**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and Responsible Party, staff, and Medical Doctor interviews, the facility failed to safely transfer a resident from the bed to the chair when one staff member used a mechanical lift resulting in the resident falling to the floor for 1 of 6 sampled residents reviewed for accidents (Resident #30). On 05/17/23, while being transferred one of the clasps attaching the sling to the mechanical lift malfunctioned resulting in Resident #30 falling out of the sling onto the floor. Upon initial nurse assessment, Resident #30 complained of no pain and had no obvious injuries but later that same day he complained of hip pain, was sent out to the hospital for evaluation, x-rays obtained revealed no hip fracture and he returned to the facility on [DATE]. On 05/22/23 additional x-rays were obtained due to complaints of neck pain that revealed Resident #30 had sustained a C7 (one of the cervical vertebrae that support the head and connect it to the shoulders and body) and T1 (vertebrae that make up the spine and located in the upper part of the back) fracture. Findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses that included progressive neurological conditions (refers to a progressive deterioration in function that can be gradual over time or rapid), Parkinson's disease, and dementia with Lewy Bodies. The annual Minimum Data Set (MDS) dated [DATE] assessed Resident #30 with moderate impairment in cognition and had impairment on both sides of the upper and lower extremities. Resident #30 required substantial/maximal staff assistance for bed mobility (roll left and right) and total staff assistance with transfers. An Activity of Daily Living (ADL) care plan, last revised 05/18/23, revealed Resident #30 had an ADL self-care performance deficit related to Lewy Body dementia, fatigue, impaired balance, limited mobility, and Parkinson's disease. Included was an intervention initiated on 08/09/22 that noted Resident #30 required a mechanical lift with a sling and two-person assistance for all transfers. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #30 with moderate impairment in cognition. Resident #30 had impairment on both sides of the upper and lower extremities and was totally dependent on staff for self-care and mobility. During a telephone interview on 01/25/24 at 10:13 AM, Resident #30's Responsible Party (RP) revealed on 05/17/23 Resident #30 was dropped from the mechanical lift during a transfer due to a malfunction of the machine. The RP stated she learned of the incident when she arrived at the facility on 05/17/23 around lunchtime and recalled Resident #30 was in pain and that afternoon he was sent out to the hospital for evaluation. The RP stated he was first sent to the county hospital and was informed the x-rays obtained revealed a hip fracture. Resident #30 was then transferred to another hospital where the x-ray results were reviewed again and this time she was informed there was no hip fracture, and he returned back to the facility. The RP recalled two days later, Resident #30 was sent back out to the hospital for evaluation due to complaints of neck pain, a Computed Tomography (abbreviated as CT and defined as a scan that uses x-rays to create pictures) was done that showed a spinal fracture and he was placed in a neck collar. The RP stated Resident #30 was later evaluated by the Neurosurgeon who recommended surgery but Resident #30 refused. The RP stated the neck collar Resident #30 was given at the hospital was uncomfortable for him and the Neurosurgeon ordered him a new one but even then, she as well the facility staff had a hard time getting him to wear it. The RP stated Resident #30's fractures just took time to heal and he did not suffer a decline from his baseline as a result. The RP stated she understood accidents happened, the staff involved in the incident were no longer employed at the facility and she felt the facility was taking good care of Resident #30. During a telephone interview on 01/26/24 at 2:22 PM, Nurse Aide (NA) #6 confirmed she attempted to transfer Resident #30 using a mechanical lift without additional staff assistance on 05/17/23 and he had fallen to the floor during the transfer. NA #6 recalled Resident #30 asked to get up in his recliner, which he did from time-to-time, and she asked the other NA working with her on the hall to assist with the transfer because they had been instructed to always have 2-person assist when using the mechanical lift. NA #6 stated the other NA was busy and she had waited for her as long as she could but Resident #30 was getting anxious so she made the decision to go ahead and transfer him by herself. NA #6 explained after she had gotten Resident #30 positioned in the sling, she made sure the sling straps were all positioned correctly and the clasps locked in place and then proceeded with the transfer. She recalled his bed was already in a high position so she didn't have to lift him any higher and used the lift to move him horizontally off the bed. He was