**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on record review, resident and staff interviews, and review of a facility reported incident, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #1) reviewed for an accident with subsequent injury. Failure to follow facility policy for proper use of a stand-lift resulted in injury. Findings include: Review of Resident #1's medical record identified diagnoses of osteoarthritis and abnormalities of gait (walking). The care plan identified, . Self-care deficit with mobility related to decreased mobility, . and other risk factors. Assist of 1 with stand aid lift for all transfers. Record review occurred on 05/21/24. The nurse's notes identified the following: 4/30/24 4:08 p.m. CNA [certified nurse aide] called nurse into resident's room @ [at] 6:30 AM. Showed nurse resident's bruise to right rib area and right breast area. Nurse assessed and measured bruise. Resident was being transferred from chair to bed with stand aid lift when bruise occurred. Resident denied pain @ this time. Assessed and measured resident [bruised area]. 18 cm (L) [centimeters in length] X 26 cm (W) [centimeters in width] dark purple bruise to right rib area and right breast area. Reported to . Nurse Manager . COTA [certified occupational therapy assistant] . checked lift for proper functioning. Machine cleared. Pain assessment completed. Resident denied pain throughout shift. During an interview with Resident #1 on 05/21/24 at 11:00 a.m., the resident stated she has been a resident at the facility for eight years. When asked about the incident that caused the bruises she described, I was all bruised along my chest and down my leg. She [CNA] had that lift backwards. It was so painful, and I told her it was wrong, and I was hurting but she ignored me. The resident explained she had never had that happen to her before or since the episode on 4/28/24. The resident acknowledged the bruises did not show up until a couple of days later and the two nurses that came to check on me were so upset and said, 'what in the world happened here?' So, I told them . During an interview with a staff member (#8) on 05/21/24 at 1:00 p.m., the staff member stated she observed bruises on the resident's chest area while assisting the resident on the morning of 04/30/24. The staff member said she was stunned to see the bruising and wondered what happened. She immediately reported it to the charge nurse. The staff member said the resident often talks about being scared now when being lifted and she had not expressed that fear before. Review of the Facility Reported Incident investigation identified, . It was noted on 4-30-24 during AM [morning] cares that [resident] has a very large bruise to her right breast mid nipple line and down and to the side area that is black /blue in color. Bruised area measures 18 x 26 cm. When [resident] was asked about the bruise, [resident] stated that two evenings ago (04/28/24) she kept telling the new CNA that the lift was hurting her, but the CNA wouldn't listen to her and kept talking over her as she proceeded with the transfer despite [resident's] continued complaints of pain. During an interview on 05/21/24 at 2:45 p.m., two administrative staff members (#1 and #2) confirmed they expected staff to follow the proper procedure for stand lift transfers. The facility failed to ensure staff followed appropriate procedure for a transfer with a sit to stand lift. 2. Based on record review, staff interviews, review of facility policy, and review of a facility reported incident, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #3) reviewed for an accident with subsequent injury. Failure to follow facility policy for proper use of a maxi-lift (mechanical full body lift) resulted in injury. Findings include: Review of the facility policy titled Mechanical Lift - Total Lift occurred on 05/21/24. This policy, revised December 2022, stated, Purpose: A mechanical lift is used appropriately to facilitate transfer of residents. *The mechanical lift is used by nursing staff. *Two persons are needed to use mechanical lift unless indicated by resident's care plan. Procedure: 3. Place lift sling under the resident; position lift over resident. 4. Attach sling clips to lift, making sure they are attached snugly. Review of Resident #3's medical record identified diagnoses of dementia and muscle weakness. The current care plan identified, . Self-care deficit related to osteoarthritis, . and other risk factors. Assist X 2 [two staff people] with maxi lift for all transfers. Record review occurred on 05/21/24. The nurse's notes identified the following: *02/23/24 at 10:32 a.m. CNA's states [sic] while lifting resident in maxi lift didn't realize straps were not properly attached causing resident to fall back and hit her head on the floor causing laceration [cut] 1 cm [centimeter] x 0.1 cm. Assist x 2 to lift resident up off floor back into her wheelchair. Writer and treatment nurse assessed resident's laceration, cleansed with NS [normal saline] applied steri strips [a type of band aid used to hold wound edges together]. Writer called [providers office] spoke to Nurse [name] states to monitor, neuro [neurological] checks every two hours and call if any other concerns. Education given to staff in prevention of future falls, to assure maxi lift sling is properly in place when attempting to lift resident. *2/27/24 11:00 a.m. f/u [follow up] to fall on 2/23/24: 2 CNAs were assisting [resident] to use the commode per maxi lift. Lift sling was properly connected between [resident's] legs, but the top hooks were not connected; neither CNA confirmed correct placement prior to lifting [resident] into the air and as she was being lift [sic], [resident's] body weight shifted her backward on her w/c [wheelchair], causing her to fall back and hit her head on the floor. [Resident] sustained a 1 cm x 0.1 cm laceration to the back of her scalp . During an interview on 05/21/24 at 1:15 p.m., a staff member (#4) stated she thought the other CNA in the room said, I hooked the back clips, but instead she said, you need to hook the back clips. She said they miscommunicated. Review of the Facility Reported Incident investigation identified, . [Resident] was being transferred from her wheelchair with the use of the maxi lift. CNA used the remote on the maxi lift to lift [resident] up in the maxi lift while [other] CNA was elsewhere in the room. Bottom lift sling clips were clipped, but upper lift sling clips were not clipped causing [resident's] wheelchair to tip backward and [resident] to fall backward and hit head on the floor. [resident] sustained a 0.1 x 1 cm laceration to the back of head. During an interview on 5/21/24 at 2:45 PM, two administrative staff members (#1 and #2) confirmed they expected staff to follow the proper procedure for mechanical full body lift transfers. The facility failed to ensure staff followed mechanical lift procedures which resulted in injury. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the corrective action for the resident affected by the deficient practice by: *Completing an investigation with interviews of staff who assisted with the transfer on 02/23/24. *Determining staff failed to follow the Maxi-lift policy and resulted in a resident's fall with injury. *Providing 1 on 1 education immediately after the incident with involved staff regarding proper use of Maxi-lift and sling with return demonstration to the rehabilitation manager. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: *Providing education to all nursing staff on proper mechanical lift transfers on 04/09/24. The survey team determined a deficient practice existed on 02/23/24. The facility implemented corrective action on 02/23/24 and completed nursing education on 04/09/24.