**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the recertification survey from 05/05/2021 to 05/11/2021, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. Specifically, the staff did not properly position the Hoyer Lift (mechanical lift) canvas (pad) underneath a resident in preparation for a Hoyer lift transfer. The staff attempted to transfer the resident from the Geri chair (medical recliner) to the bed using the Hoyer lift, and the resident slid off the canvas and fell to the floor. The resident sustained a scalp laceration requiring a staple to the head. This was evident in 1 of 7 residents reviewed for Accidents (Resident #356). This resulted in actual harm that is not immediate jeopardy. The finding is: The facility policy and procedure titled, Lifting and Transferring of Residents (Dated 06/2013) documented the following: All nursing staff (nurses and nursing assistants) are responsible for knowing the proper procedures when operating assistive devices. The Mechanical Lift Skill Competency attached documented that positioning the canvas seat (pad) under the resident, so that the lower edge of the seat is slightly below the knees and the upper edge behind the shoulders is checked during the competency. Resident #356 was readmitted on [DATE] with diagnoses which include Non-Alzheimer's dementia, muscle weakness, and hypertension. The Quarterly Minimum Data Set 3.0 (MDS) assessment, dated 01/12/2021, documented the resident had severely impaired cognition, and the resident required the total assist of two persons for transfer. The resident had bilateral upper and lower extremity range of motion (ROM) impairment, and the resident did not have any falls during the review period. The Comprehensive Care Plan (CCP) titled, The resident has Activities of Daily Living (ADL) Self-Care Performance Deficit related to Activity Intolerance, Cognitive Impairment, Dementia and present medical condition, effective 03/25/2020, documented the resident was totally dependent on staff and required a Hoyer/ Mechanical lift with the assist of two persons for transfers. The CCP titled, Resident is at risk for falls/injury related to Activity level limitation, Cognitive Impairment, effective 03/25/2020, included interventions to follow the facility fall protocol and monitor/anticipate/intervene for factors causing potential/prior falls. The Physician's orders, effective date 03/25/2020, documented orders for the resident to be transferred out of bed to the Geri chair via mechanical Hoyer lift with assist of two persons. The Physician's orders, effective date 03/26/2020, documented the resident was on fall precautions. The monthly maintenance log dated 12/10/2020 documented that the Hoyer lift was inspected and was found to be in good condition and function. The Certified Nursing Assistant (CNA) [NAME] and resident care instructions, dated 01/01/2021, documented the Resident #356 was on fall safety precautions and required the total assist of two persons using a Hoyer lift during transfers. The Accident and Incident (A/I) report dated 01/20/2021 documented the following: The resident fell to the floor when being transferred from the Geri chair to bed and sustained bleeding with back of head swelling. The physician was informed of the accident, and the resident was transferred to the hospital. The preliminary finding of the facility investigation documented during the transfer, the strap from the pad slipped out of place resulting in the fall. Staff was provided with education, in-service and completed return demonstration. An addendum was made after an inspection of the Hoyer lift was completed on 01/22/2021. The Hoyer lift was found to be functioning well. The investigation finding written by the Director of Nursing (DON) documented it was possible that the resident was not positioned exactly at the center of the pad, and the unevenness may have caused the resident to slide off the Hoyer pad and fall to the floor. Nursing Note (NN) completed by a Registered Nurse (RN #1) dated 01/20/2021 documented the following. The Resident #356 fell on the floor and resulted in some bleeding and swelling on the back of the head. The physician and family member were notified of incident and resident was transferred to the hospital. NN completed by the RN Supervisor (RN #2) dated 01/20/2021 documented the following. The Resident #356 had a fall from the Hoyer lift during a transfer from the Geri chair to the bed. When the RN and CNA were moving the resident from the Hoyer lift in mid-air, Resident #356 accidently fell hitting their head on the metal base of the lift. Resident #356 was found with bleeding and swelling on the back of the head. Ice was applied on the back of their head. The physician was notified and ordered Resident #356 to be transferred to the hospital. The Physician's Order dated 1/20/2021 documented instructions to transfer the resident to the hospital for evaluation. The CCP titled, The resident has had an actual fall related to Activity level limitation, Cognitive Impairment, Osteoporosis, Effective 03/25/2020 and revised 01/20/2021, documented the resident had a fall and sustained bleeding and swelling on the back of the head. On 1/20/21, the intervention to anticipate and meet the resident's needs was added. The