**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure adequate supervision and individualized care planned interventions to prevent/reduce risk of falls and injury. This affected one resident (#27) of three residents reviewed who were at risk for falls. Actual harm occurred on 09/02/24 when Resident #27, who was identified as a high risk for falls, was found on the floor, unable to move her left leg and in severe pain. Resident #27 was sent to the hospital for evaluation and treatment where she was diagnosed with a fractured hip. Prior to the incident, Resident #27's scheduled sitter did not show up and the family nor the contacted company that provided the sitter were notified so arrangements for a replacement could be made. In addition, there was no evidence facility fall interventions were in place at the time of the resident's fall. While unsupervised in her room, Resident #27 got up from a wheelchair and walked out to the corridor where she fell. Findings include: Review of medical record for Resident #27 revealed an admission date of 08/26/24 and a discharge date of 09/02/24. Diagnoses included restlessness and agitation, chronic kidney disease, Alzheimer's disease, and delirium due to known physiological condition. Review of the facility Fall Risk assessment dated [DATE] revealed Resident #27 was disoriented to person, place, and time daily. Resident #27 was bed bound and required use of assistive devices including wheelchair, walker, furniture, and or cane. Resident #27 scored a 17 on the assessment indicating a high risk for falls. Review of the paper initial/interim plan of care dated 08/27/24 revealed Resident #27 was at risk for falls. Interventions included keep call light signal within reach, keep bed in lowest position and locked and ensure proper footwear, non-skid with proper soles. Review of the plan of care located in the electronic medical record dated 08/27/24 revealed Resident #27 was at risk for falls. The care plan did not include any interventions to prevent falls or to protect the resident from injury. Review of a nurse progress note dated 08/26/24 timed 10:40 P.M. revealed Resident #27 did not walk; a walking goal was not clinically indicated. Review of a nurse progress note dated 08/27/24 timed 12:07 A.M. revealed Resident #27 was always disoriented to person, place, and time. Review of a nurse progress note dated 08/28/24 timed 3:08 P.M. revealed Resident #27 had a fall on 08/27/24. The progress note indicated that a fall mat and alarm were in place. The progress note provided no information regarding the time, place or specifics of the fall. Further review of the medical record revealed no evidence of a post fall assessment, monitoring, or a fall investigation related to the 08/27/24 fall. Review of an activity participation progress note dated 08/29/24 timed 2:53 P.M. revealed Resident #27 indicated she was bed bound and could not walk. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/02/24, revealed Resident #27 had impaired cognition. Behaviors identified on the MDS assessment included verbal and physical aggressiveness toward staff. Review of nurse progress note dated 09/02/24 timed 8:30 P.M. revealed Resident #27's son, who was at the facility after a fall requested that staff contact emergency services due to Resident #27's increased pain levels and long wait time for x-rays. Review of the nurse progress note dated 09/02/24 timed 8:45 P.M. revealed emergency services arrived at the facility. There was no information regarding the fall, injury, pain, or assessment of the resident. Review of nurse progress note dated 09/03/24 timed 1:57 A.M. revealed Resident #27 was admitted to the hospital with a left femur fracture. Review of the facility's undated and untimed fall incident report revealed on 09/02/24 Resident #27 was found on the floor in the hallway. Resident #27 complained of severe pain in left hip. Resident #27 was unable to straighten left leg due to severe pain. Predisposing physiological factors included gait imbalance and impaired memory. Resident #27 was ambulating without assistance. The family and physician were notified on 09/02/24 at 7:32 P.M. Interview on 09/29/24 at 8:35 A.M. with Registered Nurse (RN) #103 revealed she was not sure if Resident #27 had any alarms in place during her stay at the facility. RN #103 stated typically residents at risk for falls had bed and chair alarms, staff kept the bed at its lowest level and beds were placed with one side against the wall if possible. Interview on 09/30/24 at 10:52 A.M. with Resident #27's physician revealed she received a call from staff notifying her Resident #27 had a fall. The physician stated that Resident #27 had no rotation in her leg, could put weight on the leg and did not want to go