**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) event report review, medical record review, physical therapy evaluation review, care plan review, interview, and policy review, the provider failed to ensure one of one certified nursing assistant (CNA) (I) had followed one of one sampled resident's (7) care plan for using two staff persons to transfer resident 7 using a [NAME] Plus stand lift, resulting in a fall and a fractured hip. Findings include: 1. Review of the SD DOH event report received on 12/28/23 from the provider revealed at 12/19/23 at 7:30 p.m.: *Resident 7 was being transferred with the use of a [NAME] Plus stand lift from a wheelchair to his bed by CNA I when He slipped out of the lift. -CNA I had been supporting his upper body as he fell to the floor. *The lift had been removed from use, inspected by the physical therapist (PT), and found no fault in the lift. -The lift sling was new and in good repair. *Registered nurse (RN) L assessed resident 7 after the fall and transferred him to the hospital where he was diagnosed with a fractured hip requiring a total hip replacement. *The provider report indicated CNA I had followed the policy for using the [NAME] Plus stand lift because CNA I was eighteen years old or older so she could run a lift. Continued review of resident 7's 12/19/23 SD DOH event report revealed: *Director of Nursing (DON) B interviewed CNA I on 12/20/23 regarding resident 7's fall on 12/19/23 before her next scheduled shift revealed: *CNA I had confirmed: -She was using the [NAME] Plus stand lift independently on resident 7 at the time of his fall. -Resident 7 was in the [NAME] Plus stand lift, lifting him up to a standing position. -CNA I was standing behind him while cleaning his buttocks. -CNA I attempted to catch his fall by holding the top part of his body while protecting his head. *Review of RN L documentation confirmed his position when she entered his room. *A root cause analysis of the event completed by DON B, RN quality director P, Assistant administrator for senior living O noted that CNA I had not worked at the facility for several months because she had begun college in the fall of 2023 -She had not looked through the care plans before she stepped onto the unit to provide care for the residents she was assigned to on 12/19/23. 2. Review of resident 7's medical record revealed: *One 10/16/23 at 2:00 a.m. he was discovered on the floor beside his bed. -He had told a staff member he was attempting to retrieve his socks and shoes. *On 10/16/23 at 2:18 p.m. he was evaluated by a physician to check his injuries. *One 10/23/23 at 2:00 p.m. a nursing progress note indicated Minimum Data Set (MDS) coordinator/RN C and licensed social worker M had discussed his pain and that he had increased pain since that fall, requiring the use of a full-body mechanical lift. *He had a history of multiple sclerosis (MS), foot drop, and multiple falls, and was identified as a fall risk. *A 10/27/23 PT evaluation indicated PT N had encouraged charge nurses and CNAs to continue using the full-body mechanical lift. *A 10/30/23 PT evaluation indicated PT N recommended resident 7 to progress to the [NAME] Plus stand lift to help progress his lower extremity strength and tolerance. PT N educated the RN and CNA staff of the recommended changes. 3. Review of resident 7's care plan with a start date of 11/7/23, revealed: *For toileting he was to have had total assistance of two staff persons to transfer him with a full-body lift on and off the commode (toilet). *For transfers he was to have had two staff persons for using the [NAME] Plus stand lift. 4. Interview on 1/18/24 at 10:30 a.m. with DON B and MDS coordinator/RN C regarding resident 7's 12/19/23 fall revealed: *After a period of not working, CNA I had not reviewed the resident care plans before providing care for them on 12/19/23. *Resident 7 had been declining both physically and cognitively for the last several months. -He was care planned for two staff persons with him for all mechanical lift transfers. *When asked about a care plan specific for CNA's to use so they could carry it with them to refer to, MDS coordinator C stated she had provided a daily assignment sheet specific for each CNA to carry while working. -Resident 7's 12/19/23 daily assignment sheet provided to this surveyor had stated that he was supposed to use two staff members while using a stand lift. *DON B stated staff education was provided by her after the incident, including CNA I and all of the nursing staff. -She stated she had not kept the information provided to those staff members or a record of the attendance of the staff. *Observation at the same time, of the [NAME] Plus stand lift revealed: -MDS coordinator C was placed in the lift so that this surveyor could visualize how it worked. -A sling was placed on the person's abdomen and closed using the Velcro belt on the sling. -DON B stated the assessment after the 12/19/23 fall had determined: --The sling had been attached to the lift correctly and was tight enough