**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the hospital discharge summary, review of the fall investigation, staff interview, and review of the facility policy, the facility failed to provide Resident #64 with a safe transfer using a mechanical lift. Actual Harm occurred to Resident #64 on 10/25/22 when the resident received assistance from two staff persons using a mechanical lift without staff first securing the loop of the lift pad correctly resulting in an avoidable fall with injuries including unspecified fracture of the shaft of the right and left tibia and fibula. This affected one (Resident #64) of three residents reviewed for falls. The facility census was 64. Findings include: Review of the medical record revealed Resident #64 was re-admitted to the facility from an acute hospital stay on 10/26/22 with diagnoses including unspecified fracture of the shaft of the right and left tibia and fibula, quadriplegia, and hypertension. Review of the fall risk assessment dated [DATE] revealed Resident #64 was not at risk for falls. Review of the fall risk assessment dated [DATE] revealed Resident #64 was at high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was alert and oriented to person, place and time. Resident #64 was identified as needing total dependence on two staff persons for transfers using a mechanical lift. Review of the plan of care dated 11/04/22 revealed Resident #64 was at a risk for falls due to decreased mobility, recent (inoperable) bilateral tibia/fibula fracture, quadriplegia, weakness, decreased mobility, non ambulatory, and required a Hoyer lift for transfers. Interventions included keep call light in reach, pathways free of clutter, two person assist with transfers using a Hoyer lift, night light in bathroom, encourage resident to participate in care and may get up per Hoyer lift to wheelchair with foot extenders with immobilizers in place to bilateral lower extremities. The plan of care also revealed Resident #64 had a self-care deficit as evidenced by recent (inoperable) bilateral tibia and fibula fractures, quadriplegia, weakness, decreased endurance and impaired balance. The resident was non ambulatory. Interventions included weight bearing support of one to two staff for bed mobility, dressing, toileting, hygiene and bathing and total dependence on two staff persons using a mechanical lift for transfers. Review of the facility fall investigation dated 10/25/22 revealed Resident #64 was being transferred via Hoyer lift with two State Tested Nursing Assistants (STNA) using the appropriate mechanical lift sling. One STNA attached the upper left and right loops of the sling while the other STNA attached the lower left and right loops. The facility conclusion indicated the metal safety clip, which would secure the left shoulder strap/loop onto the hook was not engaged. The loop instead was rested on the tip of the hook. Resident #64 was elevated into the air to transfer when she began to wiggle and move attempting to reposition herself in the lift sling. During these movements the loop on the left shoulder strap of the lift sling dislodged resulting in the resident falling to the floor rapidly resulting in bilateral tibia and fibula fractures. Review of the nurse's note dated 10/25/22 at 12:45 A.M. revealed the nurse responded to calls from resident's room to find Resident #64 lying on her back with her left leg lying over the Hoyer lift leg and the right leg bent at the knee behind the leg. The STNA's reported the resident fell out of the top of the Hoyer lift sling during transfer from wheelchair to bed. Resident #64 complained of pain at level 10 out of 10 and was sent to the local emergency room for evaluation and treatment. A nurse's note dated 10/26/22 at 4:25 P.M. revealed the resident returned to the facility at approximately 11:30 A.M. with immobilizers in place to bilateral lower extremities. Review of the hospital Discharge summary dated [DATE] at 12:45 P.M. revealed the resident was seen in the emergency department after a fall at the nursing home. The orthopedic team at the hospital saw Resident #64 related to fracture in both of her legs. The orthopedic team believed the fractures would heal without any need for surgery. During the emergency room visit the resident had imaging tests completed. The x-rays of the right and left lower extremity indicated minimally displaced proximal tibial metaphyseal fracture and nondisplaced proximal fibular fracture of the left leg. The x-rays indicated mildly displaced comminuted proximal fibular and tibial metaphyseal fracture to the right leg. An interview on 02/06/23 at 10:00 A.M. with the Director of Nursing (DON) confirmed Resident #64 fell from the Hoyer lift sling while being transferred from wheelchair to bed resulting in fractures to bilateral tibia and fibulas. The DON stated the sling came out of the hook on the lift bar and the security clip was not in place. Review of the facility's policy titled Hoyer Lift Policy and Operation revealed it is the policy of this facility to provide safe transfers for all residents that are unable to transfer themselves. The method of transfer will be decided by the Interdisciplianry Team and addressed in the resident's plan of care. The deficient practice was corrected on 11/11/22, when the nurse managers provided education on the Hoyer lift sling safety checks and the policy and procedure of Hoyer lift operation to 25 nurses and 40 STNAs, and the facility implemented the following corrective actions: • On 10/25/22, Resident #64 was sent to the local emergency department for evaluation and treatment. • On 10/25/22, the Director of Patient Services inspected the residents Hoyer lift. The lift was in clean condition and showed minor wear marks on areas of movement. There were no cracks or broken areas to the main structure. All of the bolts were in place and tight. There were a total of six sling clips on the boom and all were operational and in working order. The base extended smoothly with no jerking motions and worked well with the no issues. The boom rose and fell smoothly, all four wheels moved freely and locks operated with no issues. • On 10/25/22, the DON provided education on Hoyer lift sling safety checks and policy and procedure of Hoyer lift operation to the two STNA's involved in the incident. • On 10/25/22 through 11/11/22, the nurse managers provided education on Hoyer lift sling safety checks and policy and procedure of Hoyer lift operation to 25 nurses and 40 STNA's. • On 10/25/22 and ongoing, the nurse managers completed competency checks on how to use the Hoyer lift correctly and safely with the nurses and STNA's. • On 10/25/22, the DON provided education to the laundry staff regarding how to correctly wash and inspect the Hoyer lift slings. • On 10/25/22, the DON and nurse managers numbered the mechanical lifts and corresponding lift pads. • On 10/25/22, Resident #64's plan of care was updated. • Beginning 10/25/22, ongoing audits/observations of lift transfers on lift involved weekly for four weeks, then as determined by Quality Assurance. • There were no unsafe resident transfers from 10/25/22 to 02/13/23 the time of the onsite complaint investigation. This deficiency represents non-compliance investigated under Complaint Number OH00140041.