**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to keep residents free from accidents when staff failed to use safe, professional standards of care when transferring two residents (Residents #1 and #2) using a Hoyer lift (a mechanical device that helps people with limited mobility move from one place to another, such as from bed to a wheelchair). This failure caused an injury requiring hospitalization and surgery for one resident (Resident #1). The facility also failed to investigate two improper Hoyer transfers involving one resident (Resident #2) and did not put corrective measures in place to prevent further injuries to both residents. The sample was three. The census was 88. Review of the facility's Incident/Accident Policy, dated December 9,2016, showed: -Purpose: to record any unusual situation or injury to a resident, staff member or visitor; -Examine the person for possible injury; -Administer emergency treatment as indicated; -Notify the physician and responsible party of all incidents of falls and possible head injuries of resident; -Complete Incident/Accident Report Form; -Forward report to appropriate persons per center policy. Review of the facility's Mechanical Full Body Lift policy, dated January 2017, showed: -Purpose: To ensure that all nursing staff are using proper transfer techniques to minimize the risk of injury to resident and staff, while using full body lift; -Secure the assistance of another Certified Nursing Assistant (CNA) or other qualified employee; -Positioning of transferring surfaces should be in close proximity to minimize transport area allowing enough room to move base from bed to chair or chair to bed; -Position lift sling (supports resident's weight during transfer) under the resident; -Attach the lift sling to the lift (attach to metal cradle, a frame with four attachment points for the sling); -Widen the base/legs of the lift prior to moving the lift. The lift is more stable when the legs are widened; -Begin lifting the resident, using the control panel on the lift; -The second staff member monitors the resident's body position, making sure the resident's extremities or head does not bump or swing into any object including the mast (vertical support component of the lift) of the lift; -As the first staff member moves the lift toward the chair/bed with the resident in the sling, the second staff member is guiding the resident's legs to prevent injury; -Bring the lift into position so that the resident is over the seat of the chair or centered over the bed. Do not close the support legs, while transporting residents; -While the resident is facing the person operating the lift, the second staff member will pull the sling back so that the resident will be seated properly in the chair or centered on the bed once lowered; -Lower the sling so the resident is seated in the chair or on the bed; -Remove the sling from the hooks on the lift; -Protect the resident from injury from the bar that may swing during this process; -Carefully move the lift away from the resident; watching to make sure the resident is not bumped with the lift; -There must be two staff members present when transferring a resident using a mechanical lift; -Complete competency checks with staff with orientation, semi-annually and as needed; -Failure to follow the above policy may result in immediate termination. Review of the facility's Injury Unknown Source - Investigative Protocol, dated May 2021, showed: -The following indicators of abuse/neglect are provided to help determine if abuse/neglect should be suspected. Staff are mandated to report suspected abuse. The list is not all inclusive; -Indicators of physical abuse may include, but are not limited to the following: Bruises and/or hematomas (collection of blood beneath the skin); Injures of unknown source without abuse/neglect suspected; -If a logical/reasonable explanation of the source of injury cannot be determined, notify the local state agency within two hours of discovery; -If there is reason to suspect injury was caused by abuse/neglect, staff must immediately notify the Administrator/Designee. The Administrator/Designee is responsible to report to other officials in accordance with State law, including to the State survey and Certification agency; -Staff must provide a statement as to their knowledge or lack of knowledge of the injury; -The resident's Physician must be notified; -The Resident's Representative must be notified; -A complete body assessment must be completed on the resident. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/4/24, showed: -Cognitively intact; -No behaviors noted; -Dependent on staff members assistance for toileting, showers, lower body dressing and transfers; -Height of 68 inches and weight of 379 pounds (lbs); -Diagnoses included heart failure, diabetes mellitus, anxiety, morbid obesity and polyneuropathy (damage to nerves causing pain, discomfort and mobility difficulties). Review of the resident's care plan, dated 1/23/25, showed: -Problem: The resident required assistance with activities of daily living (ADLs); Interventions included: Assume unhurried manner, allow ample time for tasks; Provide A.M. and P.M. care per facility policies and procedures; Mechanical lift used for transfers; -Problem: The resident had complaints of pain; Interventions included: observe for nonverbal indicators of pain; Accept the resident's description of