**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility failed to provide staff assistance and supervision for a safe transfer for one of sixteen residents (Resident #1), resulting in a fall with fracture (harm). The findings include: Resident #1 (R1) fell when a privately hired companion/sitter attempted to transfer R1 from the bed to a wheelchair. The private companion did not request facility staff assistance with the transfer and had no prior documented training of facility policies that prohibited private caregivers/companions from performing direct-care activities, including transfers. R1 was diagnosed with a right distal femur fracture, as a result of the fall, and required treatment with immobilization and pain medication. Resident #1 was admitted to the facility with diagnoses that included dementia, hypertension, osteoporosis, urinary tract infection, osteoarthritis, conjunctivitis, gastroesophageal reflux disease, and depression. The minimum data set (MDS - assessment tool), dated 2/22/24, assessed R1 with severely impaired cognitive skills and requiring extensive assistance of two staff for bed mobility and transfers. R1's clinical record documented a nursing note dated 4/20/24 stating, .Incident Time . [9:05 a.m.] . Rsd [Resident's] private caregiver was trying to transfer Rsd from bed to wheelchair without staff assistance. Rsd R [right] Knee gave out and Rsd slid from bed to floor with assistance from caregiver. Rsd c/o [complained of] R knee pain . (sic) The nursing note documented that the family and physician were notified, with the family requesting to not immediately send the R1 to the emergency room but assess the status the next morning. A nursing note on 4/21/24 documented that R1 developed increased swelling, bruising, and pain of the right leg and that R1 was sent to the emergency room for evaluation/treatment. The hospital Discharge summary dated [DATE] documented that R1 was diagnosed with a distal right femur fracture, as a result of the fall. R1 was assessed by orthopedics and treated with a knee immobilizer to be in place for 6 to 8 weeks, along with pain management. R1 was re-admitted to the facility on [DATE] with orders for bed rest with the right leg immobilized as ordered. R1 was administered pain medication due to right leg pain on 4/22/24 at 7:23 p.m. and on 4/23/24 at 8:54 a.m. with effective results. A note by the nurse manager dated 4/22/24 documented, After further investigation and discussion with staff r/t [regarding] fall on 4/20/24 it is determined to be of known cause. The fall is consistent with resident caregiver performing a transfer without assistance from staff causing Resident to fall. The fall resulted in a right femur fx [fracture] . R1's plan of care prior to the fall (revised 4/12/24) documented the resident required the extensive assistance of 1 to 2 staff persons with all transfers and use of a mechanical lift as needed. The care plan also listed the resident required extensive assistance of 1 to 2 staff persons for dressing, bed mobility, and toileting. R1's clinical record documented the resident was assessed/treated for a urinary tract infection starting on 4/8/24. Staff referred R1 for a therapy evaluation on 4/11/24 due to a decline in status and increased need for assistance with activities of daily living. R1's therapy communication form to nursing dated 4/11/24 documented a physical therapy recommendation for transfer with a Hoyer mechanical lift until the resident could stand, step and turn to use a walker. This recommendation was modified on 4/12/24 to use of a Hoyer lift as nursing deems necessary because the family did not want the resident to transition to total dependence with the lift. Therapy documented an additional communication to nursing on 4/16/24 recommending, When transferring pt [patient] 2 person, do not arm and arm unless the chair is touching the bed. On 4/22/24 at 3:25 p.m., the licensed practical nurse (LPN #1) caring for R1 on 4/20/24 was interviewed. LPN #1 stated R1 had private sitters/caregivers during the day. LPN #1 stated that on 4/20/24, the private caregiver was trying to transfer R1 from the bed to wheelchair, when the resident's knee gave out and the resident slid to the floor. LPN #1 stated there were no staff members with R1 at the time of the fall and the private caregiver had not requested or called for assistance with the resident. LPN #1 stated private companions/caregivers were not allowed to perform any resident transfers or provide direct ADL (activities of daily living) care for residents. LPN #1 stated a certified nurses' aide (CNA) had performed incontinence care with R1 earlier in the shift and that the private caregiver (other staff #3) transferred the resident without requesting or calling for assistance from staff. LPN #1 stated R1 required two people for a safe transfer as the resident had experienced a recent decline since diagnosed with a urinary tract infection. LPN #1 stated the resident had been weaker since the infection, was evaluated by therapy, and that two staff members were provided during transfers to ensure safety. LPN #1 stated again that the private caregivers were not supposed to transfer residents and thought they had received training about their role. LPN #1 stated she and two CNAs were working on R1's unit and were available on the morning of 4/20/24. On 4/22/24 at 3:35 p.m., CNA #4 that routinely cared for R1 was interviewed. CNA #4 stated R1 had required two-person assistance during the last several weeks because of weakness following an infection. CNA #4 stated being aware that R1 had a private companion/caregiver, but the private sitters were not supposed to provide direct care or transfers. CNA #4 stated that in the last month, he always had two people when transferring R1. On 4/22/24 at 3:43 p.m., CNA #5 that routinely cared for R1 was interviewed. CNA #5 stated she always used two people when transferring R1 because the resident had been weak in the last several weeks due to an infection. CNA #5 stated there had been times when she entered R1's room and the private caregiver had already assisted the resident into the wheelchair. CNA #5 stated she was not working on 4/20/24 when the resident fell. CNA #5 stated that the private companions/caregivers usually rang the call bell or verbally requested assistance when R1 needed care. On 4/23/24 at 11:35 a.m., CNA #3 that routinely cared for R1 was interviewed. CNA #3 stated only staff members were supposed to perform resident transfers. CNA #3 stated that she always used a two-person transfer with R1. CNA #3 stated R1's care guide required 1 to 2 staff persons or a lift for transfers. CNA #3 stated that the private companions/sitters were not supposed to transfer residents. On 4/23/24 at 11:56 a.m., the nurse manager (LPN #2) was interviewed about R1's fall/injury. LPN #2 stated R1 had sitters during the day. LPN #2 stated facility staff were supposed to perform all transfers with residents. LPN #2 stated that private caregivers had been instructed to use the call bell or come get staff for needed assistance with transfers. LPN #2 stated on 4/20/24, the private companion/caregiver did not request or call for assistance prior to the attempted transfer. LPN #2 stated no staff members were present at the time of the fall to make decisions and provide required assistance for a safe transfer. LPN #2 stated the CNAs knew and had previously provided the needed assistance for safe transfers for R1. LPN #2 stated the CNAs reported the resident's need for assistance increased after a urinary tract infection several weeks ago. LPN #2 stated R1 was referred to therapy in response to the decline. LPN #2 stated the private companions/sitters were supposed to be educated prior to working and should know to get staff for resident needs. On 4/23/24 at 1:51 p.m., the physical therapist (PT - other staff #2) that evaluated R1 was interviewed. The PT stated staff had reported a decline and R1 was recommended on 4/12/24 for transfers with the use of a mechanical Hoyer lift as needed. The PT stated she told the weekday private companion that she should not transfer or walk the resident by herself. The PT stated the fall/fracture occurred on a weekend (4/20/24) and was not sure if the transfer recommendations were communicated to the private caregiver that worked weekends. On 4/23/24 at 2:05 p.m., the director of nursing (DON) was interviewed about R1's fall/fracture. The DON stated private companions/caregivers were not allowed to provide direct ADL care or transfers for residents in the facility. The DON stated private caregivers were required to ring the call bell or verbally request assistance from the nurse or CNA assigned to the resident. The DON stated R1 had a recent decline due to a urinary tract infection, was evaluated by therapy and had the option for a mechanical lift transfer if needed. The DON stated nursing was providing 2-person assistance during transfers with R1 since the decline/infection to ensure safety. The private caregiver with R1 at the time of the fall on 4/20/24 was named by the DON and identified as other staff #3. The DON stated other staff #3 usually worked the weekends. The DON stated families were instructed upon admission that sitters were just companions and were not allowed to perform resident care. The DON stated the private caregivers and CNAs were instructed that companions/sitters were not to provide direct care including transfers. The DON stated on 4/20/24, R1's private caregiver (other staff #3) came in the hall and stated R1 was in the floor. The DON stated other staff #3 said the resident slid from the bed while attempting to transfer R1 from the bed to wheelchair and that other staff #3 had not asked for staff assistance. The DON stated the private caregiver (other staff #3) said that she knew she was supposed to call staff but did not because she thought she could do it. The DON stated it was the facility's policy/protocol for private sitters/caregivers to be only companions and were not to transfer residents. On 4/23/24 at 2:49 p.m., the private companion/caregiver (other staff #3) with R1 at the time of the fall was interviewed. The private companion stated that nurses or CNAs were supposed to transfer residents. The private companion stated on 4/20/24, R1 was sitting on the side of the bed getting ready to get up in the wheelchair. The private companion stated R1 started sliding and I couldn't stop her, so I let her go down. The private companion stated she went in the hall and got the nurse and CNA to come assess the resident. The private companion stated she had not asked or called for assistance from staff prior to getting the resident up on the bedside. The private companion stated she was sure the staff would have responded if she had requested their assistance. The private companion stated she was aware that