**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care subject to the resident's advance directives for one (Resident #1) of four residents reviewed for cardiopulmonary resuscitation. On [DATE], LVN A found Resident #1 unresponsive. LVN A said she a pulse was not felt, and a heartbeat was faintly heard. LVN A did not initiate CPR to Resident #1. LVN A failed to review Resident #1's Advance Directives choice, Full Code, when she discovered Resident #1 unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:06 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice could affect all residents who requested a full code status at risk of not receiving necessary life-saving measures. Findings included: Record review of Resident #1's admission MDS (a standardized assessment tool that measures health status in nursing home residents) assessment, dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with a BIMS score of 09, which suggested moderately impaired cognition (difficulty with problem-solving, remembering names and details, and may withdraw socially as new situations and places are challenging). Resident #1 had diagnoses of Medically Complex Conditions, active diagnoses of HF; HTN (when the pressure in the blood vessels is too high - 140/90 mmHg or higher); T2DM (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high); HLD (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides); and Pressure ulcer of sacral region, unstageable. The admission MDS assessment reflected Resident #1 required one-person physical assist with bed mobility, dressing, eating, toilet use, and personal hygiene ADLs; and required two+ persons physical assist with transfer and locomotion on/off unit. Resident #1 functional status with balance during transitions and walking reflected not steady, only able to stabilize with staff assistance moving from seated to standing position and surface-to-surface transfer. Resident #1 was always incontinent of bladder and bowel. The admission MDS did not indicate Resident #1 had any behavioral symptoms or rejection of care during the MDS review period. A significant change in status MDS assessment dated [DATE] reflected Resident #1 enrolled in a hospice program. A review of a Facility Notification of admission dated [DATE] reflected Resident #1's admission date ([DATE]) to hospice services and a Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation (action or process of reviving someone from unconsciousness or apparent death) procedures (chest compressions, intubation, and defibrillation) will be provided to sustain life. Resident #1 had a terminal diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery and comorbidities of T2DM, Hypertensive urgency (an acute, severe elevation in blood pressure without signs or symptoms of end-organ damage), chronic diastolic CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), and PU of unspecified site. Record review of Resident #1's progress notes, revealed: [DATE] at 11:31 AM, LVN B entered, [Resident #1] refused breakfast and AM medication VS taken 97/40 (BP), 71 (HR) . LVN B notified family member and hospice provider. Effective date: [DATE] at 9:30 AM; Entered date: [DATE] at 8:48 PM by LVN B reflected, [Resident #1] on oxygen via nasal canula, tolerating it well with no distress noted, ate very little took AM medication . Effective date: [DATE] at 10:30 PM; Entered date: [DATE] at 5:24 AM by LVN A reflected, [Resident #1] resting in bed, continues on hospice care, no distress noted . Effective date: [DATE] at 5:24 AM; Entered date: [DATE] at 5:27 AM by LVN A reflected, [Resident #1] is in bed, no respirations, no pulse felt, hospice notified, is on the way to evaluate pt. Effective date: [DATE] at 7:00 AM; Entered date: [DATE] at 9:01 AM by LVN B reflected, hospice nurse arrived at the facility made a pronouncement (make the determination that a person was dead) at 6:37 AM. During an interview on [DATE] at 11:22 AM, the ADON indicated that the facility was responsible for providing care 24 hours a day and 7 days a week no matter if a resident was on hospice or not. The ADON indicated that nurses and CNAs were required to check on residents every two hours which was alternated between the nurse and the CNA every hour. The ADON described Resident #1 as total care, one person assistance for ADLs, two persons assist for transfers and repositioning, was incontinent, had an indwelling catheter, and wounds. The ADON said that on [DATE] he received a call from LVN A around 6 AM to notify that Resident #1 was found unresponsive and the hospice nurse was on the way. The ADON said that when he arrived at the facility, the hospice nurse was present and had pronounced Resident #1 dead. The ADON said that he spoke with LVN A to obtain more information about Resident #1's condition prior to discovered unresponsive. During an interview on [DATE] at 2:18 PM, CNA H indicated she worked and provided care to Resident #1 on [DATE] during the 2 PM - 10 PM shift. CNA H defined a change of condition as refusing to eat, sleeping more, or changes in behavior. CNA H said that staff are expected to check on residents every two hours. CNA H said Resident #1 required repositioning every two hours by two people. CNA H said that moaning was a common pain behavior for Resident #1. CNA H said that she assisted Resident #1 with eating and notified the nurse (on [DATE]) when Resident #1 moaned and refused to eat. CNA H said she checked on Resident #1 before the end of shift, around 9 PM, and with the oncoming CNA during change of shift rounds. CNA H said that Resident #1 did not present with acute distress. During an interview on [DATE] at 2:43 PM, the DON was not able to speak to the facility's policies and procedures because she was a new hire attending orientation. During an interview on [DATE] at 4:15 PM, LVN B indicated he worked a double shift (6A - 2P and 2P - 10P) on [DATE]. LVN B said that he was relieved by LVN A for the 10P to 6A shift. LVN B said that he conducted walking rounds with and gave verbal report to LVN A. LVN B said that Resident #1 was observed in bed during walking rounds, awake and alert, no acute distress. LVN B said upon arrival to work on [DATE] for the 6A - 2P shift, LVN A reported that Resident #1 passed away around 5 AM, that she called the hospice nurse, and was on the way. LVN B said that he went to observe and assessed Resident #1 condition. LVN B said that Resident #1 was unresponsive and not breathing. LVN B did not indicate if he felt Resident #1's pulse. LVN B said that he completed walking rounds and received report from LVN A. LVN B said that he called the ADON to inform about Resident #1 and then placed a call to the RP. LVN B said that the hospice nurse arrived sometime after 6 AM and pronounced Resident #1 dead shortly after 6:30 AM. LVN B said that Resident #1's hospice binder reflected the advance directives on the front page, the face sheet, that indicated Full Code status. During a phone interview on [DATE] at 4:37 PM, LVN A stated that she worked an extra shift on [DATE], 10P - 6A and was assigned to the hall Resident #1 resided. LVN A said that she received report and conducted walking rounds ([DATE]) with LVN B. LVN A said