**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to use the appropriate type of mechanical lift sling according to the care plan for 1 of 3 residents (R1) reviewed for mechanical lift transfers. This resulted in harm when R1 was transferred with with a toileting sling resulting in subsequent pain, brusing and diagnosed humoral fracture to left arm. Findings include: A facility reported incident (FRI) submitted to the State Agency on 5/6/24, indicated R1 had an unexplained injury that staff became aware of on 5/4/24 when a nursing assistant (NA) reported R1 had dark black and blue bruising on her upper arm. R1 was sent to the hospital for further evaluation. R1's face sheet identified R1 had diagnoses that included wedge compression fracture of T7-T8 vertebra, unilateral primary osteoarthritis, impingement syndrome of left shoulder, unspecified fracture upper end of left humerus, chronic pain, and abnormalities of gait and mobility. R1's quarterly minimum data set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, moderate difficulty with hearing, unclear speech, rarely/never understood, but usually understood others. R1 had upper and lower extremity impairment on both sides that required staff assistance with all activities of daily living (ADLs). R1's care plan dated 2/13/24, indicated R1 had a progressive decline in strength and use of extremities, and had muscle weakness in right hand, and a lame left shoulder from non-use. For toileting the care plan directed 1 to 2 helpers with ARJO (brand name) blue medium sized sling -resident can use this sling for toileting- please do not use sling that goes under the arms. R1's Therapy/Restorative-Plan of Care dated 4/30/24, for transfers directed assist of 1-2 staff with ARJO Hoyer/EZ body sling, Blue/medium sling- can use this sling for toileting- do not use sling that goes under her arms. Ensure full body sling under bottom for transfers. During an interview on 5/10/24 at 9:45 a.m., trained medication aide (TMA)-A indicated R1 had decreased range of motion in her shoulders/arms and R1 could not raise her arms up. TMA-A indicated the facility had two types of lift slings, a regular full sling and the toileting sling which went under the arms. TMA-A stated R1 had been using a full body sling for approximately 1.5 years and would not be able to use the toileting sling because the sling would cause R1's arms to go up. TMA-A stated she worked the day shift on Friday, 5/3/24, and transferred R1 from the wheelchair to her bed after lunch using the full sling. TMA-A did not notice anything abnormal and did not recall R1 having any increased pain anywhere. During a phone interview on 5/9/24 at 2:27 p.m., NA-C indicated R1's arms were difficult to move because they were stiff and rigid; washing under her arms was hard because of her decreased range of motion. R1 was transferred with a mechanical full body lift by two staff. NA-C indicated she worked the night shift and did not routinely transfer R1. NA-C stated she worked the overnight shift Thursday (5/2/24) and stayed late on the day shift Friday (5/3/24). NA-C explained when she and NA-D transferred R1 from her bed to wheelchair Friday morning they used the ARJO toileting sling because that was the one in R1's room. The toileting sling shape is different from the full sling because the toileting sling goes under the arms instead of fully encompassing the upper body. The toileting sling also had a buckle that went across the upper chest at shoulder level that would cause some pressure. NA-C stated it was difficult to put the sling on R1 because they had to move R1's arms so that they were outside of the sling for the transfer. R1 made moaning noises when she was moved. NA-C indicated she had questioned at the time of the transfer if the toileting sling was the right one because of the difficulty applying it. NA-C stated R1 should have been transferred with a full sling but did not know that at the time. Calls were placed to NA-D on 5/9/24 at 2:24 p.m. and 5/10/24 at 9:37 a.m., no return call from NA-D was received. R1's progress note on 5/3/24 at 9:30 p.m., R1 had yelled out when arm was touched or moved with cares. The note did not identify which arm. During a phone interview on 5/10/24 at 10:51 a.m., licensed practical nurse (LPN)-A stated on Friday 5/3/24 she worked the evening shift. LPN-A stated the NA called her to R1's room because she was having increased pain in her right