**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and Medical Director, family member, and staff interviews, the facility failed to utilize a sit to stand lift per manufacturer's instructions which resulted in the sling slipping up and causing extensive bruising to Resident #399 under the resident's left arm, left side, and across her breast. Resident #399 was prescribed an anticoagulant (blood thinner) daily for atrial fibrillation (irregular and often rapid heart rhythm that can lead to blood clots in the heart). The following day Resident #399 experienced a syncopal episode (temporary loss of consciousness due to a sudden, temporary drop in blood flow to the brain) and when assessed it was noted she had low blood pressure and an irregular pulse. Resident #399 was evaluated in the emergency department and the physician documented the syncope was likely related to dehydration and acute blood loss anemia and was possibly worsened by atrial fibrillation with rapid ventricular rate (RVR). She was hospitalized for six days and required one unit of packed red blood cells (PRBC) due to a low hemoglobin (Hgb) (a protein in red blood cells that carries oxygen from your lungs to the rest of your body). The facility also failed to investigate the cause of the bruising and failed to have the manufacturer's manual for the sit to stand mechanical lift utilized by the facility. This deficient practice was for 1 of 6 residents reviewed for supervision to prevent accidents (Resident #399). The findings included: The manual for the sit to stand mechanical lift the facility utilized during stand strength trailing with Resident #399 was not provided by the facility. Per the manufacture's website, manufactures guidelines for the sit to stand mechanical lift, dated 11/2014, read in part: - Intended to be used on a horizontal surface for raising to a standing position and short transfer of residents in hospitals, nursing homes or other health care facilities where the resident has been clinically assessed to correspond to the following categories: · Sits in a wheelchair. · Is able to partially bear weight on at least one leg. · Has some trunk stability. · Dependent on carer in most situations. · Physically demanding for carer. · Stimulation of remaining abilities is important. - The equipment must be used for its intended purpose only and is operated within the published limitations. -intended to be used with clip slings only -except for the ' Transfer Slings ' which also have loops for attachment of the leg flaps to the central lug situated on the resident support arms. - Warning: Use only the sit to stand designated parts to avoid injuries attributable to the use of inadequate parts. Unauthorized modifications or repairs may affect its safety. Resident #399 was admitted to the facility on [DATE] with diagnoses that included mechanical complications of internal fixation device of bone of left lower leg (a surgical implant, such as a screw, plate, or rod, used to stabilize and maintain the alignment of broken bones during the healing process), physical deconditioning, anemia, atrial fibrillation with rapid ventricular rate (RVR). and obesity. Review of Resident #399's orders for September 2024 revealed the following order: Rivaroxaban (anticoagulant- decreases the clotting ability of the blood), Oral Tablet 20 MG, give 20 mg by mouth in the evening related to atrial fibrillation, give with supper. Resident #399 received daily until 09/24/24. Resident #399's admission Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. She was dependent on staff for all transfers by staff to sit to lying/lying to sitting and weighed 233 pounds. Resident #399 was also coded as receiving an anticoagulant. Resident #399's care plan, dated 07/09/24, included a focus that indicated she had the potential for injury related to mechanical lift use. No interventions were included. Another focus revealed Resident #399 was receiving anticoagulant medication. The interventions included for staff to obtain labs as ordered and report abnormal lab results to the physician, staff to monitor/document/report to physician any signs or symptoms of anticoagulant complications to include bruising, sudden changes in mental status, and significant or sudden changes in vital signs. Review of physical therapy (PT) note dated 09/04/24 at 5:16 PM, written by Physical Therapist #1 revealed she discussed trialing of the sit to stand lift to facilitate weight bearing through bilateral extremities and increase functional tolerance. Family member and Resident #399 agreeable to transfer training with the sit to stand lift. Physical Therapist #1 directed Resident #399 in static sitting at edge of bed (EOB) with maximal assistance initially to facilitate forward trunk lean but supported with bilateral upper extremity support on the sit to stand lift. Resident #399 directed in