**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 for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to properly inspect the Hoyer Lift slings, resulting in it tearing and causing the resident to have a fall and sustain a bruise to her left shoulder. Resident #1's fall caused pain at a level 9. -The facility failed to properly train the staff on how to report concerns and determine properly Hoyer sling sizes. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. While the IJ was removed on 10/12/2023 at 3:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk of serious injury and pain. Findings include: Record review of Resident #1 EMR on 10/07/2023, revealed on -she was admitted to the facility on [DATE] with diagnoses including Encephalopathy (brain disease), Sepsis, Muscle Weakness, Cognitive Communication, Stenosis (Pressure on spinal cord), Morbid Obesity, Record review of Resident #1 EMR revealed on 09/01/23 she weighed 251lbs. Record review of Resident #1's MDS dated [DATE], revealed the resident was a 2 person assist with transfers and a BIMS score of 12 (indicating the resident's cognition was intact). Record review of Resident #1's care plan dated 08/07/2023 revealed the resident was care planned for the use of a Hoyer lift. Record review of Resident #1's EMR on 10/07/2023 revealed, there was no orders for x rays. Record review of the residents Pain Levels on 10/09/2023 revealed she had pain level of 9 on 10/6, 10/07, 10/08, the resident was given her PRN pain medication when she complained of pain. Record review of Resident #1 EHR on 10/09/2023 revealed, a new order per NP of 2 view x ray of the left leg. In an interview on 10/07/2023 at 2:13PM with Resident #1, the resident stated she had a fall during a(Mechanical) lift transfer on 10/06/2023. The resident stated the mesh part of the sling tore during the transfer and she fell to the floor. The resident stated she was about waist high, 3 feet from the floor. The resident stated she landed on her left side, and she did not hit her head. The resident stated she had pain in her left buttock and upper left shoulder. The resident stated she was not sent to the hospital and x rays were not done after the fall. The resident complained of pain and stated she was on a scheduled pain medication as well as an as needed pain medication. Resident #1 stated she was now fearful of doing Hoyer lift transfers. In an interview on 10/07/2023 at 2:56PM with the DON, she stated Resident #1 had a witnessed fall on 10/06/2023 during a Hoyer lift transfer. She stated the resident was assessed by the RN and the NP was notified. She stated the resident complained of pain to her left. She stated the resident was given pain medication. She stated the resident was already on a scheduled pain medication and an as needed pain medication. She stated the resident was not sent to the hospital or for x ray because they were informed to monitor the resident. The DON stated the incident was not reported to HHSC because it was a witnessed fall. She stated the Hoyer slings did come in different sizes but she was not sure of exactly what the sizes were. The DON stated the staff were trained to identify which size sling to choose when doing a Hoyer Lift transfers but there was not any evidence of training for staff regarding choosing the correct sling for the correct weight provided In an interview on 10/07/2023 at 3:00PM with the Maintenance Supervisor, he stated he was not responsible for checking the slings for the Hoyer lifts. He stated the laundry department usually checked the slings while completing laundry. In an interview on 10/07/2023 at 3:08PM with CNA-A, she stated on 10/06/2023, she went into to assist CNA-B with a Hoyer lift transfer for Resident #1 because it was the resident's shower time. She stated they strapped the resident into the Hoyer sling/lift and they were lifting her and the mesh on the sling broke. She stated the resident was about waist level when she fell from the Hoyer lift. She stated once the resident fell, they assessed the resident and did not move her, and CNA-B called for the RN to assess her. She stated the person who started the transfer usually checked the straps to make sure it is not broken. She stated the sling was kind of old looking when she saw it. She stated the resident complained of pain on her left leg near her calf. She stated they got another sling and put the resident back on it and got her back up. She stated she thinks the sling may have been thrown away because it was broken. She stated she was last trained on Hoyer lifts about a month ago. She stated there had not been any training since the incident occurred. She stated she was not sure if the slings came in different sizes. She stated she did not know which sling to choose when doing a Hoyer lift because she thought they were all the same. She stated she only knew that some of them look different. She stated when she did a Hoyer lift transfer, she get whichever sling was available when she goes into the laundry room. She stated the risk of getting the wrong size sling when doing a transfer was someone could fall out of the sling. In an interview on 10/07/2023 at 3:18PM with CNA-B, she stated on 10/06/2023 she and CNA-A were in the process of transferring Resident #1 to her wheelchair when the incident occurred . CNA-B stated she and CNA-A placed the resident in the Hoyer sling and in the process of pivoting the resident over to the wheelchair, the mesh part of the sling tore resulting in the resident falling to the floor. CNA-B stated the resident was about waist high when she had the fall. CNA-B stated the resident landed on her left side hitting her left leg, left buttock and left shoulder, and stated she did not hit her head. CNA-B stated the resident began crying and complained of pain to her left shoulder. She stated the resident was assessed by the RN. CNA-B was asked how to determine the size of the sling needed for the residents and she stated the facility had different style slings and stated she thought all the slings were one size. She stated she accessed the sling prior to the transfer, and it did not appear to be torn or ripped. She stated the resident was assessed by the nurses. CNA-B stated she inspected the sling prior to the transfers and it looked okay. In an interview on 10/07/2023 at 3:32PM with the RN, she stated she was at the nursing station and at about 3:30 PM CNA-A informed her that she needed assistance in a room; she stated she was informed the Hoyer lift sling tore. She stated when she entered the room, Resident #1 was sitting on her buttocks and the Hoyer lift was to the side. She stated she observed the Hoyer lift sling, and it was hooked correctly. She stated the resident was alert and oriented. She stated she accessed the resident and on the resident was upset and hysterical, there was no bruising or bleeding or trauma to the skin. She stated the resident did not hit her head. She stated another Hoyer lift sling was retrieved and the resident was transferred back into bed. She stated she assessed her pain level, and she received pain PRN medication which the resident already had a prescription for. She informed the DON a soon as the incident occurred. She stated she called the NP and she was informed to monitor the resident. She stated the resident was not sent out the hospital and an x ray was not ordered. She stated she was going to call the RP, but he had already arrived to the facility and he was yelling and upset. She stated the slings came in different sizes. She stated there should be a weight on the label when doing a Hoyer lift transfer. She stated she did not see the weight on the sling at the time of the incident, but she did observe a rip in the sling. In an observation of Hoyer lift slings (2 were available in the laundry room) on 10/07/2023 at 3:53PM, revealed the weight requirements on the slings were not legible. Some of the tags were torn and some of the weight requirements were not visible at all. In an interview with Resident #1 on 10/09/2023 at 5:05PM, she stated she was still in pain at a level 8 and she reported she had just received her PRN pain medication and thought it may have been working. She stated she had a bruise on the back of her left shoulder. The residents bruised was observed to be dark purple circular bruise about the size of a grape fruit. She stated she was informed that she would be getting x rays completed that evening but they had not been completed at the time of the interview. Record review of X-Rays results dated 10/09/2023 revealed the resident did not sustain any fractures. Record review of Safe Lifting and Movement of Residents Policy revised July 2017, reflected .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints Safe lifting and movement of residents is part of an overall facility employee health and safety and injury-prevention strategies; Involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies . Continually evaluates the effectiveness of workplace safety and injury-prevention strategies On 10/09/2023 at 6:35 PM. the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 10/12/2023 8:43 AM. The POR revealed: . I. What corrective actions have been implemented for the identified residents? The following action items were implemented. a. The physician notified, immediately on 10/6/23 at 3:30pm. b. The Hoyer sling was removed immediately and disposed of. c. Visual inspection of all Hoyer lift slings inventoried and completed through 10/10/2023. No other concerns were identified in terms of residents; 1 sling was properly labeled on 10/11/2023. II. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. An in-service was initiated with direct care staff on 10-9-2023 by the Director of Nursing and Therapy designee, on Hoyer lift transfer training. b. An in-service was initiated with housekeeping and laundry staff on 10-9-2023 by the Housekeeping Supervisor, on Hoyer lift sling laundry care and factors that reduce the life of the sling. c. Another additional training was initiated to all direct care staff on 10/10/2023 to also include and highlight details of Hoyer slings sizing, colors, and proper use by demonstration. d. Staff completed a competency checklist on Hoyer Lift transfer Training with return demonstration on 10/10/2023. e. New hires will have transfer training to include Hoyer lift with therapy. f. DON/designee to perform daily random audits to ensure staff are using Hoyer lifts properly and Hoyer slings are in good condition. III. How will the system be monitored to ensure compliance? a. DON/Therapy/designee will perform random audits weekly to ensure staff are using Hoyer lifts properly and Hoyer slings are in good condition, and proper size and will be documented on a log. As an inspection routine, the log will capture the staff member and the observer, the condition of lift and sling, and proper use. Also, will highlight if staff member needs more training. So far this week there have been no similar resident occurrences or findings. b. Housekeeping will continue to monitor the condition and wear and tear of slings, also if sling needs to be replaced via a daily