**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Resident #1 and Resident #242) reviewed for adequate supervision. 1. The facility failed to transfer Resident #1 with a mechanical lift and 2 staff member assistance, resulting in a laceration to her right lower extremity requiring 16 sutures. 2. The facility did not ensure the brakes were engaged when Resident #242 was lifted and lowered with the Hoyer device (an assistive lift device that allows for transfer using electrical power). These failures could place residents at risk for injury, harm,or impairment. Findings included: 1. Record review of Resident #1's admission Record indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included senile degeneration of the brain (the mental loss of intellectual ability that is associated with old age), repeated falls, abnormalities in gait (when a person is unable to walk in the usual way), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should, and anxiety (Intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's MDS dated [DATE] revealed a BIMS with a score of 4, which indicated severely impaired cognition. The MDS also revealed, Resident #1, required extensive assistance with 2 staff members for transfers. Record review of Resident #1's Care Plan, completed by the DON, revealed a problem initiation on 12/05/2022 for a laceration to right lower posterior leg from a wheelchair transfer by hospice aide. The laceration measured 6.0cm X 4.0cm X 0.5cm and required 16 sutures in the emergency room. Care plan titled ADL assistance revealed Resident #1 required extensive assistance of 2 staff members for transfer. Record review of Resident #1's accident and injury report completed by LVN G, indicated on 12/05/2022 Resident #1, sustained an injury to her right lower extremity measuring 6.0cm X 4.0cm X 0.5cm. The accident report revealed Resident #1 was in moderate pain, there was a large amount of blood, the accident occurred during transfer, first aid was administered, and Resident #1 was sent to the emergency room. The accident report revealed the injury was a large laceration with jagged edges that needed sutures. Record review of Resident #1's nursing notes dated 12/05/2022 revealed the following: LVN G wrote: This nurse called to resident's room (Resident #1). Resident received laceration to RLE (right lower extremity) 6.0cm X 4.0cm X 0.5cm. First aid performed to stop bleeding. EMS (emergency medical service called for transfer to a local emergency room for further evaluation. NP (nurse practitioner) and family aware. Record review of a hospital exam dated 12/05/2022 indicated Resident #1 came to the emergency room after suffering a laceration to right calf area measuring 6.0cm X 3.8cm. The laceration required sutures to approximate the skin and stop the bleeding. Procedure completed and Resident #1 was sent back to the nursing facility. During observation and interview on 01/09/2023 at 2:30 p.m., Resident #1's family stated on 12/05/2022 she was called and informed that Resident #1 was being sent to the ER because she had a skin tear to her leg. Resident #1's family stated she met Resident #1 in the ER and she had more than a skin tear. She stated it was a huge laceration that required 16 sutures. She stated she stayed with Resident #1 until the sutures were completed, and the ER (emergency room) sent her back to the facility. Resident #1 was well-groomed lying-in bed with family at bedside. During an interview on 01/10/2023 at 9:40 a.m., CNA B said she had worked at the facility for several years and was the full time CNA for 100 hall (the hall Resident #1 resided on). CNA B stated she remembered the incident in which Resident #1 sustained a laceration to her right lower extremity. CNA B stated that was the day the Hospice CNA F reported to her she had transferred Resident #1 by herself with no assistance. CNA B stated she remembered it because it was a huge deal that she transferred Resident #1 alone and Resident #1 was injured in the process. CNA B explained that Resident #1 was always a 2-person mechanical lift transfer. CNA B further explained that Resident #1 was too unpredictable to attempt any kind of stand pivot transfer and for the safety of the resident and the CNA she must be transferred by mechanical lift and always have 2 staff. CNA B stated, Hospice CNA F knew Resident #1 was a mechanical lift with 2 staff because Hospice CNA F had assisted her with the mechanical lift transfer of Resident #1 several times before. During an interview on 01/10/2023 at 2:00 p.m., LVN G stated she recalled the incident that occurred on 12/05/2022 with Resident #1 and Hospice CNA F. LVN #G stated she was called down to Resident 1's room and noted a large amount of blood pooled beneath her wheelchair. She noted a large laceration to Resident #1's right posterior calf area. LVN G stated, Hospice CNA F told her she was not sure how it happened but Resident #1 had to have scratched her leg on the wheelchair during transfer. Hospice CNA F stated she did transfer Resident #1 alone. LVN G stated Hospice CNA F called her supervisor and told her the laceration occurred and the facility was sending Resident #1 to the hospital. LVN G was not aware of any education or disciplinary action for Hospice CNA F. LVN G stated the care plan, as well as the CNA kiosk had the information for each resident's care needs. LVN G stated the hospice CNAs generally asked the nurse or another CNA if they were unsure of how to transfer a resident. LVN G stated Hospice CNA F had been to the building dozens of times and was the assigned hospice CNA to Resident #1. LVN G stated Hospice CNA F had transferred Resident #1 with the assistance of herself and other staff members by mechanical lift multiple times prior to the incident. During an interview on 01/10/2023 at 3:00 p.m., Hospice CNA F stated she transferred Resident #1 alone at least once per week. Hospice CNA F stated on 12/05/2022 around 4:00 p.m., she transferred Resident #1 with a stand pivot transfer. She got ready to leave the room wheeling Resident #1 and noted a small pool of blood beneath Resident #1's wheelchair. She stated she immediately called for help, the nurse came, and first aid was administered. Hospice CNA F stated she did not have access to the facilities records to know how they had Resident #1's care planned for transfer. Hospice CNA F stated she believed hospice had Resident #1 care planned as a 1-person transfer. Hospice CNA F stated she had not reviewed the facility or hospice care plan. Hospice CNA F further explained she was tall and had not had any problem transferring Resident #1 alone in the past. Hospice CNA F stated she knew the facility used a mechanical lift to transfer Resident #1. She stated she felt the facility used a mechanical lift because the CNAs were short, and Resident #1 was tall, and they could not handle her. Hospice CNA F stated she had not received any further training on transfers by the facility of the hospice company, nor had she received any direction on how to communicate with the facility about the amount of care each resident required. Hospice CNA F stated she had been back in the facility and cared for other hospice resident's a dozen times since 12/05/2022 with no further education on transfer. Record review of hospice plan of care with a start date of 07/18/2022, revealed Resident # 1 was always a 2-person mechanical lift transfer. Hospice provided the mechanical lift and the sling required for transfer on 07/18/2022. During an interview on 01/10/2023 at 3:30 p.m., the DON revealed she was informed on 12/05/2022, that Resident #1 had sustained a laceration to her right calf during the improper transfer and was being sent to the ER for evaluation. The DON stated she reviewed the accident report and questioned Hospice CNA F. The DON stated Hospice CNA F had a horrible attitude and was loud with her when she attempted to educate her on communicating with the staff about how many people should be assisting with transfers. The DON stated she attempted to educate Hospice CNA F, but Hospice CNA F called her manager and told her the facility was demanding Resident #1's care plan be changed to 2-person mechanical lift transfer. The DON stated she told the Hospice Nurse Manager not to send the CNA back into the facility and that the facility and hospice care plans had to be the same. The DON stated she attempted to educate Hospice CNA F to ask staff, look at the hospice care plan, or look at the CNA kiosk before providing care to ensure she was giving proper safe care. The DON stated the hospice staff had to ask the facility staff for access to the facility care plan and the kiosk which contained the CNA care plan for each resident The only way for the hospice staff to know the resident's plan of care was to ask the staff to see it or look at the hospice care plan. The DON was not aware of how many times Hospice CNA F had been back to the building following the 12/05/2022 incident. No paperwork was located showing documentation of education for any CNA after the improper transfer with a laceration occurred. During an interview on 01/10/2023 at 4:40 p.m., Hospice RN manager E revealed she was called by Hospice CNA F and informed Resident #1 was being sent to the ER following an incident in which Resident #1 was injured during a transfer. Hospice RN E stated Hospice CNA F thought Resident #1 was a one-person pivot transfer and requested that Resident #1's hospice care plan be changed to reflect the 2-person mechanical lift transfer. Hospice RN manager E revealed she did not change the care plan to a 2-person mechanical transfer. She stated when she looked at it, hospice was already providing a mechanical lift and sling for the transfer of Resident #1. Hospice RN manager E stated she did not do further education with Hospice CNA F ensuring resident safety and continuity of care. Hospice RN manager E stated the hospice company educated the CNAs to always speak the nurse and CNA prior to care to ensure no changes in the resident care status had occurred. Hospice RN manager E stated the hospice CNAs were educated to follow the hospice care plan which was located in the hospice book at each nurses station. During an interview on 01/11/2023 at 10:15 a.m., the DON stated the incident from 12/05/2022 with Resident #1, could have been prevented if the Hospice CNA F had followed the plan of care set forth by the facility and transferred Resident #1 with a mechanical lift with 2 staff members present. The failure to do so resulted in a laceration to her right calf requiring 16 sutures. The DON stated she attempted to do education with Hospice CNA F, and she was not receptive to the education. The DON stated she talked to the Hospice RN E and requested Hospice CNA F not take care of Resident #1 and that all hospice care plans match facility care plans for continuity of care. The DON stated failure to provide adequate supervision for ADLs will result in injury and could result in serious injury. During an interview on 01/11/2023 at 10:30 a.m., the Administrator stated He stated that hospice should have educated their staff on following the care plan and safe transfers. The Administrator stated he knew the facility was responsible for resident safety no matter who was caring for them. The Administrator stated not providing the proper supervision during care can result in serious injury and harm. The Administrator stated the facility had monthly in services and following resident care plans was discussed at least quarterly and upon hire with each staff member. 