**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide ongoing monitoring, comprehensive assessment, and care planning, and needed care consistent with professional standards of practice, facility policy, and provider orders resulting in risk of serious illness or death related to complications of coronavirus disease 2019 (COVID-19) infections to 1 of 5 residents (R1) identified in Immediate Jeopardy. In addition to the resident in immediate jeopardy, the facility failed to update policies and procedures for comprehensive assessment, monitoring, developing, and revising person-centered care plans, and implement consistent interventions in accordance with professional standards of practice for all respiratory illnesses resulting in no actual harm with potential for more than minimal harm that is not immediate jeopardy for 4 out of 4 residents (R4, R6, R7, R8). The immediate jeopardy (IJ) began on 1/3/24 when R1 tested positive for COVID-19 and ongoing monitoring, comprehensive assessment, and care planning, and needed care was not provided for R1 and was identified on 1/24/24. The administrator, associate administrator, director of nursing, and regional nurse consultant were notified of the IJ at 6:10 p.m. on 1/24/24. The IJ was removed on 1/25/24, but noncompliance remained at the lower scope and severity level E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The facility's Covid Policy dated 9/26/23, included: Management After Identification . Monitoring of Residents: Regular monitoring of resident condition who test positive (VS [vital signs], etc.) should occur on each shift at a minimum in order to closely monitor resident condition and help determine when resident can be removed from isolation. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, diabetes, Bell's Palsy (one-sided facial weakness) hypertension (high blood pressure), and depression. R1 had a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment, was independent with toileting, transfers, and walking, utilized a wheelchair, was frequently incontinent of bowel and bladder, and needed set-up or clean-up assistance with eating. R1's care plan last dated 12/1/23, was not updated and did not include any focus or interventions related to R1's COVID-19 diagnosis. A progress note dated 1/3/24 at 2:41 p.m., indicated R1 tested positive for COVID-19 and R1's provider and family were updated. R1's provider order dated 1/3/24, indicated R1 was prescribed a five-day course of Paxlovid (an antiviral medication used to treat mild-to-moderate COVID-19 for adults at high risk of disease progression). R1's treatment administration record (TAR), progress notes, and vital sign record from 1/3/24 to 1/7/24 did not include documentation of vital signs or monitoring of R1's COVID-19. R1's medication administration record (MAR) dated the month of January 2024, indicated R1 refused to take his morning dose of Paxlovid on 1/8/24 as prescribed. A progress note by licensed practical nurse (LPN)-D dated 1/8/24 at 5:36 p.m., indicated during report at the start of their evening shift (2:00 p.m. to 10:00 p.m.) LPN-D was told R1 was not doing well, and the provider and family had been updated. LPN-D documented R1's vital signs, which were a higher-than-normal, respiratory rate (RR) (breaths per minute) of 24, oxygen saturation level (O2 sat) (the amount of oxygen circulating in a person's blood) of 96%, and a heart rate (HR) (heart beats per minute) of 76. The note indicated LPN-D called the on-call provider, nurse practitioner (NP)-A, who ordered labs (blood work), pushing fluids (encouraging fluid intake), and vital sign checks every shift. R1's provider orders from NP-A dated 1/8/24, included labs and monitoring vital signs every shift for COVID-19 for three days including oxygen saturation levels. The faxed paper orders noted an electronic signature from NP-A at 3:37 p.m. and fax machine receipt time stamp at 1:37 p.m. Pacific Standard Time, equivalent to 3:37 p.m. Central Standard Time (the time zone from which the fax was sent and received). R1's vital signs record dated 1/8/24 at 6:30 p.m. indicated R1's temperature was 98 degrees Fahrenheit, and his blood pressure was 95/56. A progress note by LPN-D dated 1/8/24 at 9:58 p.m., noted at 7:11 p.m. they checked on R1 and found him unresponsive and pulseless and confirmed his death at 7:30 p.m. R1's death certificate titled Minnesota Documentation of Death indicated R1 died on 1/8/24 at 7:30 p.m. at [AGE] years old. Causes of death included primary causes of dementia and cerebrovascular disease (conditions affecting blood flow to the brain) with COVID-19 listed under other significant conditions contributing to death. In an interview on 1/23/24 at 8:28 a.m., LPN-B stated R1 had been gradually declining from baseline since admission. R1 used to wheel themselves around in a wheelchair, transfer themselves, and have a good appetite. Over time R1 had stayed in bed more, was more lethargic and less