**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, interview with the Medical Director, and record review, the facility failed to safely transfer a dependent resident from bed to wheelchair using a mechanical lift. On 6/13/23 during a transfer by Nurse Aide (NA) #1, the resident (Resident #6) fell out of the lift and onto the floor resulting in a cervical (neck) fracture of the first and second cervical vertebrae. Resident #6 required a cervical collar (used to support the neck and spine and limit head movement after an injury) and no surgical intervention for the injury. This deficient practice affected 1 of 1 resident reviewed for accidents. Findings included: Resident #6 was admitted to the facility on [DATE]. Diagnosis included, in part, Alzheimer's Disease. A physician (MD) order dated 12/16/20 stated a mechanical lift was to be used for transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had no speech and was rarely understood by others. She exhibited impaired memory and her daily decision making skills were severely impaired. She required extensive assistance with the help of two people for transfers. The MDS further indicated Resident #6 was not on an anti-coagulant medication. The care plan, updated 5/26/23, included a focus area of risk for falls. Care plan interventions stated, Review information on past falls and attempt to determine cause of falls, record possible root causes and educate resident/family/caregivers as to causes. The NA Care [NAME], located at the nurse's desk was reviewed and stated Resident #6 required a mechanical lift for transfers and needed two staff members to complete bed mobility and mechanical lift transfers. An Incident Report dated 6/13/23 and completed by the Staff Development Nurse stated the following: At 7:19 AM on 6/13/23 the resident had a fall in her room while she was being transferred from bed to wheelchair from the mechanical lift. NA #1 was present during the incident. The report further stated Resident #6 was transported to the hospital by Emergency Medical Services (EMS) and the MD and family member were notified. Resident #6 returned to the facility on 6/13/23 with a cervical collar. NA #1 was removed from the floor during the investigation and was no longer employed at the facility. An emergency department note dated 6/13/23 stated, in part, Resident #6 presented to the ED with reports of a mechanical fall. Patient is non-verbal, typically bedbound (although gets up in a wheelchair for a few hours each day) and has contracted extremities .Family arrived shortly after patient did and is able to provide some further history that the patient is not on anticoagulants. She confirmed that Resident #6 was at her baseline mental and physical status. The note further indicated a review of systems was limited since Resident #6 had dementia and was non-verbal. An assessment of Resident #6's neck in the ED revealed a cervical collar was in place and the resident winces with midline palpation. A computerized tomography (CT) cervical spine scan was completed on 6/13/23 and revealed a closed nondisplaced fracture of the first and second cervical vertebrae. According to the ED note, there was no acute, life-threatening, or emergently surgical condition identified after evaluation. Resident #6 was sent back to the facility on 6/13/23 with a cervical collar and a recommendation to follow up with her primary care provider within one week. A MD order dated 6/14/23 revealed, Hydrocodone/acetaminophen 7.5 milligrams (mg)/325mg every six hours. The medication was discontinued on 9/6/23. A MD order dated 7/19/23 revealed the cervical collar was to be discontinued. The quarterly MDS assessment dated [DATE] revealed Resident #6 had no speech and was rarely understood by others. She exhibited impaired memory and her daily decision making skills were severely impaired. She required extensive assistance with the help of two people for transfers. A staff assessment of pain indicated the resident did not have any non-verbal indicators of pain. Attempts to interview NA #1 by telephone were unsuccessful. In an interview with NA #2 on 9/21/23 at 11:33 AM, she explained she looked at a resident's paper chart or the CNA [NAME] book for their transfer status or received the information during shift report. NA #2 had worked with Resident #6 in the past and stated her transfer status was a mechanical lift. She further explained two staff were required to operate the mechanical lift and this had always been the protocol for mechanical lift transfers for every resident in the facility. Interviews were conducted with Nurse #1 on 9/20/23 at 9:18 AM and 11:32 AM. She was at the nurse's desk when Resident #6 fell. She recalled NA #1 came out of Resident #6's room and told