**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure the resident's physician was notified of a significant change in a resident who complained of left leg pain and swelling from her leg getting tangled in a Hoyer lift pad for 1 of 4 (Resident #15) sampled residents. The facility's failure to notify the resident's physician resulted actual harm when the resident waited for approximately 20 hours and 15 minutes before being transferred to the hospital for treatment of a fractured hip. The facility had a census of 125. The findings include: 1. Review of facility's policy titled, Notification of Change of Condition Policy, dated 7/7/2022, revealed, .The facility must .consult with the resident's physician .when there is an accident involving the resident which results in an injury and has the potential for requiring physician intervention. A significant change in the resident's physical .status .Documentation of notification or notification attempts should be recorded in the resident electronic medical record .If unable to contact the physician .may contact the Medical Director . 2. Medical record review for Resident #15 revealed the resident was admitted to the facility on [DATE], with diagnoses incomplete Quadriplegia (unable to move arms and legs), Guillain-Barre Syndrome (disease of the nervous system resulting in loss of feeling to extremities), Lack of Coordination, Muscle Weakness, Anxiety Disorder, Chronic Pain Syndrome, Muscle Spasms, and Convulsions (abnormal uncontrollable body movements). Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #15 was assessed with a Brief Interview for Mental Status (BIMs) of 15, indicating the resident was cognitively intact, required total assistance from staff for activities of daily living (ADLs), and had range of motion (ROM) limitations on both sides for the upper and lower extremities. Review of the Care Plan dated 1/12/2023, revealed, .quadriplegia .transfers per mech [mechanical] lift with 2 staff . Review of a facility's Investigation report dated 3/28/2023, revealed on 3/28/2023 at 2:00 AM, Certified Nursing Assistant (CNA) #4 entered Resident #15's room to provide care and observed the resident's leg to be swollen. CNA #4 asked Resident #15 what had happened, and the resident told CNA #4 that her leg got caught in the mechanical lift pad when she was taking a shower. CNA #4 reported this to the charge nurse, Licensed Practical (LPN) #4. On 3/28/2023 at 7:00 AM, LPN #4 notified the oncoming nurse, LPN #7, of the status of Resident #15's leg. On 3/28/2023 at 7:40 AM, LPN #7 documented Resident #15's left leg was swollen and painful. Review of a Nursing Progress Note dated 3/28/2023 at 7:40 AM, electronically signed (e-signed) by LPN #4, revealed .Resident c/o [complain] of LLE [left lower extremity] pain. L. hip to foot noted to be edematous, pitting in the ankle and top of foot .Noted in NP [Nurse Practitioner] book . Review of a Nursing Progress Note dated 3/28/2023 at 8:00 AM, e-signed by the Director of Nursing (DON), revealed, At approximately 8am [8:00 AM] received report from nurse that resident was complaining of left leg pain and swelling and informed resident that an NP would see her today during rounding . Review of a Nursing Progress Note dated 3/28/2023 at 1:45 PM, revealed, NP at bedside, examined resident with new orders received. Review of a Radiology Order dated 3/28/2023, confirmed stat (immediate) x-rays were ordered for the Left Femur, Left Tiba/Fibula, and Left Ankle Stat. Review of the radiology report dated 3/28/2023 at 6:33 PM revealed, Comminuted (a type of broken bone) intertrochanteric left femur (area of the broken bone) fracture. Exam complicated by demineralized bones (bones can break easy). The facility's investigation documented that on 3/28/2023 at 6:55 PM, LPN #6 was notified of resident x-ray results from Radiology. Review of a Nursing Progress Note dated 3/28/2023 at 8:26 PM, revealed, Resident X-ray result show that resident has a sub-capital neck (area on the hip), and left hip fracture .NP gave order to send resident to hospital . The facility's investigation documented that on 3/28/2023 at 9:24 PM, the DON notified the Administrator of the events surrounding Resident #15's leg. Review of a Nursing Progress Note dated 3/28/2023 at 10:11 PM, revealed Resident #15 was transferred to the hospital by ambulance for evaluation of her left leg. Review of the Medication Administration Record (MAR) dated 3/28/2023 revealed no evidence Resident #15 had received pain medications as needed (PRN) for pain or orders for PRN pain medications. Review of the History and Physical with an admission date of 3/28/2023 revealed, .Pt [Resident #15] admit she got tangled in her Hoyer lift [mechanical lift] Saturday .resulting in current fxs [fractures] .History of Present Illness .Patient states that on Saturday [3/25/2023] an aide at the NH [nursing home] was trying to transfer her from her bed to the shower using a hoyer lift .she states that the attendant was being rough with her and moving her too fast, which caused her legs to dangle off the lift and hit various surfaces. She was then handled roughly in the shower and has had significant pain in her left leg (hip worst) since then as well as new LLE swelling (endorses a degree of swelling at baseline) .Patient underwent numerous XRs (X-Rays) of lower extremities which showed intertrochanteric [area on the hip] L hip fracture and Chronic R hip changes .Assessment / Plan .Orthopedics have evaluated and planning for operative repair when able . During an interview on 4/11/2023 at 9:40 AM, the DON was asked when were she had been notified about the Left Hip Fracture for Resident #15. The DON stated, The night we got the x-ray it was the 28th that night when the results came back . The DON confirmed that the only medication the resident received for pain was her scheduled medication for neuropathy. During an interview on 4/11/2023 at 11:21 AM, the Administrator was asked what occurred with Resident #15's left hip. The Administrator confirmed that Resident #15 was alert and oriented and she told the emergency room staff her leg got twisted and tangled in the mechanical lift and she told me that when she talked to me. The Administrator confirmed Resident #15 had stated she remembered hearing a pop. The Administrator confirmed she was unaware of any injury or swelling to Resident #15's leg until she was notified of the fracture the night of 3/28/2023. During an interview on 4/11/2023 at 5:25 PM, the DON confirmed she was unaware of the incident with Resident #15's leg getting tangled in the mechanical lift pad and verified it had not been reported to her until the x-ray results on the evening of 3/28/2023. The DON confirmed that LPN #4 should have called the NP or the physician the night of 3/28/2023 at 2:00 AM and should not have waited to pass it on to the next shift. The DON confirmed that LPN #4 should have also called her and the Administrator to report what Resident #15 had reported about the occurrence with her leg getting tangled up in the lift pad and that her documentation on 3/28/2023 at 7:41 AM in the progress notes should have contained that information along with her attempts to use the notification app and her attempts to call the NP. During an interview on 4/11/2023 at 6:48 PM, CNA #4 confirmed she worked from 11:00 PM on 3/27/2023, to 7:00 AM on 3/28/2023, and was assigned to give care to Resident #15. CNA #4 stated she was assisting with ADL care for Resident #15 and noticed the resident's left leg was swollen and asked her what occurred. CNA #4 stated Resident #15 told her that her leg got tangled in the mechanical lift. CNA #4 stated she immediately reported it to the charge nurse. CNA #4 verified this occurred around 2:30-2:35 AM. CNA #4 confirmed that Resident #15's leg was swollen more than normal that is what prompted her to ask what had happened to her leg. During an interview on 4/11/2023 at 7:37 PM, LPN #4 stated on 3/28/2023 at approximately 2:00 AM Resident #15 reported to CNA #4 that her leg was injured on Saturday (3/25/2023) while being transferred with the mechanical lift to go to the shower room. LPN #4 stated Resident #15 had said that CNA #1 and an unfamiliar CNA (CNA #2) were getting her up with the lift. LPN #4 stated she assessed Resident #15 and she attempted to notify the NP on call but was unable to access the on-call system to work. LPN confirmed she should have called the DON and the Administrator, and would have called the Medical Director instead of putting it in the NP book, and obtained an order for pain medication. During an interview on 4/12/2023 at 9:21 AM, NP #1 was asked how often she was onsite at the facility. The NP stated she was present Monday through Friday. NP #1 was asked how she communicated with staff. NP #1 stated there is an on-call system with availability around the clock for urgent issues and when there is a change in a resident's condition, and there is a communication book for non-emergent issues. NP #1 confirmed that a Registered Nurse will triage the call and determine if it is urgent or non-urgent. NP#1 confirmed that if it is during her working hours they can come find her or page her overhead. The NP was asked what if the nurse at the facility is unable to access the on-call system is there another alternative that can be utilized to contact a provider. NP #1 confirmed the Medical Director can be called at any time and he has been called in the past when there were issues with the system. NP #1 confirmed she was the NP on-call the day of 3/28/2023 and was covering the entire building because NP #2 called in sick. NP #1 was asked what time was she was informed of Resident #15's change in condition to her left leg the day of 3/28/2023. NP #1 confirmed she was not made aware of the swelling to Resident #15's left leg until she picked up the communication sheets from NP #2's communication book at approximately 7:45 AM or 8:00 AM. NP #1 confirmed that book is utilized for non-urgent issues. The NP stated staff did not describe the swelling to Resident #15's leg. NP #1 stated Resident #15 has always had some swelling from time to time around her ankles but staff failed to present the concern in an urgent manner and failed to mention about the leg being caught in a mechanical lift. NP #1 stated the communication sheet that she later reviewed was not written in an urgent manner and did not document any pain after transfer. NP #1 confirmed that the nurse never mentioned an injury occurred with the use of a mechanical lift. NP #1 confirmed she did not assess the resident until after lunch and when she assessed her she did have swelling around her left hip and she was complaining of pain. NP #1 confirmed that is when she learned that the injury occurred during the use of a Hoyer lift. NP #1 stated she ordered stat x-rays of the whole leg and that the swelling from around the ankle was normal for her. NP #1 was asked if pain medications were ordered for Resident #15's complaints of leg pain. The NP stated she thought Resident #15 had pain medication ordered already but was not certain. NP #1 confirmed that she should have been notified immediately of the situation upon arriving at the facility the morning of 3/28/2023. During an interview on 4/12/2023 at 5:23 PM, the DON verified the electronic entry made on 3/28/2023 at 8:00 AM was not made by her but was made by LPN #7. The DON verified she was unaware of Resident #15's leg until the evening of 3/28/2023. The DON confirmed this entry should not have been made by LPN #7. During an interview on 4/13/2023 at 10:38 AM, the DON confirmed that the pages of the NP communication book is addressed by the NP had been shredded. The facility was unable to provide the NP communication notification from 3/28/2023. During an interview on 4/12/2023 at 12:28, the Medical Director confirmed that he communicates with the facility Administration on a daily basis and is on site at least 4 times per week. The Medical Director was asked if the facility is unable to get in contact with the NP on call are you available. The Medical Director confirmed he is available around the clock for any facility issues. The Medical Director confirmed he was not made aware that Resident #15 had sated that she had sustained an injury from the use of a mechanical lift. During an interview on 4/12/2023 at 2:40 PM, the Medical Director was asked if Resident #15 complained of pain and they noticed swelling to the left leg should the NP or you have been notified. The Medical Director stated, Yes. The Medical Director confirmed that anything that urgent should not have waited to morning to contact the NP and should have been taken care of when it was reported and the resident's pain should have been addressed at that moment. The Medical Director confirmed the communication from nurse to provider should have been communicated urgently. During an interview on 4/13/2023 at 3:51 PM, LPN #6 confirmed she worked from 3:00 PM to 11:00 PM on 3/28/2023 and was the charge nurse assigned to give care to Resident #15. LPN #6 stated she was informed of Resident #15's x-ray results between 6:00 PM to 6:55 PM and she then notified NP #1 and was give an order to transfer Resident #15 out to the hospital. LPN #6 stated she also contacted Resident #15's RP and notified them of the xray results and that the Resident #15 would be transferred out to the hospital. LPN #6 confirmed that during nursing report at the beginning of her shift, she was informed Resident #15's left leg was swollen and that an x-ray was ordered. LPN #6 confirmed she went to tell Resident #15 about her results and that she was to be transferred to the hospital and that is when Resident #15 informed her that her leg got twisted in the lift a few days prior. LPN #6 confirmed she called the DON trying to get transportation to send Resident #15 out to the hospital. LPN #6 confirmed that LPN #7 only told her in a verbal report that Resident #15's leg was swollen and LPN #6 confirmed that Resident #15 was alert and can tell things that may have occurred to her. During an interview on 4/17/2023 at 12:02 PM, LPN #7 confirmed she worked from 7:00 AM to 3:00 PM on 3/28/2023 and was assigned the care for Resident #15. LPN #7 stated whenever there was a fall or any other occurrence with a resident that resulted in a possible injury the physician or the NP should be notified, and an event form should be completed in the electronic medical record. LPN #7 was asked did LPN #4 report to her that Resident #15 got her leg tangled in a mechanical lift and her left leg was now swollen and painful. LPN #7 confirmed that LPN #4 had asked her to go to Resident #15's room to observe the resident's leg, and that's when she observed the left leg was swollen. LPN #7 was asked if she had documented her observations in the medical record and LPN #7 stated she did not. LPN #7 stated she did not assess Resident #15. LPN #7 stated she did notify the oncoming nurse that radiology was coming to do an x-ray of Resident #15's left leg that it was swollen. The facility staff failed to notify in a timely manner the Administrator, DON, NP and /or the Physician of the injury to Resident #15 left leg that occurred during the use of a mechanical lift that resulted in a fracture to the left leg.