**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to follow manufacturer directions while using mechanical full body lifts, by not opening the stabilizing legs fully, for 3 of 3 residents (R1, R6 and R7). This resulted in an immediate jeopardy for R1 when the lift tipped over while R1 was being transferred, fracturing both femurs, and for R6 and R7 when staff were observed transferring them (both R6 and R7) not following the manufactures instructions. The immediate jeopardy began on 12/28/22, when R1 was transferred incorrectly using a full body mechanical lift, the lift tipped over and R1's legs were fractured. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 1/9/22, at 5:40 p.m. The immediate jeopardy was removed on 1/10/23, at 6:00 a.m. when it was verified the facility had educated staff and conducted competency evaluations for use of the full body mechanical lifts prior to the start of their next shift. However, noncompliance remained at the lower scope and severity of a D- isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, was completely dependent on staff for transfers and bed mobility and did not reject cares. Further, the MDS identified a diagnosis of age related osteoporosis. R1's fall care plan revised on 1/2/23, indicated R3 transferred with assist of three utilizing a mechanical lift following the fall on 12/28/22. The nursing home incident report dated 12/29/22, at 4:31 a.m. indicated on 12/28/22, at 11:05 a.m. R1 was being transferred from her bed to the electric wheelchair utilizing a mechanical lift and two staff members when the mechanical lift tipped over and R1 was lowered to the floor. R1 sustained an oblique fracture of the left femur. Audits were completed for each resident utilizing a mechanical lift for the correct sling sizes and accuracy of care planning. The Invacare Reliant 600 manufacturer was the lift being used during the transfer. X-ray results were obtained on 12/29/22, at 3:50 a.m. and R1 was updated on fracture and R1 requested to go to the emergency department. The physician was notified. A late entry nursing note dated 12/28/22, at 11:05 a.m. indicated R1 was being transferred from her bed to the electric wheelchair when during the transfer, R1 was distraught and leaned back in the sling and the lift became unsteady due to the weight redistribution. The note indicated R1 was lowered to the floor by staff. R1's Associated Clinic of Psychology note dated 12/28/22, indicated R1 had rumination regarding her recent fall and worried it could happen again, which was triggering from a previous incident as well. The note indicated R1 may be cautious in attempts to use the lift to transfer. R1's North Star mobile x-ray report dated 12/28/22, indicated R1 had a complete oblique fracture of the left femur with soft tissue swelling. R1's history and physical dated 12/29/22, at 8:44 a.m. indicated R1 was being transferred on 12/28/22, when the mechanical lift tipped over, causing R1 to fall on the floor. R1 was transported by emergency medical services for evaluation on 12/29/22, and was found to have bilateral femoral fractures. A facility audit form dated 12/30/22, indicated R1 required a mechanical lift with an extra large sling and assist of three persons for transfers. R1's physician progress note dated 1/4/23, indicated R1 was admitted to the hospital on [DATE], with bilateral subtrochanteric femur fractures after a fall from a mechanical lift at her facility. R1's hospital Discharge summary dated [DATE], indicated R1 was admitted on [DATE], with bilateral subtrochanteric femur fractures after a fall from a mechanical lift at her facility. R1 underwent a left intramedullary nail (a rod or nail placed in the bone for stablization)on 12/30/22 and no operative intervention on the right. During interview and observation on 1/9/23, at 10:24 a.m. R1 stated the mechanical lift fell over and she fell to the floor and had two fractures and one of the fractures required a rod in her leg. R1 stated she had a dull constant pain, but did not like to take pain medication because of the side effects. R1 stated she returned from the hospital on 1/5/23, and had not gotten out of bed since she returned from the hospital. R1 stated the legs on the mechanical lift were not opened all the way when she fell. R1 stated falling from the lift was scary and started to cry. During observation on 1/9/23, at 10:45 a.m. R1 was in bed and stated to the physical therapist (PT)-C that she did not get up on 1/8/23, because she was scared. During interview on 1/9/23, at 12:33 p.m. maintenance director stated the lifts were checked monthly and routine maintenance