**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure a safe transfer for one of 26 residents in the survey sample resulting in a fractured humerus (upper arm); failed to ensure a call bell was accessible for one of 26 residents in the survey sample; and failed to ensure placement of wheelchair footrests and physician ordered plates/platforms for one of 16 residents in the survey sample. 1. a) Resident #95, with inability to bilaterally grip and support the majority of her body weight, slipped during a transfer from the bed to a chair with use of a sit-to-stand mechanical lift resulting in a fractured left upper arm (humerus). The lift/transfer was attempted with the assistance of one staff person, with the resident's arms improperly positioned on the lift and without the resident gripping both handles of the lift for proper support of her body weight as required by the manufacturer to ensure safety. Resident #95 had no left hand or forearm due to a previous below elbow amputation, amputations of the distal half of both feet and staff reported a decline in condition at the time of transfer. Resident #95 had swelling, pain and her shoulder/arm immobilized for over 6 weeks for treatment of the fracture. b) Resident #95 was observed unattended in her room without access to her call light as required in her plan of care for safety and fall prevention. 2. Resident #40 was observed in her wheelchair without footrests in place and without physician ordered foot plates/platforms for proper leg/feet positioning during wheelchair transport. The findings include: 1. a) Resident #95 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #95 included left arm amputation below elbow, amputation of toes on right and left foot, peripheral vascular disease, congestive heart failure, diabetes, COPD (chronic obstructive pulmonary disease) and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #95 as cognitively intact. On 4/16/19 at 3:08 p.m., Resident #95 stated her left shoulder was still hurting since she had a fall and broke her shoulder. Resident #95 stated she did not remember exactly how she fell but knew she broke her shoulder several months ago. Resident #95's clinical record documented a nursing note dated 12/2/18 at 2:19 p.m. stating a mobile x-ray was ordered for Resident #95's left shoulder and humerus. A note dated 12/2/18 at 6:25 p.m. stated, MD [physician] noted resident's left shoulder and left humerus x-ray results of having a fractured humerus . A nursing note dated 12/2/18 at 7:33 p.m. documented, Writer was notified by CNA [certified nurses' aide] that resident had a fall. CNA stated that while she was attempting to transfer resident from bed to w/c [wheelchair] using sit-to-stand lift, resident's foot slipped and she had to ease resident to the floor. When writer entered the room resident was laying completely flat on the floor beside her bed. Resident was unable to state how she fell; she just knew she had fallen. Resident was complaining of pain to left arm. Resident was holding onto left shoulder and arm .Resident was given PRN [as needed] medication for discomfort. MD [physician] and RP [responsible party] have been made notified of fall. A left shoulder x-ray report dated 12/2/18 documented, .History of pain due to fall .There is a comminuted [broken/crushed into small pieces] fracture of the humeral head and neck with avulsion of the greater tuberosity .Impression: Acute fracture of the humeral head . The clinical record documented a physician's order dated 12/3/18 to send Resident #95 to the emergency room for evaluation following the fall. The emergency room (ER) record dated 12/3/18 documented the resident presented with pain and swelling over the left clavicle and shoulder joint with bruising noted over the left upper arm and biceps. This ER report documented, This nurse spoke with [unit manager] at [nursing facility] who states that yesterday [12/2/18] patient was being transferred [transferred] using a mechanical lift. Lift was being operated with only one CNA and patient fell out of the lift and landed on her left side. She [unit manager] states the facility called for a mobile Xray unit .found a left hurmeral [humeral] head fracture . The ER report listed the x-ray of the resident's left shoulder revealed trauma/injury and documented, Films of the shoulder/clavicle show: mild osteopenia and osteoporosis. Associated soft tissue edema present. Comminuted fracture of the left humeral head. Mild displacement of the fracture fragments . The resident was discharged from the emergency with pain documented as 8 out of 10 (on scale with 0 = no pain, 10 = worst pain) with orders for referral to orthopedics for treatment of the fractured arm and a prescription for as needed pain medication. The resident was seen by orthopedics on 12/4/18. The orthopedic consultation report dated 12/4/18 documented, .in for evaluation of a right shoulder injury. She [Resident #95] fell while being transferred using a lift device in the nursing home. X-rays confirm the presence of a displaced fracture of the surgical neck of the left humerus. Unfortunately the patient also has an amputation just below the elbow .recommendation is that a shoulder immobilizer be used to immobilize the humerus to the trunk to help decrease pain . The clinical record documented the resident was treated with immobilization of the left shoulder along with pain medication as needed. The resident was evaluated by orthopedics again on 12/20/18 and on 1/17/19. The orthopedic report dated 1/17/19 documented healing of the humeral fracture with orders for gentle range of motion and no further need for immobilization. Resident #95's clinical record documented the MDS assessment prior to the 12/2/18 fall was completed on 11/14/18. This MDS documented the resident weighed 191 pounds and required extensive physical assistance of two + persons for transfers (to and/or from bed, chair, wheelchair or to standing). This MDS also listed the resident had impaired balance and was Not steady, only able to stabilize with human assistance when moving from seated position to standing and when transferring between bed and chair. Resident #95's plan of care prior to the fall (revised 11/29/18) listed the resident was at risk for falls due to unsteady gait due to upper and lower extremity amputations (left arm, distal portions of both feet), poor balance, history of falls and history of sliding out of wheelchair. Interventions to prevent serious injury included, Resident Transfers: Requires limited to total dependence 1 or 2 person assist. This care plan documented the resident required assistance with activities of daily living (ADL's) due to upper and lower extremity amputations. Interventions to prevent a decline in ADL's included, Requires mechanical lift to aid with transfers. The resident's plan of care (revised 11/29/18) did not specify the type of mechanical lift to use for transfers (sit-to-stand versus total lift). The care plan interventions did not specify the type or number of persons required to ensure safe transfers for Resident #95. The transfer assistance listed in the care plan ranged from limited assistance to total dependence with 1 or 2 persons. The care plan interventions (limited to total assistance of 1 to 2 persons) did not match the MDS assessment indicating the provision of extensive assistance of 2 + persons for transfers. The facility's investigation of Resident #95's fall/fracture documented a written statement from CNA #3 who was with the resident at the time of the fall. CNA #3's written statement (undated) documented, I put [Resident #95's] pants on and pulled them above her ankles while she was in bed then I put her shoes on then I got her up in the bed and strapped her onto the sit to stand and eased her feet to the edge of the bed once her feet were on the sit to stand I strapped her shoes down once again because they were big on her but those were all the shoes she had. As I raised her up I was pulling up her pants and then her feet started to slip. Her shoe had came off and part of her sock had too. As I was trying to put her shoe and sock back on her other shoe came off and that foot started to slip off as well. I put both shoes back on as both of her feet touched the floor then I moved everything that was in the way out of the way while her arms were still up and attached to the sit to stand after I did that I lowered her arms and when her arms were up she told me her arm was hurting but I couldn't let her down until everything was out of the way. once I lowered and unstrapped her I held onto her as I eased her onto the floor. After she was eased onto the floor I was still holding on to her and layed her gentally [gently] on her back because she isn't strong enough to hold her back up and the I went to get help. (Sic) The facility's investigation documented a note written by the director of nursing (DON) dated 12/3/18 stating, On 12/2/18 [CNA #3] was attempting to get [Resident #95] up using a sit to stand lift .On 12/3/18, I had [CNA #3] demonstrate for me and the ADON [assistant director of nursing] the way in which the patient was positioned on the lift and what transpired. [CNA #3] states the patient did not fall and she was lowered to the floor. After investigating it is determined that using the sit to stand and the decline in the patient's condition, history of osteoarthritis and Vit [vitamin] D and Calcium levels were in combination the main factors resulting in a fracture of the left humerus. The patient's arms were bearing the weight of the body against the metal bars of the lift and the patient was not bearing any