assessments for sling size and/or care plan development for 9 of 11 residents (R1, R2, R3, R5, R6, R8, R9, R10, R11) reviewed who required mechanical lifts. The IJ began on [DATE], when staff failed to ensure the lift sling was properly secured and the environment was clear prior to the transfer causing R1 to fall from the mechanical lift. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 4:20 p.m. The IJ was removed on [DATE] at 2:11 p.m., when the facility had implemented immediate corrective action to prevent recurrence, but noncompliance remained at a lower scope and severity of a D with no actual harm with potential for more than minimal harm that was not immediate jeopardy.Findings include: A Facility Reported Incident (FRI) submitted to the State Agency (SA) on [DATE] at 9:25 a.m., alleged potential caregiver neglect when R1 fell from the mechanical lift during a transfer and sustained a large gash above right eyebrow and on her nose. R1 was transferred by ambulance to the emergency department (ED). R1's Emergency Department Note dated [DATE] at 7:49 a.m., identified R1 was seen in the ED for assessment after she fell out of a hoyer lift. R1 presented with laceration to right eyebrow, bridge of nose, and some bleeding to the gums of her mouth. R1 also complained of increased difficulty breathing through her nose as well as feeling her head was heavy. The note identified that due to R1's multiple fractures and unstable burst fracture of the first cervical vertebra, R1 was transferred to the St. Cloud Hospital for further assessment and care. Clinical impression included closed unstable burst fracture of the first cervical vertebra, closed odontoid ( is a specific type of cervical spine injury involving the second cervical vertebra (C2)) fracture with displacement, fracture of the sixth cervical vertebra, and open fracture of nasal bone. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition. Diagnoses included at the knee amputations of both legs, paraplegia and rheumatoid arthritis. Identified R1 required staff assist with toileting, dressing, bed mobility, and transferring. R1's care plan last revised on [DATE], indicated R1 had a bilateral above the knee amputation in 2019, and required total assist of two (staff) and Hoyer (brand name of a full body mechanical lift) for transfers. The care plan did not identify the sling size staff were to use for transfers. Identified R1 had sutures to her nose and right forehead above the eyebrow with suture removal scheduled for [DATE]. In addition, R1 had a C1 and C6 (neck) fractures which required a cervical (neck) collar to be worn at all times. In addition, R1 had a nasal fracture and a left femur fracture requiring a leg immobilizer to be worn when R1 was up in wheelchair and during transfers. The facility identified focus sheet (abbreviated care plan for nursing assistants (NA)) as of 714/25, indicated R1 required two staff assist with Hoyer Lift however, the sling size was not identified. R1's progress notes dated [DATE] at 10:33 a.m., identified R1 was transferred to the ED for a C1, C2, and nasal fracture after a fall from a lift while staff transferred her from bed to wheelchair. R1's progress note dated [DATE] at 4:01 p.m., identified R1 returned from the hospital with the following injuries: laceration with five stitches above her right eye brow; laceration with three stitches in the center of her nose; bruising around right eye and down to the right side of her lips; bruising to her left eye under and on the corner of her inner eye; a 2.5 centimeter (cm) x 4 cm bruise near her left lateral elbow; two bruises on her left forearm sized 2 cm x 5.5cm and 5cm x 3.5 cm; neck brace on; and leg immobilizer on. R1's last documented weight on [DATE], was 136 pounds and previous weight on [DATE], was 123.6 pounds. An undated facility document labeled Medcare Products indicated all sling sizing recommendations were provided for patient comfort and fit. For a resident weight of 100-210 lbs. (pounds) a medium sized sling would be indicated. During an observation and interview on [DATE] at 11:12 a.m., R1 was sitting in the common area and was noted to have scabs, bruises, sutures to her face with a neck collar on, and an immobilizer brace on her left upper leg. R1 stated she had just returned from the hospital and was having pain all over, all of the time. R1 further identified she fell out of the lift fell the top sling loop by the right side of her head came off. When she fell out of the lift, she hit her face and nose on the leg of the lift and her legs hit something when she fell however she was not sure what they hit. R1 stated, I don't think they had it [sling] hooked up right as she stated she used the lift for six years and it had not happened before. R1 indicated she had been in the hospital for a couple of days and had lots of pain all the time. R1 expressed fear of getting back into the lift sling. During an observation on [DATE] at 1:19 p.m., nursing assistant (NA)-G and registered nurse (RN)-A transferred R1 from wheelchair to bed. When asked about the size of the sling, NA-G stated R1 used small slings and observed R1 had a small multipurpose sling under her during transfer and a spare small sling stored in the closet. During an observation on [DATE] at 3:02 p.m., NA-F and NA-E prepared to transfer R1 from bed to wheelchair. R1 cried out and moaned in pain while they rolled her to apply a small sling under her. NA-E and NA-F put the loops onto the safety bar and began to lift R1 off the bed. This evaluator stopped the transfer when it was noted that once tension was applied to the sling straps, the sling loop on the upper left side was sitting on top of the safety bar and not down in the hook area where it was supposed to rest for a safe transfer. NA-E stated, oh-oh, didn't I put it [sling loop] all the way down? NA-F lowered the lift and reapplied the loop to the upper left safety bar in the hook, lifted R1, and attempted to transfer to wheelchair. When R1 was approximately twelve inches above the wheelchair, the lift stopped, and NA-E used a walkie talkie to page the nurse. After a few minutes, licensed practical nurse (LPN)-A responded and explained how to operate the emergency lowering mechanism to both NA's and R1 was safely lowered to the wheelchair. NA-F stated that the battery had died and needed the nurse to assist. During an interview on [DATE] at 3:21 p.m., the director of nursing (DON) indicated staff were expected to to use a medium sling for R1, not a small sling. The DON did not know why small slings were stored in R1's room. During an interview with licensed practical nurse (LPN)-A on [DATE] at 2:10 p.m., identified she responded on [DATE] at 6:50 a.m., when R1 fell from the lift but stated she thought the sling used was a medium and was unhooked and underneath R1 on the floor. LPN-A identified she was not sure what had happened to allow R1 to fall and was just more concerned with getting R1 the emergency care she needed at the time. LPN-A further indicated staff should have used a medium sling for R1 because of her weight but a small sling was R1's preference so staff had used small slings most of the time. During an interview on [DATE] at 2:25 p.m., NA-B identified he assisted NA-A with R1's transfer on [DATE], in the morning. NA-B stated they each hooked two loops of the sling up to the safety bar and raised R1 up out of bed. While they were moving the lift towards the chair, the leg of the lift got caught up in the base of R1's fan and R1 started leaning to the right and fell out of the right side of the sling. NA-B further identified one of the sling loops had come unhooked during the transfer and thought it was the one on the side R1 fell out of however stated it happened really fast and was not certain. NA-B denied double checking the placement of the loops once tension was applied to the sling straps. During an interview on [DATE] at 9:35 a.m., RN-B indicated R1 by weight should have had a medium sling used however insists on a small [sling]. R1 felt the medium sling was too big did pretty good in it [small sling] but didn't work when the fall happened. RN-B indicated staff should be checking the placement of the sling loops as soon as pressure had been applied to the sling straps. RN-B did not know where a resident assessment for proper sling size would be in the medical record and did not think it was documented anywhere. During an interview on [DATE] at 9:50 a.m., the maintenance director indicated the full body lift was inspected after R1 fell from it and was found to be in working order. During an interview on [DATE] at 11:25 a.m., Medcare customer service representative (CSR) indicated if the full body lift was in working order, the only way for a resident to fall out of a lift would be improper sling set up or not attaching it to the lift safety bar hooks correctly. R2 R2's MDS dated [DATE], identified R2 had intact cognition, and diagnosis of paraplegia. R2's care plan dated [DATE], indicated R2 transferred with two staff assist and a Hoyer (full body mechanical lift). The care plan did not identify the size sling to use. The facility identified focus sheet (abbreviated care plan for nursing assistants (NA)) as of 714/25, indicated R1 required two staff assist with Hoyer Lift but did not identify the sling size to use. R2's medical record identified R2's weight on [DATE], was 188.4 pounds. An undated facility document labeled Medcare Products indicated all sling sizing recommendations are provided for patient comfort and fit. For a resident weight of 100-210 lbs. (pounds) a medium sized sling was indicated. During an observation on [DATE] at 11:55, NA-C and NA-D transferred R2 out of the tub using a ceiling lift. NA-C indicated R2's sling was a size extra-large but after double checking the size on the sling, it had small written on the sling. NA-C stated, oh no, it looks much bigger than that, and further identified that she picked that sling out because, he [R2] likes the softer ones[slings], not the stiffer ones for his bath. NA-C further identified the resident sling size was not written anywhere and staff were directed to size the sling by the resident's weight and their body size. NA-D stated NA's or the nurses could decide what sling to use. During an interview on [DATE] at 12:00 p.m., RN-A indicated she did not know who determined what sling size a resident was supposed to use. RN-A stated she did not know how the proper sling or belt size was communicated to the NA's doing the transfers. R2's medical record lacked resident assessment for appropriate sizing of the sling. R3 R3's admission MDS dated [DATE], identified R3 had severe cognitive impairment, was dependent on staff for toileting, lower body dressing, transfers, and bed mobility. Diagnoses included dementia, encephalopathy, and osteoarthritis. R3's care plan revised [DATE], indicated R3 required assist of one staff with PAL (sit to stand lift) for transfers. The care plan did not identify what size sling belt to use. The facility identified focus sheet (abbreviated care plan for nursing assistants (NA)) as of 714/25, indicated R3 transferred with one staff assist and PAL lift (sit to stand lift) but did not identify what size belt should be used. The Medcare Operations Manual Belt Sizing Guide indicates recommended belt size was determined by waist size. R3's medical record did not contain R3's waist size. R3's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During observation and interview on [DATE] at 12:35 p.m., R3 was sitting in a recliner with an extra-large belt laying in the wheelchair. NA-D entered the room with the sit to stand lift which had a medium belt slung over the top of the lift. NA-D used the medium belt, placed the belt around R3 and hooked it to the lift. NA-D transferred R3 to the bathroom and then back to the chair. During the transfer back to the chair, R3 did remove her left hand from the lift and was holding on to the lift with her right hand only. No observation was noted of NA-D tightening the belt once R3 was lifted or applying the safety shin straps during the transfers. When asked about the two different belt sizes in R3's room, NA-D stated she did not know why there was an extra-large belt in R3's room but that it keeps showing up in here [R3's room] but had not used it. R3 indicated belt size was determined by the resident chest size and R3 was a smaller lady and if the extra-large belt were used on her, she would fall right through it. When asked about the safety shin strap, NA-D stated, I never use them [shin strap] and thought they were for a previous resident that would not keep his feet on the foot platform. R4 R4's quarterly MDS dated [DATE], identified R5 had moderate cognitive impairment and required staff assist for transfers. Diagnoses included lower limb amputation and osteoporosis. R4's care plan last revised [DATE], identified R4 required assist of one staff and stand by assist with transfers. The care plan did not identify the use of the mechanical lift or size of belt staff were to use with transfer. The facility identified focus sheet as of [DATE], indicated R4 transferred with one staff assist and PAL lift (sit to stand lift) but did not identify what size belt should be used. R4's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During an observation on [DATE] at 1:10 p.m., R4 was noted to have a sit to stand lift in her bathroom with a medium size belt draped over the top. R5 R5's quarterly MDS identified R5 had intact cognition and required staff assistance with transfers. Diagnoses included osteoarthritis and spondylosis (degenerative changes in the spine). R5's care plan last revised [DATE], identified R5 required one staff assist for transfers using a PAL lift (sit to stand lift) but did not identify what size belt should be used. The facility identified focus sheet as of [DATE], indicated R5 transferred with one staff assist and PAL lift (sit to stand lift) but did not identify what size belt staff should use. R5's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During an observation on [DATE] at 1:17 p.m., R5 was noted to have a size large belt laying on his chair in his room. R6 R6's significant change MDS dated [DATE], indicated R6 had severe cognitive impairment and required maximum staff assist with transfers. Diagnosis included dementia. R6's care plan revised initiated on [DATE], indicated R6 transferred with two assist and PAL lift but did not identify belt size to use for safe transfers. The facility identified focus sheet as of [DATE], indicated R6 transferred with two staff assist and PAL (sit to stand lift) lift for all transfers but did not identify what size belt staff should use. R6's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During observation on [DATE], R6 was noted to have a large sling belt in his room. R8 R8's quarterly MDS dated [DATE], identified R8 had moderately impaired cognition and was dependent on staff for all transfers. Diagnoses included cerebral infarction and dementia. R8's care plan reviewed on [DATE], indicated R8 transferred with assist of two and Hoyer (full body mechanical lift) but did not identify sling size to use. The facility identified focus sheet as of [DATE], indicated R8 transferred with two staff assist and Hoyer transfers but did not identify what size sling staff should use. R8's medical record lacked resident assessment for appropriate sizing of mechanical lift sling. R8's vital signs chart indicated R8's weight on [DATE], was 215 pounds which indicated a large sling was recommended. During observation and interview on [DATE] at 1:47 p.m., NA-D and NA-G transferred R8 to bed using a size large sling. Interview with NA-G indicated she determined sling size by the resident's weight and if she did not know the resident weight she would ask the nurse for the weight. NA-G further indicated R8 used a large because a medium is way too small. R9 R9's quarterly MDS dated [DATE], identified R9 had severe cognitive impairment and was dependent on staff for all transfers. Diagnoses included dementia and fracture of the left acetabulum (hip). R9's care plan on [DATE], identified R9 transferred with two staff assist and PAL lift or two staff assist and Hoyer lift but did not identify the size belt or sling to use for transfers. The facility identified focus sheet as of [DATE], indicated R9 transferred with assist of two and PAL lift or assist of two and a Hoyer lift but did not include the size of the sling or belt to use. R9's medical record lacked resident assessment for appropriate sizing of mechanical lift belt and sling. R10 R10's annual MDS dated [DATE] indicated R10 had severe cognitive impairment and required assist with all transfers. Diagnosis included Alzheimer's. R10's care plan on [DATE], identified R10 transferred with two staff assist for pivot transfer; one staff assist with ETAC (unknown meaning) from recliner, wheelchair, bed; or assist of one with PAL lift. The care plan did not identify what belt size to use. The facility identified focus sheet as of [DATE], indicated R10 transferred with assist of one and ETAC (unknown meaning); assist of two with pivot, or assist of one and PAL. R10's medical record lacked a waist size or resident assessment for appropriate sizing of mechanical lift belt. During observation and interview on [DATE] at 3:44 p.m., NA-G applied a large belt and assisted R10 to transfer. NA-G stated the size belt for the resident depended on the resident weight. R11 R11's significant change MDS dated [DATE], indicated R11 had intact cognition and required staff assist with transfers. Diagnosis included Multiple Sclerosis. R11's care plan on [DATE], identified R11 transferred with one staff assist and standing lift but did not identify what size belt to use. The facility identified focus sheet as of [DATE], indicated R11 required assist of one and PAL but did not identify what size belt to use. R11's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During an observation on [DATE] at 9:02 a.m., NA-H assisted R11 with a transfer to the commode using a medium belt. When asked about determining appropriate belt size for a resident, NA-H stated it depended on the size person they are and did not want them too loose so I just judge their size and how it fits and determine their size from there. NA-H further indicated there was not any direction on which belt size to use but most of the residents that used belts, had them hanging on their doors. R12 R12's quarterly MDS dated [DATE], indicated R12 had severe cognitive impairment and was dependent on staff for transfers. Diagnosis included Alzheimer's. R12's care plan on [DATE], identified R12 transferred with one staff assist and standing lift but did not identify what size belt to use. The facility identified focus sheet as of [DATE], indicated R12 assist of one and PAL but did not identify what size belt to use. R12's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During an interview on [DATE] at 9:13 a.m., NA-I indicated most of the residents that used lifts had slings or belts on the back of their doors that they could use but slings and belts for the mechanical lifts were based on the resident weight. NA-I denied any written communication to instruct what size sling or belt they were to use. During an interview on [DATE] at 9:20 a.m., LPN-A identified NAs should refer to the belt sizing guide in the CNA book binder at the nurse's desk when determining belt size. LPN-A further indicated all sling were determined by a resident's weight but did not know and could not find any sizing recommendation information on the sit to stand belts and stated, I guess they go by weight too. During an interview with on [DATE] at 12:20 p.m., RN C indicated she did not know who did resident assessments for sling sizing and was not aware of a specific assessment process the facility had in place. During a follow-up interview on [DATE] at 12:25 p.m., the DON identified the RN charge nurse should identify the residents sling or belt size based on the size guide sheet from the manufacturer and would be based on the resident body type and weight. The DON confirmed the facility did not have a formal assessment to determine sling or belt size and did not know where staff would document the resident sling and belt sizes. The DON indicated residents should have the appropriate size sling or belt on the back of their doors to ensure safety. The DON identified after R1's fall from the lift, she replaced the small slings in R1's room with the medium sling and did not know how the small slings ended up in use for R1 again after she had removed them. The DON confirmed the facility did not train or complete competencies for lift use on the temporary agency staff however planned to initiate that immediately. The DON verified the facility policy addressed the use of a lift that was not in service at their facility and did not have one specific to the Medcare brand lifts that were currently being used. The facility policy titled, Reliant 450 Lift and Slings (the facility is using Medcare full body lift and slings) dated [DATE], and last modified on [DATE], indicated before beginning procedure, scan the environment for obstacles to making a successful transfer and adjust environment to ensure safety of resident. Step 1 is to select the proper style and size sling (binding around each sling is color coded to size, the sizing chart is in each CNA book). Step 21 is prior to lifting an individual make sure the straps of the slings are securely placed on the hooks of the carry bar. The facility policy titled, Med Care Standing Lift dated [DATE] and last updated [DATE], identified the stand lift is intended for residents who are able to bear partial weight and require some lifting to perform activities of daily living. Appropriate use is to be determined by physical therapy department or nurse managers. Step 5 instructs to hook the leg strap around the resident's calves. Step 7 is prior to lifting an individual make sure the straps of the slings are securely placed on the hooks of the carry bar. Upon admission or change of condition, sit to stand lifts will be two assist, unless deemed to be safe with one assist by a licensed nurse or therapy. The policy does not include any language regarding how to accurately size the harnass (belt) for the resident. The Medcare Sling Sizing Guide directs staff to use the sling sizing chart as a general guide. Keep in mind the patients/residents that are the same weight may have different body types, shapes, and sizes and may require different sized slings. The Medcare Belt Sizing Guide directs staff to use the belt sizing chart as a general guide. Keep in mind the patients/residents that are the same weight may have different body types, shapes, and sizes and may require different sized belts. The sizing guide gives recommended size by waist size. Waist size of 24 inches to 48 inches recommends a small size; 30 inches to 54 inches recommends a medium size; 36 inches to 60 inches recommends a large size; and 42 inches to 66 inches recommends an extra-large size. The sizing guide does not identify that weight is used in sizing the belts. The IJ was removed on [DATE] at 2:11 p.m. when it was verified the facility implemented the following corrective actions:*The facility policy and procedure for safe mechanical lift transfers was updated to include the appropriate mechanical lift company's manufacturer's recommendations and specific time out procedures to do safety checks to ensure all loops were hooked on the appropriate hook before lifting the resident and completing an environmental scan of all the area for possible obstacles prior to beginning the lifting procedure. *The facility developed and implemented a system for an RN to comprehensively assess sling and belt sizes for individual residents utilizing the full body and sit to stand mechanical lifts by utilizing the manufacturer's guidelines and nursing judgement. * Sling and belt sizes for each resident were added to the resident's care plans and the NA care sheets (focus sheets). *The facility provided education with return demonstration to all nursing staff on manufacturer's recommendations to include a safety check, doing an environmental scan, and using proper sling sizes for the residents.