pain. Review of the resident's skin integrity event report, dated 1/23/25, at 11:52 A.M., showed: -The resident complained of pain to his/her right lower leg to Licensed Practical Nurse (LPN) C, an agency nurse; -The nurse assessed the resident and saw a bruise to resident's right shin (lower leg) measuring 9 centimeters (cm) by 10.5 cm; -The Nurse Practitioner (NP) was called to the room; -The NP arrived and gave new orders to sent the resident to the hospital immediately; -The resident was transferred to the stretcher via Hoyer lift; -The resident's emergency contact was notified; -The resident was transferred to the hospital; -Evaluation note included the resident obtained a bruise which became a rapidly growing hematoma. The resident said he/she believed he/she bumped his/her right shin while in the mechanical lift. The staff did not recall any bumps and the resident did not complain of pain to the area during or after transfer until late in the morning. The hematoma was growing rapidly so the resident was discharged to the hospital for evaluation. Review of the investigation, dated 1/23/25, no time noted, completed by the Director of Nursing (DON), showed: -On the morning of 1/23/25, at approximately 10:00 A.M., the DON was called to the resident's room by the NP, to assess the resident's hematoma located at his/her right shin; -The resident had a dollar coin sized hematoma on his/her right shin that was dark blue, purple and swollen; -The resident reported he/she hit it at some point during his/her transfer that morning but was unsure where on the lift he/she was bumped, yet he/she felt a slight bump; -The resident was sent out to the hospital for evaluation; -Both CNAs who got the resident out of the bed that morning were interviewed over the phone and gave written statements to the DON; -Both CNAs said nothing occurred during the transfer. The resident did not say ouch or complain of pain prior to, during or after the procedure; -CNA A's statement, undated, showed on 1/22/25, when getting the resident up out of bed, CNA A spotted CNA B during the transfer; CNA A was in the back, pulling and guiding the resident into his/her wheelchair; Never did the resident say Ouch, that hurt or anything to make or alert the CNAs that the resident was being injured; Before leaving the room both CNAs were laughing and joking with the resident -CNA B's statement, undated, showed on January (day left blank) 2025, at 5:05 A.M., he/she went to the resident's room to get the resident dressed and ready to get out of bed. CNA B got assistance from another aide (unnamed). The two CNAs transferred the resident into his/her bed with no inconvenience. CNA B finished dressing the resident and then gave report to the on-coming shift; -There was no documentation showing the conclusion of the investigation; -There was no documentation showing what corrective measures were taken. Review of the training sign in sheet, dated 1/30/25, showed: -Material Covered included: Mechanical Lift Policy; -There was no documentation CNA A, CNA B or LPN C received the training. Review of the resident's Medication Administration Record, dated January 2025, showed: -An order, dated 7/15/24, for Eliquis (anti-coagulant) 5 milligrams (mg) give twice a day; -The facility administered the medication as ordered from 1/1/25 through 1/23/25. Review of the resident's hospital Discharge summary, dated [DATE], showed: -Resident admitted on [DATE] due to leg pain related to swelling and bruising on the resident's right shin; -Diagnoses included: Hematoma of the right lower extremity (leg); -History of Present Illness, undated, no time noted, showed on 1/23/25, the resident came to the Emergency Department (ED) from the facility after he/she sustained an injury while being lifted in a Hoyer lift. The resident denied falling but somehow his/her leg was pushed with the transfer. A computed tomography (CT scan, combines a series of x-ray images taken from different angles around the body) of the lower right extremity showed a large superficial hematoma. On the morning of 1/24/25, the resident complained of high amount of pain to his/her right extremity. There was significant swelling and increased blistering to the injury site compared to the images taken in the ED. The resident said he/she had a decreased sensation to his/her right foot compared to his/her left which was new; -Problems addressed: Large right lower leg hematoma/abscess (pocket of pus) status post (s/p) debridement (removal of dead tissue) surgery on 1/25/25; -The resident had a wound vacuum (medical device that uses negative pressure to promote wound healing) applied to his/her right lower extremity surgical wound; -The resident required a skin graft (the removal and transplantation of healthy skin from one area of the body to another area) later to his/her right lower extremity. Review of the resident's nursing note, dated 1/29/25 at 1:30 P.M., showed the resident was readmitted to the facility from the hospital. The resident had a wound vacuum on his/her right lower extremity with new orders for wound care and antibiotic therapy. During an interview on 2/4/25 at 10:16 A.M., CNA D said: -Nursing staff were expected to always have two people present when transferring a resident with the Hoyer lift. One staff member worked the controls of the Hoyer while the second staff member guided the resident from one surface to another for