of her weight on her legs. Staff are being re-educated on the use of all lifts and patient appropriateness . CNA #3 was not available for interview during the current survey. On 4/17/19 at 2:09 p.m., the licensed practical nurse (LPN #1) caring for Resident #95 was interviewed about the fractured arm on 12/2/18. LPN #1 stated she was not working on Resident #95's unit when the incident occurred. LPN #1 stated that two people were always required when transferring residents with a mechanical lift. LPN #1 stated CNA #3 was a prn (as needed) employee and not currently at work. On 4/17/19 at 2:28 p.m., the unit manager (LPN #3) was interviewed about Resident #95's fractured left arm. LPN #3 stated two people were always required when using a mechanical lift. The DON entered the unit manager's office on 4/17/19 at 2:29 p.m. and was interviewed at this time about Resident #95's transfer with the resulting fracture. The DON stated the CNA was using the sit-to-stand lift when Resident #95's feet slipped and the CNA lowered the resident to the floor. The DON stated the CNA was by herself with Resident #95 when the incident occurred. The DON stated, There is never to be one person using a mechanical lift. The DON stated they had the CNA demonstrate the events of the incident. The DON stated the CNA did two things wrong during the transfer and was not using the lift correctly. The DON stated there should have been two people assisting with the transfer and the CNA had the resident positioned improperly on the lift. The DON stated the resident's arms were resting across the metal support bars instead of the resident holding her weight with her right hand and left stump. The DON stated the resident used the sit-to-stand lift in the past and partially supported her body weight even with only one hand. The DON stated the resident had experienced a decline in condition and was unable to participate as much during the transfer. The DON stated when the resident's feet slipped her body weight was applied to her arms. The DON stated the left upper arm was fractured near where the arm hit against the support bar. The DON presented a copy of the facility's mechanical lift policy/procedure. The policy titled (Hydraulic) Lift (undated) documented, Purpose: to enable two people to lift and move a resident safely and with as little physical effort as possible .Any resident who weights greater than 150 lbs. [pounds] and is unable to bear weight to assist with the transfer must be transferred with the Hydraulic Lift to ensure the safety of the resident and the employee. The DON presented a copy of the skills checklist for the sit-to-stand lift that was used for re-education of CNA #3 and other CNA's in the facility following the incident with Resident #95. CNA #3's skill checklist dated 12/4/18 documented to always use two people with the sit-to-stand lift and included the following requirements for use of the sit-to-stand lift: .Must be able to bear 20% of body weight on at least one leg .Must have some upper body strength and ability to grip handles AND is able to sustain pressure to mid and lower back .Must be able to participate in the transfer or lift & be able to follow simple instructions . The Points to remember included, Never leave anyone unattended during lift and/or transfer procedures .Follow all policies and procedures .Use correct number of staff required for lift and/or transfer . Steps for use of sit-to-stand lift included, .Begin with individual seated. If in bed, raise head of bed and then assist individual to sit in the dangling position. Support as needed, using two caregivers, if necessary . The lift manufacturer's manual titled Stand Up Patient Lift (revised 11/13) listed a requirement that healthcare staff determine the appropriate assistance needed to ensure a safe transfer and a requirement that the patient grip both of the lift handles and support the majority of their own weight in order to prevent injury. The manufacturer's instructions documented on page 8, The stand up lift may be operated by one healthcare professional for all lifting preparation, transferring from and transferring to procedures with a cooperative, partial weight-bearing patient. However, since medical conditions vary, [manufacturer] recommends that the healthcare professional evaluate the need for assistance and determine whether more than one assistant is appropriate in each case to safely perform the transfer. Page 14 of this manual documented, Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur. Page 15 of this manual documented, .Adjustments for safety and comfort should be made before moving the patient .Instruct the patient to hold onto the hand grips on both sides of the stand up lift . These findings were reviewed with the administrator, director of nursing and corporate