**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a transfer belt was used to assist with a safe transfer for 1 of 2 residents (R30) reviewed for falls. This resulted in actual harm for R1 who fell when being transferred without a transfer belt, which resulted in a fall with a pelvic fracture. This deficient practice is being cited at past non-compliance related to corrective action taken prior to survey to ensure proper use of transfer belt prior to the survey. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, no rejection of care, dependent on staff with toileting hygiene, toilet transfer, sit to stand, chair/bed-to-chair transfer, required substantial/maximal assistance with shower/bath and lower body dressing, required partial/maximal assistance with personal hygiene, utilized a wheelchair, with diagnoses including fracture of superior rim of right pubis (break in the pelvis), displaced intertrochanteric fracture of left femur (hip fracture), and one fall with major injury since admission. R30's care plan dated 2/21/25, indicated alteration in mobility d/t (due to) bilateral leg pain and interventions included follow PT (physical therapy) instructions, assist with transfers A1 (assist of one). R30's care plan dated 5/21/25, indicated alteration in mobility d/t bilateral leg pain and dementia,3/12/25: acute nondisplaced fracture of the right pubic rami that is nonoperative, weight bearing as tolerated and pain control as needed per ED physician and interventions included PT per MD order, follow PT instructions, assist with movement in bed and in/out of bed, assist with transfers, A1 EZ stand (mechanical transfer equipment); fall risk related to diagnosis of cognitive impairment, heart failure, alcoholism, assistance with transfers toileting needs, assistance with ADL's (activity of daily living), gets tired and weak during ambulation r/t to heart failure, 3/12/25: fall from chair, interventions included PT to eval, resident given reacher devices, in PT for ambulation program. R30's fall review evaluation dated 8/3/24, indicated history of one-two falls within last six months, unable to independently come to a standing position, risk factors include impaired mobility r/t weakness and recent fall with hip fracture, fall history, forgetfulness, and daily use of medications that may contribute to fall risk, alert, able to make needs known, 1A (one assist), EZ transfer, staff will follow therapy recommendations and update as needed, current fall interventions: appropriate footwear with transfers, room to be kept clear of clutter and debris, personal items and call light within reach. Facility document title Incident Review and Analysis dated 3/13/25, indicated on 3/12/25 at 2:10 p.m., R30 was ambulating in the hallway, felt weak tired, and was trying to sit down, NA (nursing assistant) was following behind with wheelchair, R30 missed the wheelchair when she was trying to sit down. IDT (interdisciplinary team) met to review current plan of care and fall care plan and further indicated staff was assisting R30 with walking program, R30 was to complete walking program per PT -BID (two times daily walk 15-20 feet (from room to nursing station) with right platform FWW (front wheel walker, A1, follow with w/c (wheelchair). Staff and R30 reported R30 had walked about 20 feet when R30 because tired and asked to sit down, R30 stated that as she was sitting down, she lost her balance and tipped over to her right side and feel, root cause: R30 appeared to be tired and weak during ambulation and after review walking program discontinue, PT to reassess and treat, son aware, and prefers R30 not to ambulate anymore. R30's document ED (emergency department) encounter summary dated 3/12/25, indicated R30 fell as she was leaning backwards to sit in her wheelchair and lost her balance resulting in a fall, resulting in right hemipelvis pain. R30 ED visit confirmed an acute nondisplaced fracture of the right pubic rami (pelvis fracture), and orthopedics was consulted and confirmed this was a nonoperative weight bearing as tolerated and pain control as needed, will require ongoing pain management and additional assistance at her care facility, and increased support and nonemergent outpatient physical therapy that maybe benefit to help her with the discomfort and pain. R30's progress note dated 3/12/25 at 3:49 p.m., licensed practical nurse (LPN)-A indicated R30 had a witnessed fall in the hallway on [NAME] Wing at 3:30 p.m. R30 was walking in the hallway with staff and fell, new injuries to left temp, skin tear, hematoma, left shoulder shin tear, lower back of head-lump-hematoma, nursing checked R30 for bleeding and applied pressure to her left temp and her left shoulder, bandages applied vital signs taken Neuro ok, range of motion per normal with pain 3/10 in right hip that was new, assisted off the floor with a mechanical lift and two staff to her wheelchair then to bed, provider and family notified by RN (registered nurse) manager, sent to hospital due to being on blood thinners and a head strike. R30's progress note dated 3/12/25 at 11:28 p.m., registered nurse (RN)-A indicated phone call from ED nurse identified R30 would be returning to the facility via family, and R30 had a pubic rami fracture that was inoperable. Facility document titled Internal 4 Point Plan of Correction dated 3/19/25, indicated the NA (nursing assistant) was not following the residents (R30) plan of care/not using a transfer belt during ambulation, R30 was sent to ER for evaluation on 3/12/25, complete room audit for transfer belt availability, education was initiated for appropriate staff for the use of the transfer belts for ambulation, spoke with NA who was ambulating R30 and the incident, statement was given, resident interviews initiated for transfer belt use and safe ambulation, observation audits initiated related to staff following the residents plan of care r/t ambulation and use of gait (provide support and stability during transfers and ambulation), provider update, like residents interviewed and audited for the use of transfer belts for safe ambulation, interviews initiated with staff on resident gait belt use an safe ambulation process, care plans updated and reviewed for ambulation safety, continued audits related to staff following the residents plan of care r/t use of gait belts and ambulation, education on use of transfer belts with ambulation, the incident review further indicated on 3/19/25, NA-A indicated in an email to the director of nursing, NA-A indicated R30 told me that she was trying to sit down and lost her balance, went into room [ROOM NUMBER] to asked if she (R30) wanted to