**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 2 residents (Resident #1) reviewed for accidents. -The facility failed to safely transfer Resident #1 and prevent injury during a mechanical lift transfer that resulted in Resident #1 sustaining a laceration to her left leg requiring her to be sent to the hospital This failure could place resident at risk for accidents, injuries, and hospitalization. The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. Findings Include: Intake ID #433231 Record review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her admitting diagnoses included a fracture to the lower end of the thigh bone, anemia, malnutrition, and muscle loss. Record review of Resident # 1's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. Section G: Functional Status revealed the resident required extensive assistance during transfers (resident involved activity, staff provide weight-bearing support) and two plus person physical assist. Record review of Resident #1's care plan dated [DATE] revised [DATE] revealed Resident #1 ADLs Functional Status/Rehabilitation Potential. Interventions are- Consult Physical Therapy, Occupational Therapy, Speech Therapy as needed and Resident care as per facility protocol. Record review of facility's investigation completed by the Administrator dated [DATE] revealed Resident #1 was transferred to hospital on [DATE] due to acquiring a laceration during a Hoyer lift transfer. After further investigation it was determined the resident sustained a mildly displaced and angulated, oblique fracture involving the distal left femoral(a fracture to the lower end of the left thigh bone). The Administrator provided a sign in sheet titled Hoyer Lift and Transfer dated [DATE] and received a document titled Transfer from Bed to chair with a Mechanical Lift- Training. Record review of the hospital records dated [DATE] of Report of Operative Procedure from Hospital #2 revealed, Resident #1 presented to the hospital after sustaining a laceration of the back of the calf and a fracture to the thigh bone at the skilled nursing facility. Further review of hospital records revealed during knee replacement surgery, the resident experience respiratory complications requiring chest compression. The resident was transferred to ICU and passed away. In an interview on [DATE] at 9:30AM with the Administrator, she stated during a use of a mechanical lift, two nurses (LVN A and LVN B) were transferring Resident #1 on back into bed and the resident bumped her leg which caused a laceration. She stated Resident #1 was sent out to the hospital because she had a laceration. The Administrator stated Hospital #1 transferred Resident #1 to Hospital #2 and stated the reason of the 2nd transfer was unknown. She stated the first hospital did not inform the facility that the resident had a fracture, she stated she was informed of the fracture by the 2nd hospital. The Administrator denied that the resident had a fall during the transfer. The Administrator also denied that the fracture was caused by the resident hitting her leg during the transfer. The Administrator reported she believed the fracture could have occurred during the residents transfer to the hospital. In an interview on [DATE] at 10:50AM with LVN B, he stated he had worked at the facility since [DATE] and he worked from 6am-6pm. He stated he and LVN A was assisting Resident #1 with getting back into bed via mechanical lift because the resident was a 2 person assist. He stated the resident scrapped the back of her leg while getting into the bed. LVN B stated he saw the scrape and it looked as if the resident could have required stitches, so she was sent out to the hospital. He stated the resident never fell during the transfer. She stated she was in-serviced on mechanical lift after the incident occurred. In an interview on [DATE] at 11:22AM with LVN A, she stated she had been employed at the facility for 22 years. She stated she worked the 6am-6pm shift. LVN A stated Resident #1 had been up and wanted to lay back down. She stated the CNAs were at lunch so she and LVN B helped Resident #1 get back in bed. She stated Resident #1 was in a sling for the mechanical lift, and when she and LVN B went to lay her down the resident's lower leg bumped into the bed, and the resident sustained a cut. She stated Resident #1 was sent out to the hospital because of the cut on her leg. She stated the DON and Administrator was immediately notified. LVN A denied that the resident ever had a fall during the transfer. LVN A stated she was in-serviced on lifts. Observation on [DATE] at 1:53PM of CNA A and CNA B during Resident #2's Hoyer lift transfer into bed. CNA A was observed connecting the slings to the Hoyer lift and CNA B ensured the wheelchair was locked in place. CNA B was observed standing near the residents' feet and CNA A was observed standing near the residents head. CNA A controlled the lift controller. Resident #2 was transferred into bed and there were no concerns. In an interview on [DATE] at 2:23PM with the DON, she stated she had been employed at the facility for a few weeks. She stated she was not familiar with the incident that occurred with Resident #1 because she was not employed at the facility. She stated the expectations for mechanical lift were that it takes at least 2 people to assist the resident. She stated one person should be controlling the machine and the other person should be positioning the patient. She stated the sling should be positioned under the back and bottom. She stated the staff were in-service on lifts annually and if there was an incident, the in service were repeated. Telephone call on [DATE] at 3:02 PM to NP-No answer, voicemail was full so unable to leave a message. Telephone call on [DATE] at 3:04PM to Physician- phone went to voicemail, voicemail was left. In an interview on [DATE] at 4:00PM with OT- She stated she did therapy with Resident #1 when she was at the facility for about 3 weeks until she went into the She stated the resident did need a lot of assistance due to being blind and she also required self-care skills with feeding. She stated Resident #1 had a spacer in her left knee which always kept her leg extended. She stated the resident had an elevated footrest to keep her foot to an extent. The resident had to be transferred towards her right leg and use the gait belt to keep it extended. The resident was non weight barring on that left leg. She stated the therapist used a gait belt to transfer the resident during therapy sessions and the staff members used a Mechanical Lift for transfers when the resident needed to be transferred. She stated the staff did not have to get any type of special training to transfer the resident since Mechanical lifts did not require the resident to have any weight on her legs during transfers. Telephone call on [DATE] at 10:02 AM to NP-No answer, voicemail was full so unable to leave a message. Record review of Resident #1's PT Evaluation and Plan of Treatment dated [DATE] revealed the residents weight bearing status was non weightbearing on her left lower extremity. Record review of Resident #2 face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Type 2 diabetes mellitus without complications, brain damage caused by lack of oxygen, muscle loss, contracture of muscle to the right lower leg, and contracture of muscle to the left lower leg. Record review of the Gait Belt Transfer Skills Checklist for LVN A dated on [DATE] read in part: .Comments: Education and training on 2-man Hoyer lift transfers as well . Record review of the Gait Belt Transfer Skills Checklist for LVN B dated on [DATE] read in part: .Comments: Education and training on 2-man Hoyer lift transfers as well . Record review of Hoyer Lift and Transfer training for all staff dated [DATE]. Record review of incident intake #433231 read in part: .Narrative of The Incident - Resident #1 was discharged to Hospital #1 on [DATE] after acquiring a laceration during a Hoyer transfer. On [DATE] the facility was contacted by the family of Resident #1 and informed that the resident expired on 6/25 due to a blood clot during a knee and femur surgery at Hospital #2 . Record review of the facilities Safe, Lifting and Movement of Residents policy dated [DATE] read in part: .In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents . 3.Staff will document resident transferring and lifting needs in the care plan .4. Staff responsible for direct care will be trained in the use of manual .and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents .Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies; .d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. It was determined these failures resulted in a deficient practice from [DATE] to [DATE]. facility took the following action to correct the non-compliance on [DATE]: