**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure safe transfer while utilizing a mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for R1. The immediate jeopardy began on [DATE], when R1 fell while being transferred in a full body mechanical lift that tipped over during provision of care. The facility failed to identify if the staff were correctly using the lift per manufacturer recommendation when the incident occurred. Additional transfer observations identified manufacturer's guidelines were not followed for safe use. The IJ was identified on [DATE]. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 5:05 p.m. on [DATE]. The IJ was removed on [DATE] at 3:22 p.m., but non-compliance remained at the lower scope and severity level 2, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: R1's Resident Face Sheet identified diagnosis that included chronic pain, depression, obesity and long term use of anticoagulants (blood thinners). R1's annual Minimum Data Set, dated [DATE], identified intact cognition and indicated he was dependent on staff for transfers. R1's care plan dated [DATE], identified the use of a full body mechanical lift for transfers and lift sling size 2 extra large (XL), updated [DATE]. The care plan identified a fall on [DATE], while in the mechanical lift involving two nursing assistants (NA)'s performing the transfer resulting in bruising and scrapes to the right side of R1's body. The care plan indicated staff were provided education on use of the full body lift and indicated a nurse was to be present in the room during transfers with two NA's performing the transfer to observe for safety and correct use of the lift. The care plan further indicated R1 had trauma induced signs and symptoms of nervousness and anxiety due to a previous fall from the lift. R1's Resident Progress Note dated [DATE], indicated two NA's were assisting R1 with transfer from bed to wheelchair using a full body mechanical lift. One NA was moving R1 from the bed to the chair and attempted to open the legs of the lift and the lift started to tip while R1 was in it. R1 fell with the lift and hit his head on the floor. [DATE], Resident Progress Note indicated the interdisciplinary team reviewed the fall and identified the contributing cause of the fall as; equipment tipped, staff reported R1 adjusted himself while in the lift when the lift was being moved out from under the bed to extend the legs. R1 reported the legs of the split leg sling were not crossed as recommended by the manufacturer because it caused him discomfort. Further root cause analysis indicated staff had used an XL sling and based on R1's current measurements the sling size should have been changed to a 2XL. Interventions to prevent recurrence included removing the lift from service. Facility document titled Mechanical Lift [DATE], Incident and OHFC (office of health facility complaints) Report indicated R1 fell while in full body mechanical lift sling during transfer from bed to his wheelchair. Lift tipped and R1 landed on the floor. Verified R1's weight was within range of the lift, R1's weight increased from 395 pounds to 413 pounds between [DATE], and [DATE], and sling size was updated to 2XL based on the weight gain. A nurse must be in the room for all transfers of R1 until further notice. Staff involved were interviewed. All transfers with the lift must be observed by a nurse to verify competency prior to using a lift without supervision. Lift involved was immediately removed from service and brought to maintenance, not to be used until cleared by maintenance. The incident occurred while staff were transferring R1. Staff were unable to extend the legs of the lift under R1's bed and as staff moved the lift clear of the bed to allow base to be extended, R1 adjusted himself in the lift causing the lift to tip over. R1 landed on his butt on the floor and hit his head on the floor. Staff reported R1 would not allow the straps on the sling to be criss crossed as recommended by the manufacturer. R1 also had an 18 pound weight gain over the past few months and XL sling was no longer appropriate. Reported indicated facility took the following action: Sling size was updated to 2XL based on the weight gain, staff were competency tested on full body mechanical lift and educated prior to working their next shift. Care plan was updated to include three staff present during R1's transfers to include a licensed staff member. Maintenance inspected the lift used during the transfer that resulted in the fall and removed some hair that had been hindering movement in the wheels. During interview on [DATE] at 1:36 p.m., R1 asked, Are you here about the ride I took? I hit my tailbone, it hurt so bad, but they did an X-ray and nothing was broken. R1 stated the staff had lifted him up off the bed and were going to swing the lift over and must have swung it a little too