communicative, did not want to eat or drink as much, and declined overall. In an interview on 1/23/24 at 9:03 a.m., LPN-A stated R1 was independent with minimal assistance needed on admission and walked with a walker at times. As time went by, he declined and his Parkinson's seemed to get worse with increased shaking, he could not feed himself and someone fed him, he slept most of the time or sat in his wheelchair and needed staff assistance of one to get up. In an interview on 1/23/24 at 12:57 p.m., NP-A stated she first found out R1 was diagnosed with COVID-19 when contacted by facility staff on 1/8/24. The Paxlovid must have been prescribed by the on-call provider contacted on 1/3/24 when R1 tested positive. NP-A stated for a resident with COVID-19 or another respiratory illness like pneumonia or influenza she would expect vital signs to be taken at least every shift, residents to be monitored, and to be notified right away if there was any worsening of symptoms. NP-A indicated she believed the facility's orders for COVID-19 precautions included taking vital signs every shift and thought the facility did vital signs every shift for residents with either COVID-19 or another respiratory illness. In an interview on 1/24/24 at 4:58 p.m., LPN-B stated she was the day shift nurse on R1's unit on 1/8/24. LPN-B stated on 1/8/24, she believed R1 was not eating, did not want to eat breakfast and did not want lunch if she remembered correctly, and R1 refused a meal. LPN-B stated R1 seemed sleepy and lethargic, but not more so than what had been his normal for about the last week since his diagnosis with COVID-19 on 1/3/24. LPN-B did not remember what she told oncoming nurse LPN-D during report, but thought she said to keep an eye on R1. LPN-B stated someone could have called the provider during the day about R1's clinical condition, but she did not remember calling a provider about R1 on 1/8/24. In an interview on 1/24/24 at 5:22 p.m., LPN-D stated she checked on R1 after receiving report and took his vital signs because she was told in report that R1 had COVID-19 and was not doing well. LPN-D heard R1 did not take his medications that morning because he had difficulty swallowing the pills, so they were held (not administered). LPN-D stated she contacted the on-call provider because of R1's increased RR and NP-A sent orders for labs and vital sign checks. In an interview on 1/25/24 at 11:55 a.m., NP-A stated a nurse called her on 1/8/24 but could not recall what time the facility called and was unable to locate documentation of the time of the call. NP-A stated the call could have been around noon, but she believes she sent the orders for labs and vitals electronically right away after the call and stated the orders were electronically signed at 3:37 p.m. on 1/8/24. NP-A indicated she wanted staff to get lab work, do closer monitoring of vital signs, and push fluids to further assess R1's condition before determining if transfer to a hospital for treatment was appropriate. In an interview on 1/24/24 at 9:01 a.m., director of nursing (DON) stated for residents with COVID-19 staff put in a batch of orders including monitoring of O2 sat, respirations, and temperature that every shift is supposed to do and do any time there is a change in a resident's condition. The facility policy for monitoring is regular monitoring of resident condition including vital signs every shift at a minimum. For residents with a respiratory illness like influenza, pneumonia, or respiratory syncytial virus staff should be looking at vital signs every shift because they are looking for a change in condition. The DON stated the facility's standard for COVID-19 vital signs monitoring order did not adhere to facility policy or professional standards of practice because it only included RR, O2 sat, and temperature and did not include HR or BP. The DON stated R1 tested positive for COVID-19 on 1/3/24 and his vital signs were monitored once during his illness, on 1/8/24, the day he was found deceased . The DON stated this does not meet her expectations and it appears the facility was not monitoring R1 which does not follow facility policy or professional standards of practice. The DON stated staff would not have been able to notice a change in condition or identify when R1's condition changed due to lack of monitoring. DON stated there is nothing on R1's care plan related to COVID-19. R4's MDS dated [DATE], indicated R4 was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) affecting the right dominant side after a stroke, stroke, Alzheimer's disease, aphasia (loss of ability to understand or express communication), hypertension, hyperlipidemia (high cholesterol), malnutrition, and dysphagia (difficulty swallowing). R4 had a BIMS score of zero indicating severe cognitive impairment. R4 was dependent on staff for mobility in bed and wheelchair, transfers, bathing, toileting hygiene, and was always incontinent of bowel and bladder. R4's