Based on observation, interview, and record review, the facility failed to ensure the safety of one resident (Resident #1) when staff failed to follow the care plan and use proper technique during a transfer resulting in the resident entangling his/her legs together and sustaining a fractured right tibia/fibula ((tib/fib) the long bones in the lower leg). The facility census was 59. The facility did not provide a policy regarding proper transfers. 1. Record review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 01/01/2024 showed: - Diagnoses of Alzheimer (a disease of the brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), seizure disorder; - Cognition impaired; - No behavioral symptoms; - Dependent on staff with transfers, bed mobility, dressing, toileting, and bathing; - Non ambulatory; - Incontinent of bowel and bladder; - No rejection of care. Review of Resident #1's Care Plan, dated 04/02/2024, showed: - Assistance needed for activities of daily living (ADL's) including bathing, toileting, bed mobility, transfers and meals; - Use of wheelchair for locomotion, unable to ambulate (walk), requires assist of a mechanical lift to transfer. Review of the Nursing Assistant Assignment sheets located at the nurses station showed: - Resident #1 uses a wheelchair for mobility, propelled by self; - Mechanical lift for all transfers. Review of Resident #1's Resident Progress Notes, showed: - On 04/02/2024 Licensed Practical Nurse (LPN) was called to resident's room due to resident complaints of pain to lower left extremity; - Noted large bruise and swelling to area of left lower extremity just below the knee/shin area; - Painful upon movement or touch; - Resident unaware of how or when injury occurred; - Ice pack applied to area, removed after 20 minutes then re-applied; - Primary care physician notified. Received new orders for X-ray due to swelling. - Responsible party notified. Received X-ray results with fracture if tib/fib. Orders to elevate and position for minimal movement until the resident sees the Orthopedic physician. - On 04/03/2024 family requested to have resident transferred to hospital; - On 04/04/2024 the resident admitted to the hospital for tachycardia (increased heart rate) due to administration of morphine (medication used for pain) while at the hospital. Record review of the X-ray report, dated 04/02/2024, showed an acute non-significant displaced (broken bone which are spread apart) proximal (end of bone closer to the trunk of the body) tibia and fibular fractures and diffuse soft tissue swelling (swelling around the fractured area). During an interview on 04/08/2024 at 9:00 A.M., the Administrator said she was aware of an incident involving a resident transfer that resulted in a fracture. She began an investigation immediately on 04/02/2024 after finding out about the injury. She started the investigation at the time of discovery, and went backwards interviewing staff who had worked with the resident until she got to Certified Nurse Aide (CNA) B. CNA B informed her that on the early morning hours of 04/02/2024, he/she transferred Resident #1 without the use of a mechanical lift. The resident and the employee's legs got tangled up during the transfer. CNA B reported the resident only said ouch but did not complain of pain. The CNA did not report the incident to anyone due to not suspecting any injury. The Administrator said the resident was unable to say what happened or when due to cognitive issues. The Administrator said she would expect staff to follow the resident plan of care. During an interview on 04/08/2024 at 9:45 A.M., CNA C said on 04/02/2024 he/she and CNA D went to get Resident #1 up for the lunch meal and noticed the resident's left leg and knee area was swollen, purple and red in color. CNA C said he/she immediately reported to the charge nurse for assessment. The resident can't get up or down by himself/herself, but is able to propel him/herself in the wheelchair using his/her arms only. Resident #1 frequently wonders the facility in his/her wheelchair daily. The resident is able propel self in the wheelchair using his/her arms only, he/she never uses lower extremities to move around. During an interview on 04/08/2024 at 9:50 A.M., CNA D stated the resident is mobile using his/her arms only in the wheelchair, frequently wonders around the facility. The resident is unable to answer questions appropriately. On the morning of 04/02/2024, the resident was up in the dinning room upon arrival to work. He/she only noticed the bruising and swelling after he/she and CNA C was getting the resident up for lunch. The resident did not act out like in pain. They immediately informed the charge nurse who came down and assessed the injury. During an interview on 04/08/2024 at 11:50 A.M., Licensed Practical Nurse (LPN) A said he/she was working as charge nurse on the day of 04/02/2024 when CNA's C and D reported bruising to Resident #1's left lower leg area. LPN A said the resident's leg was notably swollen near the knee area with blue color bruising. The