her the resident fell. Nurse #1 said she went to Resident #6's room, entered and saw the resident on the floor at the foot of the bed. Nurse #1 observed the mechanical lift positioned behind Resident #6's feet. Nurse #1 stated NA #1 told her the resident had fallen from the lift. Nurse #1 reported she immediately assessed Resident #6, obtained vital signs and called 911. She added the resident had not appeared to be in distress during the assessment. She explained information about a resident's transfer status was in the [NAME] book located at the nurse's desk and titled CNA Care [NAME]. Additionally, nurses also told staff what the transfer status was for each resident. She added if a mechanical lift was required for transfers there needed to be two staff who assisted with the transfer. Nurse #1 stated there were other staff members on the hall that day (NAs and nurses) who could have helped NA #1 with the transfer. She revealed Resident #6 returned from the emergency department with a neck collar and an order for pain medication. She said she had not observed Resident #6 with any non-verbal indicators of pain or discomfort following the fall and return from the emergency department. She added Resident #6 had not fidgeted with the cervical collar, and added, at times, Resident #6's family member removed the collar when she visited the resident. Nurse #1 shared the resident's typical routine prior to her fall was to get up in the morning for breakfast (ate in her room) and then was put back to bed after breakfast where she remained the rest of the day. Nurse #1 said she had not observed a disruption in Resident #6's normal routine when she wore the cervical collar. A review of pain assessments from 6/13/23-9/20/23 revealed Resident #6 did not display any non-verbal indicators of pain. During an interview with Occupational Therapist (OT) #1 on 9/20/23 at 9:42 AM, she stated the therapy department determined the safest method of transfer for a resident and made recommendations. She explained Resident #6 was totally dependent on staff for care and was unable to follow directions. OT #1 added the resident had always needed a mechanical lift for transfers since her admission to the facility and said two staff members were required to operate the mechanical lift. On 9/19/23 at 4:23 PM an interview was conducted with the Staff Development Nurse who stated when she came to the facility on 6/13/23 she was told Resident #6 was being sent out to the hospital. The Staff Development Nurse immediately went to the floor where Nurse #1 told her NA #1 used the mechanical lift by herself and dropped Resident #6 on the floor. The Staff Development Nurse said she went down to the resident's room and observed NA #1 behind the mechanical lift. Resident #6 was on the floor and both feet were over the leg of the mechanical lift. She said the resident's head was on the floor and she was on her back. The Staff Development Nurse explained that nursing staff were educated during orientation to use two people to transfer with a mechanical lift and that NA #1 knew there needed to be two staff members when Resident #6 was transferred with the mechanical lift. A joint interview was conducted with the Director of Nursing (DON) and Staff Development Nurse on 9/21/23 at 11:42 AM. The DON shared the facility protocol was whenever a resident needed a mechanical lift for transfers it required two staff members to operate the lift. She added Resident #6 was assessed as needing a mechanical lift for all transfers. She stated no other staff member witnessed Resident #6's fall from the mechanical lift. The DON said she interviewed NA #1 as part of the fall investigation and when she asked NA #1 why she had not used a second person to assist with the mechanical lift, NA #1 told her she had forgot to get a second person. The DON added NA #1 told her she normally did not operate the mechanical lift by herself and had not felt rushed when she provided care to Resident #6. The DON stated there were three other NAs and two nurses who could have helped NA #1 with the transfer that morning. She explained after the fall, all staff members were re-educated that two staff members were required when using a mechanical lift. In an interview with the Medical Director on 9/20/23 at 9:34 AM, he shared Resident #6 had end stage dementia and was non-verbal. She required total assistance with all her care. He stated he was informed by staff that one NA attempted to transfer the resident with a mechanical lift and she fell from the lift and sustained a non-displaced cervical fracture. The Medical Director further stated it was important that two staff members operated a mechanical lift to prevent falls and injuries for both residents and staff members.