**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record review, review of Joerns Hoyer user instruction manual and Invacare patient slings operator's manual, review of the facility's Self-Reported Incident (SRI) and investigation including witness statements, review of the emergency medical services (EMS) report, review of hospital documentation, review of the facility policies on transfer, mechanical lifts, and the mechanical lift checklist, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. This resulted in Immediate Jeopardy when Resident #15 experienced serious life-threatening injuries during an avoidable fall from a mechanical lift when the lift pad was incorrectly placed on the Hoyer lift and only one-person assisted in the transfer, resulting in a head injury, and severe fractures of the left lower leg which subsequently required an above the knee amputation of the left lower leg. This affected one (Resident #15) of three residents reviewed for utilization of a mechanical lift for transfers and placed an additional 14 current residents (#101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, and #114), identified by the facility as requiring the use of a mechanical lift for transfers, at risk for potential serious injuries and/or negative health outcomes as the facility was utilizing Invacare slings for the two Joerns Hoyer lifts for the 14 current residents. The facility census was 69. On 01/09/24 at 10:02 A.M., the Administrator and Chief Executive Officer (CEO) #200 were notified Immediate Jeopardy began on 12/25/23 at 10:40 A.M., when Nursing Assistant (NA) #20 transferred Resident #15 from her bed to the wheelchair using a mechanical lift without another staff member present. NA #20 utilized the wrong color-coded sling loops and positioned them incorrectly on the Hoyer lift, resulting in Resident #15 sliding out of the Hoyer lift while it was suspended five feet in the air and her head hitting the ground first and her left leg getting tangled up in the lift. The facility policy and Resident #15's plan of care required two staff members to be present when completing a mechanical lift transfer. Resident #15 was sent to a trauma level one hospital via EMS where she was diagnosed with comminuted fracture (a bone that is broken into more than two pieces) of the proximal left tibia, open fracture (a broken bone that causes an open wound in the skin) of left fibula, hemorrhagic shock requiring a blood transfusion, head contusion and multiple hematomas throughout the body. Surgical treatment of the left leg resulted in an above the knee amputation due to the severity of the traumatic wound and catastrophic fractures sustained to both the left tibia and fibula. On 01/08/24, interviews and observations revealed the facility was utilizing Invacare slings for the two Joerns Hoyer lifts for 14 current residents. Invacare manufacturer instructions state not to intermix slings and lifts of different manufacturers for the safety of the patient. The Immediate Jeopardy was removed on 01/12/24 when the facility implemented the following corrective actions: • On 12/25/23 at 11:25 A.M., Resident #15 was transferred to the hospital and did not return to the facility. • On 12/25/23 at 11:35 A.M., the Director of Nursing (DON) suspended NA #20 pending investigation. • On 12/25/23 at 11:35 A.M., the DON removed the Hoyer lift used in Resident #15's transfer (Hoyer LPL700 serial number 1000021257) and sling from service pending investigation. • On 12/25/23 at 11:50 A.M., the DON, Unit Manager (UM) #431, Registered Nurse (RN) #430, and Therapy Director (TD) #440 completed education to State Tested Nurse Aides (STNAs), licensed nursing, and therapy staff on utilizing two staff to transfer a resident using a Hoyer lift, checking the sling, and checking the Hoyer lift to ensure it was properly functioning prior to use. On 12/28/23 at 1:30 P.M., all active STNAs, licensed nursing and therapy staff had completed the education. • On 12/26/23, a Quality Assurance Performance Improvement (QAPI) meeting was held with the interdisciplinary team (IDT) which included Quality Assurance (QA) Nurse #202, CEO #200, TD #440, Maintenance Director #512, UM #518, and the DON to discuss the incident involving Resident #15 with the improper Hoyer transfer. Medical Director #500 was updated by telephone. • On 12/27/23, the DON, TD #440, and UM #518 began audits to ensure proper use of Hoyer lifts. The audits included observing nurses, STNAs, and therapy staff on proper use of lifts and slings. • On 12/29/23, NA #20's employment was terminated. • On 12/29/23, Outside Engineer Provider #500 inspected all Hoyer lifts, and they were found to be functioning. The Hoyer lift (Hoyer LPL700 serial number 1000021257) used in Resident #15's transfer on 12/25/23 was returned to service. • On 01/08/24, observations and interviews revealed the facility was utilizing Invacare slings for the two Joerns Hoyer lifts for 14 current residents. Invacare manufacturer instructions state not to intermix slings and lifts of different manufacturers for the safety of the patient. • On 01/09/24, the IDT met to discuss the plan for the day to limit any use of Hoyer lifts with the current slings until the new lifts and slings arrived that day (01/09/24). All residents' needs will be met at bedside including care, meals, activities, etc., as able. • On 01/09/24, CEO #200 ordered and received nine [NAME] Chairs from Medical Equipment Supplier #600. [NAME] Chairs allow transfer of residents from bed to chair safely without a lift. Medical Equipment Supplier #600 will provide five Hoyer lifts with corresponding slings on 01/09/24. • On 01/09/24, another QAPI meeting was held to discuss the further findings of the investigation into Resident #15's unsafe transfer. • On 01/09/24, the DON, QA Nurse #202, and TD #440 reviewed the manuals for the new chairs, mechanical lifts, and slings. They evaluated the 14 residents for the proper sling for each resident. The resident's plan of care and STNA report sheets were updated with the proper sling for each resident. Education began with nursing staff on the proper operation of the equipment. All nursing and therapy staff will be educated by 01/12/24. • On 01/10/24, the DON/designee will conduct random audits to observe staff utilizing the chairs, Hoyer lift, and slings properly. The audits will begin on 01/10/24 and three staff will be observed weekly for three weeks, monthly for three months and randomly thereafter. • On 01/10/24 at 3:15 P.M., observation of a Hoyer lift transfer with the facility's new Hoyer lift revealed the Hoyer lift legs buckled inward during Resident #112's transfer. Resident #112 did not sustain any injury because of the legs buckling inward during the transfer and the resident was safely transferred to bed. The facility immediately removed the Hoyer lift from service. All residents that were mechanical lifts were transferred using the [NAME] chairs without issues. At 4:00 P.M., maintenance staff tightened the nuts and bolts and checked the wires of the Hoyer lift to ensure nothing was loose. • On 01/10/24 and 01/11/24, interviews with STNAs #411, #318, #428, and #436 and Licensed Practical Nurse (LPN) #623 verified they received in-service training on mechanical lift transfers and had no concerns. • On 01/11/24, the DON, QA Nurse #202, UM #431, Administrator, and CEO #200 reviewed slings and mechanical lift manuals, watched sling and lift video tutorials and completed multiple transfers using the Hoyer lift among staff members to ensure the Hoyer lift and sling was functioning properly prior to putting back into service. On 01/11/24 at 1:30 P.M., the Hoyer lift was put back into service for residents. • On 01/11/24, two current residents requiring a mechanical lift for transfers were observed during the transfer process. Resident #114 was observed at 2:00 P.M. and Resident #108 was observed at 2:30 P.M. Both residents were transferred with a mechanical lift device with two staff members present, utilizing the proper lift pads that were new, in good condition, labeled with their respective names and unique identification numbers for the lift pad. There were no identified problems observed during the mechanical lift transfers. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #15's closed medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiparesis, left non-dominant side, systolic congestive heart failure, type two diabetes mellitus, contracture of left elbow, and lymphedema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had cognitive impairment. She required total dependence on staff for chair to bed transfers. Review of the plan of care dated 12/02/22 revealed Resident #15 had the potential for self-care deficits related to weakness, inability to care for self, left upper extremity contracture and limited mobility. Interventions included monitoring and assistance as needed with Activities of Daily Living (ADL), and transfer with use of mechanical lift with two staff personnel. Review of Resident #15's nursing progress notes dated 12/25/23 at 11:50 A.M. revealed LPN #240 was called into Resident #15's room by NA #20. Upon entry into the room, Resident #15 was on the floor with her left leg caught in the lift. There was blood seeping through her jeans. There was also blood from the lump on the back of her head. LPN #240 called for assistance from other staff. LPN #240 stayed with Resident #15 and applied pressure to her head while NA #20 applied pressure to the laceration on her left leg. On 12/25/23 at 12:22 P.M., RN #356 was summoned to Resident #15's room by staff. Resident #15 was lying in a prone position under the Hoyer lift. There was bleeding from the left leg and the back of the head. The left lower leg appeared to be externally rotated and a large wound noted under the left knee and fatty tissue was exposed. Cold pressure dressing applied until EMS arrived. EMS dispatcher arrived, and Resident #15 was going to be life flighted from [NAME] Park in [NAME] Liberty due to the appearance of the wound. Review of the facility's SRI dated 12/25/23 revealed on 12/25/23 at 10:40 A.M., NA #20 attempted to transfer Resident #15 with a Hoyer lift by herself, contrary to the facility policy. During the transfer of Resident #15 with the Hoyer lift, Resident #15 slipped out of the sling onto the floor. LPN #240 entered Resident #15's room and then initiated evaluation and emergency treatment for observed injuries. EMS responded and transported Resident #15 to the hospital. NA #20 was suspended. The Hoyer lift and sling involved in the incident were removed from service until they could be evaluated. Local police were informed of the incident. Review of NA #20's written statement dated 12/25/23 revealed NA #20 went to get Resident #15 changed and ready for lunch. NA #20 decided to get Resident #15 up using the Hoyer lift by herself and didn't think about asking for help. NA #20 stated she was stressed out all morning. NA #20 turned the lift to put Resident #15 into the chair and Resident #15 slid out onto floor. NA #20 stated I do know better; thought I could handle it by myself. Review of the EMS report dated 12/25/23 at 11:09 A.M. revealed EMS was on scene with Resident #15 for a call to address a fall with a laceration to the leg. EMS was advised that Resident #15 dropped from approximately five feet in the air and struck her head during the fall. A full trauma assessment was performed with finding of a small laceration to the back of the head with bleeding stopped, altered mental status, pain in the middle to lower back, and pain and deformity to the lower left leg with the laceration. Care provided to Resident #15 included left leg trauma dressing and vacuum splint, cervical collar, vital signs, and transport to life flight helicopter. Review of Resident #15's hospital records from 12/25/23, revealed Resident #15 required life flight transport to a level one trauma hospital. During the multiple physician assessments, and imaging required while at the trauma center, Resident #15 was found to have multiple traumas including a comminuted fracture of the proximal left tibia, open fracture of left fibula, hemorrhagic shock requiring a blood transfusion, head contusion and multiple hematomas throughout the body. Resident #15 required an intensive care hospital unit with intubation, intravenous pain control, intravenous antibiotics, intravenous hydration, and surgical intervention for the left leg fractures. Surgical treatment of the left leg resulted in an above the knee amputation due to the severity of the traumatic wound and catastrophic fractures sustained to both the left tibia and fibula. Review of NA #20's telephone interview statement dated 12/26/23 at 10:30 A.M. revealed NA #20 reported she thought she used the wrong color-coded sling loops which incorrectly positioned Resident #15 in the sling causing Resident #15 to slide out of the body sling. Resident #15 hit headfirst on the floor and landed on her buttocks and back. LPN #240 entered Resident #15's room to bring in medications to Resident #15. LPN #240 told STNA #318, who had entered the room, to obtain assistance. EMS asked where she had fallen from, and she told EMS she had fallen from five feet. EMS decided to life flight Resident #15. Review of RN #356's telephone interview statement dated 12/26/23 at 11:30 A.M., revealed RN #356 walked into Resident #15's room after requests for assistance, and found Resident #15 on the floor with LPN #240 holding pressure on the back of Resident #15's head. There was a small amount of blood on her head, and when RN #356 looked down toward her legs there was a pool of blood under her leg. RN #356 attempted to cut the pant leg with a small pair of bandage scissors without success but managed to rip the pant leg far enough to see a very large deep wound. RN #356 requested STNA #318 to obtain a wet compress and directed her to apply pressure and then went and called emergency 9-1-1 (EMS). EMS arrived and asked NA #20 where Resident #15 fell from. NA #20 told EMS the Hoyer lift's height had not been moved, and EMS responded that was five feet in the air and indicated the need for life flight for a trauma hospital. Review of LPN #240's telephone interview statement dated 12/27/23, revealed LPN #240 entered Resident #15's room after NA #20 had opened the door stating Resident #15 had fallen. LPN #240 found Resident #15 on