Based on record review, policy review, review of staff education, review of facility reported incident, and resident interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell out of a mechanical lift. Failure to safely use the mechanical lift resulted in a fall with injury for Resident #1. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 09/11/24. The facility immediately implemented corrective action and completed corrective action on 09/16/24. Review of the facility policy, Safe Resident Handling Program Overview occurred on 09/17/24. This policy, dated 02/28/24, stated, . Policy: . goal is to maintain a safe living . environment for residents . All caregivers . must receive thorough, documented training prior to conducting mobilization . Care givers will perform a TIME OUT safety stop while the resident is in a sling or harness and still over the surface of the bed or chair to ensure that all straps are secure before moving away from the surface. This is to be competed once the straps are taut, but before the resident leaves a surface. Review of final investigation of the facility reported incident, dated 09/17/24, stated, [name of resident] fell in his room witnessed while being transferred in a total lift by 2 staff. Staff did not loop sling on lower left side and hook to lift appropriately. Assessment completed and nurse noted right knee was swollen and indent noted. Resident was immediately seen by floor nurse post fall and assessment completed. Resident alert and orientated post fall. No concerns of abuse or neglect noted. Staff members that were involved with transfer were immediately interviewed and education provided. Competency completed by registered nurse on 2 staff post incident. Administration reviewed all staff meeting competency and education reviewed at that time. Discussed lift education with those due for annual education. Resident did not have any concerns and did not want to be seen by a provider until his primary was due to round 9/13/2024. On provider visit she discussed getting an Xray and he finally agreed. Preliminary showed fractures of right tibia and fibula. Results of Investigation: Resident was transferred with total lift by 2 staff. One staff member did not loop sling bottom appropriately which resulted in resident falling out of lift. Resident had seen orthopedics and has immobilizer . Final Action Taken: No indication of abuse or neglect. Staff education completed and competency done with 2 staff involved incident immediately. During an interview with Resident #1 on 09/17/24 at 9:00 a.m. regarding the fall from the mechanical lift, the resident stated, it was just an accident, one strap wasn't hooked up right. The resident stated his leg bent behind him, but he didn't have any pain because of his paraplegia. Resident #1 stated he didn't go to the emergency room (ER) right after it happened because there wasn't anything they could do about it anyway. Review of Resident #1's medical record occurred on the morning of 09/17/24. The record identified Resident #1 as cognitively intact and able to make decisions. Review of nursing progress notes identified the following: * 09/11/24 at 12:49 p.m., This nurse was called to residents' room. Resident was on the ground with one strap attached to the Hoyer lift and the left strap was not attached. CNA [certified nursing aide] stated that the strap was not looped into the other strap on the left side. Resident uses a multipurpose sling. Resident was being transferred from his w/c [wheelchair] back into his bed. Resident stated his leg got bent back when he fell to the floor. Residents right knee was slightly swollen and had a small indent on it under the knee. Resident did not bump his head. Resident denied any pain. Resident is a paraplegic. This nurse did ROM [range of motion] on residents left knee. Resident was Hoyer [mechanical lift device] lifted back to bed and vitals were took which were WDL's [within normal limits] for resident. This nurse assessed resident and found no bruising on resident. This nurse had therapy assess residents' knee while back in bed. A note was left for provider and resident will be seen on Friday as resident would like to see [name of provider] PA-C [Physician's Assistant - Certified]. This nurse called residents wife and explained thoroughly everything noted. * 09/12/24 at 3:55 p.m., Fall team met to discuss recent fall, education has been completed including competency with staff present during fall, all staff competency and education reviewed and discussed with those due for annual education. * 09/13/24 at 5:43 p.m., . Resident returned from his x-ray. Resident has 2 fractures in his right knee and was sent to ER. Resident denied surgery and has a splint on his right knee. Resident is suppose [sic] to see ortho in a week but at this time is going to think on it since he is being discharged next week. Resident had no other new orders noted. Residents' wife is aware of all the new orders listed and resident's wife was at ER with resident. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions as follows: * The employees involved in the incident were immediately re-educated on Safe Resident Handling and use of the mechanical lift and slings. * Provider and family notified of the fall and follow up care and treatment provided. * Education provided to all staff members on Safe Resident Handling, including use of various lift devices, types and sizes of slings, and mechanical lift scenarios.