that she observed Resident #1 in bed. LVN A said that Resident #1 verbally acknowledged when LVN A introduced herself. LVN A said that she was not familiar with Resident #1, that she conducted rounds every two hours to check on all assigned residents. LVN A said that she did not document that she conducted rounds every two hours because it was not required and the CNA that worked that night could not corroborate because she did not assist the CNA to turn and reposition Resident #1. LVN A said that she administered Resident #1 a scheduled pain pill whole in pudding around 11 PM. LVN A said that she followed up with Resident #1 around 1 AM to check the effectiveness of the pain medication and checked Resident #1's vital signs. LVN A said that Resident #1 did not speak when asked about the effectiveness of the pain medication but opened eyes when name was called. LVN A said that Resident #1's vital signs were within normal level, baseline. When asked how she determined Resident #1's vital signs were within normal level, baseline, LVN A replied she compared to other vital sign measurements in the chart. LVN A stated she did not document after she measured the vital signs. LVN A said that she checked on Resident #1 at 3AM and the rise and fall of her chest was observed. LVN A said that when she checked on Resident #1 at 5:00 AM, she called out [Resident #1] name, did not hear a response, checked for breathing by visual inspection of Resident #1's chest for rise and fall, none noted. LVN A said that she did not feel a pulse on Resident #1's wrist or neck. LVN A said that she listened to Resident #1's heart and a heartbeat was faintly heard. LVN A stated she did not start basic life support (BLS). LVN A said that she did not start CPR within 10 seconds when a pulse was not felt. LVN A said that she did not use AED to check (heart) rhythm. LVN A said that she called the hospice nurse to report Resident #1's condition (not breathing, no pulse). LVN A said that she did not know Resident #1's code status because she was not familiar with the resident and knew to call the hospice nurse first about a change in condition. LVN A said that each resident on hospice services had a binder at the nurses' station with a face sheet that has the hospice agency phone number and instructions to call if the resident had a change in condition. LVN A said she did not recall if the face sheet in the hospice binder reflected [Resident #1] code status when she looked for the hospice agency phone number. LVN A said that she did not check Resident #1's chart to verify code status. A review of the hospice agency documents received [DATE] revealed the following: A patient communication form dated [DATE] received from the hospice agency indicated a call was received from the SNF at approximately 5:15 AM ([DATE]) to notify that [Resident #1] expired. A discharge - death progress note dated [DATE], time in: 6:30 AM and time out: 7:20 AM, entered by the hospice RN indicated upon arrival RN noted patient was not breathing. Auscultation confirmed the absence of breath and heart sounds. No carotid pulse (neck pulse) present. TOD 6:37 AM . Patient was treated with fentanyl patches and oxycodone for comfort. Patient had a fast decline. A written recertification by the attending physician, dated [DATE] revealed [Resident #1] was terminally ill with less than six-month life expectancy. The certification period was [DATE] - [DATE]. The narrative statement indicated Resident #1 was admitted to hospice on [DATE] with a terminal diagnosis and had several comorbidities (the simultaneous presence of two or more diseases or medical conditions), weight declined, increased respirations when talking, [Resident #1] denied SOB, if terminal condition allowed to run its natural course, prognosis was estimated 6 months or less. Review of a typed statement dated [DATE] reflected LVN A's actions when Resident #1 was discovered unresponsive on [DATE]: .at about 5:15 AM [Resident #1] in bed no respirations, . did not response when call by name, Radial pulse not felt. Apical Pulse (pulse point of heart on left side of chest) not heard. Hospice was notified [Resident #1] has no respiration and pulse and needs further evaluation. provided facility address and [Resident #1] name. could not Reach RP . NP on call could not be reached. Hospice Nurse informed on her way . The statement revealed LVN A gave handoff report to the oncoming nurse [LVN B] at ([DATE]) 6:20 AM. LVN A reported to LVN B that Resident #1 did not have a pulse or respirations and the Hospice Nurse was on the way to the facility. LVN A's name was typed at the end of the statement. Review of an Employee Coaching and Counseling Record dated [DATE] revealed LVN A violated policy by substandard work performance. The supervisor [ADON] remarks reflected, [LVN A] failed to check code status in EMR, failed to provide CPR, failed to notify RP and management of resident change of condition/expired. The Employee Coaching and Counseling Record reflected a final warning/action plan that indicated [nurses] must know the code status of all residents in their care. When a resident has a change of condition or expire, notify management and RP. During an interview on [DATE] at 2:43 PM, the NFA stated the facility investigated the incident, other residents who may be affected were identified, measures were developed and put in place to avoid reoccurrence of the deficient practice, implemented plans to monitor corrective steps, and provided sufficient evidence. The NFA said that it was the nurse responsibility to know each resident code status they were assigned and where to locate the information for any resident. The NFA indicated LVN A was suspended during investigation, received a final written warning, was in-serviced, and participated in a BLS/CPR recertification course on [DATE] (the course was available to all licensed nurse staff on [DATE] and [DATE]). The NFA stated the medical director was notified and an emergency QAPI meeting was held on [DATE]. The Texas Board of Nursing Licensed Vocational Nurse Scope of Practice, Revised 01/2023, reflected in part, that LVNs must use clinical reasoning and established evidence-based policies, procedures, or guidelines as the basis for clinical judgment in nursing practice. LVNs are accountable and responsible for the quality of nursing care provided and must exercise prudent nursing judgment to ensure the standards of nursing practice are always met. The summary reflected, The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, regulations, and policies, procedures and guidelines of the employing health care institution or practice setting. The LVN functions under his or her own license and assumes accountability and responsibility for the quality of care provided to patients and their families according to the standards of nursing practice. The LVN demonstrates responsibility for continued competence in nursing practice, and develops insight through reflection, self-analysis, self-care, and lifelong learning. Review of the steps for responding to a cardiac arrest, according to the AHA ([NAME] et al., 2020), are: - Check for responsiveness. - Call 911 or have a bystander make the call. - Begin CPR while bystander retrieves an AED. Do not stop CPR. - If not breathing or breathing with agonal breaths (abnormal breathing that often sounds like snoring, snorting, gasping, or labored breathing), start CPR. [NAME] et al. (2020, [DATE]). Part 3: Adult basic and advanced life support - AHA/ASA journals. AHA Journals. https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000916 Record review of the facility's Advance Directives policy dated [DATE], reflected in part, the following: 5. An acknowledgement receipt for Advance Directives/Medical Treatment Decisions must be completed for each patient upon admission and upon any change . 