arm. LPN-A did not notice any bruising on R1's right arm and there was no change in R1's shoulder/arm range of motion. LPN-A added the increased pain into the computer and passed along her findings in her report to the next shift. During an interview on 5/9/24 at 10:55 a.m., NA-A stated she assisted R1 with morning cares on the morning of 5/4/24. NA-A stated R1 was always tight and constricted on her right arm but that morning the whole arm felt loose and was easily lifted compared to the left side. NA-A stated she told the nurse of her findings R1's late entry progress note dated 5/5/24 at 2:20 p.m. for 5/4/24, identified nursing assistant (NA)-A called nurse to room due to (d/t) R1's right arm hurting with movement. No bruising. Hospice nurse in the building checked her out. During a phone interview on 5/10/24 at 11:10 a.m., LPN-B stated she worked 5/4/24 during the day. LPN-B verified NA-A had her go to R1's room for R1's right arm moving more than normal. LPN-B stated she did not notice any abnormalities and had the hospice nurse look at it. LPN-B stated she looked at the arm on 5/5/24 (Sunday) morning, it had bruising on it that was not present of 5/4/24. During a phone interview on 5/10/24 at 2:47 p.m., hospice nurse (H)-A stated she examined R1 on 5/4/24 because facility staff were concerned with flaccidness of R1's right arm. I didn't think it was a huge, big deal, maybe she [R1] was more relaxed and she is pretty non-verbal. She looked comfortable. H-A was at the facility 5/5/24 and examined the change with the bruising on the right arm. H-A then notified the hospice doctor who advised the desision to send R1 to the hospital was up to R1's family. H-A stated I think that using the toileting sling that was the only thing that I could come up with that may have caused it [the injury to R1's right arm]. During an interview on 5/9/24 at 1:21 p.m., registered nurse (RN)-A stated R1 did not move her arms or legs independently on a good day. Normally, R1 liked her arms down and bent at the elbow and resting on her abdomen. RN-A explained she worked during the day on 5/5/24. That morning, (NA)-B had her come to R1's room to examine bruising. RN-A stated when she arrived to R1's room, she told NA-B don't touch, don't move [R1]. RN-A assessed R1's bruising and then called family member (FM)-A to come to the facility. H-A who was in the building examined R1 and FM-A requested R1 be sent to the emergency department. R1's progress note on 5/5/24 at 9:14 a.m., identified R1 moaned a lot for unknown reason and had right upper arm anterior (front) and posterior (back) dark purple bruising and pain with movement. At 11:23 a.m., R1 was transferred to the emergency department. At 2:46 p.m., R1 returned from the emergency department. R1's emergency department note on 5/5/24 signed at 1:37 p.m., identified R1 presented to the emergency department due to a change in the patients humeral area with significant increase in pain with movement as well as bruising. Exam consisted of significant bruising on the central aspect of the humeral area and the posterior aspect of the humeral area. Swelling and decreased range of motion noted along with pain when moving extremity away from body. R1's X-ray identified diffuse osteopenia and angulated nondisplaced proximal right humeral fracture with subluxation of the humeral head relative to the glenoid (common fracture often seen in elderly patients with osteoporotic (weak and brittle) bone usually from an outstretched arm). During a phone interview on 5/10/24 at 10:00 a.m., medical doctor (MD)-A stated with R1's condition, any kind of a pressure could cause a fracture. During an interview on 5/10/24 at 11:25 a.m., physical therapist (PT)-A reviewed emergency department notes and stated considering R1 had osteopenia, an upward force like that of using a toileting sling could be related to a dislocation or fracture, especially with R1's frailty. During an interview on 5/9/24 at 10:04 a.m., with administrator and director of nursing (DON), DON explained when R1 first transitioned from the sit-to-stand, the toileting sling was first tried, however that pulled too much on her shoulders, so it was determined R1 should use the full sling, instead. During an interview on 5/10/24 at 12:32 p.m., the administrator stated it was her expectation staff followed the care plan. The facility policy titled assisting with transfers and walks reviewed 3/2022, identified that care plans and caregiver worksheets offer guidance regarding level of assistance required by each resident. Employees will perform all transfers in compliance with these tools.