the floor on her back, requested STNA #318 to get another nurse's assistance. RN #356 arrived and requested STNA #318 apply pressure to Resident #15's leg, and RN #356 went to make phone calls. EMS arrived and questioned about the height of the Hoyer lift and noted the Hoyer was really high and EMS decided to life flight Resident #15 to a trauma center. Review of STNA #318's telephone interview statement dated 12/28/23 revealed NA #20 opened the door of Resident #15's room and stated Resident #15 was on the floor. LPN #240 requested assistance, STNA #318 obtained RN #356 and returned to Resident #15's room. RN #356 was trying to find where all the blood was coming from and was told to apply pressure. STNA #318 observed Resident #15's chair was at the other side of the room and the Hoyer with the body sling attached. STNA #318 observed the color-coded straps of the body sling with the longer straps at the resident's head and the shortest straps at the feet, which would cause the feet to be higher than the head of the patient when lifted. An observation of the use of a mechanical lift of Resident #105 on 01/08/24 at 10:10 A.M. with the DON, STNAs #318 and #411 revealed a Joerns Hoyer lift was used to lift the body sling with Resident #105 from the bed into a wheelchair. Interview with the DON, during the observation, revealed a medium size Invacare body sling was used for the transfer. Interview on 01/08/24 at 11:20 A.M. with Quality Assurance Coordinator #202 verified the facility had only Invacare slings utilized for Hoyer transfers currently. Interview on 01/08/24 at 2:05 P.M. with CEO #200 verified the facility only used two Joerns Hoyer's for mechanical lifts of residents currently. CEO #200 verified the facility concluded the investigation into Resident #15's fall from the Hoyer was a result of NA #20 transferring Resident #15 without staff assistance and NA #20 applied the body sling loops inappropriately to the Hoyer lift causing Resident #15 to slide during the transfer. CEO #200 verified it was the facility's policy and in Resident #15's plan of care to provide two persons for transfers with the Hoyer lift. Interview on 01/08/24 with RN #365 verified the sequence of events on 12/25/23 involving Resident #15, indicating Resident #15 fell from about five feet because of the extended height of the Hoyer lift when she came into the room to assist Resident #15. Interview on 01/08/24 with LPN #240 stated upon entering Resident #15's room, Resident #15 was lying on the floor on her back with blood coming from Resident #15's head. Resident #15 was under the Hoyer lift, with the body sling still attached to Hoyer. NA #20 explained she was transferring Resident #15 in the Hoyer lift by herself when Resident #15 slid out of the body sling, hitting her head on the floor. LPN #240 stated at that point she requested staff get assistance and began assessing for head injury. An attempt to interview NA #20 during the investigation was unsuccessful. Review of the facility policy titled Transfer Policy, dated 11/20/17, revealed the purpose was to assist residents with transfers and ambulation in a way that provides safety and protection to the resident and employee. The type of transfers included mechanical lifts which required two staff. Review of the facility's policy titled Mechanical Lifts, dated 07/01/18, revealed the policy was to prevent injury to yourself and residents during transfer. Steps included were to prepare the resident for transfer by attaching the sling to lift using the corresponding loops for the upright position, partial reclining position, and the full reclining position. Review of the facility's undated policy titled Mechanical Lift Checklist revealed to never use a mechanical lift by yourself. All lifts require two people for operation. Review of the undated Invacare manufacturer's operator and maintenance manual for patient slings revealed, Invacare slings are made specifically for the use with Invacare lifts. For the safety of the patient, do not intermix slings and lifts of different manufacturers. When connecting body sling color coded straps, the shortest of the straps must be at the back of the patient for support. Review of the undated manufactures user instruction manual for the Joerns Hoyer HPL700 revealed warnings included Do not use a sling unless it is recommended for use with the lift; Hoyer slings and lifts are not designed to be interchangeable with other manufacturer's products. Using other manufactures' products on Hoyer products is potentially unsafe and could result in serious injury to patient and or caregiver; Further stating caution, have someone assist you when attempting to transfer a patient. This deficiency represents non-compliance investigated under Complaint Number OH00149663 and Control Number OH00149636.