performed per manufacturer's recommendations and would be done every two weeks due to R1's fall. The maintenance director stated the Invacare Reliant 600 mechanical lift had a low base in order to fit under beds well and when the legs are open on the lift, it is less likely to tip over. During interview on 1/9/23, at 12:58 p.m. nursing assistant (NA)-H stated she worked as a float NA and stated that usually two staff were needed for a mechanical lift and stated the legs of the lift were normally shut as a resident was transferred. NA-H stated if a resident was in bed, the legs of the lift should be shut and then the lift is pulled out and another staff member brings a chair. NA-H verified R1 required three staff to assist with transfers. R6's annual MDS assessment dated [DATE], indicated R6 was severely cognitively impaired and required extensive two plus person assistance for all transfers. R6's diagnoses included dementia and age related physical debility. R6's mobility care plan revised 10/21/22 indicated R6 required total assist of two with mechanical lift for all transfers. During observation and interview on 1/9/23, at 12:48 p.m. R6 was in wheel chair waiting to be transferred back to bed. NA-A maneuvered the full mechanical lift over R6 in the wheel chair by opening the legs fully of the mechanical lift . NA-A, NA-B and LPN-A worked together to attach R6's sling to the mechanical lift. R6 was lifted out of the wheel chair and the mechanical lift was pulled away from the wheel chair. NA-A used the manual lever to close the mechanical lift legs. The mechanical lift was pushed to R6's bed, R6 was positioned over the bed and lowered to the bed. The sling was removed. Once the mechanical lift legs were closed, they remained closed throughout the transfer. LPN-A stated R6 was a two-person extensive assist with transfers, but she was helping to ensure the NAs completed the transfer properly. R7's significant change MDS assessment dated [DATE], indicated R7 was severely cognitively impaired and required extensive two plus person assistance for all transfers. R7's diagnoses included dementia, Alzheimer's disease, difficulty walking, muscle weakness and unsteady on feet. R7's mobility care plan revised 10/18/22 indicated R7 required total assist of two with mechanical lift for all transfers. During observation and interview on 1/9/23, at 1:01 p.m. R7 was wheeled into the room to transferred to bed. NA-A positioned the mechanical lift over R7's wheel chair with the mechanical lift legs fully open. NA-A and NA-B worked together to attach the sling to the mechanical lift. R7 was lifted off the wheel chair and the mechanical lift was pulled away from the wheel chair. NA-A manually closed the mechanical lift legs and the mechanical lift was turned and moved to position over R7's bed. R7 was lowered to the bed and the sling was removed. NA-B stated the proper way to use a mechanical lift was to have the legs open over the wheel chair and then closed after the mechanical lift was moved away from the wheel chair. NA-A agreed and stated the legs of the mechanical lift were closed after it was pulled away from the wheel chair and remained closed during the remainder of the transfer for both R6 and R7 and it was the proper way to transfer a resident from wheel chair to bed. During interview on 1/9/23, at 1:21 p.m. NA-G stated she reviewed care sheets in order to know how a resident transferred. NA-G stated when transferring a resident from their bed to the chair, the mechanical lift legs are kept closed when they are lifted in bed and the resident is moved in the mechanical lift to their chair, then the legs on the lift are opened prior to lowering the resident to the chair. During interview on 1/9/23, at 1:53 p.m. NA-F stated the legs of the mechanical lift were closed when R1 was transferred prior to the mechanical lift tipping and R1 lowered to the floor. NA-F also stated the legs on the lift are closed when turning a resident and once you face the chair, the legs of the lift are opened to make room for the chair. During interview on 1/9/23, at 2:31 p.m. NA-C was making R7's bed and stated mechanical lift legs should be open the entire time a resident was in the lift. NA-C stated R7's bed had sufficient room under it for the mechanical lift legs to fit while they were fully open. During interview on 1/9/23, at 2:32 p.m. LPN-C stated the legs of the mechanical lift should always be open during a transfer. LPN-C further stated she did not see that NA-A and NA-B had done this incorrectly and that not having the mechanical lift legs fully open during the transfer could result