**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 resident (Resident #1) reviewed for accidents. The facility failed to use the appropriate transfer for Resident #1 which resulted in a positive fracture to the lower left extremity (ankle). The noncompliance was identified as past non compliance. The Immediate Jeopardy began on 02/21/24 and ended on 02/27/24. This failure could place residents at risk for harm and further injuries. The findings included: Review of Resident #1's face sheet (dated 03/01/24) indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had a diagnoses of hemiplegia (paralysis of one side of the body), osteoarthritis (degenerative joint disease) and a history of falling. Review of Resident #1's comprehensive MDS dated [DATE] revealed Resident #1 had a BIMS score of 10 which indicated Resident #1 cognition was moderately impaired. The MDS Assessment for Resident #1 revealed in section I8000 that the Resident #1 had an active diagnoses of history of falling. Section J1700 revealed that Resident #1 had not had a fall within the past 6 months before admission. Section V 0200 revealed that Resident #1 did trigger for the CAA: Falls and ADL functional/Rehabilitation. Section GG revealed that upon admission that the resident did none of the effort to completed the following ADL: chair/bed transfer, tub/shower transfer and car transfer. Review of Resident #1's care plan, dated 03/01/24, revealed the following: Date initiated: 01/03/24 Date revised: 03/01/24 Focus: The resident has an ADL self-care performance deficit r/t stroke left side hemiplegia. Goal: The resident will improve current level of function in ADLs through the review date. The resident will maintain current level of function through the review date. Interventions: The resident requires total liftx2 staff assistance for transfers non-weight bearing status related to left ankle fracture Date initiated: 02/27/24 Date revised: 02/29/24 Focus: The resident had an actual fall with serious injury. Resident had poor balance, unsteady gait, and left side deficits due to history of stroke. Goal: The resident fracture to lower leg will continue to heal without complication. Intervention: CAM boot to be removed each shift for skin check, then replaced. Evaluate for pain as needed. Resident to wear CAM boot at all time for fracture healing. Date initiated: 03/01/24 Date revised: 03/01/24 Focus: The resident is high risk for falls related to hemiplegia (paralysis of one side) Goal: The resident will not sustain serious injury through the review date. Interventions: Anticipate the resident's needs. Be sure the call light is within reach and encourage the resident to use it. Provide floor mats when in bed. PT evaluate and treat as ordered or PRN. Review of Resident #1's progress notes, from 02/21/24-02/27/24 revealed the following: On O2/21/24 at 1:50 PM Called to room by CNA, resident laying on floor on back with legs stretched out, mat behind her head. CNA states 'had to lower resident to floor due to she started sliding down during transfer from W/C to bed'. Assessed resident, no apparent injuries observed, resident denies any pain or discomfort, able to move extremities as prior and is able to function as did prior to being lowered to floor. CNA states 'the resident did not hit her head'. Notified residents Family Member at 3:17 PM, ADM and DON notified. Provider present at this time and was aware Author: RN A On O2/21/24 at 3:17 PM Received results of labs and provider reviewed. New order for Amoxicillin X 5 days for laryngitis. Notified residents family member of new orders and of resident being lowered to floor during transfer from wheelchair to bed, stated 'okay, thank you'. Will continue to monitor. Author: RN A On O2/22/24 at 2:31 PM IDT reviewed fall interventions. Continue current plan of care. Author: ADM On O2/23/24 at 9:39 AM Resident with complained of pain at a rate of 9 to the lower left extremity (LLE) this morning, upon assessment edema noted from left foot up to the left hip. Orders received for x-ray of the LLE and Venous Doppler, nurse to notify provider upon receive of results. Resident did not eat breakfast this morning and was assisted back to bed. Author: LVN G On O2/23/24 at 5:30 PM Venous Doppler results received, new order noted for Lovenox 40mg SQ BID x 7days, to start Eliquis 5mg 1 PO BID, Family Member in facility, verbalized understanding for new orders. Author: LVN G On O2/23/24 (Time not indicated) Resident continues on active charting due to assisted fall to the floor with no injuries. Also on active charting due to new order for Amoxicillin for DX: Laryngitis. Resident was resting in bed with eyes closed. Respirations are even and non labored. No signs and symptoms of distress noted. Call light and fluids are within reach. Bed is in lowest locked position for residents safety. Staff will continue to monitor for changes or needs this shift. Plan of care ongoing. Author: LVN F On O2/25/24 at 3:03 AM Give 1 tablet by mouth every 6 hours as needed for Pain - Moderate. Author: LVN E On O2/26/24 at 9:52 AM IDT reviewed Resident #1's fall. Resident #1 was lowered to the ground while being transferred by CNA. Transfer status reviewed, will continue plan of care to transfer x2 staff Author: ADM On O2/26/24 at 6:50 PM New order for