log. If observer sees that sling is deemed not usable, the observer will bring sling to DON or Administrator. Quality Assurance: An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 10/10/2023 with the Medical Director. The Medical Director has reviewed and agrees with this plan. IJ monitoring included: Record review of staff competency checks revealed 69 competency checks were completed including for CNA-B and CNA-A. Record review of Mechanical lift: How to Use a Patient Lifter Transfer Guide revealed the sling size for weight ranges were included in the guide. Record review revealed the facility had policies on of Falls and Fall Risk management, Safe Lifting and Movement of Residents. Record review revealed in-services on [Mechanical] Lift Transfer trainings were conducted by the therapy department on 10/10/23 for all direct care staff. Record review revealed the facility had a policy on Sling Laundry Care dated 10/09/23 and was signed off by staff in the laundry department. In an interview with the OT on 10/12/2023 at 12:27PM, she revealed she helped train staff on how to perform a transfer of a resident by mechanical lift and what steps to follow to ensure the transfer was safe. She stated staff were to ensure the sling was free of rips or tears and to make sure the sling fit the resident they were transferring. She stated the weight/sling size guide could be found in the shower rooms and guidebook. She stated she also trained staff on how to transfer their resident from bed to wheelchair and wheelchair to bed. In an interview with the Laundry Supervisor on 10/12/2023 at 12:45PM, she stated she was to collect and wash dirty slings with no bleach or hot water. She stated slings were to be air-dried and inspected for damage to the sling hooks and/or net material, such as tears, holes, fraying, and illegible labels. She stated if damaged slings were to be identified, she would give them to the Administrator or DON to have them replaced. Record review of the Log for Daily Mechanical Sling Check reflected one of one sling was replaced on 10/11/2023 and one of 13 slings were replaced on 10/12/2023. In an interview with the Laundry Aide on 10/12/2023 at 12:57PM, she stated she washed slings separately from other linens with no bleach and only cold water. She stated she dried the slings without heat and checked if it was good for use and not broken. Record review revealed the ST completed his transfer training and competency check on 10/10/23. In an interview with the ST on 10/12/2023 at 1:02 PM, he stated to know the appropriate size of sling to use on a resident, he checked the patient's weight in the EHR and referenced the weight to sling size guide. He stated to perform a safe transfer by mechanical lift, he needed to conduct the transfer with another staff member to guide the resident as he maneuvered the mechanical lift. Record review revealed CNA-C completed her transfer training and competency check on 10/10/23. In an interview with CNA-C on 10/12/2023 at 1:17PM, she stated prior to transferring a resident using the mechanical lift, she checked for holes, rips, tears, and ensured the sling straps were intact and were the right size for the person. She stated she would refer to the label on the sling to determine the appropriate size of sling to use on the resident. Record review revealed CNA-D completed her mechanical lift sling training on 10/06/2023 and her transfer training and competency check on 10/10/23. In an interview with CNA-D on 10/12/2023 at 1:30 PM, she stated she was trained by the therapy department on how to use a mechanical lift. She stated prior to transferring a resident by mechanical lift, she checked to make sure the right size was being used, the hook and sling material were in good condition and the battery was fully charged. She would make sure to get help from another aide for the transfer. She stated if there was an injury, she would report to the nurse. Record review revealed CNA-E completed her mechanical lift sling training on 10/06/2023 and her transfer training and competency check on 10/10/23. In an interview with CNA-E on 1012/2023 at 1:44PM, she stated that prior to transferring a resident using a mechanical lift, she would check the battery, check the sling for rips and holes and for the right size based on the posted sling color codes on the guide located at the desk and linen closets. She stated the codes informed her on which color to use based on resident's weight. If the sling was not legible or if there were any issues, she would notify the nurse and the DON about it. Record review revealed CNA-F and CNA-G completed their transfer training and competency checks on 10/10/23. Observations of mechanical lift transfer of Resident #2 on 10/12/2023 at 2:18PM, by CNA-F and CNA-G revealed a safe transfer of Resident #2 from the Geri-chair to her bed and the sling was in good condition, appropriate sling size, and coordination of loops . CNA-G operated the lift machine while CNA-F guided the resident. Record review revealed the RN revealed she completed her mechanical lift sling training on 10/06/2023, transfer training and competency check on 10/10/23 and she signed off on the nurse training regarding notification of change of conditions. In an interview with RN on 10/12/2023 at 2:27PM, she stated, although she had never had to conduct a mechanical lift transfer on any of the residents while she worked at the facility, she was trained on safe mechanical lift transfers, which included to always have two people, to inspect the mechanical lift and sling, and to ensure