to prevent him from falling through the sling. --The sling was still attached to the lift even after resident 7 fell. --CNA I stated in the SD DOH event report his legs just crumbled beneath him as he fell straight down. 5. Review of the provider's January 2024 Stand Lift Therapy Equipment Policy and Procedure revealed: *The policy for the lift was to be recommended for residents deemed appropriate by licensed PT's, in collaboration with PT assistants and nursing services. *All facility staff involved in resident care would have been assigned responsibility for ensuring compliance with the policy. *If variance from a care plan was necessary, the DON or PT staff would have been consulted. *Staff members would be provided with training initially and as needed to correct improper use or understanding of safe resident handling. *Use of the stand lift required manual operation of one staff member. *Staff is required to maintain direct line of sight supervision with all residents utilizing a stand lift. *Residents would have been required to maintain upright posture, and maintain satisfactory level of safety. Review of the undated [NAME] Plus Instructions For Use revealed the [NAME] Plus stand lift was to always be handled by a trained caregiver, continuously attending to the resident. Review of the provider's November 2021 Falls and Accidents policy revealed: *The determination of supervision was based on the resident's assessed needs and identified hazards in the residents environment. *All staff would have been educated about and have access to care plans which were initialized for each resident and address potential hazards. *Effective and modification of interventions was monitored on a regular basis through QAPI (Quality assurance and performance improvement) program. *The residents care plan would specifically address any risk factors that provided a benefit, such as a mobility device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation on 2/13/23 at 4:15 p.m. of resident 28 revealed she was sitting in a reclining chair with a blood-stained incontinence pad under her. Observation on 2/14/23 at 10:10 a.m. of resident 28 revealed she was still sitting in a reclining chair. Observation and interview on 2/15/23 at 12:15 p.m. with of resident 28 revealed she: *Was in her bed lying on her left side. *Called a small black cushion in the seat of the reclining chair her special cushion. *Had a sore on her bottom. *Did not know exactly when she got it, but said that she did not have it before moving in. Review of resident 28's medical record revealed: *She was admitted on [DATE]. *The MDS assessment dated [DATE] at admission and the 1/10/23 significant change MDS coded her at risk for developing a pressure ulcer. She had a pressure reducing device for her bed and the chair. *The presence of one unstageable pressure ulcer and moisture associated skin damage were coded on the 1/10/23 MDS. *Her BIMS score on both the 3/24/22 and 1/10/23 MDS assessments were coded as 15 indicating she was cognitively intact. *The skin/wound section revealed: -No weekly skin assessments were documented after the initial screening on admission. -Photo documentation of four open areas had developed (coccyx, sacrum, left hip, and left ear). *The care plan was revised after the pressure ulcers had been identified with preventative measures implemented (gel and ROHO cushion). *She had become compliant with her treatments. Interview on 2/15/23 at 10:25 a.m. with RN B regarding resident 28 revealed: *She did not have pressure ulcers prior to her admission to the facility. *She had been noncompliant when first admitted to the facility, but she had been compliant with her treatment in the past few months. *She was supplied pressure relieving equipment (gel and ROHO cushion) but continued to get pressure ulcers. RN B was not sure why she kept getting ulcers. *CNAs look at residents' skin during bathing days and would let the nurse know of any concerns that were found. Interview on 2/15/23 at 12:21 p.m. with director of nursing A about resident 28's pressure ulcer revealed: *Resident 28 had obtained the pressure ulcers after her admission to the facility. *No skin assessments had been completed in the 11 months after resident 28 had been admitted . *CNAs were to check residents' skin during bathing and to notify the nurse of any identified issues. Interview on 2/15/23 at 6:15 p.m. with CNA C revealed only the CNAs would check the residents for skin issues during bathing and would inform the nurse if there were any identified skin issues. Review of the provider's 2/22 Skin Policy and Procedure revealed: *Full head-to-toe skin assessment was to be completed on admission and with significant changes to assess skin changes or breakdown. *The Braden Pressure Ulcer Risk Assessment tool was completed upon admission and with all MDS assessments. *Based on skin assessments, interventions were to be put into place. *Nurse Assistants were responsible to observe residents during daily care and especially during bathing