suspended approximately 2 to 3 feet from the floor and as she moved the lift toward his chair, she held on to the sling with one hand. When she let go of the sling to push the feet open on the mechanical lift so that it would go around the chair, Resident #30 fell out of the sling onto his back on the floor. NA #6 stated she told Resident #30 not to move and she immediately informed Nurse #5 who came to the room to assess Resident #30. NA #6 stated the only thing she could figure happened prior to transferring Resident #30 was when she connected the sling clasps to the mechanical lift all but one made a 'click' sound when the top of the clasp was locked into place. NA #6 restated she was instructed to always have 2-person assist when using the mechanical lift and she made the wrong decision to go ahead and transfer Resident #30 without waiting for help. A nurse progress note dated 05/17/23 at 1:00 PM and written by Nurse #5 revealed in part, called to Resident #30's room by staff. Upon entering the room, Resident #30 was observed on the floor in front the bed with the lift sling underneath him. NA #6 stated she was transferring Resident #30 to the chair with the mechanical lift when his weight shifted and the sling came out of the hook. Upon assessment, no obvious injuries were observed, Resident #30 denied pain and stated he was fine. The Medical Doctor (MD) and family were notified of Resident #30's fall. Resident #30 was secured back into the sling and placed back into bed by staff. When securing the sling to the mechanical lift, three of the hooks were noted to be snapping into place but the fourth one did not snap. The mechanical lift was taken to maintenance for repair and the hook was replaced. The Administrator and Director of Nursing (DON) were also made aware of Resident #30's fall, lift issue and replacement of hook. A second nurse progress note dated 05/17/23 at 4:10 PM and written by Nurse #5 revealed Resident #30 was sent to the hospital for evaluation due to a fall via Emergency Medical Services (EMS) transport. During a telephone interview on 01/26/24 at 9:01 AM, Nurse #5 revealed she was no longer employed at the facility and confirmed she was Resident #30's assigned nurse on 05/17/23 when she notified by the NA (could not recall her name) that Resident #30 had fallen during a transfer. When she asked the NA what had happened, the NA told her Resident #30 was on the mechanical lift when one of the clasps for the sling malfunctioned and he fell to the floor. The NA also stated she knew she shouldn't have but she had tried to transfer Resident #30 independently using the mechanical lift. Nurse #5 seemed to recall when she arrived at the room, Resident #30 was lying on his right side on the floor and he wasn't complaining of any pain. She did a full body assessment which included checking Resident #30's hips, completed a neuro assessment and there were no signs of any obvious injuries identified. She and the NA assisted Resident #30 back up into bed, she checked him thoroughly again and he voiced no complaints of pain or displayed any non-verbal indicators such as moaning or grimacing. Nurse #5 was not sure how Resident #30 fell out of the sling and stated she seemed to recall the NA had showed her how one of the sling clasps wouldn't snap closed properly. Nurse #5 immediately notified the Administrator and DON of the incident and they came to Resident #30's room to assess the situation, had maintenance inspect the lift, and pretty much took things over from there. Nurse #5 stated later that afternoon (05/17/23), the Administrator and DON made the decision to send Resident #30 out to the hospital for evaluation, even though he still was not complaining of any pain, just for precautionary measures. Nurse #5 could not recall what time Resident #30 returned from the hospital but stated a few days after his fall, he was sent back to the hospital for a full CT scan because he had started to complain of pain in his neck and being sore all over. She didn't remember what the x-rays revealed but he had returned wearing a neck collar. Nurse #5 stated prior to the fall on 05/17/23, Resident #30 required total staff assistance with ADL and when he returned to the facility after his second hospital evaluation, he was pretty much at his normal baseline. Nurse #5 stated she never noticed any change in his physical or mental condition as a result of the fall. He rarely complained of pain other than soreness in his neck and did not like wearing the neck collar because it was uncomfortable. During a telephone interview on 01/26/24 at 3:44 PM, the Director of Nursing (DON) stated on 05/17/23 she was informed by a staff member, could not recall whom, that Resident #30 had fallen during a transfer. The DON immediately informed the Administrator and they both went to Resident #30's room to assess the situation. By the time they arrived at the room, Resident #30 had already been placed back into bed. The DON stated she had maintenance inspect the mechanical lift and it did have a faulty sling