X-Ray to left ankle d/t tenderness and redness to area. Family notified. Results pending. Author: LVN D On O2/26/24 at 7:56 PM FNP in facility visiting and assessing the resident. The resident continued to have edema to left lower leg with increased tenderness to left ankle area. X-ray ordered and provider reviewed images, it appears for resident to have a fracture to left ankle. New order for resident to be NPO after midnight. Physician C contacted family. Author: RN B O2/27/24 at 12:49 PM Resident went to the Podiatrist by staff via gerichair for fracture. Returned with the orders to keep CAM Boot to Left Lower Extremity, Re-xray in 3 weeks. There was no apparent distress at this time. Staff will continue to monitor. Author: RN A Record review of the provider investigator report (3613) dated 03/01/24 revealed the following: Allegation: CNA A was assisting Resident #1 in transfer and had to lower her to the floor when Resident #1 started to slide down during the transfer. Provider Response: Swelling and tenderness started 2/23, resident positive for DVT. Symptoms continued, x-ray showed positive fracture 2/26. CNA transferring at time of fall was suspended. Parties notified: family, physician, DON, administrator Investigation Findings: Confirmed Provider Action Taken Post-Investigation: Re-education, mentor assignment, minimal 3 week transfer observations, 100% audit of transfer status Investigative Summary: 2/21/24 - NA H was assisting Resident #1 in transfer and had to lower her to the floor when NA H started to slide down during the transfer. RN A assessed and found resident was able to move extremities as prior level of function and resident denied pain or discomfort. Notification was made to DON, Administrator and provider and family. RN A gave immediate re-education to NA H on transfer status as Resident #1 should have been transferred with the assistance of 2 people. Formal re-education was given by RN Q and LVN R to aides working with Resident #1. 2/23/24 - Resident #1 complained of pain (9) to the left lower extremity, upon assessment edema noted from left foot up to the left hip. Orders received from, X-Ray of the left lower extremity and Venous Doppler. Venous Doppler results received positive for DVT, new order noted for Lovenox 40mg SQ BID x 7days, to start Eliquis 5mg 1 PO BID, D/C ASA per provider, Son notified. Provider stated X-ray to left lower leg cancelled due to positive DVT. [family member]in facility and verbalized understanding of new orders. Resident #1 is to remain on bedrest and use lift for transfers. 2/26/24 - Provider ordered x-ray to left ankle due to tenderness and redness to the area. XRay result was positive for ankle fracture. Order received for NPO after midnight and arrangements made to see podiatrist in the morning. Upon discovery of fracture, aide was suspended pending investigation. 2/27/24 - Podiatrist diagnosed a bimalleolar fracture to the left ankle. Resident has been bound with CAM boot in place to left lower extremity. Podiatrist and Provider indicated the resident was not a candidate for surgery, [family member] agrees. Resident has been medicated for pain with Tramadol and Tylenol prn. 1:1 counseling was completed by DON before NA H provided patient care. ADM and DON reviewed the incident. On 1/24/2024 all staff including aide involved were educated on fall prevention, care plan and [NAME] use. 2/27/24 a complete audit of transfer status was completed by DON. A in-service started re-educating all CNAs on [NAME] transfer status and compliance. Transfer competencies completed by nurse managers on all CNAs. In order to achieve/maintain compliance, nurse managers will observe 3 transfers per day Monday through Friday for 3 weeks and floor nurses will complete 3 transfer observations twice daily for 3 weeks or until substantial compliance is achieved. Upon discovery of fracture, aide was suspended pending investigation. 1:1 counseling was completed by DON before NA H provided patient care. The administrator and DON acknowledge the transfer status was not followed appropriately. NA H acknowledges she made a mistake and failure to read the [NAME] caused the fall. While injury did occur, it was not intentional rather a mistake was made and therefore, abuse is unsubstantiated. A review of NA H performance, attitude and aptitude have been considered by the management team. NA H has demonstrated compassion, care, and willingness to learn. She will be paired with a mentor for 4 weeks with a weekly nurse manager review. NA H was advised that any further failure to follow a resident's [NAME] will result in termination. An interview on 03/07/24 at 3:55 PM with Resident #1 revealed that she did not know how she fractured her ankle. She said that she was not in any pain at the time of the interview. She said the staff at the facility were nice to her, and she had no concerns. She said staff usually clip her call light or lay it near her. She said the only downside was now having to wear a brief and be changed because she could go to the restroom on her own before. She said she had COVID and wanted to rest. Observation on 03/07/24 at 3:55 PM, Resident #1 was observed lying in bed. Her bed was in the lowest position, and a floor mat was on the side of the bed. She had a CAM boot on her left ankle. An