safety, ensuring the resident was not bumped into any surfaces; -He/She came in to work on 1/23/25 at 6:45 A.M. and was assigned to care for the resident; -The resident was dressed and in his/her wheelchair when CNA D first saw the resident during rounds; -The resident went to his/her meeting after breakfast; -The resident first complained of pain at his/her right lower extremity when he/she returned from his/her meeting around 11:00 A.M.; -The resident said he/she was hit by the Hoyer that morning during a transfer; -CNA D told the agency nurse, LPN C, who came and assessed the resident; -The resident was sent out the hospital. Observation on 1/31/25 at 12:41 P.M., showed the resident lay in his/her bed, with pillows placed under his/her right lower extremity. There was a wound vacuum attached to the resident's right lower extremity wound, actively running. The resident was visiting with a guest and was grimacing in pain. Observation on 1/31/25 at 1:17 P.M., showed the facility's bariatric Hoyer lift in the hall. The remote control to the Hoyer was approximately 10 inches long and two inches wide. During an interview on 1/31/25 at 1:29 P.M., the resident said: -He/She was hurt when staff moved him/her from the bed to his/her wheelchair while using the Hoyer lift; -While the resident was up in the air, one of the two CNAs was pushing on his/her right leg, trying to open the resident's legs up wider; -The CNA had the Hoyer remote control in his/her hand while the CNA was pushing on the resident's right leg; -The resident told them to stop, they were hurting him/her, and to be careful with his/her legs; -The resident told the CNA who was pushing on his/her right leg with the remote control in his/her hand, to stop because the CNA was hurting him/her. The CNA ignored the resident and kept pushing the remote control into the resident's right lower leg; -After the resident was placed in his/her wheelchair, the resident went to the sink to clean him/herself up before going out to the meeting; -During the meeting, the resident's right lower leg started to hurt more and more; -The resident did not want to interrupt the meeting by complaining of pain so he/she was quiet and tried to ignore the pain, which kept increasing; -The resident was in his/her room right after the meeting and decided to look at his/her right lower leg to try to find out why it hurt so badly; -The resident raised his/her pant leg and saw a black and blue, swollen area on his/her right lower leg; -The resident described the pain as throbbing really hard; -The resident put the call light on and the nurse came to look at his/her leg; -Then the DON and NP came to look at his/her leg and told the resident he/she needed to go out to the hospital; -The resident had surgery on his/her right lower leg to clean the dead tissue out; -He/She was in constant pain, he/she could barely stand to look at his/her right leg as it made him/her sick to see it; -The resident had not transferred out of his/her bed since he/she was readmitted to the facility due to the horrible pain in his/her right leg; -The resident always had to tell the CNAs to be careful of his/her legs, told them to stop when they were hurting him/her and the staff never listened, even before the incident on 1/23/25. During an interview on 2/4/25 at 10:52 A.M., the DON said: -On 1/23/25, she was notified by the NP to come to the resident's room to assess the resident's right lower leg; -The resident was complaining of severe pain to his/her right lower leg after he/she left a meeting; -When she got to the room, she saw a black and blue bruise that was swollen and growing at a fast rate; -The resident said he/she had bumped his/her right leg on the Hoyer lift, maybe on the mast, when the CNAs had gotten him/her up that morning; -The resident was sent out to the hospital for evaluation, as the bruise on his/her right lower leg kept spreading; -When the resident returned from the hospital, he/she said the injury on his/her right lower leg was because one of the CNAs bumped his/her right lower leg with the Hoyer lift remote control. The resident could not describe the event; -It was not appropriate to push on a resident while there was an object in the staff's hand as it increased the risk of injury to the resident; -She interviewed both CNAs who denied anything happened during the transfer, saying the resident never voiced he/she was in pain or was hurt; -The CNAs did not perform an improper transfer because there were two staff members present, one to control the machine and the other to guide the resident to prevent injury, and they had the Hoyer lift legs open for stability; -She did not write up, counsel or provide in-services to the CNAs involved in the event because they said nothing occurred that could have caused injury to the resident; -Injury of unknown origin was when the facility had no explanation of how the injury occurred; -The injury was called an injury with a mechanical lift because the resident said it happened during the transfer, although the resident could not say how it occurred exactly and the CNAs denied any action occurred to cause injury; -She did not feel any corrective measures or interventions were necessary since the CNAs were unaware of how the injury could have occurred and it was unintentional; -She did not update the resident's plan of care to prevent further accidents. 