clasp that was immediately replaced. The DON stated upon initial assessment following the fall Resident #30 was ok but then he started complaining of a headache, was given Tylenol and monitored. She explained anytime you asked him how he was feeling he stated he was ok but just for precautions, she and the Administrator decided to send him out to the hospital for evaluation. The DON stated when she talked with NA #6 on 05/17/23 about what had happened she seemed to recall NA #6 stating she had asked another NA to help assist her with transferring Resident #30 and they had told her they would but if would be a little bit before they could assist and then for whatever reason, she chose not to wait. The DON stated NA #6 was immediately suspended and her contract with the staffing agency was terminated. The DON stated it was an unfortunate, isolated event and while she did not feel NA #6 had any malicious intent when she attempted to transfer Resident #30 independently, NA #6 made the bad decision not to follow facility protocol. The DON stated she started immediate re-education of nursing staff on 05/17/23 regarding mechanical lift transfers with an emphasis on always having 2-person assist when using a mechanical lift. During telephone interviews on 01/25/24 at 11:47 AM and 01/26/24 at 3:06 PM, the Administrator confirmed he was notified of the incident involving Resident #30 and immediately went with the DON to Resident #30's room to assess. He stated the DON took NA #6 out in the hall to discuss what happened while he stayed in the room to talk with Resident #30. The Administrator stated although Resident #30 wasn't complaining of any pain at the time of the fall, he and the DON decided to go ahead and send Resident #30 out to the hospital for an evaluation just as a precaution. The Administrator stated the hospital initially thought he had a hip fracture but then determined he did not and Resident #30 returned to the facility. A few days later, Resident #30 started complaining of a headache and was sent back to the hospital for CT scan which revealed spinal fractures. The Administrator stated it was facility protocol for staff to always have 2-person assist for mechanical lift transfers and felt it was neglectful on NA #6's part because she attempted to transfer Resident #30 without additional staff assistance. NA #6 was immediately suspended due to her not following facility protocol and her contract with the staffing agency was terminated. The Administrator stated he felt the incident involving Resident #30 was an isolated event, they implemented an internal plan of correction and put measures in place that included audits and monitoring with no further concerns identified. As part of the monitoring process, the Administrator stated he visited with Resident #30 daily to ask him if he was having any pain and Resident #30 had no complaints nor did he decline from his baseline as a result of the injury he sustained from the fall. A Hospital Discharge summary dated [DATE] for Resident #30 read in part, was reported he was being transferred at the skilled nursing facility using a mechanical lift when it broke and Resident #30 landed on his hip. Reports of hip pain. Original x-ray was read as negative and CT scan of the hip was ordered which was read as equivocal (result could not be interpreted as positive or negative) and correlate clinically. CT scan showed no visible fracture of proximal right femur (hip) or right pelvis, there was reported posterior angulation of the intertrochanteric (point where the muscles of the thigh and hip attach) right femur as well as advanced osteoarthropathy (disease of the joints or bones) of the right hip. Pelvic and right hip x-rays were read as negative for fracture by Radiology. Resident #30 was evaluated today with his relative at bedside and is reporting no pain. His baseline is bed-bound and usually does not ambulate. He was discharged in stable medical condition back to the skilled nursing facility. A nurse progress note written on 05/19/23 at 6:54 AM revealed in part, Resident #30 was complaining of discomfort to the right hip and lumbar region. The MD was contacted and pain medication requested. Review of Resident #30's May 2023 Medication Administration Record (MAR) revealed a physician's order dated 05/19/23 for Tylenol 325 milligrams (mg) two tablets every 6 hours as needed for pain. Resident #30 received doses on 05/19/23 at 7:35 AM, 1:08 PM with a pain level of 05/10 (numerical pain rating scale with 10 being the worst level of pain), and 8:25 PM with a pain level of 05/10; 05/20/23 at 8:15 PM with a pain level 08/10; 05/21/23 at 11:46 PM with a pain level 07/10; and 05/22/23 at 7:59 AM with a pain level 05/10. All doses administered were noted to be effective. A nurse progress note written on 05/21/23 at 11:06 AM revealed in part, Resident #30 was displaying pain to the left upper back, neck and shoulder which made it hard for him to turn. The nurse contacted the hospital to have the x-rays sent to the skilled nursing facility and was