fast because it went over. R1 indicated the wheelchair was between the bed and the closet and said, I was in it [the lift] and when they started turning to put me in the chair, that's when it hit [tipped over]. R1 stated he was scared the last time the lift had tipped during a transfer but said, I'm getting used to it now. R1 stated he was scared it was going to happen again, and it did, indicated he was afraid and said, It will probably be more serious next time. During interview on [DATE] at 1:58 p.m., NA-A stated on [DATE], when the lift had tipped over during R1's transfer, she had been behind the wheelchair while NA-B was running the lift. NA-A said the legs on the lift were closed until it cleared the bed and when NA-B opened the legs the lift started tipping. NA-A stated she had not assisted with the transfer, only stood behind the chair. NA-A further stated the straps of the sling that go between R1's legs had not been crossed as recommended by the manufacturer and said staff had not been doing it for a long time because R1 did not like it that way. NA-A stated since the fall staff now crossed the sling between R1's legs and kept the legs of the lift open during the entire transfer. During interview on [DATE] at 2:06 p.m., registered nurse (RN)-A stated on [DATE], she had been called to R1's room and found him on the ground next to his wheelchair. RN-A said she was told staff had been transferring R1 from his bed to the wheelchair and the lift had tipped. RN-A said staff reported they could not open the legs of the lift while it was under the bed and when they pulled out the lift and tried to open the legs, the lift tipped over. RN-A stated one staff should have been operating the lift and the second staff should have been holding onto the handles of the sling to assist with guiding during the transfer. RN-A stated R1 had a trapeze to assist with movement in bed and the legs were under the bed and interfered with opening the legs of the lift. RN-A said since the incident occurred, staff had received more training and said everyone had been educated and said a nurse was observing transfers in R1's room. RN-A further stated R1 should have been assessed for a new sling during his assessment period in February 2024, and said at that time he may have needed a new sling size. During interview on [DATE] at 2:49 p.m., the lift company's representative stated other than a mechanical issue, the only way a lift could tip over was if the resident's weight was centered on the outside of one of the legs which would cause the lift to become unbalanced. The representative stated debris in the wheels may make the lift harder to push but would not cause it to tip over. The representative indicated using the incorrect sling would only affect comfort but would not affect the balance of the lift and said if the resident was attempting to re-adjust in the sling there was no way they could get enough leverage to get themselves outside the area where the legs are balanced. He added, they trained staff to make turns with the legs open but they should be able to safely turn the lift with the legs closed. The lift representative stated unless something on the lift failed, user error was usually the cause of a lift tipping over and if the lift tipped over it would have been during the maneuvering and a leg getting hung up on something. During interview on [DATE] at 3:37 p.m., NA-B stated she had been assisting with the transfer when the lift tipped over with R1 in it. NA-B stated she had been operating the lift and said as she pulled the lift back it tipped over. NA-B stated she could not fully extend the legs under the bed and when she tried to extend them they got stuck and the lift tipped. During interview on [DATE] at 3:50 p.m., the lift used during the transfer that resulted in R1's fall was observed with maintenance worker (MW)-A. The lift was a Volaro PC 450 Series. MW-A indicated there had been some hair stuck in the wheels and said he had removed some small strands. MW-A stated it had not been a significant amount of hair and said everything else had been in good working condition with no other mechanical concerns identified. During observation and interview on [DATE] at 11:25 a.m., NA-C and NA-D prepared to transfer R1 from his bed to wheelchair using the full body mechanical lift. NA-C moved the bed away from the wall so the legs of the trapeze would not interfere and they hooked the straps of the sling to the mechanical lift. When the lift was raised the battery was observed to be low powered and a sling strap came unhooked from the machine. NA-C stated he visualized the straps after hooking them up but did not pull on the straps to ensure they were secure. NA-C and NA-D secured the strap and completed the transfer. RN-B was present in the room to observe the transfer and did not intervene or question the low power warning or when the