attempted standing with sit to stand lift times four trials with Resident #399 unable to clear buttocks from EOB due to pain to bilateral knees during each attempt. Review of Physical Therapy (PT) notes for Resident #399 dated 09/05/24, 09/09/24, 09/11/24, 09/12/24, 09/13/24, 09/17/24, and 09/18/24 revealed Physical Therapists #1 utilizing the sit to stand lift for stand strengthening. Review of physical therapy (PT) note dated 09/23/24, written by Physical Therapist #1 revealed Physical Therapist #1 instructed Resident #399 in supine (lying flat on back with face upwards) to sit with moderate assistance x 2 people. Physical Therapist #1 directed in static sitting at edge of bed requiring moderate assistance to correct posterior lean when supported. Physical Therapist #1 instructed Resident #399 to transfer from bed to wheelchair using the sit to stand mechanical lift followed by standing tolerance using the sit to stand mechanical lift and an additional support strap at her buttocks to achieve full upright posture. Resident # 399 tolerated 15 minutes and 17 seconds. An interview was conducted on 04/16/25 at 10:15 AM with the Community Rehabilitation Director. She verified Resident #399 was on the therapy case load for strengthening after a hospitalization for surgical ankle repair. She stated Resident #399 did have lower extremity impairments and her overall strength was diminished due to deconditioning and that the Nursing Assistants (NAs) used the mechanical lift for all transfers. The Community Rehabilitation Director indicated Resident #399 did not want to go to the therapy gym and that the therapist would do her treatments in her room. A follow up interview was conducted on 04/16/25 at 2:17 PM with the Community Rehabilitation Director. She explained residents were normally brought to the therapy gym for stand strengthening using the parallel bars and/or the standing frame. She stated Resident #399 did not want to go to the therapy gym and Physical Therapist #1 thought of using the sit to stand with an additional strap under her buttocks to aid in keeping her in the standing position for stand strengthening. The Community Rehabilitation Director verified there was no written therapy plan for utilizing the sit to stand lift for stand strengthening training for Resident #399. She verified the added strap was not recommended by the manufacturer's guidelines. She indicated Occupational Therapist (OT) #1 assisted Physical Therapist #1 with the treatment. The Community Rehabilitation Director also explained that she was made aware at the beginning of 09/2024 by Physical Therapist #1 that she was going to try utilizing the sit to stand lift for stand strength training on Resident #399, however she could not recall the specific date. She stated she trusted Physical Therapist #1 and supported her decision to use the sit to stand lift with the additional strap for stand strengthening training. The Community Rehabilitation Director indicated she personally would not use the sit to stand lift for stand strengthening, as it was intended to transfer residents, not for strengthening. She explained she was made aware by Physical Therapist #1 of the bruising to Resident #399's breasts, side, and under her arms caused by the sling sliding while Physical Therapist #1 utilized the sit to stand lift on 09/23/24 after Resident #399 was sent to the emergency room on [DATE]. Review of nursing note dated 09/24/24 at 12:44 PM written by Nurse # 2, revealed Resident #399 had an area of bruising noted on her left side, underneath her left arm, and breast area. The bruise was possibly caused by an apparatus used by physical therapy on 09/23/24. The area was examined by the Unit Manager and Nurse Practitioner (NP) #1 was notified. The area was also examined by Occupational Therapist #1. A phone interview was conducted on 04/16/25 at 8:17 PM with Nurse #2. She explained that Resident #399's family member came to her on 09/24/24 and told her Resident #399 was complaining of pain under her arms and on her left side. Nurse #2 stated upon assessment of the areas she noted extensive bruising under residents left arm, left side, and across her breast. The family member told Nurse #2 that staff had used the sit to stand lift for stand strengthening on 09/23/24 and that the sling slipped and that was what caused the extensive bruising. She indicated she immediately reported the bruising to the Clinical Care Coordinator and Nurse Practitioner #1 (NP) who went in to assess Resident #399. NP #1 gave no orders at that time other than to monitor Resident #399. She also stated Resident #399 did not get out of bed often and that her legs were on the bigger side which made it hard for her to use them. After the incident the PT department did not use the lift with her again. Nurse #2 indicated Resident #399 could not stand unassisted at all, and