informed x-rays were only taken on the lower body, none were completed of the shoulder or back. The MD was notified and orders were obtained for x-rays of the neck, back and rib area. A nurse progress note written on 05/21/23 at 6:38 PM revealed in part, the mobile X-ray Tech arrived at the facility to take Resident #30's x-rays and was unable to obtain views. The MD was notified and orders received to send Resident #30 for outpatient x-rays. A message was left with outpatient radiology for an appointment. A nurse progress note written on 05/22/23 at 8:35 AM revealed in part, x-ray orders were clarified and the MD will fax the order to outpatient radiology for the appointment to be scheduled. A nurse progress note written on 05/22/23 at 10:10 AM written by Nurse #5 revealed in part, outpatient radiology confirmed receipt of the faxed physician's order for x-rays and an appointment was made for 2:00 PM. RP was notified. Resident #30 received Tylenol this morning per physician order and reported good results. A Hospital Discharge summary dated [DATE] for Resident #30 read in part, fell from a mechanical lift 3 days ago and was evaluated here with complaints of hip pain on the right side. Imaging studies were equivocal and hip fracture was suspected and he was transferred to another hospital for further evaluation by orthopedics. Hip fracture was not confirmed and he was sent back to the skilled nursing facility that day. Since then, he has complained of posterior neck and bilateral posterior shoulder pain. He is bed-bound with dementia, Parkinson's disease and rheumatoid arthritis. Because of ongoing complaints of pain, the patient was sent by the skilled nursing facility for CT scans of the cervical spine, chest, abdomen and pelvis today. The Radiologist read the study showing acute fractures at C7 and T1. Case discussed with the Neurosurgeon who recommends placement of a cervical collar. He expects these injuries to heal completely without surgical intervention. Resident #30 returned to the skilled nursing facility on 05/22/23. During an interview on 01/26/24 at 1:13 PM, the facility's Maintenance Director revealed on 05/17/23 he was called down to Resident #30's room after the incident to inspect the mechanical lift. He checked the hydraulics, hooks and all the components to make sure everything was working properly. He stated the mechanical lifts had four hooks which he described as U-shaped with a safety clasp across the top to ensure the sling straps stayed in place when attached to the lift. Upon inspecting the mechanical lift used to transfer Resident #30, he discovered the safety clasp on one of the lift hooks had malfunctioned, it had either collapsed or broke completely, which was how the sling strap came loose from the hook on the mechanical lift. The Maintenance Director explained when a person was suspended in the sling, the weight of the person caused the string straps to pull down and tighten but when the mechanical lift was lowered, the sling straps loosen and rise up and when functioning properly, the safety clasps prevented the sling straps from coming out of the top of the hook. The Maintenance Director stated either he or the Maintenance Assistant checked the mechanical lifts daily and when the lifts were inspected on 05/17/23 the hooks all appeared fine. He stated he kept a supply of replacement hooks in stock and the hook on the lift used to transfer Resident #30 was immediately replaced. During a telephone interview on 01/26/24 at 4:03 PM, the Medical Director (MD) stated he recalled being informed Resident #30 had a fall from a mechanical lift but did not remember all the exact details of the incident. The MD stated prior to his fall on 05/17/23 Resident #30 required total staff assistance with ADL. The MD stated he would expect there be some sort of decline for anyone who fell from a mechanical lift but did not recall anyone mentioning Resident #30 experiencing increased pain or further decline from his normal baseline as a result of the fall. The facility provided the following Corrective Action Plan with a completion date of 05/29/23: On 05/17/23, Resident #30 was lowered to the floor by a Nurse Aide during a transfer using a Hoyer lift. The Nurse Aide reported Resident #30's weight shifted and the sling came out of the clip that holds the sling in place. Resident #30 did not initially complain of pain but did later in the shift. The physician was notified of the incident by the Charge Nurse on 05/17/23 and received an order for Resident #30 to be evaluated in the emergency room (ER) due to the new complaints of pain. Resident #30 was evaluated at the hospital on [DATE] and returned to the facility on [DATE]. On 05/22/23, additional x-rays were completed on an outpatient basis and revealed a C7/T1 fracture. He had a referral to see a neurosurgeon and is to wear a neck collar until released by the neurosurgeon. Resident #30 was seen on 06/08/23 by Spine and Neurosurgery. Resident #30 remains at the facility and has pain medication ordered with effective