Based on interview, record review, document review, and facility policy review, the facility failed to ensure a certified nursing assistant (CNA) transferred a resident according to the resident's care plan for 1 (R2) of 4 sampled residents reviewed for accidents. Certified Nursing Assistant (CNA)1 used a sit to stand lift with one person instead of a mechanical sling lift with two people as specified by the resident's care plan. The failure resulted in R2 sustaining a fractured femur. Findings included: A facility policy titled, Lifting Machine, Using a Mechanical, revised 07/2017, indicated, Purpose The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines 1. A least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. A facility policy titled, Safe Lifting and Movement of Residents, revised 07/2017, indicated, Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy specified, 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. An admission Record revealed the facility admitted R2 on 10/17/2022. According to the admission Record, the resident had a medical history that included diagnoses of late onset Alzheimer's disease, anxiety disorder, unspecified dementia with other behavioral disturbance, unspecified psychosis, and vitamin D deficiency. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for chair/bed-to-chair transfers. R2's Care Plan, included a focus area initiated 10/25/2022, that indicated the resident required assistance with activities of daily living related to limited range of motion and weakness. Interventions directed staff to utilize a Mechanical/Hoyer lift with the assistance of two people to transfer the resident (initiated 08/12/2024). R2's Nurse's Note, documented by Registered Nurse (RN)2 and dated 11/18/2024 at 5:00 PM, indicated R2 was observed grimacing during patient care, swelling was noted to the resident's left femur, and an order was received to complete an x-ray. A Visit Note Report, dated 11/18/2024, revealed RN2 notified hospice that R2 complained of pain in their left leg. Per the Visit Note Report, there had been no reported falls, but the resident's leg was swollen, and RN2 thought the resident's leg might be dislocated. Per the Visit Note Report, RN6 visited the facility on 11/18/2024 at 8:47 PM and noted the resident's left ankle was turned out. The Visit Note Report indicated, the resident had pain and swelling in their left lower hip area, with pain seemingly present only when their leg was moved, and RN6 applied a soft splint. R2's Order Summary Report, contained an order dated 11/19/2024, for an x-ray of the resident's left knee and hip. The Radiology Results Report, dated 11/19/2024 at 9:20 AM, revealed R2 had an acute appearing femoral fracture. Contained within the facility's investigation was CNA1's Witness Statement, dated 11/18/2024, which indicated CNA1 acknowledged she alone transferred R2 to the bed by using a stand up lift. The Five-Day Follow-Up Report, dated 11/22/2024, revealed R2 had a fracture of the mid femoral shaft with malalignment. Per the Five-Day Follow-Up Report, a CNA transferred the resident to the bed by usage of a stand-up lift. The Five-Day Follow-Up Report, while the CNA had been trained on resident transfers, the CNA did not transfer the resident per the resident's plan of care and the CNA's employment with the facility was terminated. The Post Falls Assessment and Root Cause Investigative Report, dated 11/20/2024, revealed R2 was improperly transferred with a mechanical lift and the assistance of one staff. An Employee Counseling Form, signed by CNA1 and dated 11/28/2024, revealed the nature of the infraction was the CNA transferred a resident without assistance. Per the Employee Counseling Form, CNA1 was terminated. During an interview on 01/02/2025 at 1:31 PM, RN2 stated she was in the room with another resident on 11/18/2024 and was called to come and check R2. RN2 stated she noticed something was wrong with the resident's leg and asked the resident what happened. RN2 stated the resident said they did not know, and it was not like that earlier that morning. RN2 stated the resident required a sling type mechanical lift and she was not present with the resident to know how the resident was transferred. RN2 stated there had not been any issues with transfers prior to the incident because everyone knew with a mechanical lift, there always needed to be two people for assistance. During an interview on 01/02/2025 at 1:22 PM, CNA3 stated she was working on the day of the incident, but she did not recall anything unusual. CNA3 stated R2 had not had any