and report concerns promptly to the charge nurse. *A nurse identifying a skin issue was to promptly document a thorough assessment in the medical record, determine treatment, and communicate the issue to staff. *The charge nurse was responsible to communicate skin concerns to physician and request treatment orders. *All skin injuries would receive daily monitoring by the charge nurses. *Documentation, at a minimum, of a weekly skin assessment would include skin injury location, type of injury, size, and integrity. Based on observation, interview, record review, and policy review, the provider failed to ensure: *Ongoing and timely skin assessments were conducted and documented by licensed nurses prior to the development of pressure ulcers for three of three sampled residents (9, 28, and 33) who had been identified as at risk for pressure ulcers. *Complete and accurate ongoing documentation of identified pressure ulcers for three of three sampled residents (9, 28, and 33) who developed pressure ulcers. Documentation to reflect: -Location and staging. -Size, depth, and presence, location and extent of any undermining g or tunneling. -Exudate, if present. -Pain, if present. -Wound bed, color and type of tissue/character, including evidence of healing. -Description of wound edges and surrounding tissues as appropriate. Findings include: 1. Observation and interview on 2/14/23 at 11:24 a.m. with resident 9 in his room revealed he: *Was sitting in a wheelchair on a ROHO pressure relieving cushion. There was a pressure relieving cushion in his recliner. *Had a prosthetic on his right leg and said the amputation above his knee happened in the past year due to his diabetes. *Received a whirlpool bath with staff assistance once a week. *Walked with staff three times a day in the hallway. *Had reported pain to his back side several months ago, and then the nurse looked and found a sore on his bottom. *Now, they were looking at it every day, they had placed a patch over it, and the pain was finally getting better. Review of resident 9's medical record revealed: *He was admitted on [DATE]. *His diagnoses included Type 2 diabetes with neuropathy, peripheral vascular disease, muscle weakness, right above the knee amputation, left toe amputation, malignant neoplasm of the bone and prostrate, and chronic kidney disease stage 3. *The Minimum Data Set (MDS) assessments dated 1/3/22 at admission and the significant change assessments dated 2/10/22, 6/8/22, 9/3/22, and 12/27/22 all coded him at risk for developing a pressure ulcer and he had a pressure reducing device for his bed and his chair. None of them coded the presence of a pressure ulcer until the 12/27/22 MDS that coded a Stage 2 pressure ulcer (top two layers of skin broken open, usually tender and painful, may also be an intact or broken open filled blister). *His Brief Interview for Mental Status (BIMS) score was 15 on all the above MDS assessments, and that indicated he was cognitively intact. *All eight Braden Scale assessment scores (used to determine the risk of developing a pressure ulcer) completed in 2022 indicated he was at risk for developing a pressure ulcer. *Skin/Wound Note documentation included: -On 12/28/21 00:12 a.m., No skin issues at this time noted other than recent amputation of right great toe with wound vac [vacuum] attached. dressing CDI [clean, dry, intact] with scheduled changes. -On 4/19/22 1:07 p.m., Resident has what appears to be a red welted area on his right buttock. Will continue to monitor and pass on to other shifts. -On 5/1/22 2:38 p.m., Resident has areas on inner coccyx that are deep red and look like they are about ready to open. Zinc spray applied and ROHO cushion placed in chair. Encourage resident to sleep with a pillow under one side and turn frequently when in bed to prevent further breakdown. -On 5/2/22 1:07 p.m., This RN [registered nurse] looked at resident bottom. Noted open area to left buttock with redness around the area. Area hard touch. No blanching. Resident does have scar tissue noted above open area. Area noted to have no s/sx [signs/symptoms] of infection and no odor. Noted edges to be wet. Resident did have pressure reducing air mattress and resident wanted to [the] air mattress taken off bed. Again this RN asked resident if he would think about air mattress told this RN to 'Keep thinking. I am not having that on my bed.' Resident does have pressure relieving cushion in recliner and wheelchair. Resident was cleaned up and area dried. Cream applied to area. This RN instructed staff and resident that he needs to relieve pressure off of bottom every two hours. Staff verbalized understanding. Resident also verbalized understanding. Will continue to monitor. -On 8/17/22 5:44 p.m., Resident has an area on buttocks that is very thin and has previously been open. This is currently being covered with a hydrocellular [silicone] foam dressing to protect the thin skin from shearing when resident slides forward in his w/c [wheelchair], recliner, or bed. -On 9/3/22 9:36 a.m., Resident has open areas on sacrum that are bleeding at this time. Area cleansed thoroughly and dressing applied. Will continue to monitor and update other staff. -On 9/16/22 11:07 a.m., Dressing removed from bottom area does have a foul smell however, suspect it could be from old drainage. dressing was not reapplied. would like to be able to monitor without dressing for a couple of days. nursing to utilize barrier cream at this time. -On 11/6/22 2:43 p.m., Resident's coccygeal area shows the fragile epithelialization to be opening up in two spots. Area was gently cleansed and Medihoney and a hydrocolloid dressing [two layers of beginning biodegradable, breathable, and adhesive material] was placed to cover. Will monitor closely. *His current medical orders included the following: -Juven nutritional supplement twice daily for wound healing. -Medihoney applied topically to the wound bed on his coccyx and then covered with a wound dressing every three days or sooner if the dressing became contaminated. -Nursing to check his coccyx wound/dressing daily and change it [the dressing] as needed until it [the wound] healed. Review of resident 9's care plan regarding skin integrity initiated on 1/14/22 and revised through 2/13/23 revealed: *Impairment of skin integrity at his coccyx related to peripheral vascular disease, type 2 diabetes, and stage 3 chronic kidney disease. *Interventions to prevent pressure ulcers and then to promote wound healing included: -A pressure reducing air mattress on his bed, that he refused, so after he was educated about the risks, the air mattress was replaced with a different pressure reducing mattress. -A pressure relieving cushion in his recliner and wheelchair. -Wound dressings to be completed as ordered by his physician. Observation and interview on 2/15/23 from 12:25 p.m. to 1:14 p.m. with RN B while performing wound care for resident 9 revealed: *Resident 9's stage 2 coccyx pressure ulcer was discovered when he complained about pain in his coccyx area. *They had placed a pressure reduction mattress on his bed, but he did not like it. He was educated on the risk versus benefits but still wanted it removed, so they honored his choice. *He had a gel cushion in his recliner and wheelchair until the pressure ulcer was discovered and then a ROHO cushion was placed in his recliner and wheelchair. *His stage 2 pressure ulcer was healing. 2. Observation and interview on 12/14/23 at 10:47 a.m. with resident 33 revealed he: *Was sitting in a wheelchair on a pressure relieving cushion. *Was able to move himself in his wheelchair using his arms and feet to his wife's room in a different location of the facility to visit her, and he did that several times a day. *Required assistance from staff for dressing and bathing. *Had compression stockings and shoes on his feet. *Denied any skin breakdown or skin concerns. Review of resident 33's medical record revealed: *He was admitted on [DATE]. *His diagnoses included: History of venous thrombosis and embolism, pulmonary embolism without acute cor pulmonale, cerebral infarction, and aphasia. *The MDS assessment dated [DATE] at admission and the 12/9/22 significant change MDS coded him as at risk for developing a pressure ulcer, and there was a pressure reducing device for his bed and chair. *His BIMS score on the 9/27/22 MDS was 15 and then 13 on the 12/9/22 MDS, both indicating he was cognitively intact. *All five Braden Scale assessment scores completed in 2022 indicated he was at risk for developing a pressure ulcer. *Skin/Wound Note documentation included: -On 11/7/22 6:12 a.m., Resident had scab/corn on left great toe in two spots. -On 2/10/23 9:00 a.m., This RN was informed of sore on resident left great toe. This RN assessed left great toe noted area to tip of left great toe with slight amount of drainage blood tint colored. Resident denies any pain to left foot or toe. After talking with staff noted that resident does wear TED [thromboembolism-deterrent] hose and the TED hose are tight to his toes. Right now resident just has gripper socks on and the socks are pulled away from his toes. Dressing was applied to left great toe. Order sent over to PCP [primary care physician] for Aquacel dressing for the great left toe. Resident son [name] notified of area on great left toe. Dietician notified of area on left great toe. Will continue to monitor. -On 2/11/23 4:12 p.m., CNA [certified nursing assistant] assessed resident's toe. He denied pain but stated he did feel some pain with cleansing of the wound. He states that he feels pressure and touching on his foot in general and his pedal pulses are palpable. His foot is normal temp [temperature] for his body. The wound bed is dark red granulation tissue with pale, hard tissue immediately surrounding, almost like an old blister. the periwound [sic] is dark red. Area cleansed and a hydrocolloid dressing applied. -On 2/13/23 2:00 p.m., This wound was rechecked as it did say right instead of left great toe. [physician] did see wound on Friday 2/10 and today 2/13. [resident 33] was started on antibiotics and he also will not wear TED hose as there is pressure from the TED hose. Also will talk with family about getting new shoes that are softer. Dressing continues to be foam to help keep moisture away from the wound. *His current medical orders included: -Juven nutritional supplement twice daily for wound healing. -A podiatry referral. -Bactrim antibiotic two times daily for left great toe infection for five days. -Routine wound care for left great toe. -An X-ray of left great toe. *The X-ray results were negative for any bone infection. Review of resident 33's care plan regarding skin integrity initiated on 10/3/22 and revised through 2/11/23 revealed: *He had impairment to skin integrity related to a left great toe pressure ulcer. *Interventions to prevent pressure ulcers and then to promote wound healing included: -A pressure reducing mattress on his bed. -A pressure relieving cushion in his recliner and wheelchair. -Physician orders for antibiotics, wound dressings, a podiatry referral, and an X-ray of his left great toe. Observation and interview on 2/15/23 from 12:25 p.m. to 1:14 p.m. with RN B while performing wound care for resident 33 revealed: *The stage 2 left great toe pressure ulcer was discovered when a CNA was putting on his TED compression stockings, and she alerted the nurse. *He wore TED compression stockings for his 3 plus pitting edema [fluid retention], and they attributed his ulcer to the TED compression stocking rubbing on his toe. *The CNAs had been educated to pull the TED compression stocking away from the toe when they put them on. *They had ordered toeless TED compression stockings for him. *He had an X-ray of the toe yesterday and there was no bone infection. *He moved himself in his wheelchair with his arms and feet. *He denied pain and said he did not feel the pressure ulcer on his toe, and it does not hurt me. *She further explained the process for identifying, reporting, and preventing the development of pressure ulcers included: -The charge nurse completed a comprehensive skin assessment for residents at admission. -Braden Scale assessments were completed by nursing at admission and quarterly with the MDS assessments and with significant changes. -Interventions such as cushions in chairs and wheelchairs, pressure reducing mattresses, and repositioning were put in place for residents at risk for skin breakdown. -Skin concerns or changes were identified and reported to nursing staff by CNA observations while assisting with personal care and bathing, or by residents reporting their concerns. -Once the nurse received a report of skin concerns or changes, the nurse would complete a skin assessment, decide on the plan of care and treatment, notify the physician for treatment orders, implement daily skin/wound checks, and complete weekly wound assessments with measurements. Interview on 2/15/23 at 3:49 p.m. with director of nursing (DON) A regarding nurses completing skin assessments revealed: *Braden Scale assessments were completed for residents by the nurse on admission, quarterly with the MDS and with any significant changes. *If the Braden score indicated a resident was at risk for pressure ulcers, interventions were put into place, such as pressure relieving devices, and repositioning programs. *A resident received a thorough skin assessment completed by the night charge nurse at admission. *CNAs observed resident's skin during personal cares and bathing and were to report to the charge nurse any skin concerns such as redness or bruising. *Outside of the CNA certification course that addressed dry skin, applying lotion etc . CNAs had no additional training for their delegated resident skin observations. *They held a daily huddle where staff were asked about any resident skin issues or observed skin changes. *When the charge nurse was notified of resident skin issues, she completed a skin assessment, notified the provider, and implemented a daily nurse skin/wound check. Interview on 2/15/23 at 6:12 p.m. with CNA D regarding skin observations revealed she: *Had worked at the facility for 50 years. *Had not received any additional training on observing residents' skin and/or wounds outside of her CNA certification course. *Completed skin observations when assisting residents with personal cares, activities of daily living and bathing. *Reported any observed resident skin concerns such as bruises, redness on the coccyx, under the breasts, armpits, skin folds or the feet to the charge nurse. *Had shared with the charge nurse any resident concerns voiced to her, such as redness or irritation in folds of skin or pain in pressure spots like bottoms or heels. *Attended the daily staff huddle and would bring up resident skin concerns at that time. *Had worked with residents who had skin concerns and had pressure ulcer prevention interventions in place such as, a gel or ROHO cushion, an alternating air mattress, a schedule to reposition every 2 hours, and/or a schedule to walk or go to the toilet depending on the resident's mobility.