**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** S. On 02/23/24 at 9:10 am, during an observation of a Sara lift located in Pod/Unit/Hall 4 revealed there was not a leg strap attached to the lift. Further observation revealed there was a loose leg strap near the lift. T. On 02/27/24 at 5:06 pm, during an interview with DON, she stated the leg straps were now tethered to the mechanical lift, because there were times when leg straps were misplaced or unavailable when needed. She stated this change, attaching the leg straps by a tether (tying) to the machines, was implemented prior to R #4's fall in October 2023. The DON stated it was implemented at the same time as a training on lifts in May 2023. U. On 02/27/24 at 5:15 pm during a random observation of Sara lift in Pod 4 revealed there was not a leg strap attached to the lift. Further observation revealed there was a loose leg strap near the lift. V. On 02/28/24 at 9:04 am during an interview with the Maintenance Director, he stated all the Sara lifts came with the leg straps. W. On 02/28/24 at 2:32 pm during an interview with CNA #6, she stated she was a CNA for nine years and trained on lifts while she was employed at another facility. CNA #6 stated she could not remember if she trained on lifts at this facility. Based upon observations and interviews, Immediate Jeopardy was identified on 02/28/24 at 10:52 am. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 02/28/24 at 4:00 pm. Implementation of the POR was onsite on 02/28/24 by conducting observations, record reviews, and staff interviews. Plan of removal: Effective February 28, 2024, Communication via [NAME] (a form of communication) testing to all staff that Sara lift leg straps must be used on all residents during every transfer with the Sara lift. Effective immediately February 28, 2024, all lift transfers, Maxi, [NAME], Sara Steady must be done with two person assist. This will continue until the reassessment of residents using lifts is completed on February 29, 2024. Training for all direct care staff to ensure they use the Sara lift, Maxi Lift, and Sara Steady. The training will include the mandatory use of leg straps when transferring residents. This training will be held February 28, 2024, at 8:15 AM and repeated at 2:00 PM. All residents that are transferred with a lift will be reassessed to determine the most appropriate and safe means of transfer including one or two person transfers. This will be completed by Therapy and/or the Director of Nursing. This will begin today (February 28, 2024) and will be completed on February 29, 2024. Based on observations, record review, and interview the facility failed to prevent an accident by not providing a safe transfer for 1 (R #4) of 4 (R #3, 4, 5 and 6) residents reviewed for falls when the facility failed to: 1. Ensure staff were adequately trained on how to use transfer lifts. 2. Identify number of staff needed for each resident to ensure a safe transfer. 3. Have a method for staff to determine for which residents the leg strap should be used. This deficient practice likely resulted in R #4 falling during transfer and sustaining a new fracture around the hardware in her femur (thigh bone) and a broken pelvis. The findings are: A. Record review of the face sheet for R #4 revealed that she was admitted to the facility on [DATE] and went out to the emergency room (ER) due to a fall on 10/11/23. B. Record review of the physical therapy assessment for R #4, dated 10/10/23, indicated she was at the facility for the following: orthopedic aftercare (recovery from surgery) fracture of unspecified part of neck of left femur (break in the thigh bone), fracture of superior rim of unspecified pubis (pelvis), wedge compression fracture of second lumbar vertebra [collapsed vertebra (the bone that makes the spine.)] C. Record review of the baseline care plan for R #4, completed on 10/11/23, did not indicate if resident required one or two staff for transfers. D. Record review of a progress note for R #4, dated 10/11/23, indicated the following: POC (plan of care) meeting sons here, resident refused to come to POC meeting. Therapy says she is challenging with therapy. She is very deconditioned (loss of physical fitness). She is very weak. Therapy is hoping with scheduled pain medications that will help. She has low activity tolerance, wants to stay in bed. OT (occupational therapy) is looking at reducing frequency to less than 5 days a week. E. Record review of the progress notes, dated 10/11/23, indicated the following: Writer called to patient room at 1655 (4:55 pm) code green (fall), upon initial assessment resident sitting on ground in front of bed, [NAME] [sic] lift (a type of mechanical lift used to transfer from one surface to another) cattycorner to resident. CNA (certified nursing assistant) reports while using lift, the resident's left leg slipped out from in front of her, causing her to slowly slip out of lift. CNA reports she slowly lowered resident to ground. CNA reports sling was in place