2.Record review of the Resident #242's physician order report indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, epilepsy (a brain disorder that causes recurring, unprovoked seizures), Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and muscle spasm. Record review of the active physician order dated 1/6/23 indicated Resident #242 was to have fall precautions in place. Record review of the care plan reviewed by the facility on 1/10/22 indicated Resident #242's environment would be monitored to decrease risk for falls. During an observation on 1/10/23 at 11:40 a.m., CNA H had positioned the Hoyer net under Resident #242 in her wheelchair. CNA H left the room and returned with LVN G to complete the transfer. CNA H moved the mechanical lift into place in front of the wheelchair. CNA H then lowered the device (brought the cradle into appropriate position to secure the mechanical lift net). LVN G and CNA H secured the mechanical lift net to the cradle. CNA H did not lock the brakes of the mechanical lift. CNA H raised Resident #242 up in the mechanical lift. CNA H and LVN G moved the lift and positioned Resident #242 over her bed. CNA H, without locking the brakes, lowered Resident #242 onto her bed. During an interview on 1/10/23 at 11:49 a.m., CNA H said she should have locked the brakes before she lifted or lowered Resident #242. CNA H said she did not lock the brakes because she forgot. CNA H said it was important to lock the brakes of the mechanical lift before a resident was lifted or lowered because the lift could move which might cause the resident to bang into something or fall. During an interview on 1/10/23 at 11:50 a.m., LVN K said staff should always make sure the brakes are applied on the mechanical lift before a resident was lifted/lowered. LVN K said leaving the brakes unlocked while a resident was lifted/lowered could cause the lift to jerk or slide, which could startle the resident. LVN K elaborated, the Resident could fall out of the lift or the lift could fall over with the Resident in the lift. During an interview on 1/11/23 at 10:36 a.m., LVN G said she did not realize CNA H had not locked the brakes of the mechanical lift before lifting/lowering Resident #242 yesterday (1/10/22). LVN G said it was very important to lock the brakes of the mechanical lift before a resident was lifted/lowered because the resident could fall out or the lift could tip over. During an interview on 1/11/23 at 1:45 p.m., the DON said she expected staff to ensure brakes were applied on the mechanical lift before a resident was lifted/lowered. The DON said she expected staff to ensure brakes were applied on the device (bed or chair) the Resident was lifted from, the device the Resident was lowered to (bed or chair) and the mechanical lift brakes were locked before lifting or lowering the Resident. She said these safety mechanisms (locking the brakes) were in place to prevent injury. The DON said failure to ensure the brakes were locked on the mechanical lift device could have resulted in significant injury. During an interview on 1/11/23 at 2:06 p.m., the Administrator said staff should have locked the brakes on the Mechanical lift before lifting/lowering Resident #242. The Administrator said he expected staff to utilize all approaches to safety. Record review of an undated policy entitled Accidents and Supervision revealed, Avoidable Accident means that an accident occurred because the facility failed to: * identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or * Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or * Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and/or * Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. Record review of the undated facility policy titled, General Safety Policy stated, In general, all employees will maintain a safe environment and report any issues immediately. Procedure: 1. Employees will report all unsafe or potentially hazardous acts or conditions to the supervisor immediately. Supervisors/managers will be responsible for implementing protocol to resolve the unsafe or potentially hazardous condition immediately .8. Any incident (e.g., any unusual occurrence that is not consistent with routine facility activity) must be reported immediately. Reporting incidents will assist in providing a safe and secure environment for residents, visitors, and employees. An Incident Report form must be completed within one hour of the occurrence and submitted to your supervisor as soon as possible after completing the report form. 9. The supervisor must investigate the incident report immediately. After the investigation is complete, the supervisor will complete a follow-up report, attach it to the original incident report and submit both reports to the DON before the end of the shift. 10. If the incident involves an employee or resident injury, first aid and subsequent medical evaluation as needed will be provided first. The incident reports will reflect the delay in submitting the report to the DON.