the hospital. Follow up interview on 09/29/24 at 11:15 A.M. with RN #103 revealed she found Resident #27 on the floor in the hallway just outside the resident's room around 7:00 P.M. RN #103 assessed Resident #27 who indicated her left hip was hurting and she could not move the leg. RN #103 stated it took three staff members to transfer Resident #27 from the floor to her wheelchair and then to her bed. RN #103 contacted the physician who ordered x-rays. RN #103 said a sitter the family hired to stay with Resident #27 was not working at the time of the fall. RN #103 did not know why the sitter was not working or why staff did not contact the family to report the scheduled sitter did not show for the assigned shift. RN #103 did not recall an alarm sounding when she found Resident #27 on the floor. RN #103 did not send Resident #27 to the hospital immediately because the physician wanted x-rays prior to sending the resident to the hospital. Resident #27 could not bear weight on the left leg. Resident #27 was sent to the hospital upon the son's request. Interview on 09/30/24 at 12:12 P.M. with the Director of Nursing (DON) and Resident Care Coordinator (RCC) #106 confirmed there were no progress notes regarding Resident #27's falls on 08/27/24 and 09/02/24. They indicated the facility had not completed a fall investigation related to the 08/27/24 fall to determine the root cause which could have potentially prevent another fall. They verified the electronic plan of care dated 08/27/24 indicated Resident #27 was at risk for falls but did not include interventions to prevent falls or protect the resident from injury if a fall occurred. RCC #106 stated Resident #27 had an alarm on her wheelchair and bed and a fall mat next to the bed but verified there was no documentation to support they were implemented. RCC #106 indicated a sitter for Resident #27 had been at the facility (on 09/02/24) and then left. The DON and RCC #106 did not know why the sitter left the facility or why the family was not informed of the sitter leaving. Upon the sitter leaving Resident #27's supervision by facility staff was not increased. Interview on 09/30/14 at 2:25 P.M. with agency State Tested Nurse Assistant (STNA) #107 revealed she worked 2:30 P.M. to 11:00 P.M. on 09/02/24 the day Resident #27 fell. STNA #107 stated Resident #27 had no sitter while STNA #107 was working which was the 2:00 P.M. to 11:00 P.M. shift. STNA #107 stated when the family arrived after being notified of the fall they asked where the sitter was. STNA #107 stated Resident #27 had a bed alarm only, there was no alarm on the wheelchair. STNA #107 explained a sitter for another resident observed Resident #27 stand up from wheelchair and walk into the hallway by herself. Resident #27 was in excruciating pain and screamed out every time staff tried to move her. The physician wrote an order for x-rays which did not happen because of the long wait time. The family requested for staff to send Resident #27 to the hospital. Resident #27 left for the hospital at approximately 8:30 P.M. Interview on 09/30/24 at 3:54 P.M. with Unit Supervisor (US) #108 revealed she was informed of Resident #27's fall at 7:00 P.M. The x-ray technician did not arrive at the facility until after Resident #27 left the facility. Resident #27 left the facility around 8:30 P.M. Interview on 09/30/24 at 4:10 P.M. with the DON revealed Resident #27 should have had an alarm on her wheelchair. Interview on 10/01/24 at 11:23 A.M. with the director of the company responsible for providing sitters for residents at the facility revealed the sitter for Resident #27 flat out lied to the company indicating she/he was at the facility providing services for Resident #27 at the time of the fall. The director stated if the facility would have contacted the company when the sitter did not show the sitter would have been replaced. The director stated it was an unfortunate situation. Review of the facility's visitor/contractor sign in log revealed the sitter assigned to work with Resident #27 did not sign into the facility on [DATE]. Review of the facility Falls Policy, dated 2020 indicated all residents would be assessed for fall risk. Interventions would be incorporated into the plan of care utilizing the Fall Assessment Follow-up Tool as guidance for interventions. This deficiency represents non-compliance investigated under Complaint Number OH00157559.