Based on record review, review of the facility reported incident investigation, review of facility policy, personnel record review, and staff interview, the facility failed to immediately start Cardiopulmonary Resuscitation (CPR) on 1 of 4 closed resident records (Resident #1) who requested CPR in the event of absence of pulse or respirations. Failure to immediately start CPR may have contributed to Resident #1's death and placed all residents requiring CPR at risk for death. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) occurred on 11/16/22. This policy, revised 07/21/22, stated, . PURPOSE: To provide each resident the opportunity to make decisions regarding future medical care . Initiation of Cardiopulmonary resuscitation (CPR): 1. If cardiac arrests [sic] occurs, CPR must be initiated unless the resident has: a. A valid DNR [do not resuscitate] order on file . 2. The resident has obvious signs of clinical death (e.g., rigor mortis [stiffening of the joints/muscles of a body a few hours after death], dependent lividity [settling of the blood in the dependent portion of the body postmortem, causing a purplish red discoloration of the skin.] .) 3. The initiation of CPR could cause injury or peril to the rescuer. Review of Resident #1's medical record occurred on 11/16/22. Diagnoses included severe protein-calorie malnutrition, adult failure to thrive, anorexia (eating disorder), interstitial pulmonary disease (group of lung conditions that causes scarring of lung tissue), atherosclerotic heart disease of native coronary artery (hardening of the arteries supplying blood to the heart), COVID-19 (coronavirus disease), and bifascicular block (conduction abnormality of the heart). A physician's order, dated 08/17/22, stated, ND POLST [North Dakota Physician Orders for Life Sustaining Treatment] (A): CPR/Attempt Resuscitation. The progress notes, dated 11/09/22, identified the following: * 9:25 a.m., . Level of consciousness: Alert. Verbal. Responds to stimuli. Orientation: Person. Place. Time. Situation. Other circulatory issues: None. Related System: Respiratory Infection is potentially a result of COVID-19. Resident is in isolation Airborne precautions. Contact isolation precautions. Single room isolation . All services are being rendered in the resident's room. All meals are brought to the room and cares are done in the room. Other Notes: Resident takes off oxygen. * 9:28 a.m., . Continues to have moist cough and oxygen dependent. She refuses to keep the oxygen in place. Remains in isolation. * 12:40 p.m., . Informed daughter that resident had stopped breathing and facility staff started CPR. Facility called 911 and will be transported to [name of hospital]. * 1:27 p.m. [staff failed to note entry as a late entry], . RN [registered nurse] called to room via floor staff. Upon assessment resident was not breathing and no pulse noted, body temp warm, CPR started. 911 called. EMS [emergency medical services] arrived LUCAS [automated chest compression system] in place, Artificial airway placed, Line accessed [sic] placed. Paper work given to EMS. Report called to Emergency department. * 4:30 p.m., . Late Entry: Date and time vital signs ceased: 1228 [12:28 p.m.] . Name/date/time Provider/Coroner pronounced death: Time of death 1319 [1:19 p.m.] [Name of hospital] ED [Emergency Department,] MD [medical doctor] notified via phone 1630 [4:30 p.m.] Date, time and details of family/responsible party notification: 1319 via ED staff . The initial report to the State Survey Agency (SSA) Initial Allegation of Mistreatment, Abuse, Neglect, or Theft and Facility Reported Incidents Reporting Form regarding an incident on 11/09/22 concerning Resident #1 and a nurse (#1) stated, . Briefly describe the alleged incident and/or injury: Registered nurse on duty did not initiate CPR immediately on full code resident. The facility's final report to the SSA stated, . Date and time of the Allegation/Incident: 11/9/22 12:23 [p.m.] 8. Briefly Describe the Alleged Incident and/or Injury: C.N.A. [certified nurse aide] found resident unresponsive and called nurse on duty for assistance. Nurse promptly reported to resident room and staff called for additional support. [Nurse #1] directed staff to obtain crash cart. [Nurse #1] did not initiate CPR immediately. Additional staff were called to room, [Nurse #2] initiated CPR immediately upon arrival. Resident left facility with active CPR in progress with EMS staff. Provider and family updated at time of incident. 9. How do you plan to protect all residents during the time you are investigating this allegation? Immediately post incident all staff involved were interviewed. Education on CPR policy was completed on all licensed nurses. Results of Investigation: Nurse [#1] educated on CPR policy and counseled per administration and human resources. Final Action Taken: Nurse [#1] verbalized understanding of immediately performing CPR per policy indicators. Review of the facility's investigation identified the following timeline of events on 11/09/22 per the unit camera footage: * 12:23 p.m. - [CNA #3] enters room with meal and comes out of room to call for help * 12:24 p.m. - [CNA #4] enters room and [CNA #4] exits room and [CNA #3] waits in doorway * 12:24 p.m. - [Nurse #1] enters room * 12:25 p.m. - [CNA #4] brings crash cart * 12:27 p.m. - [Nurse #1] peaks out of bubble [plastic covering for isolation purposes over Resident #1's room door] and appears to be calling someone for help. * 12:27 p.m. - [Nurse #2] enters the room and initiates CPR * 12:28 p.m. - [Nurse #1] grabs [back] board off crash cart. * 12:29 p.m. - [CNA #3] pushes crash cart into resident room. * 12:31 p.m. - [Administrative staff member #5] take AED into room * 12:36 p.m. - EMS arrives in building [exits building after 11 minutes] The facility's investigation included the following staff interviews completed on 11/09/22: * CNA #3 - . [CNA #3] went to [Resident #1's] room walkied [walkie talkie] for nurse as [Resident #1] was not responsive. [Nurse #1] told [CNA #3] that resident had passed after checking pulse. [Nurse #1] did not give any instructions to [CNA #3]. [CNA #3] called [Nurse #2] for assistance. * CNA #4 - [CNA #3] and [CNA #4] were taking resident food trays to those Covid positive residents when [CNA #3] found [Resident #1] unresponsive. [CNA #3] called [Nurse #1] on the walkie to request assistance. [Nurse #1] came to resident room within two minutes. [Nurse #1] did not start compressions. [Nurse #1] told [CNA #4] to grab crash cart. Compressions were started as soon as [Nurse #2] arrived a few minutes later. * Nurse #1 - [CNA #3] called [Nurse #1] in to [Resident #1's] room. [Nurse #1] responded to request within two minutes. [CNA #3] said she thinks [Resident #1] had died. Before [Nurse #1] went in, asked [CNA #4] to get the [crash] cart. [Nurse #1] knew she was a full code. [Nurse #1] did not start compressions initially. [Nurse #1] called 911 as [Nurse #2] started compressions. [Nurse #2] did compressions, followed by [CNA #3] followed by [Nurse #1]. [Nurse #1] stated her mind froze when it came to doing CPR. * Nurse #2 - Responded to a call to room [Resident #1's room number]. When [Nurse #2] got to room, nurse on duty [Nurse #1] told [Nurse #2] this resident was a full code. [Nurse #2] initiated CPR and instructed [Nurse #1] to call 911. [Nurse #2 was assisted by [CNA #3] and [Nurse #1] with the code. During an interview on 11/16/22 at 9:30 a.m., an administrative nurse (#6) stated Resident #1 tested positive for COVID-19 in the week prior to the incident, and the facility placed the resident and her room in an isolation bubble with plastic sheeting with a zipper opening over her door. Once the nurse (#1) donned personal protective equipment (PPE) and entered the room, she assessed Resident #1 and determined the resident lacked a pulse and respirations and her extremities felt cold. The administrative nurse (#6) stated the nurse (#1) froze and didn't know what to do immediately as she felt the resident had been expired for a while and CPR would be futile. During this time, the nurse (#1) actively sought and called on the walkie for help and the crash cart and activated the EMS protocol. Once the crash cart arrived, the nurse (#1) retrieved the ambu (artificial manual breathing unit) bag and got things ready to start CPR. The administrative nurse (#6) stated when the second nurse (#2) arrived, the nurse (#2) started CPR even though the nurse's (#2) initial assessment and impression was Resident #1 had been deceased for some time. During an interview on 11/16/22 at 11:34 a.m., an administrative staff member (#5) verified the nurse (#1) checked Resident #1's pulse several times between 12:24 and 12:25 p.m. on 11/09/22, retrieved items from the crash cart outside the isolation wall, and called for the second nurse and EMS. Staff removed the barrier wall to take the crash cart inside Resident #1's room. The administrative staff member (#5) stated the second nurse (#2) stated during the investigation that starting CPR two or three minutes earlier would not have changed the outcome as the resident was already gone. She stated the nurse (#1) realized afterwards she should have started CPR immediately. At 1:57 p.m., an administrative staff member (#5) stated the camera time stamp included a second hand and showed the nurse (#1) entered Resident #1's room at 12:24:59 p.m., peaked out of bubble to call for help at 12:27:14, and the other nurse (#2) entered and started CPR at 12:27:48 p.m. Review of personnel records on 11/16/22 identified: * All licensed nurses held current CPR certification, including Nurse #1. * All staff completed annual advance directive education in the past year. * All licensed nurses completed Mock Code Education between May and August 2022. * The administrator, CNAs, medication assistants, and activities assistants completed Response to an Unconscious Person between April and August 2022. * Nurse #1's orientation in 2021 included oxygen and supplies, code status, death & dying process, orientation to crash cart, AED, and how to reach EMS services. Based on the following information, non-compliance at F678 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 Resident #1 during the incident on 11/16/22. * Determining the investigation showed Nurse #1 failed to follow the CPR policy which may have contributed to Resident #1's death. * Providing one-on-one education with Nurse #1 on the CPR policy immediately after the incident. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: * Providing all nurses with face-to-face education on the policy for Advance Directives/CPR following the incident on 11/09/22. * Continuing with evaluation of all code situations and/or conducting mock codes a minimum of twice yearly, a practice started in 2020. The facility provided additional training based on outcomes of the mock and real codes (one mock code and four actual codes in the past 12 months). The survey team determined a deficient practice existed on 11/09/22. The facility implemented corrective action on 11/09/22 and completed nursing education on 11/11/22.