6. Upon completion of an Out-of-Hospital DNR; a telephone order must be entered into the electronic medical record. 7. The Advanced Directive report must be reviewed daily for all patients. Record review of the facility's Hospice Services policy dated [DATE], reflected in part, the following: The facility must meet the following requirements: ensure hospice services meet professional standards . have a written agreement with the hospice of the services hospice will provide . hospice's responsibilities determining the hospice plan of care . services the facility will continue . a communication process. The facility immediately notifies the hospice about a significant change . clinical complications that suggest a need to alter the plan of care . need to transfer the resident from the facility . the resident's death. The NFA was notified of an Immediate Jeopardy (IJ) on [DATE] at 5:06 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on [DATE] at 5:46 PM. The POR reflected immediate action to take the deficiency out of the IJ level of severity; systematic approach of how and when the facility would ensure residents were no longer at a high risk of serious injury, harm, impairment, or death; staff education; and monitoring to prevent recurrence of deficient practice. Immediate action The Medical Director was notified on [DATE] at 11:38 am and an emergency QAPI meeting was conducted with the focus on Hospice residents without a DNR and all care plans reflected resident code status. Root-cause identified that re-education of the CPR procedure was needed. Systematic Approach: 1. The Social Workers conducted chart audits and verified all residents' charts had the appropriate code status in their charts. This was completed on [DATE]. 2. An Advance Directives audit verified actual DNR orders and documentation in the chart. 3. The RDCS educated the NFA, AIT, DON and Unit manager on the CPR policy and procedure. This was completed [DATE] 4. On [DATE], [LVN A] was re-educated on the proper CPR procedure with focus on determining resident code status prior to beginning CPR. 5. The DON & Nurse Managers initiated an in-service on [DATE] to licensed nurses on the proper CPR procedure with focus on determining code status prior to beginning CPR. 6. The facility conducted an audit on [DATE] and verified licensed nursing staff files contained current CPR certification. CPR Training Courses were scheduled for licensed nursing staff. 7. Nurse Management conducted Mock code blue scenarios from [DATE] to [DATE] to ensure lifesaving procedures were understood and followed. A skills checkoff was completed for the nurses participated. The DON will continue to schedule monthly. Licensed nursing staff will be educated upon hires on CPR/Code Blue procedure. Any deficient practice will be corrected and reported to the ED immediately and all findings will be discussed monthly/and as necessary. 8. [LVN A] was suspended on [DATE] pending completion of a thorough investigation. 9. MDS nurses conducted a care plan audit on all resident's code status. This was completed on [DATE]. Education: I. Education began [DATE] on proper CPR procedures. Education will continue until 100% of licensed nursing - FT, PRN, new hire, agency staff have been educated by the DON/Unit Manager/Designee prior to working a scheduled shift. Education included: I. Assessing resident for vital signs to include breath and pulse in multiple locations. Staff should not leave the resident once found unresponsive, staff should stay and call for help. II. All licensed staff must respond to any Code Blue when doing so would not endanger other residents. III. Identifying Code Stats by checking Dr. Order, RN/LVN's checking EMR system and MA/CNA Daily care guides. IV. Elements of Full Code. A. Calling Code Blue/Paging for assistance. B. Division of duties during code. a. Calling 911 b. Crash Cart c. Performing Compressions d. AED use e. Suctioning f. Staff must notify DON to conduct Post incident review upon completion of code to ensure g. proper procedures were followed. Reviews will become part of our monthly QA process. 3. Scope of Practice LVN/RN A. Initiating Code B. Transfer of Code to EMS C. Requirements for ending Code - The facility in-service on scope of practice. CPR to be continued until transfer of care to emergency service personnel. CPR is not to be interrupted until transfer of care. 4. The ED, Unit Manager, and Clinical designee(s) conducted in-services on [DATE] for non-licensed staff regarding the following elements: I. Paging for Code Blue can be done by any staff member. II. Contacting 911 for assistance. III. Reporting to management. IV. AED and Crash Cart location. Monitoring: 1. On-going education competency to ensure understanding of CPR procedure and include: A. Verbal questions/ answers to ensure understanding. B. Daily review of Code status in the morning Clinical stand-up meeting. C. The Nurse will report all code status and changes during the Clinical stand-up meeting. D. DON or designated nurse will observe Code status weekly x 2 and then once monthly thereafter. E. The Executive Director will participate in the Stand-Up and the verbal review by the nurse or designee and review Management Meeting. 2. The Medical Director was notified of the Immediate Jeopardy status. 3. Rounding to ensure prevention methods are in place was completed [DATE]. Quality Assurance: 1. DON or designee will conduct a weekly random audit for a period of 4 weeks ensuring nursing staff will continue to follow Policies & Procedures for Code status. 2. DON or designee will conduct documentation review to ensure all code status is correct. 3. Monitored shifts include 6a-2p, 2p-10p 10p-6a, and the double weekends (6a-10p). 4. The DON will submit audit findings to the QA Committee for review, analysis and to give recommendations. 