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 3 residents (R1) reviewed who was at risk for pressure ulcer development. The facility's failure resulted in R1 sustaining harm when the resident developed a Stage IV (extend into the muscle, tendon, ligament, cartilage or even bone) pressure ulcer to the sacral/coccyx (triangular bone found between end of lumbar 5 of the spine and coccyx (end of spine area) area. Findings include: R1's face sheet printed 11/7/22, included diagnoses of chronic obstructive pulmonary disease (airflow limitations), anxiety disorder, heart failure, peripheral vascular disease (narrowing, blockage or spasm in any vessels outside of the heart), and personal history of COVID-19. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 as having intact cognition, understands and is understood and moderate hearing loss. The MDS further indicated R1 had no rejection of cares, required no staff assistance with mobility needs and used a walker and wheelchair. The MDS included R1 was at risk for pressure ulcers, currently had no skin issues and had a pressure reducing device for bed and chair. R1's discharge MDS assessment dated [DATE], identified R1 as requiring limited assist with transfers, was independent with bed mobility and required extensive assistance with dressing, personal hygiene and toileting. R1's Care Area Assessment (CAA) dated 5/30/22, indicated R1 had no pressure ulcers but had a history of healed pressure ulcers and the head of the bed is elevated all or most of the time. The CAA further stated R1's skin in good condition but remains at risk due to frail and fragile condition, weight declining but able to continue with activities of daily living and walking. R1 rests most of the time in bed, doesn't change position in bed and just keeps the same position on the right edge of bed so she can get up to the bathroom as she desires and chooses. R1's Braden Scale (the gold standard used to identify risk of developing a pressure injury) dated 5/23/22, indicated a score of 19/23 (indicating no risk). However, added text indicated R1 was at risk due to age, due to always laying on the same area on back and side and never alternated her position in bed, weight is low and bony prominence's at risk. R1's care plan dated 3/21/22, for skin care indicated nursing assistants (NA) was to use pressure redistribution devices on the bed, pillows to reduce pressure and friction between R1 and the bed or chair with cushion in wheelchair when used. Keep R1 clean and dry by providing pericare when needed and noting when incontinence pad needs changing. Report redness, check skin folds, keep dry, and treat as ordered. The goal was to keep skin healthy and intact and avoid injury. Record review revealed the following weekly skin assessments: 9/9/22: no open areas on skin. 9/16/22: bruise present on right knee and top of head which is resolving. 9/23/22: no open areas. 9/30/22: no open areas 10/7/22: red area under chin. 10/21/22: no new skin issues 10/13/22: no current skin lesion or problems. Skin is within normal limits A progress note dated 10/17/22, at 7:41 a.m., indicated R1 tested positive for COVID-19. A progress note on 10/17/22, at 12:08 p.m., indicated R1 refused meal and acetaminophen. Oxygen saturation was 90% on 1 liter of oxygen. A progress note on 10/17/22, at 2:25 p.m. indicated R1 had been unresponsive a couple times during shift, refused meds and meal but refused to go to the hospital. A progress note dated 10/18/22, at 4:34 a.m., included R1 continued to refuse to be treated at the hospital and required assistance to the bathroom. A progress note dated 10/22/22, at 10:34 p.m. indicated R1 was feeling tired with very little energy and slept for most of the shift. A progress note dated 10/24/22, at 1:47 a.m. indicated acetaminophen 325 mg tablet was given for pain on R1's bottom and rated the pain at a 6. At 7:54 a.m., R1 was transferred to acute care hospital by ambulance for evaluation of breathing pattern that is fast, breath sounds abnormal, crackles heard, diminished. Cough was congested. Temperature was 99.6 degrees Fahrenheit. A History and Physical dated 10/24/22, from hospital admission indicated a 3 centimeter (cm) sacral ulcer was present with surrounding erythema (superficial reddening of the skin, as a result of injury or irritation) present. Wound not deep enough to see the bone but extends through the subcutaneous fat. Inside the wound, the tissue is gray and black and foul smelling. Assessment and plan included sacral decubitus ulcer (pressure ulcer), stage IV. The nursing home reported they were unaware of this. Will clean the wound with microsyne wound spray (safe hypochlorous acid based antimicrobial treatment for the cleansing, irrigation and moistening of wounds) and bandage as appropriate. Nurses will frequently reposition. A hospital Discharge summary dated [DATE], included sacral decubitus ulcer (pressure ulcer) stage 4: R1 was found to have a large sacral ulcer with surrounding erythema and severe tenderness. Area is very painful. PU has a small opening on the surface but is quite deep. There is a large amount of necrotic (death of cells) tissue within the wound. R1 is not a candidate for surgical debridement. Cleaning of the wound is done daily with microsyne wound spray and covering with Mepilex border dressing (absorbent, dressing that acts as a barrier to liquid and microorganisms). R1 will need ongoing wound care after discharge. It is extremely important to have an appropriate mattress and assist her to off load the sacral area. Physician orders dated 10/28/22, included: Cleanse wound on sacrum/coccyx with microsyne and change Mepilex on sacrum/coccyx daily until healed. Measure PU, explain condition, treatment, stage 4 on sacrum/coccyx 1 time per week starting Friday until healed. During observation and interview on 11/6/22, at 12:58 p.m., nursing assistant (NA)-D assisted R1 to the bathroom. R1 had Mepilex on sacrum/coccyx. NA-D indicated R1 was in the hospital and returned with a pressure ulcer. R1 refused to be interviewed. During observation on 11/6/22, 5:55 p.m. R1 was brought to the dining room in her wheelchair. R1's bottom was in the center of the chair and R1 was leaning back casing her to appear slouched in the wheelchair with pressure on sacral/coccyx area. R1 was able to sit up to eat and then would lean back again. R1 took her medications, ate 1/2 of her chicken noodle soup and requested to go back to her room. R1 was assisted back to her room, toileted with Mepilex still in place and settled into bed on her back with head of the bed observed to be at 30 degrees. During observation on 11/7/22, at 12:41 p.m., R1 was laying in bed on her back with head of the bed at 30 degrees. Air mattress was present on bed. During observation and interview on 11/7/22, at 1:32 p.m., registered nurse (RN)-B entered R1's room to complete a dressing change. RN-B indicated R1 returned from the hospital with wound at the end of October when she had COVID-19. RN-B indicated R1 had no redness or signs of a pressure ulcer prior to her transfer to the hospital. Trained medication assistant (TMA)-B rolled R1 onto her left side. RN-B removed Mepilex covering wound and per RN-B a moderate amount of serosanguinous drainage was present with a yellow-greenish tint. RN-B indicated the wound had increased redness around the edges and inside the wound, bone was visible with exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation) present. RN-B cleansed wound with microsyne and gauze. RN-B measured tunneling of the wound which was 6.5 centimeters (cm). Wound length was 5 cm and 4 cm wide. Depth of wound was 1 cm. RN-B indicated the wound was larger, had more drainage and redness than previous on 11/4/22. A new Mepilex was placed on the wound. RN-B indicated the air mattress was placed on R1's bed when she returned from the hospital. RN-B said they have educated R1 about getting off her back and bottom but R1 refuses and prefers to lay on her back. A progress note on 10/28/22, at 11:49 a.m. indicated R1 was readmitted to the facility at 11:40 a.m. via ambulance from the acute care hospital. Hospital orders included wound care for stage 4 ulcer/coccyx and to cleanse wound with microsyne and cover with Mepilex daily and as needed. A transfer assessment completed on 10/28/22, at 1:05 p.m. indicated R1 could assist with standing, bear full weight for a least 4 seconds and follows directions. Transfer instructions included standing pivot with assist of 1 and gait belt. Stand in front of resident, pull resident to feet with both hands and gait belt and feet in a staggered stance. Pain present on buttocks. R1 is usually understood by others and usually understands others, but misses some part or intent of message but comprehends most conversation. A progress note dated 10/29/22, at 10:21 a.m. indicated PU stage 4, full thickness of skin and subcutaneous tissue loss, exposing muscle and or bone. Tissue type is slough (dead skin tissue yellow or white in appearance) with wound tissue white. Light drainage, yellow in color noted on Mepilex when removed. Surrounding tissue is cyanotic (bluish discoloration of the skin resulting from poor circulation). Wound length was 4 cm, width, 3 cm and depth 2 cm. A Braden Scale completed on 10/31/22, indicated score of 17/23, meaning no risk. No mention of current pressure ulcer present. A progress note dated 11/4/22, indicated PU stage 4 with wound tissue yellow, surrounding tissue reddened, and no change with healing progress. Length of wound is 4 cm, width is 6 cm and depth 0.3 cm. A progress note dated 11/5/22, indicated PU stage 4, area was painful with dressing change and cleansing of the area. [NAME] drainage on changed Mepilex and has a foul odor. R1's care plan revised 11/7/22, indicated R1 had the potential for skin injury, bruise easily and developed a pressure ulcer due to poor tissue perfusion, saggy skin and wanting to lay in the position R1 chooses not be moved or have things in bed unless R1 requests it. In the past R1 had a history of open areas, bruises, moist skin folds and had lost so much weight that bony prominence's was at a great risk, also risk of slow healing because of minimal intake. R1 needs extra protection to prevent skin injury. R1 has a pressure reducing mattress to prevent and reduce risk of skin breakdown. R1 needs PU care and to stay off area, but doesn't like others to position her, as always R1 doesn't want anything changed in her cares. Keep good padding around bony areas as needed, report redness, check skin folds, keep dry and treat as ordered. Keep wrinkles out of sheets as best as possible. Nurses need to reduce pressure and friction between R1 and the bed or chair, monitor nutrition, check skin weekly, monitor pressure areas especially the left hip due to always lying the same way in bed. During interview on 11/8/22, at 9:25 a.m. the director of nursing (DON) indicated R1 did not have a pressure ulcer when she was transferred to the hospital. The DON indicated she returned with a stage IV sacral ulcer. The DON indicated R1's last skin assessment at facility was normal prior to R1 discharging to the hospital and R1 is very independent and does her own thing. During interview on 11/8/22, at 9:40 a.m. RN-C indicated R1 had a history of PU but on her right hip. RN-C indicated she completes the quarterly assessments and always puts R1 as high risk even though her Braden Scale doesn't show she is high risk. RN-C indicated R1 always lays on her back, and has a history of PU on her right hip over 5 years ago, which is not the same area as this PU. RN-C indicated R1 has always wanted to maintain her independent and wants to be left alone. R1 had toileted, transferred and got around the facility by herself. RN-C added since R1 got COVID-19 in October, she now requires assistance for all her activities of daily living including transfers and toileting. During interview on 11/8/22, at 11:10 a.m. the DON indicated R1 had been at the facility a long time and had been independent with bed mobility, transfers and ambulation until she got COVID-19. The DON indicated there would not be any documentation about her refusing assistance with turning or education on risks and benefits of refusing to stay off her bottom due to her length of stay at the facility. During interview on 11/08/22, at 11:13 a.m., RN-B indicated prior to, and after R1's hospitalization she had educated R1 about not laying on her bottom, but R1 refuses the use of pillows for positioning, or assistance with position changes, which is probably how she got the PU to begin with. RN-B indicated R1 was independent with all her activities of daily living, but when she got COVID-19 in October, she needed assistance with transfers, bed mobility and toileting. RN-B did not think any barrier cream was used on R1 and indicated the air mattress was new when she returned following hospitalization. During interview on 11/8/22, at 11:29 a.m., nursing assistant (NA)-J indicated she cared for R1 throughout her isolation period for COVID-19. NA-J indicated R1 was very weak and required assistance