interview with NA H on 03/13/24 at 10:30 AM revealed that she no longer worked at the facility. She said that due to the incident, she was no longer confident in her ability to transfer residents safely. She said this was a decision that she made on her own. She said that she was bringing Resident #1 back from labs. She said she got her as close to the bed and locked her wheelchair. She said it slipped her mind that she was weak on her left side, and that was the side that she transferred on. She said she used the gait belt. She said she thought she was a one-person transfer at the time. She said that when Resident #1 first arrived, she was a two-person with the Hoyer, then went to a two-person without the Hoyer. She said she thought she was a one-person transfer with the gait belt. She said that after she saw that Resident #1 was sliding down, she eased her to the floor and placed the floor mat behind her to make her comfortable. She said she looked out of the room and asked her coworkers for help. She said they told her to get a nurse. She said she did, and after Resident #1 was assessed, they were permitted to transfer her to the bed. She said that she was immediately counseled that she was a two-person transfer. She said that during the nurse assessment and transfer into the bed, the resident did not indicate that she was in pain at the time of the incident. She said she was counseled and retrained at least twice and had to demonstrate that she knew where to find resident transfers and that she could safely transfer using the gate belt, a second person, and the Hoyer lift. An interview on 03/07/24 at 2:36 PM with CNA J revealed she had worked with Resident #1 but does not have any firsthand information about the incident that occurred with NA H. She said she was working with another patient when NA H asked her for assistance. She said she walked into the room and observed Resident #1 on the floor. She said she advised NA H to get the nurse. NA H explained that she had to sit Resident #1 down. She said the nurse conducted her assessment and then had them transfer Resident #1 to the bed. She said Resident #1 did not appear to be in any pain when she arrived in the room. She said Resident #1 looked at her and smiled when she walked into the room. She said that Resident #1 did not appear to be in pain during the transfer. She said NA H did not express why she transferred Resident #1 alone. She said she had never transferred Resident #1 alone because she required two people. She said she had been trained and had to demonstrate her knowledge and use of the gait belt and where to find the transfer in the computer and the Hoyer lift. An interview with the ADM on 03/07/24 at 12:37 PM revealed that she investigated the incident involving Resident #1 and NA H. She said she found that on 02/21/24, NA H was assisting Resident #1 in a transfer when she had to assist her down to the floor. She stated that a nurse assessed Resident #1. She stated that Resident #1 did not exhibit any signs of pain at the time of the incident. She stated the family, and the physician were notified of the incident. She stated that NA H was counseled immediately due to the incident because there should have been two staff to complete the transfer for Resident #1. She stated that two additional superior nursing staff later counseled NA H about transfer status. She stated the staff continued to monitor Resident #1. She stated on 02/23/24, Resident #1 was complaining of pain at a 9. She stated that the staff noticed that she had edema from her left foot up to her left hip. She stated that this information was reported to the provider, and an X-ray and Doppler were ordered. She stated because of the findings of a DVT then, they held off on the X-ray because I believed the issue had been found. She stated that Resident #1 had been notified of the finding. She said Resident #1 was to remain on bed rest, and the transfer had been upgraded to using the Hoyer lift. She said 02/26/24 an X-ray was conducted, and an X-ray was found. She stated the provider was notified and ordered that she be NPO on this date to see the podiatrist the next day (02/27/24). She said the podiatrist confirmed the fracture on 02/27/24. The podiatrist stated that Resident #1 was not a candidate for surgery. She said once the fracture was confirmed NA H was suspended. She said the DON provided one-on-one training before they allowed NA H to return. NA H was brought back to the facility on [DATE]. As a result of the incident, she said that education was provided to 100 percent of all certified nurse aides. She stated that 6 transfers are monitored per shift moving forward. She said that during the training of all NAs, they had to demonstrate back their ability to do a proper transfer. She stated that the wrong transfer was used, but they unsubstantiated their investigation for abuse because it was unintentional. She said NA H was an aide who had shown much promise and had no issues before the incident with Resident #1 or other residents. She said that in addition to the training provided, they partnered NA H with a mentor. NA H ultimately decided she no longer wanted to be an aide and resigned. She said when she asked NA H why she chose to transfer Resident #1 on her own, she was told by NA H that she had seen other staff transfer that way. The ADM said Resident #1 was a fall risk before the incident. The ADM indicated that NA H had completed the certified nurse aide course and was waiting to take her test and was able to provide services to the residents in the facility. An interview with the DON on 03/07/24 at 12:38 PM agreed with what the ADM said happened between NA H and Resident #1. She said that due to the incident, nurses are rounding more frequently and observing transfers throughout the day. She said the nurses had to sign off and verify that the CNAs were using the proper lift. She said before the incident, she required two people to assist her in transferring, but now she still needed two people, and the staff should be using the Hoyer lift. She said when the Doppler picked up the DVT (blood clot), they thought they had found the problem. When they observed the redness and swelling, they got an X-ray. She said at the time of the incident, the X-ray and Doppler were not done because the resident did not show any signs of pain, and there was no swelling. An interview with RN A on 03/15/24 at 12:18 PM revealed that she was the nurse on duty on the day when Resident #1 fell. She said she was unsure of the exact date because she was PRN. She said she did know that it was in February of 2024. She said she got called to Resident #1's room by staff. She said she did not know the name of the staff. She said Resident #1 was propped up on the closet door when she arrived with a cushion behind her. She said she assessed the resident and found nothing indicating that Resident #1 was in pain or had injuries. She said the assessment included taking her vital signs, asking her if she was in pain, and if she could move her upper and lower extremities. She said Resident #1 was not in pain and that she and another staff member had transferred her to bed. She said she rechecked her for bruises and swelling and saw nothing. She said she notified the ADM, DON, provider, and family of the incident. She said she spoke with the staff member who initially transferred her and asked what happened. She said the staff told her she was attempting to transfer her, but Resident #1 started going down. She said that when Resident #1 started falling, she eased Resident #1 to the floor. RN A said she was told that Resident #1 did not hit her head. She said that she asked if the staff knew where to go to find the residents' transfers and that the staff told her no. She said that she reported this information to management. She said that she (RN A) did not specifically know what Resident #1's transfer was but that based on her weak left side and history of a stroke, she would have assumed that she required two staff. She said she was familiar with the facility's paper version to indicate transfers, but the electronic version was new. She said that in-servicing on transfers started the day she worked when Resident #1 fell. She said that she was unaware that Resident #1 had a fracture until the day Resident #1 went to the podiatrist because that was the next time she worked. Record review of the facility in-service, ANE, Fall Prevention, Care Plan and [NAME] interventions, dated 01/24/24 17 staff had been in serviced. Record review of the facility in-service, dignity, transfers/gait belts/ lift, dated 01/26/24 57 staff had been in serviced. This inservice did include NA H. Record review of NA H Nurse Aide Performance Record, dated 12/13/23-1/05/23 revealed that she had satisfactory performance for all procedural guidelines to include basic restoration services (assisting resident to transfer to chair or wheelchair) Record review of one-to one in-service for NA H, dated 02/21/24, revealed the following: Reviewed resident transfer status and [NAME] location/utilization. Staff educated were able to state they do know location of [NAME] information and where to find transfer status. Return demonstration of finding [NAME] provided by staff. Education provided to refer to [NAME] prior to transferring to ensure proper transfer status is used. (signed by NA H). Record review of Employee Counseling Report dated 02/27/24 revealed NA H was suspended until reeducation with transfers and where to find transfers status and that this decision was a result to the incident that occurred on 02/21/24 when she assisted Resident #1 to the floor. It stated the expectation was for NA H to use the [NAME] to ensure proper transfer status is being used and she should follow the plan of care. It explained the next action would be termination. Record review of transfer audit dated 3/02/24-03/07/24 revealed a total of 96 audits had been observed, verified by a licensed nurse and completed appropriately. An interview on 03/07/24 at 4:28 PM with the ADM revealed there was no specific policy for incident and accident prevention but that they used the fall prevention policy. Review of the facility policy and procedure, Fall Evaluation and Prevention, dated 08/2020, reflected: Purpose To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. Policy The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. INTERVENTION SUGGESTIONS FOR FALL PREVENTION Encourage resident to request assistance with transfers and ambulation. Position bed so that the exit is toward the resident strong side.