strap came undone from the lift. During interview on [DATE] at 12:39 p.m., R1 stated each fall he had from the lift occurred when staff were turning him so he told the staff to eliminate turning the lift when he was in it to avoid more falls. R1 said during the transfer at 11:25 a.m. staff had the sling hooked up right but when it got weight on it, the strap came unhooked and out of his hand as he had been holding onto the straps. R1 stated it was okay this time because he was over the bed, but said it was nerve wracking because the strap could have come off when he was not over the bed and he could have fallen again. During observation on [DATE] at 12:49 p.m., NA-E and NA-B prepared to transfer R1 in the mechanical lift while RN-A observed. R1 verbalized he did not want staff to have to turn the lift whatsoever. The staff placed R1 in his wheelchair with his back to the bed and lifted him straight up and pulled him backward approximately 6-8 feet, removed the chair and pushed him the same distance back to the bed. During the transfer the lift was moving very slowly and NA-E acknowledged the battery light was red indicating it was not fully charged. RN-A did not intervene during the transfer even though NA-D and NA-B did not follow manufacturers recommendations to move the resident in the lift the shortest possible distance nor did RN-A suggest the battery be replaced when staff identified it was low. During the transfer R1 stated, I don't want to fall on my head again. During interview on [DATE] at 12:58 p.m., RN-A stated the competency checklist indicated if the lift battery was low staff were supposed to stop and change it before transferring the resident. RN-A said she had not intervened because she did not want to step on their toes. During interview on [DATE] at 1:02 p.m., NA-E stated she had received competency testing after R1's last fall on [DATE]. NA-E said she was aware the checklist said to change the battery if it was reading low but she did not want to stop the transfer to change it. NA-E said if the battery would have died she would have called for help. During interview on [DATE] at 3:11 p.m., the director of nursing (DON) stated the reason they had implemented having a third person in the room during R1's transfers was to ensure his safety by adding another set of eyes. The DON stated if the third person identified something staff were not doing correctly she would have expected them to intervene. The DON indicated if the battery was low, staff should have lowered R1 back down and got a new battery. Volaro Series 4 Lift Operator's Manual dated 3/2019 included the following Safety Notes: - the Volaro lift is designed for patient transfer only. Using the lift for transport can create an unsafe patient handling situation. - legs must be fully extended in the wide position when lifting a patient or resident. - Make sure all four loops from the sling are properly nested in the bottom of the hooks before lifting or transferring the resident. Also make sure all four retainer springs are functioning correctly. Volaro PC450 General Procedure Guide for Training indicated: - Have assistant stand on opposite side of bed to assist with transfer. - Position wheelchair at foot of bed. - Make sure power pac indicator does not indicate a low power pac. (if so, replace) - Make sure the correct sized sling is to be applied. - Check that the legs are in the widest position, where applicable. If base position must remain in narrow position, make sure the lift area between the bed and chair are clear of any obstacles. Widen once clear from bed. - Attach straps on the sling with strap nesting in the bottom of the hook. Remember with a divided leg sling, the straps at the thigh area must be criss crossed before lifting. - As you begin to left the resident from the bed, once there is tension on the straps check to make sure all four loops are still nested in the bottom of the hooks before lifting. The immediate jeopardy that began on [DATE], was removed on [DATE], when the facility implemented the following actions which were verified through interview and observation. - R1's bed will be moved away from trapeze for transfers with mechanical lift. - The wheelchair will be placed at the end of the bed to allow minimal movement of the lift. - Straps will be checked to make sure all four strap loops are nested in hooks. - Therapy evaluation for safe and appropriate transfer process. - Retrain all staff who use Full Body Mechanical Lift to ensure proper use of Lift for R1 along with return demonstration for all staff working and for oncoming staff prior to their next scheduled shift. - Observe a minimum of one transfer for each resident using a full body lift. If concerns/issues are identified observation will be repeated. - Any resident with significant change in weight, physical ability, cognitive ability will have therapy evaluate