care plan last dated 12/10/23 included a focus on potential risk for exposure to the virus causing COVID-19 due to residing in a congregate living facility, co-morbid conditions, advanced age, and dependency on caregiver assistance. It did not include a focus or interventions related to R4's COVID-19 diagnosis. A progress note dated 1/21/24 at 10:33 a.m., indicated R4 tested positive for COVID-19. A second progress note at 10:43 a.m., indicated provider and family were updated and the provider was faxing over new orders. R4's provider orders dated 1/21/24, indicated prescription of a five-day course of Paxlovid to treat COVID-19 and COVID-19 positive monitoring including check temperature, O2 sat, and RR every four hours. A provider note dated 1/22/24, indicated R4 was at high risk for complications related to COVID-19. The documented treatment plan included monitoring R4's vital signs every shift with instruction to call provider if O2 sat was less than 90% or resident had a fever. R4's vital sign record included RR documented once on 1/21/24 and once on 1/23/24. O2 sat and temperature were documented twice on 1/21/24, once on 1/22/24, and twice on 1/23/24. HR and BP were documented once on 1/21/24 and once on 1/23/24. A nursing progress note dated 1/22/24 at 2:28 p.m., indicated the writer assessed R4's vital signs including BP, HR, and RR. No other recorded vital signs were noted on R4's MAR, TAR, progress notes, or vital sign record between 1/21/24 and 1/23/24. In an interview on 1/24/24 at 9:01 a.m., The DON stated R4's O2 sat had not been monitored every shift and the facility policy for monitoring was not being followed. The DON noted they did not see anything on R4's care plan related to COVID-19 except the risk for exposure to COVID-19. R6's MDS dated [DATE], indicated R6 was admitted [DATE] with diagnoses including acute and subacute hepatic failure (liver failure), alcoholic liver cirrhosis with ascites (alcohol-induced liver disease with abdominal fluid build-up), hyponatremia (low sodium level in the blood), malnutrition, depression, portal hypertension (high blood pressure in the major vein leading to the liver), muscle weakness, latent tuberculosis (tuberculosis bacteria in the body without symptoms of tuberculosis), and a thyroid disorder. R6 spoke Spanish, had some difficulty making themselves understood and understanding others, and had a BIMS score of nine indicating moderate cognitive impairment. R6 required supervisory assistance with transfers, ambulation, and toileting. A progress note dated 1/14/24 at 2:08 p.m., indicated R6 tested positive for COVID-19 and family and on-call provider were contacted. R6's provider orders dated 1/14/24, indicated prescription of a five-day course of Molnupiravir (an antiviral medication used to treat mild-to-moderate COVID-19 for adults at high risk of disease progression) and COVID-19 monitoring including check temperature, O2 sat, and RR every four hours ending 1/24/24. R6's care plan interventions last dated 1/15/24, included COVID-19 isolation precautions of infection control precautions per protocol, sign on resident's door, and treatment for current per order. R6's care plan did not include other interventions related to his COVID-19 infection. R6's vital sign record, MAR, TAR, and progress notes included RR, O2 sat, and temperature taken at least once per shift between 1/14/24 and 1/23/24. R6's HR and BP were documented once on 1/14/24 through 1/16/24, zero times on 1/17/24, twice on 1/18/24, once on 1/19/24, twice on 1/20/24 through 1/22/24, and once on 1/23/24. In an interview on 1/24/24 at 9:01 a.m., The DON stated R6's care plan included isolation precautions related to COVID-19, but no other interventions related to R6's COVID-19 diagnosis. She would not describe the care plan as individualized related to COVID-19. The DON stated professional standards of practice for a set of vital signs include BP, HR, temperature, RR, and O2 sat, and facility policy directed vital signs be monitored every shift for residents with COVID-19. The DON noted R6's vital signs were not monitored per facility policy and professional standards of practice and nursing staff were not monitoring him for a change in condition because there was not enough vital sign data to do so. R7's MDS dated [DATE], indicated R7 was admitted [DATE] with diagnoses including acute on chronic diastolic heart failure (an episode of worsened chronic heart failure), anemia, rheumatoid arthritis, acute and chronic respiratory failure with hypoxia (a condition where the respiratory system cannot provide enough oxygen to the body), and used supplemental oxygen. R7 had a BIMS score of 12 indicating moderate cognitive impairment, and was independent with toileting, ambulation, and transfers. R7's care plan last dated 12/10/23, did not include any focus or interventions related to R7's COVID-19 diagnosis. A progress note dated 1/17/24 at 11:00 a.m., indicated R7 tested positive for