in the mechanical lift tipping over. During interview on 1/9/23, at 2:35 p.m. the assistant director of nursing (ADON) stated R1 used an Invacare 600 lift and used this lift when she fell from it. R1 was an assist of two for transfers with the mechanical lift, but since returning from the hospital, R1 would be transferred with three person assist, but had not gotten up since returning per R1's request. The ADON stated she thought R1 was fearful because she fell and had discomfort from the fall. The ADON stated manufacturer recommendations are the legs of the mechanical lift are to be open at all times, and stated she could not recall if the legs of the mechanical lift were opened or closed when she was called to R1's room post fall. During interview on 1/9/23, at 3:02 p.m. the director of nursing (DON) stated when R1 fell, she was off balance, NA-D tried to step on the leg of the mechanical lift to prevent it from tipping over. The DON stated the legs of the lift should be open when resident is being hooked up and stated NA-D and NA-F stated the legs of the lift were open the entire time. The DON stated the legs of the mechanical lift should be open anytime anyone is in a lift because there needed to be a wider base of support if a resident shifted their weight so they wouldn't tip over. During interview on 1/9/23, at 3:47 p.m. the administrator stated there was no policy on mechanical lifts, they just used the competency. The mechanical lift competency was reviewed and lacked instruction on the position of the legs for transfers. During interview on 1/9/23, at 4:43 p.m. the DON stated for competencies on the mechanical lifts, they trained the trainer, signed them off, and went off the competency check list and verified there was no competency to verify the opening of the mechanical lift legs. During interview on 1/10/23, at 9:15 a.m. the Invacare Reliant 600 manufacturer customer service representative stated after talking to their technical support that the legs of the mechanical lift should not be in the closed position during a transfer because it could cause the lift to be unstable and fall over. She stated the use of the lift is not meant to be used in a closed position. During interview and observation on 1/10/23, at 10:47 a.m. the medical director stated R1's fall contributed to her fractures and stated R1's osteoporosis caused her to be more prone to fractures and wasn't aware the legs of the lift were not opened. A form, Competency 2.0 Mechanical Lifts dated 12/28/22, signed by NA-F indicated 18 specific steps for the skill: mechanical lifts per manufacturer guidelines and Monarch Healthcare management policy and procedure, but it lacked instruction on opening the legs of the lift during transfers. A manufacturer user manual was provided for the Invacare Reliant 450 RPL450-1/2 and Invacare Reliant 600 RPL600-1/2 battery powered patient lift that indicated danger, warning, and caution symbols used within the manual. Danger indicated an imminently hazardous situation which, if not avoided, will result in death or serious injury. Warning indicated a potentially hazardous situation which, if not avoided, could result in death or serious injury. Caution indicated a potentially hazardous situation which, if not avoided, may result in property damage or minor injury or both. A warning symbol for lifting the patient indicated the legs must be in the maximum open/locked position before lifting the patient. Under operation the warning indicated the legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. The IJ was removed on 1/10/23, at 6:00 a.m. when the facility developed and implemented a systemic plan which was verified by observation, interview and document review: The plan included: - The maintenance director inspected and performed routine maintenance per manufacturer's recommendations on the facility's mechanical lifts and will continue to inspect and perform routine maintenance on the facility's mechanical lifts every two weeks. This was verified through interview and document review. - The nursing staff were educated on the manufacturer's instructions on a full body transfer utilizing a mechanical lift. -The nursing staff completed the mechanical lift competency with return demonstration. This was verified through interview and document review. -The mechanical lift manufacturer's instructions were reviewed on 1/9/23, by the DON and will be utilized as the facility policy on mechanical lift full body transfers. This was verified by interview. -R1 was observed for transfer and staff demonstrated knowledge of the manufacturer's recommendations for transfers.