Based on closed medical record review, staff interview, review of emergency medical services report, review of hospital records, review of facility policy, and review of manufacturer's guidelines, the facility failed to ensure resident safety during a Hoyer lift transfer. Actual harm occurred on 02/21/24 when Resident #30, who was cognitively impaired, at risk for falls and dependent on staff for transfers using a mechanical (Hoyer) lift, fell from the Hoyer lift during a staff assisted transfer resulting in hospitalization with injuries including a right frontal bone fracture extending into superior orbit, bilateral maxillary bone fractures, and bilateral inferior orbital wall fractures with involvement of right nasal lacrimal duct. This affected one resident (#30) of three reviewed for safe transfers. The facility census was 24. Findings include: Review of the closed medical record for Resident #30 revealed an admission date of 02/08/24 and a discharge date of 02/21/24. Diagnoses included vascular Parkinsonism, mild cognitive impairment, vascular dementia, congestive heart failure, and chronic peripheral venous insufficiency. Review of the admission nursing assessment for Resident #30 dated 02/08/24 revealed the resident arrived at the facility by stretcher and was disoriented, confused, and required verbal cues. Resident #30 was on hospice care, had contractures and impaired range of motion to the bilateral lower extremities. Review of the restorative nursing screener for Resident #30 dated 02/08/24 revealed the resident was dependent on staff for transfers to and from a bed to a chair or wheelchair and used a manual wheelchair for mobility. Review of fall risk evaluation for Resident #30 dated 02/09/24 revealed the resident was at risk for falls and was bed bound. Review of the Minimum Data Set (MDS) assessment for Resident #30 dated 02/21/24 revealed the resident was dependent on staff for transfers to and from a bed to a chair or wheelchair. Review of an incident note for Resident #30 dated 02/21/24 timed at 9:46 A.M. revealed the resident was being lifted in a Hoyer lift when he slipped out and landed on his right side. The staff called 911 and the resident was transported to the hospital per emergency medical services (EMS.) Review of a witnessed fall incident report for Resident #30 dated 02/21/24 timed at 9:58 A.M. revealed the resident had fallen out of Hoyer lift during transfer. Resident #30 had observed injuries including an abrasion to top of the scalp, unspecified injury to back of head, skin tear to right antecubital space, and an unspecified injury to right upper arm. Resident #30 was stuporous (responsive only to vigorous stimulation) following the incident. Review of an EMS report for Resident #30 dated 02/21/24 revealed EMS arrived at the facility at 9:14 A.M. and the resident arrived at hospital at 9:32 A.M. Resident #30 was found lying supine on floor of his room, and facility staff reported the resident had fallen out of Hoyer lift while being transferred. The resident had an abrasion with bleeding to the forehead and right forearm and deformity of right upper arm and right elbow. Resident #30 was confused and unable to answer questions or recall what had happened. Review of the health status note for Resident #30 dated 02/21/24 revealed the resident was admitted to hospital. Review of the hospital record for Resident #30 dated 02/21/24 revealed the resident was transported to the hospital after sustaining a fall from a Hoyer lift at the facility in which he was dropped by the facility nursing staff. Upon arrival at the hospital Resident #30 complained of right arm pain and right sided frontal head pain. Resident #30 sustained injuries including the following: right frontal bone fracture extending into superior orbit, bilateral maxillary bone fractures, bilateral inferior orbital wall fractures with involvement of right nasal lacrimal duct, superficial skin tears of right side of the forehead, a large superficial skin tear of the right forearm. Review of the incident statement for Resident #30 dated 02/22/24 per State Tested Nursing Assistant (STNA) #803 revealed she was not the assigned caregiver for Resident #30 on 02/21/24 but she did assist STNA #804 with a transfer. Review of the statement revealed Resident #30 went forward out of Hoyer pad during the transfer, and STNA #803 notified Licensed Practical Nurse (LPN) #802. Review of the incident statement for Resident #30 dated 02/22/24 per STNA #804 revealed she was the assigned caregiver for Resident #30 on 02/21/24. Review of the statement revealed Resident #30 was being lifted into his Broda chair per the Hoyer lift when he fell out. Further review of the statement revealed Resident #30 rolled out of the Hoyer lift and onto the floor because he was contracted, and Resident Care Manager (RCM) #800 and LPN #802 were notified. Interview on 03/06/24 at 10:00 A.M. with LPN #802 confirmed on 02/21/24 STNA #803 notified her Resident #30 had fallen out of the Hoyer lift, and she and RCM #800 found the resident in his room lying on his right side bleeding profusely. Initially, LPN #802 was unable to confirm where the blood was coming from, but after further assessment she determined he was bleeding from his nose. LPN #802 asked RCM #800 to call 911. The resident had bruising on his right arm from shoulder to elbow, bruising on right knee, a skin tear on his right arm, and his right eye was swollen shut. LPN #802 confirmed there were no mechanical issues with the Hoyer lift or the Hoyer pad nor were there any environmental hazards present in the room at the time of the fall. Interview on 03/06/24 at 10:44 A.M. with STNA #803 confirmed on 02/21/24 she had assisted STNA #804 with a Hoyer lift transfer of Resident #30 from his bed to a Broda chair. STNA #803 indicated she was controlling the Hoyer lift and STNA #804 was guiding. STNA #803 indicated when she began to lower Resident #30 down into the chair, he fell forward out of the Hoyer sling, and she was unsure how or why the resident fell forward. STNA #803 confirmed after resident fell, she ran for help while STNA #804 stayed with the resident. STNA #803 confirmed there were no mechanical issues with the Hoyer lift or Hoyer sling nor were there any environmental hazards present in the room at the time of fall. Interview on 03/06/24 at 11:06 A.M. with STNA #804 confirmed on 02/21/24 she requested assistance from STNA #803 to transfer Resident #30 out of bed. STNA #804 confirmed she prepared Resident #30 on the Hoyer pad and brought in the Hoyer lift. STNA #804 confirmed Resident #30 had contractures of his legs and he resembled a ball. STNA #804 confirmed STNA #803 helped her hook up the straps to the Hoyer lift, and she was guiding while STNA #803 was operating the lift. STNA #804 confirmed she was unsure why Resident #30 fell out of the Hoyer sling. STNA #804 confirmed as soon as STNA #803 turned the Hoyer from over the bed Resident #30 fell forward. STNA #804 reported she stayed with Resident #30 while STNA #803 went to get help. STNA #804 confirmed Resident #30 was bleeding after the fall and she supported his head. STNA #804 confirmed there were no mechanical issues with the Hoyer lift or Hoyer sling nor were there any environmental hazards present in the room at the time of fall. Interview on 03/06/24 at 12:22 P.M. with the [NAME] President (VP) of Health Services revealed the facility conducted an investigation regarding Resident #30's fall on 02/21/24. The VP of Health Services indicated the Hoyer lift used for the transfer for Resident #30 was checked (following the incident) with no equipment failure identified. The VP of Health Services revealed the facility was unsure if the size of the Hoyer lift sling was appropriate for the resident, and the facility had concluded the root cause of Resident #30's fall from Hoyer lift was user error. Interview on 03/06/24 at 12:42 P.M. with RCM #800 confirmed LPN #802 called her to Resident #30's room on 02/21/24 because STNA #803 and STNA #804 reported the resident had fallen during a Hoyer lift transfer. RCM #800 indicated she went to call 911 while LPN #802 assessed Resident #30. RCM #800 confirmed Resident #30 had a large bulge on right arm, a laceration to his elbow, and was bleeding from an unknown source. RCM #800 confirmed she waited on floor with Resident #30 until EMS arrived. Interview on 03/06/24 at 2:22 P.M. with the Director of Nursing (DON) confirmed the facility conducted an investigation regarding Resident #30's fall from the Hoyer lift on 02/21/24. The DON confirmed Resident #30 had contractures which caused him to be top heavy while being transported in a Hoyer sling. The DON confirmed she interviewed STNA #803 who confirmed Resident #30 was leaning forward in Hoyer sling during the transfer due to contractures. The DON questioned STNA #804 if she maintained hands on contact with Resident #30 while he was being transferred, and STNA #804 revealed she did not have hands on the resident but stated she was standing by while the resident was lifted in Hoyer lift. Interview with the DON confirmed the root cause of Resident #30's fall from the Hoyer lift was staff failed to recognize Resident #30 was top heavy due to contractures and failed to maintain hands on contact with the resident during the transfer. Review of facility policy titled Hoyer Lift Transfer dated 03/10/14 revealed one staff member should control the lift while the second staff member should oversee the positioning of the resident for safe transfer. When raising a resident, the staff member overseeing positioning must have their hands on the resident. Review of manufacturer's guidelines for the Hoyer lift dated 2011 revealed two assistants were recommended for all lifting, preparation, and transferring of residents. This deficiency represents non-compliance investigated under Complaint Number OH00151335.