5. Completion date [DATE]. On [DATE] the surveyor began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Record review of an Advance Directive report printed [DATE] revealed the code status of all admitted residents. The type of directive, Full Code or DNR, was reviewed in sampled residents' charts for accuracy. Record review of QAPI meeting minutes dated [DATE] at 6:15 PM revealed special discussion items that included CPR procedure with focus on determining code status prior to beginning CPR and the focus on hospice residents without DNR advance directives. Record review of a code status report revised [DATE] of all hospice residents, revealed 16 total hospice residents. All hospice residents were DNR except for three residents that reflected a Full Code status. On [DATE], staff interviews were conducted with nurses scheduled on the 6A-2P [LVN B, RN G, LVN P, and RN F] and during the 2P-10P shifts [LVN L, LVN Q, and LVN R] indicated they participated in an in-service training about changes in condition that may require CPR, code status verification, and initiating CPR. Each nurse stated in their own words their responsibility to review the Advanced Directives report at the start of shift and where to locate the code status in the chart. Record review indicated the RDCS held an in-service on [DATE] with the NFA, AIT, DON, and ADON that reflected the immediate concerns, facility expectations, and topic of discussion covered in the in-services with staff. Record review of the POR education bundle was conducted to determine which staff participated in the immediate in-service training as part of the POR. Record review of in-services dated [DATE] titled CPR for LVNs/RNs; Code Status and Change of condition and notifying MD, RP, Management, Hospice for All Nursing Department conducted by the ADON were on-going and reflected the following: In-services conducted by the ADON beginning [DATE] and on-going, titled Code Status revealed a summary of training that code status must be checked at all times during change of condition even if the resident is a hospice patient. The sign in sheet reflected the following staff participated in the in-service: LVN E, LVN AS, LVN AG, LVN AF, LVN W, MDS K, MDS C, LVN Y, RN AT, RN F, LVN AX, RN G, LVN D, LVN S, LVN R, LVN Q, and LVN L. In-services conducted by the ADON beginning [DATE] and on-going, titled Change of Condition and notifying MD, RP, Management, and Hospice revealed a summary of training that Every change of condition must be communicated to the MD, RP, Management and Hospice must also be notified of any change with resident that are on hospice. SBAR (framework for communication between members of the health care team about a patient's condition) and documentation must be completed immediately when there is a change of condition with the resident The sign in sheet reflected the following staff participated in the in-service: RN F, LVN AX, RN AT, CNA H, RN G, CNA AD, LVN D, CNA V, LVN S, CNA I, LVN R, CNA BG, LVN Q, LVN L, CNA AL, LVN E, CNA AC, LVN AS, LVN AG, CNA AJ, LVN AF, LVN W, MDS C, MDS K, LVN Y, CNA BT, and CNA N. In-services conducted by the ADON beginning [DATE] and on-going, titled CPR revealed a summary of training that If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally a licensed staff member who is certified CPR/BLS shall initiate CPR unless: It is know that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for the individual; or There are obvious signs of irreversible death (e.g. rigor mortis [stiffening of the joints and muscles of a body a few hours after death]); if the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a Physician's order not to administer CPR. The sign in sheet reflected the following staff participated in the in-service: LVN W, LVN AS, LVN E, RN AR, LVN AY, LVN AG, RN F, LVN AX, LVN Q, LVN L, RN G, RN AT, LVN R, MDS K, MDS C, and LVN Y. Record review of course participants sign in sheet of the American Heart Association (AHA) BLS/CPR training reflected the following staff participated in the training and a skills check off was completed on [DATE]: LVN AM, LVN P, LVN W, LVN AP, RN AQ, LVN Y, LVN AX, ADON, LVN AS, RN AT, LVN Z, LVN B, MDS C, MDS K, RN AV, LVN AW, LVN D, RN BG, LVN AY, LVN BB, LVN BC, LVN BD, LVN BE, and RN AV. Record review of course participants sign in sheet for the American Heart Association (AHA) BLS/CPR training reflected the following staff participated in the training and skills check off was completed on [DATE]: LVN Q, RN G, LVN R, LVN AF, RN F, LVN P, LVN S, RN AZ, LVN Z, LVN BC, LVN E, LVN L and LVN BA. On [DATE] at 5:46 PM the NFA was notified the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive proper assistive devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents. The facility failed to ensure Resident #1 was properly fitted for a Hoyer lift sling during a two person transfer as a result the patient fell. An Immediate Jeopardy (IJ) situation was determined to have existed on 10/28/22. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could affect residents placing each at risk of injury related to falls . Findings Included: Review of Resident #1 face sheet dated 11/2/22 reflected Resident #1 admitted to the facility on [DATE], she was a [AGE] year old female diagnosed with cerebral infarction (a disruption of blood flow to the brain due to problems with blood vessels that supply it), dementia, dysphagia/aphasia ( language disorder resulting in partial to full loss of language), diabetes, gastrostomy (surgical opening into the stomach from the abdominal wall for introduction of food), hypertension, presence of cardiac pacemaker, pain unspecified, diastolic congestive heart failure (condition in which the heart's left ventricle becomes stiff and unable to fil properly), nausea with vomiting unspecified, personal history of urinary tract infections, and Alzheimer's disease. The face sheet reflected Resident #1 discharged from the facility to the hospital on [DATE]. Review of Resident #1's Quarterly Minimum Data Set, dated [DATE] reflected the resident to be absent of spoken words, rarely to never understood, had problems with both long- and short-term memory, never to rarely displayed cognitive skills for decision making. The resident was totally dependent on staff for activities of daily living such as: bed mobility, dressing, eating, personal hygiene, transfers, and required a wheelchair for mobility. Review of an admission progress note dated 06/28/17 reflected Resident #1 required two person staff assist with bed mobility, transfers, and required use of Hoyer lift. Review of Resident #1's most recent physical and occupational therapy assessment dated [DATE] reflected Resident #1 at her baseline functional mobility was totally dependent. Review of facility's care plan report dated 11/01/22 reflected Resident #1 required total assistance two persons for transfer with Hoyer Lift, was a risk for falls, had impaired communication as evidenced by aphasia, was a potential risk for injury due to unsafe transfers as identified by the nursing/rehabilitation assessment. The care plan report also reflected Resident #1's EC (essential caregiver) was instructed on use the facility sling for transfers and insisted on using the sling she brought to the facility. Review of the facility accident/incident report dated 10/28/22 reflected at 11:30 AM, the MD was notified by LVN B and CNA A: The nurse was assisting aide to transfer patient (Resident #1) from bed to chair with [NAME] (s/p Hoyer) lift, on the process of the transfer the sling was not properly fit, and the patient slipped but nurse quickly held the patient up and assisted her to the floor. Patient was assisted back to the bed, head to toe assessment completed no injury noted, vital sign (s/p signs) within the normal range. The supervisors, MD, and the patient family member notified. Will continue to monitor. Vital signs recorded at time of incident BP 137/78, Temp 97.80, Resp 18 breaths per minute, Pulse 74, O2 98. Review of facility treatment record for Resident #1 dated 10/28/22 reflected serial neurological checks and vital signs were conducted 12:00PM, 12:30 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, and 5:00 PM with her systolic BP ranged from 142-126/ diastolic BP ranged from 84-75, respirations remained at 18 breaths per minute, pulse 68-89 beats per minute, also assessed for neurological function were hand grasp, loss of consciousness, motor function, and pupil reaction were all assessed with no noted changes from her baseline neurological function. Review of facility nursing home to hospital transfer form dated 11/01/22 reflected Resident #1 was sent to the hospital on [DATE] with primary diagnosis nausea with vomiting, time of transfer was 9:30pm emergency contact was notified, physician was notified. The transfer form reflected Resident #1's vital signs at time of transfer were BP 127/77, Pulse 89, Temp 97.7, Resp 18, O2 97% on room air, pain evaluation indicated none, neurological evaluation indicated no changes observed. The transfer form summary stated: Pt was having N/V(nausea/vomiting) X1 on the evening shift while the family member was present in the room, and she requested for her to be sent to the hospital for further evaluation. Review of facility self-report to Texas Health and Human Services Commission(HHSC) dated 11/01/22, reflected an incident occurred involving Resident #1 and was reported to the facility by the resident's family. The self-report indicated it reported the incident to HHSC at 10:00 PM. The reported indicated alleged perpetrators as LVN B and CNA A. The allegation description reflected, The patient family member reported that her mom had a fall when the nurse (LVN B) and CNA (CNA A) were transferring her mom via mechanical lift. The nurse (LVN B) stated that she went to the patient room to assist the CNA (CNA A) with the transfer from the bed to the wheelchair. The CNA (CNA A) hooked the sling to the mechanical lift; during the movement of the lift one of the hooks on the sling pulled away from the lift causing the patient body to shift and her lower body to touch the floor. The nurse and CNA (CNA A) denies the patient hit her head when she was going down with the sling. The self-report described no injury at the time of an assessment completed 10/28/22 at 12:30 PM, it noted there were no bruises, no hematoma, or skin impairments to Resident #1. Review of the facility self-report investigation summary dated 11/01/22 reflected, The nurse (LVN B) reported that the family member wanted her mom up OOB (out of bed) for 2 hours in her chair. During the transfer the nurse and the CNA (CNA A) was transferring the patient via Hoyer lift and suddenly one of the sling hooks came apart from the lift. Leaving 3 hooks still intact to the lift, while the nurse immediate (s/p) jump to assist with protection the patient from hitting her head. The nurse (LVN B) and CNA (CNA A) denies hitting her (Resident #1) head. The family provided video footage and it appears that one of the sling hooks came un-hedged from the lift. All nurses and CNAs were provided with in-service on mechanical lift, including return demonstrations and skills check off, ongoing education to continue. Both the nurse and CNA were terminated due to inappropriate use of the sling. Review of facility witness statement dated 10/28/22, made by LVN B reflected, During the process of transferring the patient (Resident #1) from the bed to chair with Hoyer lift, with the sling provided by the family member. I noticed that one end of the lower part of the sling suddenly came apart. I quickly jumped over to the other side to stop the patient from completely hitting floor, but the patient body was intact on the sling, lowered to the floor. I did not see the patient (Resident #1) head hit the floor. Head to toe assessment was completed. There was no sign of bruises or skin break down noted. The managers were notified and when they came to observe the patient, no distress noted. The family member always lay (s/p lays) out the patient clothes the night before; we was following her instructions. In an interview on 11/01/22 at 11:48 AM with LVN B she stated Resident #1 required total care with transfers and need two-person assistance with a Hoyer lift. She stated on 10/28/22 ADON C, in morning meeting, told her Resident #1's family member wanted to have the resident transferred from the bed to the wheelchair. LVN B stated between 11:00 AM and 11:30 AM she went to assist CNA A and observed a sling in the wheelchair of Resident #1. She stated the family member of Resident #1 the night before would lay out in the resident's room the items staff were to use to care for her mother. LVN B stated CNA A placed the sling under Resident #1 and she positioned herself behind the resident's wheelchair. She stated CNA A hooked the sling to the Hoyer lift spreader bar and prior to lifting the resident from the bed they both ensured the hooks or loops of the sling were secure to the Hoyer lift spreader bar. LVN B stated the sling used had been provided by the resident family member and was not a facility sling. She stated it was different in color, there was only one hook at either corner of the sling provided and facility slings had multiple hooks of different colors at each corner of the sling. LVN B stated during the transfer she positioned herself behind the wheelchair attempted to move the wheelchair under the resident when she noticed one end of the sling suddenly came off of the Hoyer lift spreader bar hook. She stated she then jumped to the side of the patient but by the time she got there Resident #1 had been lowered with the sling to the floor closer to CNA A. LVN B stated Resident #1 was still in the sling and the end of the sling that disconnected was the attachment point nearest the resident's leg. LVN B stated she supported Resident #1's head as CNA A lowered the resident completely to the floor. She stated CNA A went to get a facility sling and they transferred the resident back to bed. LVN B stated she performed a head-to-toe assessment and checked Resident #1 for injuries which she had none. She stated there were no noted bruises, signs or symptoms of distress, resident vital signs were normal, the resident had not vomited, and she noted no signs or symptoms of pain like grimacing. LVN B stated she called the unit managers and physician immediately notified them what happened and that she did not witness the resident hit her head on the floor. She stated ADON C notified Resident #1's family member of what happened, and she notified the resident's family member of a change in the resident's condition when she vomited later in the day at 2:00 PM. LVN B stated after the incident at 11:30 PM every 15 minutes for the 1st hour after the incident and then every 30 minutes for the next hour she monitored Resident #1 for any changes in condition and there were none. She stated at 2:00 PM CNA A notified her Resident #1 vomited but had a hx (history) of vomiting with her gastrostomy tube feedings, she notified the NP who told her to hold the tube feedings and she administered physician ordered breathing treatment. LVN B stated during a Hoyer lift transfer as one person was operating the lift the second person was to ensure the resident is well positioned with the wheelchair. She stated she believed the accident occurred because one of the sling ends suddenly came apart. LVN B stated she had been trained on use of the Hoyer lift with in-service training and before using the lift she should check the sling to ensure it was intact, there were no rips, and the hooks were in proper position. She stated also being trained to check the Hoyer battery was charged. She stated before the incident with Resident #1 she and CNA A checked to see the Hoyer lift battery was operation and the sling hooks and attachments of the sling were intact. Review of facility witness statement dated 10/28/22, made by CNA A reflected, I (CNA A) went into the patient (Resident #1) room and the patient family member had the patient clothes was hanging up in front of the closet and she (family member) laid the sling in the chair. The family member always demands to use what she brings in for her mother. The nurse in charge (LVN B) and myself went to transfer Resident #1 from the bed to her chair with the Hoyer lift. We hooked the four ends of the sling on the lift. While lifting her up one of the sling ends came apart from the lift, the other 3 ends including the two at the top of the head was still on the Hoyer lift. I begin lowering the lift to prevent the patient from falling completing on the floor. While my nurse rushed to hold the patient head, I lowered the lift to the floor. Then we put her back in bed for the nurse to examine her body for any injuries. She also checks her vital signs, there was no injury and vital signs were good, we then transfer her in her chair for two hours. In an interview on 11/01/22 at 10:48 AM with CNA A she stated Resident #1 was total care dependent for transfers and positioning and could not assist with any of her activities of daily living. She stated 10/28/22 was the first time she had helped Resident #1 up from her bed to the wheelchair. CNA A stated LVN B told her Resident #1's family member requested the resident be transferred from her bed to the wheelchair. CNA A stated Resident #1's family member came to the facility each evening and prepared the items staff were to use to care for Resident #1. She stated in her room were laid out the dress Resident #1 was to wear and a sling on the wheelchair the family member left for staff to use to transfer Resident #1. CNA A stated the sling she observed was not a facility sling and on the sling Resident #1's name was in black marker with the note personal property of Resident #1. CNA A stated she had not seen the sling she described prior to 10/28/22. CNA A stated the items Resident #1's family member wished for her to use in the care of her mother were laid out for her as they had been in the past. CNA A stated she told LVN B the sling was not a facility sling because the name of the resident was on the sling, it was one piece of cloth and the facility sling was netted, it had only one attachment hook at each of the four corners and the facility sling had multiple points of attachment at each corner. CNA A stated she did not see anything to be wrong or defective with Resident #1's sling. CNA A stated LVN B responded Resident #1 did not get up from bed often but did not comment on the sling when she stated it looked different. CNA A stated it had been her experience while caring for Resident #1 for the last 8 months that the resident's family member wanted staff to use the items she provided to care for her mother and not facility items. CNA A stated she and LVN B placed the sling under Resident #1 and then hooked the four end of the sling to the hooks of the Hoyer lift. CNA A stated she operated the Hoyer controls from one side of the resident's bed while LVN B positioned herself on the opposite side of the bed. CNA A stated she then slowly lifted Resident #1 from the bed and lowered the resident's bed. She stated then moving the resident's bed out of the way to have enough space to move the lift and Resident #1 over the wheelchair. CNA A stated as she raised the Hoyer lift with Resident #1 in the sling LVN B stabilized the resident in the sling with her hands to move the resident toward her wheelchair. She stated LVN B then moved behind the wheelchair to position the wheelchair under Resident #1. She stated as LVN B attempted to position the wheelchair under the resident they heard a bang and one of the ends where the sling was hooked to the Hoyer lift spreader bar came apart. CNA A stated Resident #1 started to fall down because the sling was not balanced, and the resident's weight was shifted to one side. CNA A stated Resident # 1 did not entirely come out of the sling, LVN A jumped the bed and positioned herself next to the resident as she lowered Resident #1 in the sling to the ground. CNA stated she did not see Resident #1 hit her head at any time and that things happened quickly within seconds. CNA A stated LVN B ensured Resident #1's head did not hit the floor. CNA A stated once Resident # 1 was on the floor she removed the damaged sling, ran to get a facility Hoyer sling, placed the new sling under the resident, and with LVN B assisted Resident #1 back to bed. She stated she assisted LVN B with turning the resident in bed as LVN B assessed the resident for injuries. CNA A stated LVN B assessed the resident entire body. CNA A stated Resident #1 had not vomited during the assessment. CNA A stated during the assessment she did not observe any bruising or other injuries. She stated Resident #1 normally was not verbal and was not vocal after the incident. She revealed no other changes in Resident #1's behavior and stated Resident #1 did not grimace as if in pain. CNA A stated she continued to work with Resident #1 after the incident up to 10:00 PM. CNA A stated she was assigned to Resident #1 that day because the resident's family member had issues with other aides abiding by her directions for caring for her mother and she did follow the direction of the resident's family member. CNA A stated Resident #1's family member did not tell her to use the sling but after working with the resident for 8 months it was normal behavior for the family member to provide the items, she wished for staff to use in the care of Resident #1 and that is why she used the sling she was placed in Resident #1's wheelchair with her name on it. CNA A stated after LVN B assessed the resident they placed Resident #1 in her wheelchair using facility sling and LVN B called the other two-unit managers ADON C and ADON D to assist her and she left the room. CNA A stated when Resident #1 was assisted to the wheelchair she was had not vomited. She stated Resident #1 remained in up in the wheelchair for approximately 2 hours. She stated during the two hours she observed LVN B continue to monitor Resident #1's BP. CNA A stated at 2:00 PM when Resident #1 was assisted back to bed she noticed the resident had vomited and notified LVN B who immediately notified the unit managers. She stated Resident #1's family member arrived at the facility between 