with transfers and toileting. NA-J indicated she laid on her back in bed throughout her isolation until she went to the hospital. NA-J indicated she did notice redness on her sacral/coccyx area when assisting her with toileting but doesn't remember if she notified anyone about the redness. During interview on 11/8/22, at 12:25 p.m. RN-C indicated when R1 returned from hospitalization, she went into observe wound care and noted very saggy skin which required pulling up of the skin to visualize the wound. RN-C indicated obviously we missed this. During interview on 11/8/22, at 12:36 p.m., NA-G indicated she cared for R1 while in isolation for COVID-19 while still at the facility. NA-G indicated R1 had loose stools, was weak requiring assistance and wasn't eating. NA-G included R1 was normally independent but with COVID-19 required assistance to the bathroom and with all her cares, including eating, but refused to let us help her with eating. R1 wasn ' t patient with staff and would start to stand up before staff was ready for her to do so, therefor, NA-G didn't get a good look at R1's bottom. NA-G added she had never been aware of a repositioning program for R1. During observation and interview on 11/8/22, at 12:35 p.m., R1 returned to her room and with staff assistance laid down in her bed with head of bed at 30 degrees, oxygen on at 2 liters per nasal cannula. R1 indicated she just does not feel good and is so tired. R1 was asked if she would lay on her side and R1 stated No. R1 was asked if staff ask her to lay on her side and R1 responded I'm not going to. Continuous observation on 11/8/22 included: 12:35 p.m., laid down in bed on her back with head of the bed at 30 degrees. 12:54 p.m., no change in position. Room was dark and R1 is resting. 1:20 p.m., no change in position. 1:36 p.m., no change in position, no staff have checked on R1. 1:48 p.m., no change in position, room remains dark and R1 appears to be sleeping. 2:02 p.m., no change in position. 2:14 p.m., no change in position. 2:26 p.m., no change in position and no staff into room. 2:43 p.m. - no change in position. 2:56 p.m. - no change in position and no staff into room. R1 continued to rest in bed. During interview on 11/8/22, at 3:06 p.m., the DON indicated when R1 had COVID-19 she was weak, always laying on the left side of the bed. The DON confirmed R1 had a change in condition when she had COVID-19 and does not believe she was reassessed during that time. The DON indicated a discussion was held on placing an air mattress on her bed but was worried as people have rolled off of them so choose not to implement prior to R1's hospitalization. The DON added that R1 will not turn and reposition even a slight tilt. Throughout the past the facility has tried protein supplements, including Magic Cup, Great Shakes and concentrated protein drinks but R1 refuses them. The DON confirmed the stage IV pressure ulcer was discovered on admission to the hospital per documentation and likely was present while she was at the facility but was not discovered. During interview on 11/8/22, at 12:47 p.m., the certified dietary manager (CDM) indicated R1 is on the registered dietician's risk list and being seen monthly. The CDM indicated monitoring R1's intake which varies from 0% to 100% of her meals. CDM indicated having tried Resources, Magic Cup and Arginade (supplements to support the unique nutritional needs of wound care) but she refuses to drink them. CDM did indicate R1 will eat ice cream with each of her meals but have not tried shakes with supplements because R1 likes things her way and likely will not drink those. Facility policy and procedure for prevention of pressure ulcers was requested and none was received. Facility policy and procedure titled Wound Care, Dressing Guidelines, last revised 12/2017 included care for skin tears, minor cuts or abrasions, surgical wounds, but did not include pressure ulcer wound care. A policy and procedure on Wound Assessment dated 4/2016 (Copyright: NPUAP) - Pressure ulcer definition as a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated pressure ulcers. -Stage I: intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tone. May indicate at risk person. - Stage II: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling of the wound. Stage IV: Full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling. The depth of stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.