2. Review of Resident #2's nurse note, dated 11/20/24 at 6:26 P.M., showed LPN G wrote the resident was pushed into room in wheelchair and left medial (middle) foot was bumped against the transfer pole, assessment showed no tenderness, no bruising or swelling was present and the resident was not complaining of pain. The primary care physician (PCP) and family were made aware. Review of the resident's Miscellaneous Event report, dated 11/20/24 at 6:46 P.M., showed: -Description: Left foot bumped on transfer pole; -No injury noted; -Evaluation note: the resident was being transferred in the lift when his/her leg was bumped on the wall., No injury noted. Monitored for 72 hours with no concerns. Review of the resident's care plan, dated 1/2/25, showed: -Problem: The resident was at risk for discomfort related to diagnosis of chronic pain syndrome; Interventions included: The resident was in a mechanical lift when it tilted his/her body when lowering him/her to the bed and the resident said it caused pain to his/her shoulder. No injuries were noted and the next day the resident said his/her shoulder was fine. The resident was non-compliant with care and moves unsafely in the mechanical lift. Multiple staff members go into the room when transferring the resident to keep him/her safe; Assess level of pain and provide comfort measures; -Problem: The resident was at risk for falls related to impaired mobility and weakness. Interventions included: The resident was lowered to the floor after the mechanical lift being used started to tilt. Employees lowered the lift down to the floor and reconnected to another lift to place the resident into his/her chair. The resident had a small bruise to his/her right cheek. Two employees were present during transfer; -Problem: The resident requires care in pairs with ADL assistance due to history of embellished stories; Interventions included: Direct care staff may pair two staff members together when providing care; -There was no documentation the resident required a Hoyer lift for transfers. Review of the resident's annual MDS, dated [DATE], showed: -Cognitively intact; -No behaviors noted; -Dependent on staff members' assistance for toileting, showers, lower body dressing and transfers; -Height of 66 inches and weight of 287 lbs; -Diagnoses included atrial fibrillation (irregular heart rate), heart failure, anxiety, morbid obesity and polyneuropathy. Review of the resident's nurse progress note, dated 1/29/25 at 9:53 P.M., showed LPN G wrote an aide informed him/her that during a transfer with a Hoyer lift with two aides, the resident was hit with the hook on the Hoyer lift. The resident said the Hoyer hook hit his/her right temple; on assessment no bruising or swelling was noted. Neuro checks were within normal limits and the resident denied pain. The PCP and resident's responsible party (RRP) was notified. Review of the resident's Miscellaneous Event report, dated 1/29/25 at 10:05 P.M., showed: -Description: The resident was hit with Hoyer hooks to the right temple with no injury; -Neurological check (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) were started; -Evaluation notes: Event still open. During an interview on 2/4/25 at 10:39 A.M., LPN G said: -He/She did not remember an incident, on 11/20/24, involving the resident getting his/her foot bumped during a Hoyer transfer; -On 1/29/25, he/she was the nurse assigned to the resident when the resident was struck in the face by the lift bar during a Hoyer transfer; -He/She was alerted by a CNA (unknown) that the resident was struck by the lift bar during a Hoyer transfer; -He/She went and assessed the resident, who confirmed he/she was hit in the right side of his/her temple by the metal lift bar; -The resident did not have any bruising, swelling, and did not complain of pain to his/her right temple; -The nurse competed a neuro-check and found the resident was within his/her normal limits, called the PCP and RRP; -The nurse then completed an event report in the resident's EMR with the PCP's new orders to monitor the resident's neurological status for 72 hours; -The nurse started the neurological checks and passed on in report to the next nurse; -The DON asked the nurse the next day about what happened; -The DON did not instruct the nurse to make any changes to the resident's plan of care; -He/She had not received any in-services on Mechanical Lift Policy in the last year; -He/She expected CNAs to transfer resident's safely while using a Hoyer lift by always having two staff present, one to work the machine and the other to guide the resident in the sling to prevent injury. During an interview on 2/4/25, at 12:51 P.M., the resident said: -Last week, he/she was hit in the head with the lift arm during a Hoyer transfer. The CNAs jerked the strap of the sling off of the lift arm so hard, it smacked the resident in his/her right temple; -The resident had neuropathy in his/her legs which made them very sensitive and painful; -He/She did not feel safe when CNAs transferred him/her with the Hoyer lift; -CNAs did not listen to the resident during transfers, ignoring the resident's pleas to be careful when moving his/her legs, to make sure he/she does not bump into objects while up in the sling; -When the resident was up in the Hoyer lift, he/she would swing without any support and hit his/her legs and feet against the wall; -The CNAs would say they were doing the best they could when the