only facility staff were supposed to provide direct care and transfers for residents. When asked if she had transferred the resident before without staff, the private caregiver stated she had transferred R1 to the wheelchair and taken R1 to the bathroom by herself, but this was prior to the resident's recent urinary tract infection. On 4/24/24 at 8:49 a.m., CNA #6 working on R1's unit on the morning of 4/20/24 was interviewed. CNA #6 stated the R1's weekday sitter always called for help with the resident. CNA #6 stated she did not work with the other sitter (other staff #3) very often because other staff #3 usually worked on the weekends. CNA #6 stated on 4/20/24, the private companion (other staff #3) did not ring the call bell or ask for assistance until after R1 was in the floor. On 4/24/24 at 8:57 a.m., CNA #7 working on R1's unit on the morning of 4/20/24 was interviewed. CNA #7 stated she was helping another resident when R1's private companion (other staff #3) came down the hall and said the resident was in the floor. CNA #7 stated she went to R1's room and saw the resident in the floor, parallel to the bed with her back against the nightstand. CNA #7 stated when she asked what happened, the private companion stated she did not know. CNA #7 stated the private companion did not call or ask for assistance until after R1 was in the floor. CNA #7 stated the private sitter that worked during the weekdays always called staff for transfers and ADL tasks. CNA #7 stated there had been times when the weekend sitter (other staff #3) had transferred R1 without staff assistance because R1 would be up in the wheelchair when she entered the room. CNA #7 stated she did not know why the private companion did not ask for help on the morning of 4/20/24 because she, LPN #1 and CNA #6 were on the unit. The facility's policy titled Guidelines for Companions (revised 5/30/2014) documented, It is our policy, as well as our responsibility, to meet the needs of resident while they are at [the nursing facility]. However, there may be times when residents and/or their families wish to employ companions .The role of the private duty companion is to provide fellowship and social support through activities which might include .Taking residents (in a wheelchair) to programs .Joining residents in recreational activities .Taking the resident to meals at mealtime if needed, and to assist with menu selection .enhancing grooming, manicures, hairstyling, choosing clothing, donning a sweater .Light housekeeping . This policy documented under companion guidelines, .Nursing care will be provided by [nursing facility] staff; a companion in [the nursing facility] may, with proper state approved training and physical ability, assist in the presence of staff .[In the nursing facility] a resident is not lifted or transferred without the assistance of a staff member and only if the companion has proper state approved training and is physically capable .The nursing staff is responsible for all nursing care . This policy documented all companions were required to complete an orientation that included key information such as emergency protocols, safety, infection control, resident rights and that the orientation requirements must be completed prior to the day the companion starts. The policy documented that a list of approved companions meeting the requirements was maintained and available upon request. On 4/24/24 at 8:30 a.m., the administrator and DON were interviewed about R1's private companion/caregiver (other staff #3) and any prior training/orientation regarding the private caregiver role/duties. The administrator stated R1's private companion (other staff #3) had worked with R1 in independent living, prior to her admission to skilled, but had served as companion to R1 mostly on weekends since admission to the long-term care facility. The administrator stated R1's private caregiver (other staff #3) was not included on the facility's list of approved companions. The DON stated that she found no documented training and/or orientation for R1's companion (other staff #3). The DON stated that the companion (other staff #3) had said that she completed paperwork before she started working as a sitter, but the DON stated, We don't have it. The DON stated that the companion (other staff #3) was not a CNA and had no record of any state approved training for resident care. The administrator stated the training and orientation requirements regarding the private companion's role/duties should have been completed prior to her working in the nursing home facility. On 4/24/24 at 9:30 a.m., the human resources assistant (HR - other staff #4) was interviewed about private companion/caregiver (other staff #3). The HR assistant stated that companion candidates required an orientation/training process prior to working with any residents in the long-term care facility. The HR assistant stated he did not know what happened regarding training/orientation for other staff #3. The HR assistant stated he researched back several years and found none of the required training, orientation, or annual in-services for R1's companion (other staff #3) and that other staff #3 was not on the facility's list of approved companions. These findings were reviewed with the administrator, DON and nurse manager during meetings on 4/23/24 at 4:10 p.m. and on 4/24/24 at 11:00 a.m. with no further information presented prior to the end of the survey.