the right size sling was being used. She stated in the case of any injury, she would instantly notify the family, the DON and the resident's physician. She stated she would call the nurse practitioner/physician to report any changes in condition observed following an injury for up to 72 hrs. Record review revealed CNA-B completed her mechanical lift sling training on 10/06/2023 and her transfer training and competency check on 10/10/23. In an interview with CNA-B on 10/12/2023 at 2:40PM, she stated for mechanical lift transfers she would ensure the battery was fully charged, made she had a second staff to the spot the resident, she would check the sling for holes, rips, frays, tears or wear. She stated the linen closet and book at the nursing station had the guides for weight sling size she could reference prior to transferring residents. Record review revealed CNA-H completed her mechanical lift sling training on 10/06/2023 and her transfer training and competency check on 10/10/23. In an interview with CNA-H on 10/12/2023 at 2:52PM, she stated for mechanical lift transfers, she needed two staff to conduct a safe transfer with one person guiding the patient and the other person maneuvering the mechanical lift. She stated she checked to ensure the battery was charged, checked for tears or rips in the slings, and if the appropriate size was being used depending on the resident's weight. Record review revealed CNA-I completed her mechanical lift training and competency check on 10/10/23. In an interview with CNA-I on 10/12/2023 at 3:02PM, she stated two people were needed to conduct a mechanical lift transfer and she had to check to ensure the sling was in good condition with no loose strings, tears, the appropriate size for the resident was used, and the battery needed to be fully charged,. She stated if the tag on a sling was illegible, then she would not use it but instead report it to her charge nurse. Record review revealed LVN completed her mechanical lift sling training on 10/06/2023, transfer training and competency check on 10/10/23 and she signed off on the nurse training regarding notification of change of conditions. In a phone interview with LVN on 10/12/2023 at 3:10 she stated she was trained on how to use the mechanical lift and on notifications after change of conditions. She stated she would monitor a resident up to 72 hours following an incident to ensure there was no change of condition, and if there was a change, she would report to the NP or the physician. She said she was tested on how to use the mechanical lift but never had to perform a transfer on the floor. She stated generally two people were needed for the transfer, one person was needed to control the mechanical lift and the other was there to stabilize the resident from bed to chair or chair to bed. She stated she checked the battery level, sling condition for lack of rips, tears or frays, and the sling size using the posted weight to sling size reference guide. Record review revealed the DON kept a running log on any resident injuries that occurred in the facility. In an interview with the DON on 10/12 2023 at 3:25PM, she stated staff were to check battery to ensure it was fully charged, check the sling for any tears or rips and loops were intact, and for the right size. She stated the staff were to make sure two people performed a mechanical lift transfer, positioned the resident not too high or not too low and to make sure the lift was locked upon descent. She stated for falls or injuries, nurses were to notify the NP, the DON and family, do a pain and fall assessment as well as a skin assessment by the wound care nurse (for every fall). She stated they were to document up to 72 hours on any changes of condition or if the resident remained stable. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. While the IJ was removed on 10/12/2023 at 3:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for pain management, in that; Resident #1 experienced pain after a fall on 10/06/2023 and the pain was not reported to the NP until 10/09/2023. The facility failed to contacted the NP or Physician after the fall when Resident #1's pain level increased to a level 9, resulting in an increase PRN pain medications. These failures affected one resident who was placed at risk of pain, bruising, and increased use of PRN pain medication. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. While the IJ was removed on 10/12/2023 at 3:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk of injury and pain. Findings include: In an interview with RP on 10/07/2023 at 12:40PM, he stated he did not witness the incident that occurred with Resident #1 on 10/06/2023. He stated his Resident #1 called and informed him that one of the loops that hooked onto the Hoyer lift broke and Resident #1 fell. He stated Resident #1 was not sent to the hospital. He stated he spoke to the facility administrator, and he was informed that the facility has to go through a process when an incident happens, the process was not provided. He stated a little mesh on the harness sling tore and they gently lowered her to the ground. He stated Resident #1 informed him she fell out of the harness and it was not gently lowered to the ground. He stated Resident #1 informed him that she landed on her left side. In an interview on 10/07/2023 at 2:13PM with Resident #1, the resident stated she had a fall during a Hoyer (Mechanical) lift transfer on 10/06/2023. The resident stated the mesh part of the sling tore during the transfer and she fell to the floor. The resident stated she