results noted. Maintenance replaced the clip on the lift on 05/17/23 that was used by Resident #30. The Nurse Aide was working under a contract with an agency and her contract was terminated on 05/18/23. The Nurse Aide had completed competency training on mechanical lifts on 03/07/23 that was competed by a Registered Nurse. All residents that are transferred with a mechanical lift have the potential to be affected by the same practice. The clips had been checked by the maintenance assistant at the beginning of the shift on 05/17/23. The clips on the other mechanical lifts were checked again on 05/17/23 by the Maintenance Assistant and no issues were found upon visual inspection after the incident. The Medical Records/Central Supply Clerk performed a visual inspection of the slings and all slings were in good condition on 05/17/23. The Director of Nursing initiated staff education on 05/17/23 on mechanical lifts with the staff on duty. Education was continued by a Registered Nurse with additional nursing staff on the proper use of mechanical lifts by 05/18/23. Nursing staff members not present during the initial training had education completed on the first day back to work. Education with the nursing staff was completed by 05/29/23. Mechanical lift education was added to new employee orientation by the Human Resources Director on 05/18/23. A visual cue (laminated sign) was added to the mechanical lifts as a reminder to staff that two staff members must be present to use the mechanical lift. Written reminders were posed in different areas of the building stating that two staff members are required to use mechanical lifts. The visual cue and written reminders were added to the mechanical lift by the Director of Nursing on 05/18/23. The Maintenance Director and/or Maintenance Assistant will perform a visual inspection of the mechanical lifts, focusing on the clips, daily for two weeks, then three times a week, then reducing to weekly. Maintenance will repair/replace any issues noted on the inspection or will remove the lift from use if necessary. The inspections were initiated by the maintenance department on 05/18/23. The Director of Nursing, Assistant Director of Nursing or other Registered Nurse will perform mechanical lift transfer audit weekly for a minimum of 4 weeks then monthly until the QAPI committee changes the frequency of the audits. The assigned Registered Nurse will review at least 4 transfers per week for the audit. The mechanical lift audits will be documented on the mechanical lift audit form and will review that the sign is present on the lift and that two Nurse Aides are using the lift during the transfers properly. Re-education and/or return demonstration will be completed as needed based on the transfer observations. Any deficient practice will have corrective action taken at the time of discovery by the Registered Nurse. The mechanical lift audits were initiated on 05/26/23 by the Director of Nursing and will continue until substantial compliance has been achieved as deemed by the QAPI committee. The facility held an ad-hoc QAPI meeting on 05/29/23 with the Medical Director in attendance by phone. The topic of the meeting was a review of the mechanical lift issue and further development of the performance improvement plan. The Director of Nursing reviewed the results of the audits with the QAPI committed on July 31, 2023 when the facility held the quarterly meeting. No trends, patterns or issues were identified during the audits. The audit will continue at a minimum of monthly per recommendation of the committee. Date of compliance: 05/29/23 The Corrective Action plan was validated on 01/26/24 and concluded the facility had implemented an acceptable corrective action plan on 05/29/23. Interviews with nursing staff, including agency staff, revealed the facility had provided education and training on use of mechanical lift transfers that included requiring two-person assistance for all transfers, proper positioning in the sling and checking the security of the sling hooks and clasps to the mechanical lift. Staff interviewed all verbalized they were observed performing a mechanical lift transfer after receiving reeducation. Review of the monitoring tools of mechanical lift transfers that began on 05/26/23 and continued weekly through 09/26/23 were completed as outlined in the corrective action plan with no concerns identified. Review of the mechanical lift inspection audits 05/18/23 through 01/24/24 revealed inspections were completed daily and any issues identified were immediately repaired.