nursing consultants during a meeting on 4/17/19 at 4:45 p.m. On 4/18/19 at 9:55 a.m., the DON requested to share further information about Resident #95's lift incident and resulting fractured arm. The DON stated the resident had last been evaluated by therapy on 8/3/18 indicating the resident's use of the mechanical standing lift. The DON stated after completion of a root cause analysis the resident had osteoporosis, staff were re-educated on the lift procedures and the resident was switched to a total mechanical lift after the fall. The DON stated, We can have one person with the sit-to-stand. The DON stated the resident's foot slipped and the requirement for two person assistance with the use of the sit-to stand was not started until after Resident #95's slip/fracture on 12/2/18. This was opposite to what the DON stated during an interview on 4/17/18 at 2:29 p.m. indicating mechanical lifts always required assistance of two persons. The occupational therapy (OT) note presented by the DON (dated 8/3/18) was an evaluation regarding poor wheelchair positioning and use of a new wheelchair and cushion. The OT evaluation was not an assessment regarding safe use of any type of mechanical lift. This evaluation listed the resident used a mechanical lift during transfers under the section regarding the resident's medical history. On 4/18/19 at 10:36 a.m., the corporate nursing consultant stated before Resident #95's fall on 12/2/18 the care plan listed one to two person assistance for transfers and did not indicate a requirement for two people. On 4/18/19 at 11:04 a.m., the corporate nursing consultant stated the Hydraulic lift procedure presented on 4/17/19 did not apply to the sit-to-stand lift but only to total lifts. The corporate nursing consultant stated the facility did not have a policy about use of the sit-to-stand lift. The corporate nursing consultant stated that since they had no policy about use of the sit-to-stand, they referenced the manufacturer's manual as a guide for proper use of the lift. When asked who decided when to use limited or total assistance or one or two people for transferring Resident #95 as listed in the care plan, the corporate nursing consultant stated, the decision was multi-faceted because the resident had a variety of health issues. When asked how the resident could grip both lift handles when she only had one hand, the corporate nursing consultant stated the resident had used the lift in the past pulling her weight with one hand. Additional interviews were conducted with CNA's caring for other residents in the facility identified as using the sit-to-stand lift. On 4/18/19 at 2:35 p.m., CNA #1 was interviewed about assistance required with sit-to-stand lifts. CNA #1 stated two staff members were always required when she used the sit to stand lift. CNA #4 was interviewed on 04/18/19 at 2:50 p.m. regarding use of a sit to stand lift. CNA #4 stated, We always use two people. I have worked here for almost three years and have used two people when using any kind of lift. On 4/18/19 at 3:00 p.m., two CNA's were interviewed independently regarding transfer procedures for residents who use the sit-to-stand lift. Both CNA #5 and CNA #6 said they had been employed at the facility for a little over two years. When asked if they ever transferred residents by themselves, both stated that two people were always used during a sit-to-stand lift transfer. CNA # 5 said, We've been using two people for at least two years. CNA # 6 stated, As long as I've been here we've been using two people to transfer. There was no explanation from the DON about her conflicting statements regarding assistance required with use of the sit-to-stand lift on 4/17/19 and on 4/18/19. The DON stated on 4/17/19 that two people were always required when using mechanical lifts and that CNA's had been re-educated regarding that requirement after Resident #95's injury. On 4/18/19, the DON stated the requirement of two people with the sit-to-stand lift was not started until after Resident 95's fracture on 12/2/18. This statement conflicted with the unit manager report to the emergency room on [DATE] and other direct care staff interviews that indicated mechanical lifts had always required the assistance of two persons. There was also no explanation provided for why the resident's plan of care in place at the time of the fall did not specify the number of staff persons required to ensure safe transfers for Resident #95. These findings were reviewed with the administrator, director of nursing and corporate nursing consultants again during a meeting on 4/18/19 at 3:00 p.m. 1. b) 04/16/19 at 3:24 p.m., Resident #95 was observed seated in a specialized wheelchair in her room. The resident was unattended by staff. When asked if she had a call light, Resident #95 stated she did not