for safe and appropriate transfer process. - Maintenance inspection of the hooks on all mechanical lifts. - Mechanical lift competency will include section of if no for staff observing to enter actions to correct staff with just in time education. - DON, or designee, will utilize all steps of the competency steps in checklist for competency testing, per manufacturers recommendations, using return demonstration of all staff using mechanical lift in both the operator and assist position prior to their next shift. - DON, or designee, will competency test with return demonstration, per manufacturers recommendations, all licensed staff for supervision of staff using a mechanical lift. - All staff will have education and knowledge verification on troubleshooting items. - Review and revise Mechanical Lift Standard Work as needed per policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to evaluate and analyze hazards following a resident fall from a Hoyer lift resulting in a laceration to the elbow and hematoma on the head. A second, near miss incident occurred one week later for the same resident (R1) using the same lift. This resulted in an immediate jeopardy for R1. The immediate jeopardy began on 5/9/23, when R1 fell from the Hoyer lift during provision of care. The facility failed to thoroughly investigate and identify if the staff were correctly using the lift per manufacturer recommendation when the incident occurred. The IJ was identified on 5/19/23. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 12:34 p.m. on 5/19/23. The IJ was removed on 5/22/23, but non-compliance remained at the lower scope and severity level 2, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set, dated [DATE], identified intact cognition and indicated he required total assistance from two staff for transfers. R1's care plan dated 4/26/23, identified decreased independence and the need for assistance with activities of daily living due to limited mobility. The care plan directed staff to use a full body mechanical lift to perform transfers. R1's facility Progress Notes identified the following: -5/9/23, recorded as a late entry on 5/22/23, at 1:03 a.m. following surveyor inquiry, indicated R1 was on his left side on the floor. The mechanical lift tipped as he was being transferred. R1 had a small open area on his left elbow, Steri-strips applied and a small bump on the back of his head. The lift was removed from use at that time. The progress note was written by licensed practical nurse (LPN)-A. -5/9/23, recorded as a late entry on 5/16/23, writer arrived in room and R1 was on the floor on his side. R1 had fallen when the lift tipped. R1 was checked for injuries, had a cut on his left elbow and a small bump on the back of his head. Lift removed from use. -5/10/23, recorded as a late entry on 5/16/23, interdisciplinary team review identified contributing cause of the fall: mechanical lift tipped during transfer. Staff and resident interviewed and confirmed correct use of equipment. Maintenance found the latching mechanism for the lift legs did not catch as it should. Part ordered to fix. The lift was removed from service to have maintenance assess/fix. -5/17/23, recorded as a late entry on 5/21/23, following surveyor inquiry: Near miss fall: nursing assistant (NA) reported to nursing staff that mechanical lift was making odd noises as staff was using machine to lift resident from bed. NA reported lifting arm of machine appears off center as well. NA reported that resident was laid back down in bed and a different lift was used to safely transfer R1. Nursing instructed NA to put lift out of service to prevent further use. A handwritten note by NA-A indicated on 5/9/23, while lifting R1 in the mechanical lift, on the way to the commode the lift tipped over and R1 fell hitting his head on the commode and his elbow on the floor. NA-A wrote she was trying to pull the wheelchair back as another staff lifted him up and was attempting to pull the lift back before turning it toward the commode. NA-A wrote R1 was hooked up correctly and was not moving around. NA-A wrote, R1 was not moving around, the hoyer [mechanical lift] tipped from his weight. I believe [R1] should not be using that type of hoyer machine and should switch to the other we have been using since. A facility document titled, EH (Essentia Health) SNF (skilled nursing facility) Vulnerable Adult (VA) Template dated 5/15/23, indicated on 5/9/23, R1 fell due to a lift tipping over. The document indicated maintenance was involved due to equipment involvement and indicated R1 did not feel safe using any of the lifts. The document indicated all staff involved in the incident should be interviewed as well as staff who normally work with the resident and determine if education, coaching or corrective action needed to be implemented. The document further indicated all staff would be educated on