falls or anything of which she was aware. CNA3 stated for residents that required a mechanical lift for transfers, there should always be two people. During an interview on 01/02/2025 at 1:43 PM, CNA #4 stated she did restorative, trained the CNAs on the mechanical lift, and instructed them to make sure they always had two people with them, especially for safety reasons. During an interview on 01/02/2025 at 3:50 PM, the Administrator stated he contacted the Director of Nursing (DON), and she stated CNA1 did not give a reason for why she did not have two people present for the transfer of R2. During a follow-up interview on 01/02/2025 at 5:04 PM, the Administrator stated he expected residents to be transferred per their care plan, with the correct number of staff for assistance. On 01/02/2025 at 12:42 PM and 1:54 PM and 01/03/2025 at 8:35 AM, a telephone interview was attempted with CNA1. There was no answer and each time a voicemail message was left, and no return telephone call was received. CN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interviews, the facility failed to ensure 2 out of 2 residents (Residents (R) 36 and R86) reviewed for resident-to-resident abuse out of a total sample of 30 residents were free from abuse. R37 was the aggressor in two resident-to-resident altercations, one which resulted in harm when R86 sustained a hip fracture from a fall after being pushed. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed: Policy Statement Residents have the right to be free from abuse . This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse . Policy Interpretation and Implementation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents;. Review of R37's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 05/26/22 with medical diagnoses that included depression, dementia with behavioral disturbance, lack of coordination, cognitive communication deficit, mood (affective) disorder, and insomnia. Review of R37's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/01/22 revealed R37 had a Brief Interview for Mental Status (BIMS) score of 06 out of 15, indicative of severe cognitive impairment. Review of a Behavior Care Plan, dated 08/24/22 and located in the Care Plan tab of the EMR showed documentation that R37, has risk for combative or aggressive behaviors. history and or potential to demonstrate verbally abusive behavior towards others. Review of R86's admission Record from the EMR Profile tab showed a facility admission date of 05/27/22, a readmission date of 08/22/22, with medical diagnoses that included senile degeneration of the brain, late onset Alzheimer's disease, dementia without behavioral disturbance, delusional disorders, and adult failure to thrive. Review of R86's admission MDS with an ARD of 07/12/22 revealed R86 had a BIMS score of 00 out of 15, indicative of severe cognitive impairment. The MDS revealed R86 was assessed by staff as needing only supervision when ambulating and steady at all times when walking. Review of R37's Progress Notes EMR tab showed: 8/23/2022 20:34 [8:34 PM] Behavior Note Note Text: Resident highly agitated stating 'Get out of her house.' Entered another residents [sic] room and attempted to physically strike him with closed fist. This nurse was able to redirect hands and resident angrily exited room on own stating this was her house. Resident currently requiring 1:1 [one on one] care for other resident safety. 8/23/2022 21:28 [9:28 PM] Alert Note Note Text: On call, [Nurse Practitioner], notified of patients behavioral issues. On call ordered 2.5mg [milligrams] IM [intramuscular] Haldol x1 [one time]. UA [urinary analysis] C&S [culture and sensitivity]. Will continue to observe. 8/23/2022 21:47 [9:47 PM] Behavior Note Note Text: NP on call contacted about resident's agitated behavior. N/O [new order] received. Attempt to contact family resulted in busy signal will cont [continue] to attempt contact. Then an SBAR (Situation, Background, Assessment, Recommendation) on 08/23/22 at 10:15 PM that stated: .Resident has had increased behavior (wandering and argumentative speech with staff) in past 24 hours. This shift resident swearing at staff and other residents. Placed hands on another resident and pushed her causing a fall. Then attempted to enter other residents' rooms, when staff attempted to redirect resident became belligerent yelling loudly and cursing but exited room. 1:1 required this shift for other residents' safety. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Haldol 2.5mg IM x 1 dose now. Attempt to obtain UA C&S prior to injection. If unable to obtain or resident resistant obtain on 8/24. If resident is asleep do not wake to obtain. Review of R86's EMR Progress notes tab showed: 08/23/2022 20:17 [8:17 PM] Alert Note Note Text: Pt [patient] was approached by agitated resident. Agitated resident placed hands angrily on patients [sic] chest and pushed causing her to fall on left side. Patient and agitated resident separated. Staff assisted pt X2 [two staff] from floor to chair. Patient placed at nurses station for safety and observation. Pt was visibly upset, crying and grimacing. Pt vital signs . No visible skin discoloration or alternation [sic] noted at this time. Pt complains of pain in left leg. Pt unable to specify where pain is located. Pt refusing to weight bear and favoring left side. Pt grimacing and visibly upset with tears streaming down face when staff attempted a two person assist stand from chair. Pt given Tylenol PRN [as needed], standing order. DON [Director of Nursing] notified. Family Notified. Hospice Notified. Hospice physician en route to further evaluate pt for adverse reaction to fall. Will continue to observe. 08/23/2022 21:37 [9:37 PM] Alert Note Note Text: Hospice [name] arrived to evaluate patient following incident. Hospice suggests patient be sent to ED [emergency department] for further evaluation. Family notified of condition. EMS [emergency medical services] called for transer [sic]. Will continue to monitor. 08/24/22 02:06 [2:06 AM] Alert Note Note Text: Patient returned to facility via EMS at 0205 [2:05 AM]. Patient has a fractured trochanter, non-operable. Pt nonweight [sic] bearing. DON notified. Will continue to observe. A voicemail message was left for Registered Nurse (RN) 62 regarding the incident notes for R37 on 09/09/22 at 4:03 PM. No return call received. During an interview on 09/09/22 at 8:15 PM with the Administrator and Operations Manager (OM), neither was in the facility at the time of the incident but they were notified by staff. The two agreed there were no signs prior to the day of the incident that R37 would become physical with another resident. Both residents were independently ambulatory at the time of the incident and there had been no incidents with R37 and R86 prior to the event and no other incidents with R37 other than the one involving R38. The Administrator stated, We changed [R37's] room and ordered a psychiatric evaluation, which, unfortunately, did not occur prior to the incident with [R38]. Staff have been educated to keep [R37] away from other residents. The Administrator expressed an expectation that she absolutely positively prefers to never have resident to resident altercations. A voice mail message was left for RN6 on 09/09/22 at 8:37 PM and returned on 09/10/22 at 6:04 PM. RN6 stated she was working the night of the incident and R37 gave no indication that she would have an altercation with another resident. RN6 stated the two residents (R37 and R86) were just passing in the hall and she pushed her. RN6 examined R86 after the fall and noted pain; she contacted hospice and R86 was sent to the emergency room. R86 returned later that night with a trochanter fracture and was not a candidate for surgery so she is now non-weightbearing and in bed. 2. Review of the admission Record located in the Profile tab of the EMR revealed R38 was admitted to the facility on [DATE] with diagnoses that included depression. Review of the quarterly MDS assessment with and ARD of 06/04/22 revealed a BIMS score of seven out of 10 which indicated R38 was impaired in cognition for daily decision-making and had no behaviors. R38 was not interviewable. Review of the investigation provided by the facility for an incident on 08/28/22 at 8:49 PM, revealed, .Staff member reported that resident, [R37], was with resident, [R38] in the doorway of their [room]. [R38] stated that resident, [R37] wanted to close the door to the room and R38 wanted the door left open [R37] then hit R38 in the face. Staff separated residents. Resident, [R38] was assessed for injury with a scratch to the bridge of her nose and a scratch to left eyelid. During an interview on 09/09/22 at 8:15 PM with the Administrator and OM, they confirmed that R37 had not been involved in any other incidents since the incident with R38. The Administrator stated, We changed [R37's] room and ordered a psychiatric evaluation, which, unfortunately, did not occur prior to the incident with [R38]. Staff have been educated to keep [R37] away from other residents. In a follow up interview on 09/09/22 at 9:00 PM, the OM confirmed R37's behavior health evaluation occurred on 08/30/22.