nursing assistants (NAs) used the mechanical lift for all transfers with Resident #399. Nurse #2 did not recall if she completed an incident report. Nurse Practitioner (NP) #1 did not document the assessment and was not available for interview. Review of physical therapy (PT) note dated 09/24/24, written by Physical Therapist #1 revealed Resident #399 with new bruising to left upper flank, possible due to pressure from sit to stand mechanical lift sling. Nursing requested PT to withhold sit to stand treatment training at this time. Resident #399 required maximal assistance to maintain unsupported sitting due to heavy posterior lean. Resident #399 sat on edge of bed less than 2 minutes prior to exhibiting unresponsive episode. Resident was left with OT to monitor while PT immediately notified nursing who came and assessed vital signs. Resident #399 was left with nursing and ultimately ended up getting sent to the emergency room. Attempts to reach Physical Therapist #1 by phone were not successful. Attempts to reach Occupational Therapist #1, who no longer worked at the facility, were not successful. Review of nursing note dated 09/24/24 at 9:35, written by Nurse #6 revealed Resident #399 had a syncopal episode while working with PT. Nurse Practitioner#1 and Unit Manager assessed resident at bedside. Stated blood pressure was soft, and pulse was elevated and irregular. Emergency medical services were called. Resident #399 was gray and had fine tremors noted while on stretcher. Attempts to reach Nurse #6 by phone were not successful. Record review revealed vital signs, dated 09/24/24 at 3:30 PM (time of syncope episode) was blood pressure 90/50, blood sugar 285, pulse irregular, and respirations 16. An interview was conducted on 04/17/25 at 8:35 AM with the Unit Manager. She stated she worked Monday through Friday, and no one had reported an incident on 09/23/24 related to the sit to stand lift and the sling sliding up on Resident #399. She was made aware of the bruising on 09/24/24 by Nurse #2 and upon observation of the area she noted very extensive bruising to Resident #399's left side, under her arms, and her breast. She did not fill out an incident report because Physical Therapist #1 indicated the incident with the sling slipping occurred with Physical Therapist #1, and she assumed they had reported it to the Director of Nursing. The Unit Manager verified she did assist Nurse Practitioner #1 with assessing Resident #399 when her blood pressure dropped after sitting up on the side of the bed with PT, and she passed out. She stated NP #1 gave the order to send Resident #399 to the emergency room for evaluation. She indicated Nursing Assistants (NAs) used the mechanical lift for all transfers with Resident #399. A phone interview was conducted on 04/15/25 at 11:42 AM with Resident #399's family member. He explained on 09/23/24 he observed staff utilizing the sit to stand lift to aid with stand strengthening with Resident #399, after 15 minutes of being in a semi standing position, the sling around her slipped up, and she complained that the sling was hurting her under her arms. He indicated the sling was wrapped around Resident #399's torso and it had 2 buckles that were fastened in the front under her breasts. The sling hooks were connected to the lift at the handles where the slots were located. The additional strap was hooked in the same area as the sling connections, and it went across her buttocks, there was a pillow between her buttocks and the strap. Resident #399 was then lowered back down to her bed. He stated when he arrived at the facility on 09/24/24 Resident #399 was complaining of pain under her arms and to her breast areas. The family member explained he looked at the areas and observed extensive bruising under her arms, her left side, and her breasts. He then stated he notified Nurse #2 to make her aware. He stated he took pictures of Resident #399 in the sit to stand lift, she had a pillow under her buttocks and the additional strap on top of the pillow. He also had pictures of the extensive bruising to her breasts, under her arms, and down her side. The family member provided copies of the pictures he had taken which were reviewed by this surveyor. Review of hospital Discharge summary dated [DATE] revealed Resident #399 was brought to the emergency department on 09/24/24 after suffering a syncopal episode. At the time her blood pressure was 91/50. In the emergency department she was found to be tachycardic (high pulse) with heart rates 118-143 beats a minute. Resident #399's hospital course description included syncope was likely related to dehydration and acute blood loss anemia and possible worsened by atrial fibrillation with rapid ventricular rate (RVR). Extensive bruising/bleeding into the skin under left arm-acute blood loss anemia. Due to use of anticoagulant as well as lift at facility