8:00 PM and 9:00 PM and Resident #1 had a small portion of vomit on her shirt. CNA A stated she was trained on using the Hoyer lift with in-service training approximately every 2-3 weeks. She stated being trained to ensure the sling was in good condition, the hooks of the sling were not cut, and ensure the Hoyer lift moved up and down before using it on a resident. She stated she performed the checks as trained with the Hoyer lift equipment and that is why she noticed the sling used was different than facility slings. She stated the facility sling had multiple points of attachment and if one were to break other points of attachment would have caught the sling. She stated she did not like the sling provided by the family member and would not have used that sling, but the family member had arguments with other aides not using the equipment she provided for Resident #1, and she used the sling provided to avoid the family member having issues with her. Review of facility witness statement dated 10/28/22, made by a Student bystander reflected, On October 28th, 2022 at approximately 11:20 (A.M), I witnessed an incident involving a resident and two staff members of which I cannot name because I am not aware of their names; I stood across the hall and witnessed the Hoyer lift being used on a resident incapable of moving and at a moments' notice I noticed that the resident was falling and had abruptly fallen on the ground. The resident had sharply and suddenly hit the ground, and from where I was standing, it seemed as if the resident first hit their back and buttocks; I had heard groaning but could not distinguish whether it was the resident as mentioned earlier or another resident. After that, the staff members checked the resident to ensure they were okay, and shortly after, I made my way toward my classmate and partner to alert her of what had just happened. After notifying my partner, I made conversation with the resident I was currently with, then slowly made my way toward the scene and asked about another resident's bed bath. I was told something along the lines of: Can't you see we're busy? Can't you see there's a resident on the ground? I believe the room number was 811, Resident #1. The Hoyer lift sling did not look damaged or torn it any shape or form from my standpoint of view. All I know about the care staff involved is that it was a nurse and a NA (nurse aide) assigned to the 800 hall, on [DATE]th. Record Review of facility Continuing Care Network Mechanical Lift Competency Skills Checklist dated 8/19/22 for LVN B and CNA A. Record Review of facility photograph provided 11/2/22 of sling used by LVN B and CNA A during the incident involving Resident #1. The sling was grey in color, had four points of attachment (loops one at each corner of sling) for the Hoyer lift spreader bar (portion of lift where sling is to be attached), written on the sling was Personal Property of Resident #1 RM [ROOM NUMBER]. In an interview on 11/01/22 at 12:38 PM with ADON C stated Resident #1 required total staff assistance with transfers. He stated Resident #1 was nonverbal in speech and he had been involved in her care for over 2 years. ADON C stated 10/28/22 LVN B retrieved he and ADON D and stated Resident #1 during a transfer from bed to wheelchair using the Hoyer lift was falling but she assisted the resident to the floor breaking her fall and lowered the resident to the ground. He stated asking LVN B specifically if Resident #1 hit her head to which she replied no and LVN B stated she had assisted Resident #1 with her hands lowered her to the floor. ADON C stated he and ADON D went to Resident #1's room around 11:45 AM and 12:00 PM and the resident had already been placed in the wheelchair by LVN B and CNA A. ADON C stated he observed Resident #1 to be comfortable, with no signs or symptoms of pain like moaning, abnormal body movements, or grimacing to the face. ADON C stated when he was in the room, he noticed the sling LVN B and CNA A used to transfer Resident #1 was not a facility sling and both LVN B and CNA A told him the resident's family member and EC brought the sling to the facility. ADON C stated the sling used was smaller than the facility slings, there was only 1 attachment hooks of the sling one at each of the four corners of the sling and facility slings had 4 different attachment hooks at each of the four corners of the sling. ADON C stated the sling used appeared to have one of the attachment hooks come apart as though it loosened but did not complete break. ADON C stated he believed the sling used was too little and the weight of the resident in the sling loosened the attachment point. ADON C stated when he initially responded to the room to see Resident #1, she had not vomited. He stated at the time of the incident around 11:45 AM and 12:00PM he along with LVN B and ADON D called the resident's family member to report the incident. He stated he returned to Resident #1's room around 3:00 PM to assess the resident and at that time the resident had no injuries, no vomit was noted, she was not showing any changes in condition nor pain. ADON C stated between 8:00 PM and 9:00 PM Resident #1 had vomited, he along with the assigned nurse went to the room called 911 at the request of the family member and EC who was present, and the resident was taken to the hospital. ADON C stated he had spoken to the family member after Resident #1 has been admitted to the hospital and was told the resident passed away. He stated in August 2022 he trained staff himself on the use of Hoyer lift transfers and each had to return demonstration on safety measures. ADON C stated a Hoyer lift required use of minimum two persons at all times, before equipment was used staff are to ensure it if functioned well by plugging it in to check it elevates and descends, the battery was charged, inspect the sling hooks for tears and worn areas, and if any defects are noted in the equipment, it should be discarded and not used. He stated in Resident #1's situation the family member was very involved in her care and wanted it performed a particular way. He stated he believed LVN B and CNA A when they stated the family member provided the sling used, but he was not sure how long ago it had been brought into the facility. ADON C stated he had not been told by LVN B or CNA A the sling used was in the resident's room, he stated the risk of using the sling provided by the family member was it might not hold the resident and the resident may fall. He stated he had not instructed staff to use the sling provided by the family member during his Hoyer Lift training. In an interview on 11/01/22 at 1:28PM with ADON D she stated on 10/28/22 around 11:00 AM she and ADON C were summoned to Resident #1's room by LVN B. She stated LVN B told her during a transfer of Resident #1 from bed to the chair the resident was almost falling but LVN B told her she broke the resident fall and lowered her to the ground. ADON D stated she immediate went to Resident #1's room and saw the resident seated in her wheelchair. ADON D stated she had cared for Resident #1 in the past for 2 to 3 years and when in the room did not note any changes in the resident's condition. She stated