was about waist high, 3 feet from the floor. The resident stated she landed on her left side, and she did not hit her head. The resident stated she had pain in her left buttocks and upper left shoulder. The resident stated she was not sent to the hospital and x rays were not done after the fall. The resident complained of pain and stated she was on a scheduled pain medication as well as an as needed pain medication. Resident #1 stated. during the interview and stated she was now fearful of doing Hoyer lift transfers. Record review of Resident #1 EMR on 10/07/2023, revealed on she was admitted to the facility on [DATE] with diagnoses including Encephalopathy (brain disease), Sepsis, Muscle Weakness, Cognitive Communication, Stenosis (Pressure on spinal cord), Morbid Obesity, Record review of Resident #1 EMR revealed on 09/01/23 she weighed 251lbs. Record review of Resident #1's and the MDS dated [DATE], revealed the resident was a 2 person assist with transfers and a BIMS score of 12 (indicating the resident's cognition was intact). Record review of Resident #1's care plan dated 08/07/2023 revealed the resident was care planned for the use of a Hoyer lift . In an interview on 10/07/2023 at 3:08PM with CNA-A, she stated she went into to assist CNA-B with a Hoyer lift transfer for Resident #1 because it was the residents shower time. She stated during the transfer the sling ripped and the resident had a fall. She stated the resident complained of pain on her left leg near her calf. She stated she thinks the sling may have been thrown away because it was broken. In an interview on 10/07/2023 at 3:18PM with CNA-B, CNA-B stated she and CNA-A placed the resident on the Hoyer sling and in the process of pivoting the resident over to the wheelchair, the mesh part of the sling tore resulting in the resident falling to the floor. CNA-B stated the resident began crying and complained of pain in her left shoulder. She stated the resident was assessed by the nurses. CNA-B stated she inspected the sling prior to the transfers and it looked okay. In an interview on 10/07/2023 at 3:32PM with RN, she was at the nursing station and at about 3:30 PM CNA-A informed her that she needed assistance in a room, she stated she was informed the Hoyer lift tore. She stated when she entered the room the resident was sitting on her buttocks and the Hoyer lift was to the side. She stated the resident was upset and hysterical, there was no bruising or bleeding or trauma to the skin. She stated the resident did not hit her head. She stated she assessed her pain level and she received pain PRN medication which the resident already had a prescription for. She stated she called the NP and she was informed to monitor the resident. She stated the resident was not sent out the hospital and X ray were not ordered. She stated the residents PRN medications were increased due to her pain. In an interview on 10/07/2023 at 4:00PM with DON, she stated the resident was not sent to the hospital or for X ray because they were informed to Monitor the resident. She stated the Hoyer slings does come in different sizes, but she was not sure of exactly what the sizes were. The DON stated the staff were trained to identify which size sling to choose when doing a Hoyer Lift transfers but there was not any evidence of training for staff regarding choosing the correct sling for the correct weight provided . Record review of Resident #1 EHR on 10/07/2023 revealed, there was no orders for X rays. Record review of the residents Pain Levels on 10/09/2023 revealed she had pain level of 9 on 10/6, 10/07, 10/08, the resident was given her PRN pain medication when she complained of pain. Record review of Resident #1 EHR on 10/09/2023 revealed, a new order per NP of 2 view X ray of the left leg. In an interview with Resident #1 on 10/09/2023 at 5:05PM, she stated she was still in pain at a level 8 and she reported she had just received her PRN pain medication and thought it may have been working. She stated she had a bruise on the back of her left shoulder. The residents bruised was observed to be dark purple circular bruise about the size of a grape fruit. She stated she was informed that she would be getting x rays completed that evening but they had not been completed at the time of the interview. In an interview with the NP on 10/09/2023 at 5:37PM, he stated the facility contacted him on 10/06/2023 to inform him that Resident #1 had a fall during a Hoyer lift transfer. He stated he informed the staff to do neurological checks on the resident and notify the provider if there was any significant change. He stated he was off over the weekend, so he was unsure if the facility reached out to any of the on-call staff. He stated the facility reached out to him again today and informed him the resident was complaining of pain in her left lower extremities. He stated he ordered x-rays for the resident. In an interview with the Administrator on 10/09/2023 at 5:51PM, she stated she was working the 10/06/2023, the incident occurred. She stated the RP came to her and stated he wanted to file a incident. She stated she did not know what was going on at the time but the DON and ADON had tried contacting her via phone on 10/06/2023, but she missed the call. She stated the DON informed her that it was not a hard fall, that the resident went down slowly. She stated the aides got the nurse immediately to assess the resident. She stated she immediately in-serviced the staff. She stated the RP seemed to be calm at that point. She stated the incident occurred the evening of 10/06/2023. She