use of lifts and potential issues. An e-mail dated 5/22/23, from registered nurse (RN)-A to the administrator and the DON identified the following: below completed 5/10/23 - 5/14/23. - R1 reported staff helped him get in the lift sling as they usually did. They had the commode to the side and as they were going from the wheelchair to the commode, NA-B was lifting him up, the legs were wide like they usually do and when he was moving toward the commode, it just tipped over. R1 stated it surprised all of them and said he was on his left side with the lift on his right side. R1 said his elbow hurt at first and he could tell he bumped his head. - NA-B reported they needed to transfer R1 to the commode. NA-B said she opened the legs of the lift and lifted R1 up. NA-B reported all seemed to be going well and when she was moving the lift so she could get R1 on the commode the lift tipped, landing partially on R1. NA-B said they helped get the lift off R1 and called for the nurse. - NA-A reported while lifting R1 in the mechanical lift, on the way to the commode the lift tipped over and R1 fell hitting his head on the commode and his elbow on the floor. NA-A said he was hooked up correctly and the legs were open. NA-A said R1 had not been moving around and said she believed the lift tipped due to R1's weight. An e-mail dated 5/22/23, indicated maintenance noted the locking mechanism on the legs of the lift were worn and likely caused the lift to tip as the legs would have closed during the transfer. During observation and interview on 5/18/23, at 1:14 p.m. R1 was seated outside the dining room in a standard wheelchair. R1 stated on 5/9/23, two staff were transferring him from the wheelchair to the commode. R1 said when they went to move sideways, one leg turned in and we swiveled a little and we all went down. R1 stated they were in a tangled heap with the lift between them. R1 said he got a cut on his elbow and a big bump on the back of his head. R1 said he had a few aches and pains from the fall. R1 stated, Yesterday the same thing happened, I didn't fall, we caught it in time. R1 said staff started lifting him and turning and said as the lift was raised it kind of turned to one side. R1 said when the staff tried to turn, the lift over balanced. R1 said staff went and got another lift to complete the transfer. R1 said three staff were assisting him, NA-C, NA-B, who was assisting on 5/9/23, when the lift tipped over, and a third NA. R1 said when the first incident occurred, he was seated in his wheelchair next to the second bed when staff started to push him in the lift toward where the commode was sitting, then it happened. At 3:55 p.m. R1 described the position of the wheelchair and the commode in the room at the time of the fall. R1 said he was seated in the wheelchair between the two beds and said the commode was in the pathway near the bathroom (approximately 8 feet away). R1 said the staff were pushing the lift to the commode and when they started to make the turn the lift tipped over. R1 confirmed he was not interviewed by the facility following the second incident on 5/17/23. During interview on 5/18/23, at 1:29 p.m. NA-C stated the previous day R1 was hooked up to the mechanical lift and said three NAs were present including herself. NA-C said they started to lift R1 and as soon as she lifted him up, the lift tipped. NA-C stated the head of R1's bed was upright and that was the only thing that kept him from falling. NA-C stated they lowered R1 back to the bed and went and got a different lift. NA-C stated she had not received any training on lifts following the incident on 5/9/23, and said she was only told to use three staff. NA-C confirmed the lift used was lift number six and confirmed it was the same lift used during the fall on 5/9/23. NA-C stated she had reported the incident to the nurse on the floor. During interview on 5/18/23, at 1:34 p.m. NA-D stated she was aware of the incident involving R1 falling from the lift. NA-D said she had not received any training following the incident and said all the lifts in the facility could be used for any resident who required the use of a lift. During interview on 5/18/23, at 2:07 p.m. LPN-A said he was called to R1's room after the fall on 5/9/23. LPN-A stated according to the NAs, the lift tipped over and R1 landed on the floor. LPN-A said R1 had a cut on his elbow and a bump on his head. LPN-A said the lift was taken out of R1's room and a different lift was used to get him up off the floor. LPN-A said the lift had not been removed from the floor and said there was nothing wrong with the lift, R1 was too heavy for it. LPN-A said after the incident staff were told to be more careful when using the lifts. During interview on 5/18/23, at 1:38 p.m. the DON stated she had received a text message the evening of 5/9/23, that R1 had fallen out of the lift. The DON said staff removed