and correctly buckled onto resident. Resident denies pain at this time. Left leg is showing visible shortening compared to right leg. Left leg is positioned slightly abducted towards the left side. Patient has copious bleeding noted around her leg and bottom. Sx (symptom) wound dressing is over saturated with blood and leaking out onto floor. No skin tears noted at this time. Assisted pt (patient) off the floor x4 (using four staff members) transfer into bed. Once laying supine, left leg was secured away from right leg. Dressing was removed from sx site. Sx site appears to have opened on top portion. Stitches were not present on open area. Site was actively bleeding .Spoke with hospital, resident (R #4) has a broken pelvis and femur and is being flown to Lubbock. F. Record review of the hospital records, dated 10/11/23, indicated R #4 had an acute fracture of the left pubic ramus (a fracture of the pelvis from a high impact trauma, falls, or repetitive strain) and an acute communicated periprosthetic fracture of the midshaft left femur (a broken bone that occurs around implants. It can happen during the surgery, within a few weeks after the procedure, or from a fall or other trauma). G. On 02/22/24 at 3:17 pm, during an interview with the Director of Rehabilitation (DOR), she stated she did not work with R #4 much. She stated R #4 was weight bearing (able to stand without support) as tolerated without restrictions. She required substantial assistance. R #4 did not help with transfers (R #4 would not help staff when they transferred her.) The DOR stated the only way to transfer the resident was with the Sara lift. She stated the resident was not strong enough for the [NAME] steady (non-powered device that assist with sit to stand transfers), a Hoyer lift (a mechanical lift designed to transfer a resident safely) was not appropriate due to her surgery, and she was too heavy for two staff to transfer without a machine. The DOR stated staff transferred the resident with the Sara lift three of four times before she fell. The DOR was not clear how many people were required when using the Sara lift. She stated two people are needed for the Hoyer lift and only one is needed for the Sara Steady (manual sit to transfer aid that enables one caregiver to transfer a patient). H. On 02/22/24 at 4:03 pm, during an interview, the son of R #4 indicated his mother fell and broke her hip and femur at her assisted living home. R #4 had surgery and came to the facility for rehabilitation. The son stated his mother was at the facility for one day when she had a fall and rebroke her femur. He stated she called him and told him she could not do what the staff wanted her to do. He said she was [AGE] years old, just had surgery, and she was tired. He stated he wanted his mom to get better so she could go back to the assisted living home. The son stated his brother walked into their mother's room at the facility on 10/11/24 [right after the fall], and she was on the floor. His brother told him there was a lot of blood. He stated the staff got R #4 back into bed and called 911. When she got to the emergency room, the hospital staff took some x-rays that revealed R #4 re-broke the area that had just been fixed. I. On 02/23/24 at 9:11 am, during an interview with the Director of Nursing (DON), she stated R #4 came in with a partial or full hip replacement. The DON stated a CNA lowered R #4 to the floor during a transfer. The DON stated the resident's leg became twisted. R #4 stated the sling choked her, because it was around her neck. Then R #4 let go of the handles on the Sara lift. The DON stated the staff got the resident back into bed. She said there was an observable discrepancy in her leg length, and her leg was twisted out a little bit. The DON confirmed that during her investigation after the incident, it was determined that the leg strap on the lift was not used during R #4's transfer, and without the leg strap a resident was able to step off the machine. The DON stated the leg strap should have been used. J. On 02/23/24 at approximately 9:30 am, the DON performed a demonstration of the Sara lift (same type of lift involved with the fall) being used with the CNA Coordinator as the resident. The first sling the DON used did not stay tight. The DON tighten it, and it loosened up. She took the sling off and put another sling on. The second sling stayed in place. The CNA Coordinator sat in the sling, and it stayed tight. The Sara lift had the leg strap, and the DON used it during the presentation. The CNA Coordinator wore the sling around his waist and the leg strap around his legs, and the CNA Coordinator did not move during the transfer demonstration. K. On 02/23/24 at 10:15 am during an interview with the Licensed Practical Nurse (LPN) #1, she stated when she entered the room on 10/11/23, R #4 was on the ground with her legs spread apart. LPN #1 said there was a lot of blood, but she could not tell where it was coming from. She said, when the staff tried to lift the resident back