Based on record review and staff interviews the facility failed to meet the staff vaccination requirement when the Director of Housekeeping and Laundry, Laundry Aide #1, and Dietary Aide #1 worked without being fully vaccinated and without an exemption. The facility also failed to implement an effective process for tracking COVID-19 Vaccination Status for 3 of 3 facility staff. The facility went into outbreak status during survey on 07/13/22 when two facility staff and one contract staff and three residents (Residents #46, 45, and 36) tested positive for COVID-19 on 07/13/22. The findings included: The facility's *COVID-19 Vaccine* policy with no reviewed date, read in part: It is the policy that all persons be offered the COVID-19 vaccine. This facility will ensure that all eligible employees are fully vaccinated against COVID-19, unless received religious or medical exemptions. Staff includes all fulltime, part-time, as needed employees, and contract staff. The facility COVID- 19 staffs vaccination spreadsheet 92provided by the Administrator on 07/12/22 was reviewed and included in-house staff and contract staff. Director of Housekeeping and Laundry, Dietary Aide #1 and Laundry Aide #1 who were all listed as facility staff were listed as partially vaccinated and had only received one dose of a two-dose vaccine. A review of on 05/13/22 of the National Healthcare Safety Network (NHSN) data for the week ending 06/26/22 revealed the following staff and resident vaccination information: Recent Percentage of Staff who are Fully Vaccinated = 81.8% Recent Percentage of Resident's who are Fully Vaccinated = 92.2% Review of medical records and facility vaccination documents revealed Resident #46 and Resident #36 were not vaccinated and tested positive for COVID-19 on 07/13/22. Resident #45 was partially vaccinated and tested positive for COVID-19 on 07/13/22. An interview was conducted with Director of Housekeeping and Laundry on 07/13/22 at 2:15 PM revealed she had received the first shot of the COVID-19 vaccine in November 2021 and was planning to receive the second shot of the vaccine. She stated each time she planned to go and receive the second shot something would come up at home or at work and she was not able to go. She revealed she was planning to go within the next week and receive the second shot of the vaccine. The Director of Housekeeping and Laundry was observed wearing an N95 mask and stated because she is not fully vaccinated, she always wears an N95 mask in the facility and is tested bi-weekly. An interview was conducted with Laundry Aide #1 on 07/13/22 at 2:17 PM revealed she had received the first shot of the COVID-19 vaccine in March 2022 and was then diagnosed with Rheumatoid Arthritis. She stated she was going to discuss receiving the second shot with her physician at her next appointment. Laundry Aide #1 was observed wearing an N95 mask and stated she wears an N95 mask while in the facility and is tested bi-weekly. Dietary Aide #1 was not available for interview. An interview was conducted with the Administrator on 07/13/22 at 11:02 AM revealed Dietary Aide #1 received her first does of the vaccine in December 2021 and had not received second dose of vaccine due to her cerebral palsy diagnosis. She stated Dietary Aide #1 was supposed to discuss a medical exemption with her physician. A telephone interview was conducted with Infection Preventionist (IP) on 07/13/22 at 1:13 PM revealed she was responsible for COVID-19 testing, tracking staff and resident vaccinations, weekly NHSN reporting, and updating tracking reports weekly. She also revealed she reports staff vaccination status to the Administrator and Human Resources. She stated she was aware of the three staff members not being fully vaccinated. The IP stated she realized the seriousness of the tracking of the vaccination status of the employees and indicated she had reminded the three staff not fully vaccinated weekly they needed to receive their second vaccine. She also stated she reported to the Administrator and Human Resources multiple times of the three staff not being fully vaccinated and needing to receive their second vaccine. She further indicated the three staff members not fully vaccinated had not requested exemptions. She stated the facility has held initial vaccine and first booster clinics for staff and residents and will be scheduling a second booster clinic for staff and residents as soon as vaccine arrives. An interview was conducted with Director of Nursing (DON) on 07/15/22 at 1:30 PM revealed IP handled all of staff vaccination. The DON stated staff that were not fully vaccinated were required to wear an N95 mask. She revealed she was not aware staff were employed at facility and worked who were not fully vaccinated and had no exemption. She stated staff should follow vaccination policy and be vaccinated or wear an N95 mask if not vaccinated. An interview was conducted with Administrator on 07/15/22 at 2:04 PM revealed according to staff vaccination policy, staff should be fully vaccinated or have an approved exemption. She stated she was aware of staff not having received their 2nd doses of vaccine. She also stated she had reached out to staff who had not received their second doses of vaccine and discussed with IP about those staff receiving their second dose of vaccine and or an exemption. The Administrator revealed all staff should be vaccinated according to policy and the facility should have followed up more closely to make sure the policy was being followed.