stated the resident was not sent out to the hospital because the NP was contacted, and they were informed to monitor the resident. She stated they did order x-rays from what she understood; she stated she thought x rays were ordered today (10/09/2023). She stated the incident was not reported to HHSC because she did not see it at the time as a reportable. She stated she investigated the incident immediately and there was no injury due to the Hoyer or the sling at the time. She stated the Hoyer slings did come in different sizes. She stated when she heard of the incident, she immediately knew that the training would be done. She stated she did not know what size sling was used for the resident. She stated the housekeepers should be looking at the Hoyer slings when they are doing laundry. Record review of X-Rays results dated 10/09/2023 revealed the resident did not sustain any fractures. On 10/09/2023 at 6:35 PM. the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 10/12/2023 8:43 AM. The POR revealed: IV. What corrective actions have been implemented for the identified residents? The following action items were implemented. d. The physician notified, immediately on 10/6/23 at 3:30pm, of the resident's condition and x-ray ordered on 10/09/23. e. Resident assessed immediately, no redness or bruising, and no abnormalities. f. Follow -up documentation on fall every shift completed. g. Social Services set up psychosocial appointments to address and help with the resident having any feelings of fear of not being safe while Hoyer lifted. h. Files for all residents using mechanical lifts were audited on 10/7/2023 and no other accidents were identified as 10/11/2023. V. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? g. Licensed nurses will be in-serviced to ensure they are aware to notify Physician of any changes following an incident for 72 hours on 10/9/2023. VI. How will the system be monitored to ensure compliance? a. DON/ Designee will follow up daily on incidents and changes of conditions log to ensure proper documentation is in place to include NP and Physician notifications. A 24-hour review and incident review log will be used to audit notifications etc. b. This audit will be reported for the following 3 months in QAPI. c. Management will actively monitor for any subsequent or related complaints and addressing those as they arrive. Quality Assurance: An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 10/10/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. IJ monitoring included: Record review revealed the RN completed her mechanical lift sling training on 10/06/2023, transfer training and competency check on 10/10/23 and she signed off on the nurse training regarding notification of change of conditions. In an interview with RN on 10/12/2023 at 2:27PM, she stated, although she had never had to conduct a mechanical lift transfer on any of the residents while she worked here in the facility, she was trained on safe mechanical lift transfers, which included to always have to have two people, to inspect the mechanical lift and sling, and to ensure the right size sling was being used. She stated in the case of any injury, she would instantly notify the family, DON and the resident's physician. She stated she would call the nurse practitioner/physician to report any changes in condition observed following an injury for up to 72 hrs. Record review on revealed the LVN completed her mechanical lift sling training on 10/06/2023, transfer training and competency check on 10/10/23 and she signed off on the nurse training regarding notification of change of conditions. In a phone interview with the LVN on 10/12/2023 at 3:10PM she stated she was trained on how to use the mechanical lift and on notifications after change of conditions. She stated she would monitor a resident up to 72 hours following an incident to ensure there was no change of condition, and if there was a change, she would report to the NP or the physician. She said she was tested on how to use the mechanical lift but never had to perform a transfer on the floor. She stated generally two people were needed for the transfer, one person was needed to control the mechanical and the other was there to stabilize the patient from bed to chair or chair to bed. She stated she checked the battery level, sling condition for lack of rips, tears or frays, and the sling size using the posted weight to sling size reference guide. Record review on 10/12/2023 revealed the DON kept a running log on any resident injuries that occurred in the facility. In an interview with the DON on 10/12 2023 at 3:25PM, she stated staff were to check battery to ensure it was fully charged, check the sling for any tears or rips and loops were intact, and for the right size. She stated the staff were to make sure two people performed a mechanical lift transfer, positioning the resident not too high or not too low and to make the lift was locked upon decent. She stated for falls or injuries, nurses were to notify the NP, DON and family, do a pain and fall assessment as well as a skin assessment by the wound care nurse (for every fall). She stated they were to document up to 72 hours on any changes of condition or if the resident remained stable. She stated only one resident on her log so far had experienced an injury with change of condition and the resident was still discharged at the hospital until further notice. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. While the IJ was removed on 10/12/2023 at 3:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.