COVID-19. A provider note dated 1/17/24, indicated R7 was at high risk for complications related to COVID-19. The treatment plan included prescription of Molnupiravir (an antiviral medication used to treat mild-to-moderate COVID-19 for adults at high risk of disease progression) for five days and instruction to monitor vital signs every shift and call provider if O2 sat was less than 90% or resident had a fever. R7's provider order dated 1/17/24 indicated COVID-19 positive monitoring including check temperature, O2 sat, and RR every four hours through 1/27/24. R7's vital sign record, MAR, TAR, and progress notes did not include full sets of vital signs every 4 hours per provider orders between 1/17/24 and 1/23/24. R7's HR was documented zero times on 1/17/24 and BP was recorded once. HR and BP were noted twice on 1/18/24 and 1/19/24, three times on 1/20/24 and 1/21/24, twice on 1/22/24, and three times on 1/23/24. In an interview on 1/24/24 at 11:46 a.m., the DON stated R7's care plan was not updated and was not resident-centered regarding COVID-19. The DON stated R8's vital signs monitoring was missing some vital sign components and did not follow facility policy or professional standards of practice. R8's MDS dated [DATE], noted R8 was admitted on [DATE] with diagnoses including schizophrenia, diabetes, morbid obesity, obstructive sleep apnea (intermittent interruptions in breathing while asleep), acute and chronic respiratory failure, and utilized continuous supplementary oxygen. R8 had a BIMS score of 13 indicating no cognitive impairment, required substantial assistance with mobility in bed, and was dependent on staff for transfers, bathing, and dressing. The initial physician visit note dated 1/17/24, notes R8 was admitted to the facility after a hospitalization in December of 2023 for influenza and pneumonia with respiratory failure requiring intubation (severe respiratory failure requiring mechanical assistance to breathe). A progress note dated 1/21/24 at 1:11 p.m., indicated R8 tested positive for COVID-19. R8's care plan without date of last review due to R8's recent admission included interventions most recently added on 1/14/24 but did not contain any focus or interventions related to COVID-19. R8's provider orders dated 1/21/24, indicated COVID-19 positive monitoring including check temperature, O2 sat, and RR every four hours ending 1/31/24 and directed to update provider every shift with any changes in vital signs. A provider order dated 1/22/24, noted a prescription for Molnupiravir (an antiviral medication used to treat mild-to-moderate COVID-19 for adults at high risk of disease progression) for five days to treat COVID-19. R8's vital sign record, MAR, TAR, and progress notes did not include full sets of vital signs every four hours per provider orders. On 1/21/24, R8's RR, HR, BP, and temperature were each recorded once and O2 sat was recorded three times. On 1/22/24, RR, HR, BP, and temperature were each recorded twice, though O2 was recorded six times. On 1/23/24, RR, HR, BP, and temperature were each recorded once and O2 sat was recorded four times. In an interview on 1/24/24 at 11:46 a.m., the DON stated R8's care plan was not updated or resident-centered regarding COVID-19. The DON stated R8's vital signs monitoring did not follow facility policy or professional standards of practice. The facility's Care Planning policy dated 11/2023, included: (2) A comprehensive care plan must be: A) Developed within 7 days after completion of the comprehensive assessment. B) Prepared by an interdisciplinary team, that includes but is not limited to: i)The attending physician; ii) A registered nurse with responsibility for the resident; iii) A nurse aide with responsibility for the resident; iv) A member of food and nutrition services staff; v) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan; vi) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. C) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive, quarterly, and significant change review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must: A) Meet professional standards of quality. B) Be provided by qualified persons in accordance with each resident's written plan of care. C) Be culturally-competent and trauma-informed. The IJ that began on 1/3/24, was removed on 1/25/24, when the facility updated order sets for residents with COVID-19 to include monitoring of full sets of vital signs every shift and implemented these orders for all residents affected, revised the process for activating these orders, integrated vital sign monitoring mandatory task into TARs, updated care plans for all residents with COVID-19 to include appropriate interventions, created skilled nursing progress note templates for residents with COIVD-19 and other respiratory illnesses to be completed every shift that include vital signs and assessment of clinical condition, provided nursing staff with education about the new processes and reinforced education about notification of providers for changes in condition, and implemented audits of charting and monitoring, but the noncompliance remained at the lower scope and severity level of E because the facility needs to update policies update policies and procedures for comprehensive assessment, monitoring, developing and revising person-centered care plans, and implementing interventions in accordance with professional standards of practice for all respiratory illnesses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure R1's safety when a mechanical lift was not used in accordance with the manufacturer's instructions resulting in life threatening injury for 1 of 3 residents (R1) reviewed who used mechanical lifts. This resulted in an Immediate Jeopardy (IJ) when R1 fell from the mechanical lift sling during a transfer, landing with his head on the mechanical lift legs, and his legs partially suspended in the air. The IJ began on [DATE] at 7:42 a.m. when staff were transferring R1 from his bed to his wheelchair using the mechanical lift. While transferring R1, staff did not ensure the sling loops were properly secured to the mechanical lift prior to removing him from his bed. R1 was partially suspended in the air when R1 fell from the sling landing on his head. The administrator and the director of nursing (DON) were informed of the IJ on [DATE] at approximately 8:05 a.m. The facility implemented corrective action as of [DATE], and the IJ was issued at past non-compliance. Findings Include: R1's admission Minimum Data Set (MDS) assessment, dated [DATE], indicated R1 was admitted to the facility on [DATE]. R1's admitting diagnoses included pulmonary embolism, congestive heart failure, atrial fibrillation, dysphagia, and generalized muscle weakness. R1's care plan, dated [DATE], indicated R1 was only to be transferred using a mechanical lift. R1's facility Lift/Mobility Status form, dated [DATE], indicated R1 required a full body mechanical lift with the assistance of two staff for transfers. R1's significant change in status MDS assessment, dated [DATE], indicated R1 was dependent on staff for all transfers. R1's Brief Interview for Mental Status (BIMS) score was 14 out of 15, indicating he was cognitively intact. R1's incident note dated [DATE], indicated R1 sustained a fall from a mechanical lift. R1 was hanging from the sling with his feet up in the air and his head was on the base of the of the mechanical lift. Family and EMS were immediately called. R1 was transported by EMS to the hospital. Video footage of R1 was reviewed with the administrator on [DATE] at 2:50 p.m., of the hallway outside R1's room. This video footage revealed the following: On [DATE] at 7:24 a.m., nursing assistant (NA)-A and NA-B brought the mechanical lift into R1's room and shut the door. At 7:42 a.m., NA-B opened the door and called for licensed practical nurse (LPN)-A to come to the room. LPN-A entered the room immediately and closed the door. NA-A and NA-B left the room to retrieve supplies and additional staff. Nursing staff ran into the room for support, and others began making phone calls to emergency medical services (EMS). At 7:47 a.m., LPN-A exited the room and paged a code blue (emergency staff response) then immediately returned to R1's room. Multiple staff ran to the room, brought an AED, and crash cart. EMS arrived at 7:53 a.m., and R1 was transported out of his room at 8:06 a.m. R1's hospital record dated [DATE] to [DATE], indicated R1 arrived at the hospital emergency department (ED) via EMS at 8:50 a.m. after he fell from a mechanical lift at his home facility on [DATE]. ED records indicated R1 presented with multiple lacerations to his head, extremities with altered mental status (AMS) following a loss of consciousness during the initial fall. R1 had age indeterminate fractures of the T12, L1 and L2 that were most likely acute as evidenced by characteristics of the fractures. R1 was awake and alert, without the ability to follow commands or answer all questions appropriately. R1's was admitted to the hospital for emergent interventions for life-threatening injuries. Palliative medicine was contacted and through discussion with family member (FA)-A, R1 was transitioned to partial comfort cares with medicinal interventions for comfort. Hospital nursing notes on [DATE], indicated R1 had become unresponsive and did not increase level of consciousness for the remainder of his hospitalization. R1's physician evaluation indicated R1 had a high probability of imminent life or limb-threatening deterioration due to closed head injury with AMS with multiple trauma from a fall. R1 was being treated for acute metabolic/toxic encephalopathy, and FM-A had transitioned to full comfort cares. R1 expired [DATE]. During an interview on [DATE] at 1:31 p.m., FM-A stated he was informed by hospital physicians R1 had passed away from injuries sustained during the fall on [DATE]. During an interview on [DATE] at 2:07 p.m., licensed practical nurse (LPN)-A stated she was called into R1's room by (NA)-A on [DATE] at approximately 7:40 a.m. LPN-A stated when she entered the room, she saw R1 partially suspended by his legs in the mechanical lift sling, and the right side of his head resting at an unnatural angle on the mechanical lift support legs. LPN-A stated all the sling clips on the left side were completely intact, and only two of the straps on the right side of the sling were attached to the mechanical lift. LPN-A stated she worked with NA-A and NA-B to reposition R1, and immediately noted a bloody laceration to R1's posterior scalp. LPN-A stated R1 was not responding to verbal or tactile stimuli and his face from the neck up was unnaturally cyanotic. LPN-A stated she had NA-A and NA-B retrieve additional staff and EMS were contacted. LPN-A stated she placed supplemental oxygen on R1 and activated a code blue. LPN-A stated she was aware R1 was DNR and activated a code blue at that time to get additional nursing staff to help her. LPN-A stated NA-A and NA-B could not explain to her what happened. LPN-A stated staff must always pause when using a mechanical lift and ensure all sling loops are engaged prior to transferring a resident away from a stationary surface. During an interview on [DATE] at 2:50 p.m., the Administrator stated NA-A and NA-B were immediately removed from the patient care following this incident. The Administrator stated NA-A had completed her mechanical lift competency upon hire in 2023 and NA-B was rehired within the last 30 days and had completed a lift competency for the facility in 2021. The Administrator stated following this incident, R1's sling was inspected and found to be without defect. The Administrator stated the mechanical lift from the incident was removed from patient care, inspected by maintenance, and had no functional defects. During an interview on [DATE] at 3:41 p.m., NA-A stated she had entered R1's room the morning of [DATE] with NA-B to provide bowel and bladder care and intended to transfer R1 to his wheelchair for breakfast. NA-A stated R1 had been incontinent of bowel that morning, and once they had completed with a brief change, they placed the sling underneath him. NA-A stated she attached all three loops on the left side of the sling, then verbally reminded NA-B to place all three loops on the right side of the sling into the appropriate clip. NA-A stated she turned to the side to use the bed remote to slightly lower the bed so they could use the scale function of the mechanical lift to obtain a daily weight on R1. NA-A stated NA-B then pulled the mechanical lift away from the bed and began to turn without communicating to NA-A. NA-A stated R1 fell out of the sling and she told NA-B to go get LPN-A. NA-A stated she did not check to ensure all loops were attached to the mechanical lift at any point. NA-A stated she had completed her mechanical lift competency during her orientation, and she knew she needed to check the loops for secure attachment prior to transferring a resident. During an interview on [DATE] at 3:54 p.m., NA-B stated she had entered R1's room the morning of [DATE] with NA-A to provide bowel and bladder care and intended to transfer R1 to his wheelchair for breakfast. NA-B stated after they had cleaned R1 up, she and NA-B placed the sling underneath R1 and attached the loops to mechanical lift. NA-B stated she attached all loops on the right side and did not notice one of them was not properly attached. NA-B stated when NA-A lowered R1's bed, NA-B slightly raised the lift. NA-B stated she did not notify NA-A of her intentions and pulled the mechanical lift away from the bed. NA-B stated R1 immediately fell out of the sling. NA-B stated she notified LPN-A of the fall immediately. NA-B stated she did not check to ensure all loops were attached to the mechanical lift at any point. NA-B stated she had completed her mechanical lift competency when she was originally hired in 2021, and she knew she needed to check the loops for secure attachment prior to transferring a resident. During an interview on [DATE] at 11:25 a.m., NA-C stated prior to moving a resident with a mechanical lift, you must pause and ensure all loops are securely connected to the mechanical lift. During an interview on [DATE] at 11:29 a.m., NA-D stated prior to moving a resident with a mechanical lift, you must pause and ensure all loops are securely connected to the mechanical lift. During an interview on [DATE] at 11:33 a.m., LPN-B stated prior to moving a resident with a mechanical lift, you must pause and ensure all loops are securely connected to the mechanical lift. During an interview on [DATE] at 11:55 a.m., the Director of Nursing (DON) stated NA-A and NA-B were immediately removed from direct patient care following the incident. The DON stated NA-B admitted she must not have attached one of the loops on the left side of R1's sling. The DON stated every time a mechanical lift is used to transfer residents, operating staff must ensure the sling loops are attached securely prior to continuing. An electronic communication from the DON on [DATE] at 11:20 a.m. indicated the facility does not have a mechanical lift policy, and directly follow the manufacturer instructions while training staff. An electronic communication from the administrator on [DATE] at 3:14 p.m., indicated NA-A completed her mechanical lift competency on [DATE], and NA-B completed hers on [DATE]. During an interview on [DATE] at 4:42 p.m., physician-A stated the injuries R1 sustained during his fall were lift-threatening and contributed to his decompensation and death. Physician-A stated she discussed the option of completing an autopsy with FA-A to determine R1's exact cause of death. A facility document titled Facility Competency 2.0 for Mechanical Lifts indicated step 7 for transferring a resident with a mechanical lift is to ensure all sling loops are secured appropriately prior to moving the resident. The Invacare Reliant 600 RPL600-2 Battery Powered Patient Lift User Manual, dated 2018, indicated each time the sling is used to transfer a resident, the operator must ensure the sling loops are securely attached prior to removing the resident from the original object. The past noncompliant immediate jeopardy began on [DATE] at 7:42 a.m. The immediate jeopardy was removed, and the deficient practice was corrected by [DATE], after the facility implemented a systemic plan that included the following actions: - The mechanical lift was removed from the unit for further inspection by maintenance staff - Both NA-A and NA-B were placed on administrative suspension during the investigation and their employment has been terminated by the facility - Facility removed and inspected all mechanical lifts in the building and completed any necessary repairs. - Facility completed an audit of all employee's mechanical lift competencies and ensured all staff and agency staff had current competencies before their next working shift. - Facility completed education for all applicable staff to focus on pausing over the original stationary object and ensuring the sling loops are secured before continuing. - Facility completed daily audits of staff using mechanical lifts on residents and will continue to do so five times per week. - Facility completed a thorough investigation which resulted in the identification of a root cause. As a result of the facility implementation, this will be issued at past noncompliance.

Based on interview and document review, the facility failed to ensure R1's safety when the mechanical lift was not used in accordance with the manufacturer's instructions resulting in risk of potential serious harm, injury, impairment, or death for 1 of 3 residents (R1) reviewed who use mechanical lifts. As a result, the lift tilted and fell to one side while the resident was suspended. R1 was held against the side of the bed until lowered to the floor and placed in a sitting position. The IJ began on 12/6/22, at 2:15 p.m. when staff were transferring R1 and moving R1 in the lift from chair to bed. While moving R1, staff did not open the legs of the Invacare mechanical lift. R1 was suspended in the air, the Invacare mechanical lift tilted and fell to one side. The administrator and director of nursing (DON) were informed of the IJ on 12/29/2022, at 2:15 p.m. The facility implemented corrective action as of 12/9/2022, and the IJ was issued as past non-compliance. Findings included: Minimum Set Data (MDS) assessment, dated 11/7/2022, indicated R1's diagnoses included severe morbid obesity, bilateral lower extremity lymphedema, chronic obstructive pulmonary disease, asthma, and myalgia. R1 required the assistance of two staff with transfers, bed mobility, and locomotion on the unit. R1's Brief Interview for Mental Status (BIMS) score was 15 of 15, indicating he is cognitively intact. R1's quarterly Fall Risk Evaluations, dated 6/20/2022 and 9/19/2022, indicated R1 was at high risk for falls related to their comorbidities. R1's quarterly Resident Transfer Ability Tool, dated 9/19/2022, indicated R1 required a sit-to-stand mechanical lift for transfer from bed to chair. R1's care plan, last updated 11/25/2022, indicated staff are to use a sit-to-stand mechanical lift while transferring R1. During an interview on 12/27/2022 at 12:58 p.m. R1 stated on the day of the incident he was sitting in his chair and staff weighed him using the mechanical lift. R1 stated that while he was suspended in the air, being weighed, he told the staff he wanted to go to bed and not return to the chair. As the staff moved him towards the bed the mechanical lift tipped over. During an interview on 12/27/2022 at 1:25 p.m., nursing assistant (NA)-C stated R1 had his own sling for use with the mechanical lift, R1 preferred to use the mechanical lift to transfer from chair to bed. NA-C stated training on the use of the mechanical took place for all staff after the incident. During an interview on 12/27/2022, at 1:35 p.m., registered nurse (RN)-A stated on the day of the incident, he heard a commotion and reported to R1's room where he saw R1 being pinned against the side of the bed by NA-A and NA-B. RN-A stated he assisted in lowering R1 onto the floor to a sitting position. Once sitting, R1 was assisted into a supine position. RN-A conducted a physical assessment and found no apparent injury. R1 complained of generalized pain. RN-A had staff call 911 for assistance. RN-A stated he had received additional training on the use of the lift after R1's fall. During an interview on 12/27/2022, at 2:20 p.m., clinical nurse manager (CNM)-B stated the root cause of the incident was the legs of the lift were not extended while moving R1 from chair to bed. CNM-B stated re-education had been done and she was conducting audits of staff using the mechanical lifts. During an interview on 12/27/2022, at 3:08 p.m., director of nursing (DON) stated she responded to the fall shortly after it occurred and began the investigation immediately after R1 was transported to the hospital by ambulance. The DON stated NA-A and NA-B re-enacted the event and stated the legs of the lift were not extended in attempt to ease the lift closer to the bed. DON stated she does not recall any similar incident with the use of the mechanical lift. Stated both NA-A and NA-B were re-educated prior to returning for another shift and all nursing staff were re-educated on proper use of the lift. During an interview on 12/27/2022 at 3:40 p.m., NA-A stated he and NA-B used the Invacare mechanical lift to move R1 from his chair to weigh him. During this time, R1 asked to be put into his bed. NA-A and NA-B moved R1 about five feet to the side of his bed. NA-A stated he did not extend the legs of the lift. Once near the bed, the lift began to tilt towards the bed. NA-A stated he and NA-B called for help and pinned R1 to the side of the bed to keep him from falling further. R1 did not fall to the floor. RN-A came in and they lowered R1 to the floor in a sitting position. NA-A stated he had received additional training on the use of the lift prior to returning to work. During an interview on 12/27/2022 at 3:55 p.m., NA-B stated once he and NA-A started moving the lift towards the bed, the lift began to tilt until it tipped over. NA-B stated he helped pin R1 to the side of the bed and then assisted in lowering R1 to a sitting position on the floor. NA-B stated R1 did not hit his head. When asked if the legs to the lift were extended prior to moving the lift, NA-B stated, I have been a CNA for 32 years and this has not happened to me before, I have moved residents in the lift without extending the legs. NA-B stated he had received additional training on the use of the lift prior to returning to work. During an interview on 12/29/2022 at 11:38 a.m. Invacare representative (IC)-A stated, if you move a patient in a lift with the legs drawn in, the lift will become unstable, this should never be done. The legs must always be extended when a patient is suspended. The only exception is moving under a bed and the patient is above the bed. You must never turn the lift without extending the legs. IC-A stated failure to follow the manufacture instructions of the lift equipment and open the legs of the lift to the maximum position prior to maneuvering the lift, impairs the stability of the lift and risks a serious adverse outcome to residents. According to the Invacare Reliant 450 RPL450-2 & Reliant 600 RPL600-2 Battery Operated Lift User Manual, published 10/2018; Page 9, section entitled Lifting the Patient, Warning, When using an adjustable base lift, the legs MUST be in the maximum Opened/Locked position before lifting the patient. Page 20, section entitled Introduction Warning, and page 24 section entitled Warning, 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 the 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 past noncompliance immediate jeopardy began on 12/6/22, at 2:15 p.m. The immediate jeopardy was removed, and the deficient practice was corrected by 12/9/2022, after the facility implemented a systemic plan that included the following actions: -The mechanical lift was removed from the unit for further inspection by the manufacturer's representative. -Both NA-A and NA-B were placed on administrative suspension during the investigation and re-educated prior to their return to work. -Facility reviewed all residents who used mechanical lifts to ensure appropriate use and sling size. -Facility completed a thorough investigation which resulted in the identification of a root cause. -Based on the facility's findings of the investigation, the facility provided re-education to all nursing staff to ensure the appropriate use of the mechanical lifts and reinforcement of the mechanical lift transfer policy. As a result of the facility implementation, this will be issued at past noncompliance.