resident complained of pain in the bruised area when moving or changing positions. LPN A notified the physician of the injury and followed physician orders as received. LPN A said CNA's are expected to look at the assignment sheets kept at the nurse's station for the level and type of assistance each resident has been assessed for. During an interview on 04/08/2024 at 2:50 P.M., CNA B said he/she transferred Resident #1 on the morning of 04/02/2024, with no assistance from other staff. He/She did not use a gait belt or mechanical lift. He/She said, during the transfer on 04/02/2024, his/her and the resident's legs got tangled when he/she moved the resident from the bed to the wheelchair. CNA B stated he/she was unable to describe how their legs got tangled. The resident said ouch but then did not complain of anything after that. CNA B denied the resident falling or having any other concerns. CNA B said he/she knew some staff used the mechanical lift and some did not, so he/she chose not to use the lift. CNA B said he/she can find the information for the level of assistance each resident needs at the nurse's station. CNA B did not remember what level of assistance Resident #1 required and would have to look before answering MO234196

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff provided the necessary care and services in accordance with professional standards of practice for one resident (Resident #1) out of three sampled residents. Staff failed to notify the physician of the resident's critical lab values in a timely manner which resulted in the resident being admitted to the hospital from [DATE] through 09/01/23. The facility census was 60. Review of the facility's policy titled, Lab Reporting Guidelines, dated March 2015, showed: - Once lab results are returned to the facility, the nurse will notify the physician via fax and follow-up call within 12 hours for routine labs or within one hour for stat labs; - The nurse will document on the lab report that the physician has been notified and to include how they are notified, when (time and date) and the nurse's signature. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated, 08/21/23, showed: - admission to the facility on [DATE]; - Diagnoses of hypertension (high blood pressure) and malnutrition (lack of proper nutrition); - Cognition moderately impaired; - The resident with a legal guardian. Review of the resident's progress notes showed: - On 08/25/23 at 2:42 A.M., a chemistry panel (lab) obtained, which included the sodium lab; - On 08/25/23 at 11:12 P.M., (Friday night) the sodium critical lab value of 165 (normal lab sodium values 136-145) faxed to the physician's office; - On 08/27/23 at 12:47 P.M., the nurse notified the nurse practitioner notified by phone of the sodium critical lab value of 165 and received a new order to send the resident by ambulance to the emergency room for evaluation and treatment; - admitted to the hospital for hypernatremia (a high concentration of sodium in the blood); - The hospital re-checked the sodium lab and received a value of 166 on 08/27/23. The resident's hospital history and physical, dated 08/27/23, showed: - The resident admitted with severe hypernatremia; - admitted to the intensive care unit; - Required cardiac (heart) monitoring. During an interview on 09/05/23 at 9:50 A.M., Licensed Practical Nurse (LPN) A said labs were usually drawn early in the morning. He/she said lab reports were usually back the same day, unless it was a send out lab. The resident's lab was not a send out. When there was a critical lab value, the lab would call the facility and speak with a nurse. The nurse should then notify the physician on call and the responsible party as well. During an interview on 09/05/23 at 10:00 A.M., the Administrator said she knew the nurse practitioner was notified and the resident had been sent out on 08/27/23. There was a nurse on-call for the evening and night shift. The LPN could have reached out to the on-call nurse or called the Administrator. During an interview on 09/05/23 at 11:07 A.M., the Nurse Practitioner (NP) said if a facility faxed labs to his/her office during the hours of operation, the staff would call him/her with the lab values. However, after hours in this situation, the labs would not be reviewed until Monday morning on 08/28/23. When the lab calls the facilities with critical lab values, then the nurse should call the on-call physician. There was a 24 hour, seven day a week on-call service. He/She was actually on call that particular weekend and was not contacted by facility until 08/27/23, when the nurse notified him/her of the resident's critical lab value and the order was given to send the resident to the emergency room for evaluation and treatment. During a telephone interview on 09/05/23 at 11:12 A.M., LPN B said he/she was notified between 8:00 P.M. - 9:00 P.M., on 08/25/23 of the critical lab value. He/She notified the nurse practitioner's office by faxing the lab report. He/She did not know what to do in that situation. Complaint #MO223597