resident said they were hurting him/her and would continue with their task; -The resident would remind the CNAs to be careful with his/her left shoulder, as it was always in pain, when removing the sling from the lift bar; -The CNAs would jerk the sling off of the lift bar causing the resident to fall back into his/her wheelchair or bed, causing him/her pain; -There have been several near misses with the lift bar because the CNAs would not hold it still when they attached or removed the sling from it, causing the lift bar to swing back and forth in front of the resident's face; -There were some CNAs who were very kind and listened to the resident but most of them acted so angry and worked hastily; -The resident feared retribution from staff if he/she complained about the treatment and the fear he/she has when up in the Hoyer lift during transfers; -He/She did not feel that his/her concerns or complaints were taken seriously; -During the interview the resident was often tearful and whispered because he/she was afraid others might hear him/her. During an interview on 2/4/25 at 10:52 A.M., the DON said: -She did not recall an event on 11/20/24 involving the resident and a Hoyer lift transfer; -The facility did not investigate the event on 11/20/24; -She was not aware of the event that occurred on 1/29/25 and had not started investigation on the event; -She expected staff to report any accidents to her so she could conduct an investigation; -Nurses were not expected to report all events to the DON as nursing staff were able to take care of them independently; -She was responsible for reviewing events daily or at least every couple of days; -Staff conducted an improper Hoyer transfer if a resident was struck in the face by the metal arms of the cradle when staff removed the sling from the hook; -Staff conducted an improper Hoyer transfer if the resident's foot bumped into an object, causing them pain, due to staff not guiding the resident to prevent injury; -She did not update the resident's plan of care to prevent further accidents. 3. During an interview on 1/31/25 at 11:36 A.M., LPN E said: -When a resident had a fall, an accident or injury of unknown origin, nurses were responsible for assessing the resident for injury or any change of condition, notify the PCP for any new orders, notify the RRP, list what interventions were tried or put in place, and the plan of care going forward. All of that information was then documented on an event note found in the resident's electronic medical record (EMR); -Nurses would try to find out what caused the fall, accident or injury of unknown injury by talking to their staff; -Neglect was defined as any time a staff member did not care for a residents' needs, by ignoring them or acting carelessly, causing the residents harm; -Nurses were expected to report any suspicion of abuse or neglect to their supervisor. Supervisors were expected to then investigate the incident by interviewing all residents and/or staff involved and making report to the appropriate agencies. During an interview on 2/4/25 at 10:27 A.M., LPN F said: -Nursing staff were expected to always use two people during a Hoyer Lift, one to operate the machine and the other to guide the resident to make sure the resident was safe and did not bump into any surfaces; -He/She would report to a Supervisor if a resident had an injury due to an unsafe transfer so they could investigate the incident. During an interview on 2/4/25 at 10:52 A.M., the DON said: -She expected nursing staff to have knowledge of and to follow facility policies; -An incident or accident was defined as a fall, an injury to the skin, anything that changed the condition of the resident unexpectedly; -An incident or accident also included events where staff caused harm or injury to the resident due to not following facility policies or professional standards of care; -She expected nurses to complete an event report in residents' EMR for any incident that changed the condition of the resident; -The facility would investigate events by interviewing staff and residents to see what occurred and based on what was found would provide in-services to staff to address the issue; -If staff conducted a transfer incorrectly, she would write-up the staff involved and provide education and counseling; -If staff conducted a transfer incorrectly that caused injury to a resident, she would suspend the staff involved pending investigation; -In-services to staff were started right after the event occurred, provided by the DON or the Assistant Director of Nursing (ADON); -Staff were expected to retain the education they received during in-services; -In-services were based on professional standards of care and facility policies; -If there was a pattern of the same type of accidents occurring again and again, she would do more in-services to staff and try to find out why the issue was still occurring; -She was not aware of any improper Hoyer transfers in her facility; -A proper Hoyer transfer consisted of two staff members, one to control machine, the other to spot the resident for safety and to keep the Hoyer legs open for stability; -She recently gave nursing staff education on Hoyer lift transfers as part of a mock survey and had not completed it as of time of interview; -She did not recognize a pattern of improper mechanical lifts in the facility. 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