hospital summary of medical treatment dated 01/21/2021 documented the resident received an x-ray of the chest and pelvis and a Computed Tomography (CT) of the head and spine which all showed no fracture or other traumatic injury. The resident was treated for a small posterior scalp laceration that was repaired with one staple. A NN completed by a RN dated 01/21/2021 documented the following. The resident returned from the hospital with a small posterior scalp laceration repaired with one staple. Treatment with Bacitracin was recommended. Physician orders dated 01/21/2021 documented resident was prescribed with the following treatment. Clean wound with DermaKlenz, apply Bacitracin, cover with dry protective dressing (DPD) to back of head laceration as needed and every night for wound care for 14 days. Order was discontinued on 02/22/2021. The Director of Maintenance statement dated 01/22/2021 documented the following. The Hoyer lift was inspected by both the maintenance department and Scale USA (lift company). The machine was found to be in good working order. The monthly maintenance log dated 01/22/2021 documented the Hoyer lift was inspected and was found to be in good condition and function. Physician orders dated 01/28/2021 documented orders for the staple to be removed from the back of the resident's head. The Medication and Treatment Administration Records dated January 2021 and February 2021 documented the resident received treatment to the head laceration as ordered. On 05/06/2021 at 10:42 AM, the resident's designated representative was interviewed. The family member stated that the resident had a fall maybe about a month ago in their room. During a transfer from the bed to the wheelchair, the resident slipped out of the lift and fell on the floor hitting their head on a table. The resident was sent to the hospital for observation, and they were okay. The family member stated the facility had provided notification and updates right after the incident occurred and notification on resident's return from the hospital. The family member believed that the resident slipped and fell due to the way the staff lifted the resident, but they were not sure. The Registered Nurse (RN #1) was interviewed on 05/10/2021 at 04:23 PM and 05/11/2021 at 02:30 PM. RN #1 stated CNA #1 asked for assistance with transferring the resident from the Geri chair to bed using the Hoyer lift. The proper way to transfer a resident is to make sure the pad is positioned correctly underneath the resident, by the neck and legs. The straps are hooked to the machine. The RN stated the resident was on the Geri chair at first, and the Hoyer lift pad was already under the resident. RN #1 stated that the pad was under the resident's shoulder area instead of the neck area. Then both RN #1 and CNA #1 hooked the straps onto the machine. As the resident was being lifted, the resident slipped backwards, hitting their head at the edge of the machine. The RN supervisor was contacted right away. RN #1 stated that the padding was not positioned correctly on the resident prior to transfer. RN #1 received an in-service afterwards on how to properly use the Hoyer lift which includes padding placement, checking the straps, and leg positioning. During a follow up interview, the next day, RN #1 stated the padding was not fully underneath the resident during the transfer which resulted in the resident falling. On 05/10/2021 at 04:35 PM, RN #2 was interviewed. Upon notification of the incident, Resident #356 was assessed and found to have bleeding and swelling in the back of the head. The resident was sent to the hospital and had a CT scan which revealed no fractures. The RN #2 further stated that the Hoyer lift padding was not positioned correctly under the resident resulting in the resident falling out. On 05/11/2021 at 11:07 AM, CNA #1 who was involved in the incident was attempted to be interviewed. As per administrative staff, CNA #1 resigned, and the contact number provided was no longer active. On 05/11/2021 at 11:35 AM, the Assistant Director of Nursing (ADON) was interviewed. Resident #356 fell from the Hoyer lift during a transfer from the chair to the bed. RN #1 assisted CNA #1 with transferring Resident #356. The ADON and RN Supervisor assessed the resident, provided first aid, and the resident was transferred to the hospital. They asked the involved staff to do a return demonstration following the incident, and the staff did it correctly by showing how the resident was transferred. At that moment, they concluded that maybe it was a strap malfunction. However, upon completion of investigation, the DON further concluded that equipment malfunction was ruled out and an addendum to the investigation was made that the incident occurred was not due to the pad or machine. It was proposed that the cause of fall was improper positioning of the Resident on the canvas. Resident #356 was not positioned in the center of the pad. On 05/11/2021 at 12:20 PM, the Director of Nursing (DON) was interviewed. The DON was unfamiliar with incident since it occurred before employment at the facility. On 05/11/2021 at 12:42 PM, the Administrator was interviewed. The Administrator was not present during the time of incident since it occurred before employment at facility. 415.12(h)(1)