walk she said yes I made sure she had good shoes on and forgot a gait belt, had the wheelchair behind her the whole time and we took a little break to rest, she started moving her feet and I thought she was going to start walking again but she lost her balance and fell. On 5/19/25 at 12:56 p.m., R30 was observed seated in a wheelchair in her room. R30 stated about a month ago while staff were helping her walk in the hallway she fell and broke her pelvis. R30 stated she lost her balance and fell, R30 confirmed staff were not using the gait belt when she fell. R30 stated since the fall staff used a mechanical lift for toilet transfers, and stated when staff transferred her now staff always use the gait belt. On 5/20/25 at 10:00 a.m., the director of nursing (DON) stated on 3/12/25 R30 experienced a fall on resulting in a fractured pelvis. The DON reported that during the initial fall review, the facility was unaware that a gait belt had not been used. However, upon completion of a comprehensive fall investigation, it was concluded that nursing assistant (NA)-A did not use the gait belt during the transfer and while assisting R30 to ambulate in the hallway with her walker. The DON confirmed that NA-A acknowledged the gait belt was not applied as expected during the ambulation on 3/12/25. The DON stated that the facility's policy and expectation was that a gait belt be used when transferring and walking residents. The DON further confirmed that following the incident, the facility initiated education for staff regarding the importance of transfer belt use, and ensured all staff received training on proper use of gait belts and safe transfer techniques On 5/20/25 at 10:16 a.m., NA-C stated a transfer belt should always be used for any resident who required assist with transfers or ambulation, and confirmed the facility provided recent education on resident transfers. On 5/20/25 at 10:21 a.m., RN-C stated that all facility nursing staff had received training and education on the use of gait belts. RN-C confirmed that it was the facility's policy and expectation that staff use a gait belt during all resident transfers and ambulation to ensure resident safety. On 5/20/25 at 1:01 p.m., NA-B stated a gait belt was expected for any resident transfer and confirmed the facility provided training on resident transfers and use of gait belt when transfer or ambulating residents. On 05/20/25 at 2:43 p.m., RN-B stated when someone required assistance with transfers staff were expected to always use a transfer belt. A transfer belt was used for stability and safety in case the resident got weak. On 5/20/25 at 2:46 p.m., NA-D stated a transfer belt should always be used when a resident required assistance with transfers. NA-D stated the facility provided recent education on the use of transfer belts with all residents to help prevent falls. On 5/21/25 at 7:36 a.m., during a telephone interview nursing assistant NA-A stated that on 3/12/25, she assisted R30 to ambulate out of her room. R30 used a walker, and NA-A followed behind the resident with a wheelchair while holding the back of R30's pants. NA-A confirmed that a gait belt was not applied to R30's waist during ambulation as required. She stated she completely forgot to use the gait belt and stated a gait belt was expected when walking with residents. NA-A stated that while assisting R30 in the hallway, approximately 100 feet from her room, R30 attempted to sit in the wheelchair without verbalizing the intent to do so. As a result, R30 lost her balance and fell. NA-A stated that following the fall, R30 immediately complained of pain to her leg and head, and she observed visible skin tears. NA-A stated she had been trained by the facility to use a gait belt when transferring or ambulating residents. She acknowledged this was the first time she failed to use the gait belt, stating it was an oversight. NA-A confirmed that gait belts are designated and readily available in all resident rooms, including R30's. NA-A stated that a nurse, whose name she could not recall, responded to the incident, assessed the R30, obtained vital signs, and staff used a mechanical lift to transfer R30 to a wheelchair. NA-A stated R30 was transferred to the hospital. NA-A stated that after the fall, she experienced a panic attack and left the scene. NA-A stated she accepted full accountability for the incident and, following R30's fall she provided a statement to the facility, received re-education on gait belt use, transfer safety, corrective action, and completed a competency evaluation, including a return demonstration on proper ambulation techniques. On 5/21/25 at 8:28 a.m., NA-E stated that in March 2025, the facility provided staff education on the proper use of gait belts. NA-E reported that gait belts were available in each resident room and confirmed that, per the facility, two staff members were required to assist when ambulating a resident. She further stated that the use of a gait belt during ambulation was expected On 5/21/25 at 8:29 a.m., during an interview NA-F stated that when ambulating a resident, two staff members are expected to assist. One staff member was to walk alongside the resident, holding the gait belt, while the second staff member walks behind the resident pushing a wheelchair for safety. NA-F stated the facility had provided education and training to staff regarding the use of gait belts at all times during transfers and ambulation to ensure resident safety. During the survey resident observations, resident and staff interviews, and review of staff education records identified the facility was using transfer belts during all non-mechanical transfers that required staff assistance, and the facility had corrected the non-compliance of not transferring residents without a transfer belt who required the use of a transfer belt prior to entrance on 5/19/25, prior to survey entrance. Facility Fall Prevention and Management policy dated 2/24, indicated: The purpose of this protocol is to identify residents at risk for fall implement fall prevention interventions, provide guidelines for assessing a resident after a fall and to assist staff in identifying causes off the fall. Avoidable Accident- means that an accident occurred because the facility failed to : -Identify environmental hazards and/or assess individual resident risk of an accident, including the the need for supervision and/or assitive devices and/or -Implement interventions including adequate supervision and assistive devices consistent with a resident's needs, goals, care plan and current professional standard of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident.