**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, observation, and review of witness statements, facility investigation, mechanical lift policy and fall policy and procedure the facility failed to ensure Resident #27 was safely transferred with a Hoyer (mechanical) lift to prevent a fall with injury and failed to ensure a physician ordered fall intervention was implemented for Resident #48. This affected two residents (#27 and #48) of three residents reviewed for falls. The facility census was 95. Actual Harm occurred on 10/30/23 at 7:45 P.M. when State Tested Nurse Aide (STNA) #520 attempted to transfer Resident #27 without another staff member from her wheelchair to her bed using a Hoyer lift with the Hoyer pad in the incorrect position. This resulted in Resident #27 sliding through the lift pad and falling onto the floor with subsequent transfer to emergency room for evaluation where Resident #27 was diagnosed with a closed non-displaced fracture of her left clavicle and a hematoma to her left ear. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 10/14/21 with diagnoses including heart failure, mild cognitive impairment, muscle weakness and non-displaced fracture of the left clavicle (10/30/23). Review of Resident #27's care plan dated 10/15/21 revealed Resident #27 had a self-care deficit related to heart failure with complications, hypertension, anxiety, depression, insomnia, and malnutrition and needed assist with most activities of daily living. An intervention dated 11/01/22 revealed Resident #27 required a mechanical lift for transfers using a full body sling Hoyer pad. Review of the physician's orders for Resident #27 revealed an order dated 05/16/23 for mechanical lift for transfers and an order dated 11/02/23 to use a full sling Hoyer pad for transfers. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had intact cognition and was dependent on staff for transfers from the chair to the bed. Review of the fall risk assessment dated [DATE] revealed Resident #27 had intermittent confusion and was at high risk for falls. Review of the nursing progress note dated 10/30/23 timed 7:45 P.M. authored by Licensed Practical Nurse (LPN) #560 revealed LPN #560 was called to Resident #27's room by a STNA. The STNA stated Resident #27 had fallen out of the Hoyer pad onto the floor. Resident #27 was assessed, and a new order was obtained to send her to the emergency room for evaluation. There was no mention Resident #27 was being transferred using the Hoyer lift by only one staff member. Review of LPN #560's witness statement dated 10/30/23 revealed STNA #520 reported to her Resident #27 had fallen to the floor from the Hoyer lift. There was no mention Resident #27 was being transferred using the Hoyer lift by only one staff member. Review of LPN #624's witness statement dated 10/30/23 revealed STNA #520 came out to the hallway yelling for LPN #560 because Resident #27 had fallen and was on the floor. LPN #624 indicated Resident #27 was observed on the floor and complained of back and left ear pain. The statement indicated Resident #27 was a Hoyer lift and STNA #520 stated the lift had malfunctioned. There was no mention Resident #27 was being transferred using the Hoyer lift by only one staff member. Review of STNA #520's witness statement dated 10/30/23 revealed STNA #520 had witnessed the incident. STNA #520 indicated he was transferring Resident #27 from the wheelchair to the bed with the Hoyer lift. While transferring, Resident #27 slipped through the Hoyer pad and landed on the floor. STNA #520 indicated the Hoyer straps let loose from the machine. STNA #520 did not mention he was transferring Resident #27 using the Hoyer lift by himself. Review of the fall investigation for the incident which occurred on 10/30/23, signed by the Director of Nursing (DON) dated 11/02/23, revealed Resident #27 was dependent for transfers and mobility. On 10/30/23 during a transfer, Resident #27 was being transferred from her wheelchair to her bed. The green sling (Hoyer pad) was attached to the mechanical lift while in the wheelchair. The back straps and leg straps were crossed between the resident's legs. As Resident #27 was being lifted from her wheelchair toward the bed, the Hoyer pad slid from under her buttocks, and she slipped through the lift pad. Resident #27 landed on the floor on her bottom and rolled to her left side. The resident was assessed, and a new order was obtained to send her to the emergency room for evaluation. At the emergency room, it was noted Resident #27 had a closed non-displaced fracture of her clavicle and a hematoma to her left ear. Upon Resident #27's return to the facility an order was obtained to use a full sling for transferring Resident #27. During the DON's investigation, it was noted if the resident was sitting in the sling and it was placed too high on her, it provided enough room for her to slide through the straps due to Resident #27 having little lower body control. Resident #27's sling was changed to a full body sling and the staff were re-educated on the use and placement of the sling and educated on mechanical lift transfers. The root cause of the incident was that Resident #27 had minimal control of her lower body and her legs lifted up enough for her to slide out of the sling. There was no mention of STNA #520 transferring Resident #27 with the Hoyer lift by himself in the investigation. Review of the hospital emergency department documentation dated 10/30/23 revealed Resident #27 had an x-ray of her left shoulder. The impression indicated suspected non-displaced distal clavicular fracture. Review of the nursing progress note date 10/31/23 timed 12:30 A.M. revealed Resident #27 returned from the emergency room and was noted to have a closed non-displaced fracture of the left clavicle and hematoma to her left ear. Review of STNA #520's employee file revealed a disciplinary action dated 10/31/23 due to a new or ongoing deficiency in his conduct or performance. The notification indicated during transfer it was the facility's policy to have two people present. STNA #520 was suspended for two days. Also, in STNA #520's employee file was his job description signed and dated 08/05/20. Under the section of special skills and requirements it indicated STNA #520 would perform, and complete resident care as outlined on the care needs sheet including lifting residents as determined as a one-person, two-person or Hoyer lift as well as follow safety policies including following proper transfer techniques. Interview on 04/03/24 at 7:58 A.M. with the DON verified STNA #520 had transferred Resident #27 by himself with the Hoyer lift on 10/30/23 when Resident #27 slid out of the Hoyer pad and landed on the floor. Interview on 04/03/24 at 9:30 A.M. with STNA #520 verified he transferred Resident #27 with the Hoyer lift on 10/30/23 by himself. He stated the strap came loose and she slid through the Hoyer pad onto the floor. He stated he had been educated on hire that two staff were required to utilize the Hoyer lift. STNA #520 stated he had been in a hurry to transfer her and did not wait on another staff member because Resident #27 was visibly upset and crying and wanted to go to bed. Interview on 04/03/24 at 10:07 A.M. with STNA #552 revealed staff were trained by the facility on Hoyer lifts on hire. She stated two staff were always required when using the lift. Review of the facility policy titled, Lifting Machine, Using a Portable, revised March 2004, revealed the portable lift could be used by one nursing assistant if the resident could participate in the lifting procedures. If not, two nursing assistants were required to perform the procedure. 2. Review of the medical record for Resident #48 revealed an admission date of 09/20/23. Diagnoses included anxiety disorder, falls, subdural hemorrhage with unknown loss of consciousness, muscle weakness, difficulty walking, need for assistance with personal care, and orthostatic hypotension. Review of the care plan dated 09/21/23 revealed Resident #48 was at risk for falls related to multiple recent falls, decreased balance, mobility, and safety awareness and use of antidepressant and antianxiety medications. Resident had a history of removing and hiding alarms from staff, so they did not sound. Resident #48 had a history of a fall resulting in a subdural hemorrhage. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had impaired cognition, required partial and moderate assistance with sit to stand, chair/bed to chair transfer, and toilet transfer, and had falls. Interventions included Dycem (non-slip mat) above and below wheelchair cushion. Review of the fall risk evaluation dated 03/18/24 revealed Resident #48 was a high fall risk. Review of the physician orders for April 2024 revealed active orders for Dycem above and below wheelchair cushion with a start date of 01/02/24. Observation on 04/02/24 at 8:17 A.M. revealed Resident #48 was sitting in her wheelchair in the hall. Further observation revealed a blue Dycem in Resident #48' room sitting on the nightstand near her bed. Interview on 04/02/24 at 8:23 A.M. with Licensed Practical Nurse (LPN) #572 revealed therapy got Resident #48 a new cushion for her wheelchair. Observation with LPN #572 confirmed the blue Dycem on the nightstand in Resident #48's room. LPN #572 stated she did not know what the blue thing was. Interview on 04/02/24 at 8:26 A.M. with Resident #48 who sitting in her wheelchair in the common area revealed there was not a blue Dycem on her wheelchair cushion. Resident #48 stated the Dycem helped to keep her from sliding and it was her fault the Dycem was not in the cushion because she did not put it on the cushion before transferring to the wheelchair. Resident #48 stated she could not transfer herself into the wheelchair, State Tested Nurse Aide (STNA) #536 helped her into her chair. Interview on 04/02/24 at 8:29 A.M. with STNA #536 revealed she had not been to work in the past three days but knew they were waiting on a larger Dycem for Resident #48. STNA #536 stated Resident #48 received a new cushion for wheelchair and she would check to see if a Dycem was on Resident #48's wheelchair cushion. Observation revealed STNA #536 wheeling Resident #48 to a handrail, locking the wheelchair, and assisting Resident #48 to a standing position as Resident #48 held onto the handrail. There was not a Dycem on the wheelchair cushion. STNA #536 lifted up the wheelchair cushion and there was a blue Dycem under the cushion. STNA #536 verified there was not a Dycem on top of the resident's wheelchair cushion and assisted Resident #48 to sit back down in the wheelchair. Further observation revealed another staff member giving STNA #536 a large blue Dycem. STNA #536 then pushed Resident #48 to her room. Upon entering Resident #48's room, STNA #536 verified the blue Dycem sitting on the nightstand and stated it was a smaller Dycem but it should had been in the resident's wheelchair because Resident #48 slid in forward while in the wheelchair and was a high fall risk. Review of the facility policy titled Falls Policy and Procedure, revised 09/06/19 revealed the facility strived to reduce the risk of falls and injuries by implementing the falls policy and procedure. Residents were assessed for fall risk factors. The interdisciplinary team worked with the resident and family to identify and implement appropriate interventions to prevent falls or injuries while maximizing dignity and independence.