Resident #1 was seated comfortably in the wheelchair with a facility sling behind her. ADON D stated she observed the sling used during the initial transfer and it was the first time she had seen the sling and noted it was not one used normally in the facility. She stated the sling had only one attachment point at each of its 4 corners and facility slings had multiple points of attachment at each of its 4 coroners. She stated the resident's sling appeared to be big enough and CNA A told her the resident's family member brought the sling to the facility for her to use. ADON D stated LVN B told her one of the attachment points of the sling came loose during the transfer of Resident ##1 who was falling but both LVN B and CNA A had broken the fall of the resident. ADON D stated LVN B did not tell her Resident # 1 hit her head during the transfer and based upon her assessment of the resident and interactions with her in the past she did not note any changes in the resident's condition. ADON D stated being told by LVN B later in the day she was unsure what time it was, but that Resident #1 had vomited, and she saw the emesis on the resident's chest. She stated was a gastrostomy tube feeding resident with a history of vomiting in the past. ADON C stated she and LVN B sopped the resident gastrostomy tube feeding, notified the NP and assisted the resident back to bed from her wheelchair with the head of the bed elevated. In an interview on 11/01/22 at 2:36pm with NP she revealed she provided care for Resident # 1 for 3 to 4 years. She stated Resident #1 required maximum assistance from staff for transfers with the use of a Hoyer lift. NP stated she was notified Resident #1 had an incident on 10/28/22 and asked LVN B if there were any injuries and was told Resident #1 was assisted to the floor after a malfunction of the Hoyer lift. She stated based upon initial reports provided by LVN B of the incident she did not provide LVN B any additional physician orders to administer for Resident #1. The NP stated she was notified by LVN B around lunch time on 10/28/22 Resident #1 vomited, staff held the gastrostomy tube feeding and the resident had no other changes in her condition or vital signs at that time. She stated Resident #1 had a history of vomiting with her gastrostomy feedings in the past and the facility with adjusting her tube feeding rates it would resolve. The NP stated the Resident #1 was transferred to the hospital and her family member and EC left a message on her phone which indicated Resident #1 later passed away at the hospital. She stated Resident #1's attending MD told her he had spoken with Resident #1's family, and it was reported to him the resident was treated for a subdural hematoma, sepsis as result of a urinary tract infection, and pneumonia. She stated Resident #1's family with the resident at the hospital decided comfort care as a treatment plan for the resident. The NP stated she viewed a video clip of the incident Resident #1's family member and EC sent to her Sunday 11/01/22. She stated based on the video she could not actually see if the Resident #1 hits or falls to the floor because at a point the resident was out of camera view. She stated Resident #1 could have sustained an injury or possible trauma as result of the incident, but she could not tell for certain without seeing what happened from the video clip provided. An interview on 11/2/22 at 9:55 AM with Resident #1's the attending MD revealed he was her physician for the last couple years. He stated Resident #1 required total assistance with Hoyer lift transfers, was totally bed bound with advanced dementia, and had a history of recurrent urinary tract infections. MD stated his NP was notified on 10/28/22 of the incident at the facility with Resident #1. He stated based upon his review of Resident #1's hospital medical records revealed she expired but he did not know the cause of death. He stated he believed Resident #1 at the hospital was treated for a fall and an infection, as a result the family choose comfort care and Resident #1 expired in the hospital. The MD stated the hospital did perform a computerized tomography (CT-series of x-ray images taken from different angles around the body creating cross-sectional images of bones, blood vessels and soft tissue) of her brain an noted a subdural hematoma. He stated he did not know if the subdural hematoma was acute or chronic and could not correlate any of Resident #1's injuries with the incident that occurred at the facility. The MD stated Resident #1 was an elderly dementia patient with multiple comorbidities, multiple infections over course of her treatment, multiple gastrostomy tube feeding issues and all of the above along with the incident on 10/28/22 could have contributed to her death. He stated it was difficult for him to state the incident on 10/28/22 was Resident #1's cause of death but all of her comorbidities could have contributed to her outcomes at the hospital. He stated Resident #1 had a history of vomiting at times during his care for her. He stated at times in the past when Resident #1 would not tolerate her gastrostomy feeding staff would stop the feeding allowing her stomach to adjust and start it again afterwards and had been doing so for over the last 2 years. He stated the reported vomiting for Resident #1 based upon her history and staff response to remedy it wound not be something staff would send her to the hospital for. The MD stated he was not aware Resident #1's family member and EC provided a sling to the facility to use for her mother. An observation and interview on 11/2/22 at 10:28 AM of video reported by Regional RN was provided by Resident #1's family member and EC. The video was 4 minutes and 59 seconds in length and observation was made with Regional Nurse. Regional Nurse stated video started with Resident # 1 in her room HOB elevated resident in the bed with sling under her, two staff members LVN B and CNA A standing on opposite sides of the bed. He stated CNA A was nearest the Hoyer lift controls and LVN B was nearest the side of the bed closest the bathroom door. Regional Nurse stated Resident #1 at the opening of the video in the sling with four hooks of the sling attached to the Hoyer lift spreader bar Resident #1's body still resting on the bed, with both CNA A and LVN B talking to each other but not in English. At 4 minutes 09 seconds time stamp on the video Regional RN stated he observed Resident #1 in bed HOB elevated, seated in the sling, all hooks of the sling attached to the Hoyer lift spreader bar when CNA A started to raise the resident from the bed and tension with tension applied to all 4 hooks of the sling straps. At 3 minutes 59 seconds time stamp on the video Regional RN stated he observed Resident #1 suspended off of the bed with both CNA A and LVN B with hand on the sling attachment points closest the resident knees, tension in all 4 attachments of the sling and he described there did not appear to be any failure in the sling. Regional RN stated he did not identify the sling in the video as being a facility sling, stated the difference was it was grey and facility slings have multiple hooks at each corner with the sling [TRUNCATED]