the lift from the floor right away and confirmed the lift was lift number six. The DON stated maintenance took the lift and inspected it and determined the mechanism that secured the legs was not working and if something bumped the leg during a transfer the leg could close. The DON stated the lift was repaired and tested and put back into use however, the DON indicated the lift had not been tested to ensure worked correctly. The DON said on 5/17/23, staff said the lift was loud when using it so she and maintenance again removed it from the floor. On 5/18/23, at 1:49 p.m. the maintenance worker (MW) stated all the mechanical lifts received routine inspections each month to include checking bolts, breaks, controls, pivots, etc. The MW said after R1 fell, he identified the lift used during the transfer had a manual bar that opened and closed the legs and the notches were worn. The MW said the parts were ordered and replaced. The MW said the whole machine had been checked out and was put back on the floor. MW said he became aware on 5/18/23, there was a problem with the lifting part and said the lift was an older lift. During interview on 5/18/23, at 2:31 p.m. RN-A stated after the fall on 5/9/23, she contacted both of the NAs involved to ask what happened. RN-A said the NAs said R1 was hooked up, they started lifting him up and when bringing him over to the next surface the lift tipped over. RN-A stated NA-B told her she did not know what had happened so the lift was sent to maintenance to inspect it and see if something needed to be fixed. RN-A said maintenance looked at the lift and said the only way it could have tipped over was if the legs closed so he replaced the parts. RN-A stated she had not been aware there was a second incident with lift number six until this morning, so the lift was again put out of service this morning (5/18/23). RN-A stated an LPN reported to her that staff were transferring R1 and the lift was making some noise so they lowered him back down, unhooked him and used a different lift. RN-A stated she had not spoken to the staff involved. The DON was present and stated staff told her the lift had been making a weird noise during the incident on 5/17/23, but did not remember who had told her. The DON stated she had not asked R1 about the incident. When asked about staff education following the two incidents, the DON said for a couple of shifts the nurses had watched transfers but said there was no documentation. The DON said she was planning to do staff education at the next staff meeting in June. The DON further stated there was no evidence NA-As concern about R1's safety when using lift number six had been addressed. RN-A and the DON stated they felt the issue had been addressed when maintenance replaced the part on the lift. Despite facility's documented interviews with staff involved in the lift incidents detailing the incorrect use of the lift (transporting resident in lift), the facility failed to identify concern, interview resident for more details and contact Hoyer Lift manufacturer following lift failures. On 5/19/23, at 10:24 a.m. the facility's customer service representative (CSR) for the Volaro lifts used in the facility was interviewed. The CSR stated typically when they heard of a lift tipping, it was due to the legs being closed or if the lift was positioned too close to the bed and staff turned and pushed the resident, the weight would start to pull the lift over especially if the resident was too heavy. The CSR stated the lifts were not designed to transport any distance, only surface to surface and if staff transported a resident too far in the lift it could create a situation. On 5/19/23, at 10:59 a.m. NA-F stated when transferring a resident in the mechanical lift she would bring the chair or commode to the resident. NA-F stated she would not transport a resident more than 5 feet in the lift. The Volaro 4 Series Operators Manual, safety notes indicated The Volaro lift is designed for patient lift only. Using the lift for transport can create an unsafe patient handling situation. Facility policy, Fall Standard Work, undated, indicated the following: Review Devices in use/involved in fall and determine if location of device played a factor, if device was used by resident/staff properly, ensure device is working properly and if any adjustments need to be made involve maintenance staff or therapy staff as appropriate. The immediate jeopardy that began on 5/9/23, was removed on 5/22/23, when the facility identified and assessed all residents who utilized a mechanical lift for safety, completed a thorough analysis of the incidents on 5/9/23 and 5/17/23, completed an inspection of all lifts in the facility and completed training with staff to include return demonstration of the correct use of mechanical lifts and implemented a plan to educate all staff prior to working with the lifts.