which appears to secure under the arms-holding anticoagulant for now. On 09/24/24 Resident #399's hemoglobin (Hgb) was 10.6 (normal range of Hgb 12.0-16.0), 09/25/24 Hgb 8.7, and on 09/26/24 Resident #399's Hgb dropped to 7.0 and required a blood transfusion of 1 unit of packed red blood cells (PRBC). Resident #399's Hgb was 8.2 on 9/27/24. It was noted Resident #399's Hgb was trending upward at the time of discharge and to continue to hold anticoagulant for now and recheck hemoglobin in 3-5 days. Permanent atrial fibrillation with acute RVR likely driven by volume depletion/acute blood loss and diagnoses with urinary tract infection. Disposition: Discharge back to skilled nursing facility (SNF) for rehabilitation stay. Hospital discharge orders included restarting previous medications with the following exceptions. Furosemide 20 milligram (mg) by mouth daily-start on 10/01/24 (note dosage change), rivaroxaban (anticoagulant) 20 mg by mouth daily with supper (start taking on 10/07/24), and recheck Hgb in 3-5 days. Review of Medical Director note dated 10/03/24 revealed Resident #399 was sent to the emergency room on [DATE] and discharged to our facility on 09/30/24 due to a syncopal episode (a temporary loss of consciousness, also known as fainting). Resident #399 was noted to have extensive bruising/bleeding into the skin under left arm, right arm with blood loss anemia. Resident #399 was transfused 1 unit of packed red blood cells (RBC), and her anticoagulant was held. During physical examination Resident #399 was awake and oriented, did not look in any distress. Vital signs: temperature 97.6, blood pressure 120/72, heart rate 70, respiratory rate 18, and saturation 96% on room air. Lungs clear, no wheeze or rales, abdomen soft, nontender, extremities with no pedal edema and neurologically no focal neurological sign. An interview was conducted on 04/17/25 at 8:45 AM with the Director of Nursing (DON). She verified therapy was using the sit to stand mechanical lift with Resident #399 for stand strengthening. She stated that Physical Therapist #1 was the only therapist that used the sit to stand lift for stand strengthening and Resident #399 was the only resident that received stand strengthening with the sit to stand mechanical lift. The DON explained that she was unaware of this prior to 09/24/24 and was informed the day Resident #399 was sent to the emergency room. She explained after Resident #399's transfer to the hospital, she was asking the nursing staff why Resident #399 was being sent out to the hospital. Physical Therapist #1 told her (DON) she utilized the sit to stand mechanical lift with an additional strap positioned under Resident #399's buttocks for stand strengthening on 09/23/24 and the sling strap slid up some causing her to lower Resident #399 back down to the bed. Physical Therapist #1 told the DON she was unaware that the sling caused any trauma until the husband brought it to the staff's attention on 09/24/24. The DON indicated it wasn't until the next day that a family member reported to nurse#2 that the resident had pain and bruising under her arms and side. The DON verified the added strap was not recommended by the manufacture's manual guidelines. Nursing Assistants (NAs) used the mechanical lift for all transfers with Resident #399. An interview was conducted on 04/17/25 at 8:45 AM with the Director of Nursing (DON). She stated she was made aware of the bruising to Resident #399's torso that was caused by the sling sliding after Resident #399 was sent to the emergency room on [DATE]. The DON indicated an incident report, and an investigation should have been completed. The DON provided a manufacturer's manual for a sit to stand mechanical lift utilized by the facility, the manual provided was the incorrect manual for the specific sit to stand mechanical lift that was utilized with Resident #399. An interview was conducted on 04/17/25 at 11:25 AM with the Medical Director. He stated he was not aware that therapy was utilizing the sit to stand lift for stand strengthening and he had never heard of anyone doing that. He indicated according to the hospital records Resident #399 had an episode of syncope after therapy had sat her up on the side of the bed and her blood pressure dropped. He explained that bruising could cause acute bleeding, dropping the hemoglobin (Hgb), if the bruising was bad enough, however, he did not think this was the case with Resident #399. He further explained that Resident #399's blood pressure ran on the lower side, and he believed when Psychical Therapist #1 sat her up on the side of the bed she had a period of orthostatic hypotension (a sudden drop in blood pressure when you sit up after lying down) which caused her to black out. The Medical Director then stated Resident #399's Hgb dropped because of the blood draws she was getting during the hospital stay.