have the call light with her and did not know where it was located. The call light was observed in the middle of her bed and out of the resident's reach. On 4/17/19 at 10:15 a.m., Resident #95 was observed in bed. When asked about her call light, Resident #95 looked about her bed and stated she did not know where her call light was located. The call light was observed on top of the bed table to the left of the resident. The resident's left lower arm was amputated just below the elbow. The resident stated she was unable to reach the call light. The resident stated the call light needed to be on her right side as that was her only hand. Resident #95's plan of care (revised 4/4/19) listed the resident was at risk of falls due to a history of falls, upper and lower extremity amputations, poor balance and sliding out of her wheelchair. Interventions for fall and injury prevention included, Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance .Provide a safe environment with .a working and reachable call light .staff to remind to call for assistance if an item is not in close reach, she needs to avoid over reaching and losing balance . On 4/17/19 02:40 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about call light access for Resident #95. LPN #3 stated call lights were supposed to be available to residents when in the bed and/or in the chair. LPN #3 stated the resident could have been brought back from an activity and the call light not placed within reach. This finding was reviewed with the administrator and director of nursing during a meeting on 4/17/19 at 4:45 p.m. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses that included diabetes, diabetic neuropathy, depression, bipolar disorder, schizophrenia, high blood pressure and osteoporosis. The minimum data set (MDS) dated [DATE] assessed Resident #40 as cognitively intact and as totally dependent upon one person for mobility on and/or off her unit with use of a wheelchair. On 4/16/19 at 2:38 p.m., Resident #40 was observed in her room in her wheelchair. The wheelchair had no footrests or foot pedals in place. The resident was interviewed at this time about any type of footrests for the chair. The resident stated she did not self-propel in the wheelchair but required staff to push her for transport in and out of her room. The resident stated she did not know where the footrests were for her wheelchair. Resident #40's clinical record documented a physician's order dated 3/19/19 stating, Patient to have foot plate/platform added when patent is in the wheelchair to prevent feet from falling off legrest. Resident #40's plan of care (revised 3/25/19) listed the resident had limited mobility due to obesity and bilateral upper extremity tremors. Included in interventions to prevent decline in function was, Foot plate/platform when in wheelchair to prevent feet from sliding off legrest. On 4/17/19 at 2:17 p.m., the certified nurses' aide (CNA #2) caring for Resident #40 was interviewed. CNA #2 stated she did know anything about footrests for the resident's wheelchair. CNA #2 stated, As far as I know, she has no footrests. CNA #2 stated the resident was unable to self-propel in the wheelchair and described the resident as total assist. CNA #2 stated she did not know anything about a plate or platform on the wheelchair. On 4/17/19 at 3:00 p.m., the unit manager (LPN #3) was interviewed about footrests and the physician ordered foot plate/platform for Resident #40. LPN #3 stated she did not recall anything about use of a plate or platform. LPN #3 stated the resident should have footrests somewhere and stated she would look for them in her room. LPN #3 stated the resident should have footrests in place when in the wheelchair. On 4/17/19 at 4:05 p.m., the occupation therapist (OT) was interviewed about Resident #40 footrests and the physician ordered plates/platforms. The OT stated the resident should have footrests in place when in the wheelchair to keep her feet and/legs from going under the chair during transport. The OT stated therapy recommended the order for the platform to help keep the resident's feet on the footrest pedal and prevent her feet/legs from going under the chair during movement. The OT stated nursing was responsible for putting the footrests and ordered platforms on the chair. This finding was reviewed with the administrator and director of nursing during a meeting on 4/17/19 at 4:45 p.m. On 4/18/19 at 8:30 a.m., the OT stated the resident's footrests were found in the dresser drawer. The OT stated they did not find the physician ordered platforms/plates. The OT stated she did not know why the footrests and plates were not installed as ordered. The OT stated the footrests were needed to ensure resident safety during transportation in the wheelchair as the resident did not self-propel.