into bed, R #4 was not able to assist (help lift herself up). The LPN stated the resident was dead weight and required four staff members to assist her back into bed. L. On 02/23/24 at 2:01 pm, during an interview, CNA #1 stated she was transferring R #4 from the bed to the wheelchair on 10/11/23, and the resident's leg started to contort. She stated she really did not know what happened with R #4's leg. She said the resident's leg just started to move, and the resident did not want to continue with the transfer. CNA #1 realized the resident slipped down, and she was not able to transfer R #4 back to the bed. CNA #1 stated she was not trained to use the Sara lift she used that day (10/11/23). She was trained on a different Sara lift. She stated the one she trained on had two leg straps, one for each leg, and they buckled in place sort of like a seat belt. The CNA stated, on the first day R #4 was at the facility, they transferred her with two staff using the Sara lift, and the resident was fine. The CNA said the next day when she went to transfer R #4, it was just her and there was not a second staff member. She stated she did not ask for a second staff to assist her, because they do not need two staff to use the Sara lift. CNA #1 stated the Sara lift she used to transfer R #4 on 10/11/23 did not have a leg strap so she did not use a leg strap. She stated, during the transfer, R#4 felt like she was choking due to the sling, but the sling was never around the resident's neck. CNA #1 stated she was not sure why R #4 felt like she was choking, because the sling was tight around the resident. The CNA stated the resident may have felt like she was choking when the sling came off over her head and arms. CNA #1 stated that during the transfer, the sling came completely off the resident. M. On 02/27/24 at 2:15 pm, during an interview with CNA #2, she stated she always used two people with any of the lifts, because it was safer. She stated the leg strap was always used as well. She stated the leg strap was attached to the machine so it was never lost. N. On 02/27/24 at 4:36 pm, during an interview with CNA #1, she stated she trained on the lift in Hall 6 that had the two leg straps. She was never told the leg strap had to be used for the specific Sara lift that she used with R #4 on 10/11/23. She also was not aware she needed two people to transfer the resident. She stated the lift she used with R #4 on 10/11/24 only required one person to transfer so she felt like that would be fine. She stated the day prior (10/10/24) there were three staff in the room when she transferred R #4. CNA #1 stated, No one said that she was two-person transfer. Regarding the incident, CNA #1 stated the resident slipped out of the sling. She said she really did not know how that happened, because the sling was tight. O. On 02/27/24 at 4:45 pm, during an interview with the DOR, she stated the lift did not have leg support when she [CNA #1] used it on 10/10/24 with R #4. She stated she thought the leg strap implementation came after the incident with R #4 occurred, but she was not sure. P. On 02/28/24 at 8:48 am during an interview with the CNA Coordinator, he stated everyone who provided direct care was taught on every lift they have in the building. New hires are trained on the lifts during their orientation. The Sara lifts the facility used through out the whole building, except the one on Hall 6 (which had a different type of leg strap), did not require the use of the leg strap to operate the machine. He said it had been optional to use the leg strap. He stated that sometime in April or May 2023, they did a training on the lifts that included putting the resident in the lift correctly and making sure you understand the lift before using it. He stated the DON implemented using the leg strap for all lifts at that time. Prior to this, staff did not use the leg straps on anyone. He stated the use of leg straps could vary. He said the leg straps could be used as needed and based on resident behavior. The CNA Coordinator did not have an answer on how staff would determine if a new resident needed to use the leg strap during a transfer. Q. On 02/28/24 at 2:20 pm, during an interview with CNA #3, she stated they always used the leg attachment. She said if they did not use the leg attachment then a resident would step off of the lift. CNA #3 stated it was a safety issue not to use it. She stated she always used two staff when using any of the lifts, for the protection of the CNA and the resident. R. On 02/28/2 at 2:30 pm, during an interview with CNA #4, she stated she always used the leg straps on the Sara lift. She said the resident had to be positioned correctly for the resident safety. CNA #4 said the resident cannot sit at an angle or lean to the side, and staff had to position the sling right or the resident could slip out of it. CNA #4 stated there was a lot that went into the use of lifts. CNA #4 also stated she used another staff to assist her when she used the lift, because it was safer.