**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure each resident receives the necessary care and services in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) after experiencing a change of condition for 1 of 11 residents reviewed (R20). R20 had an unintended sudden change of plane while being transferred by a sit to stand lift by a lone Certified Nursing Assistant (CNA). While in the lift sling, the lift's battery died, and resident ended up in a squatting position with her buttocks touching the foot pads of the lift. This sudden change of plane resulted in a hip fracture. Staff did not follow R20's plan of care which included using 2 staff for transfers with a sit to stand lift, and staff moved resident twice without a Registered Nurse (RN) assessment after the change of plane. The facility failed to report R20 having a change of plane to the oncoming shift, failed to give details regarding R20's incident to R20's provider delaying medical treatment, failed to complete a thorough assessment including vital signs at the time of the incident, failed to provide continued monitoring with change in condition including completion of a thorough RN assessment when R20 reported 8 out of 10 pain and 9 out of 10 pain, failed to complete an RN assessment when CNA K reported changes to the appearance of R20's leg and that something was wrong, and failed to document known changes in condition in R20's medical record, including internal rotation of lower right extremity. The facility's failure to ensure each resident received the necessary care and services in accordance with professional standards of practice after experiencing a change of condition led to a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on [DATE] at 11:35 AM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a severity/scope of D (potential for no more than minimal harm/isolated) as the facility continues to implement its action plan. Evidenced by: Facility policy, titled Notification of Changes, implemented [DATE], includes: The purpose of this policy is to ensure the facility promptly informs resident, consults with the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Definitions . Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction), or commence a new form of treatment to deal with a problem; for example the use of any medical procedure, or therapy that has not been used on that resident before . Clinical complications: examples- development of stage 2 pressure injury, recurrent episodes of delirium, recurrent UTIs or onset of depression . Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Accidents- Resulting in injury. Potential to require physician intervention. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration. This may include: Life threatening conditions, or Clinical complications. Circumstances that require a need to alter treatment. This may include: New treatment. Discontinuation of current treatment due to: adverse consequences, acute condition, exacerbation of a chronic condition . An article from the Nation Library of Medicine, titled, Risk Factors for Preoperative Deep Venous Thrombosis in hip fracture patients: a meta-analysis, by J Orthop Traumatol. 2022, includes: . Hip fracture (HF), including intertrochanteric fracture, femur neck fracture, and subtrochanteric fracture, as one of the most geriatric fractures associated with osteoporosis, is expected to affect about 6 million people by the year 2050 worldwide. Previous studies have demonstrated a close relationship between geriatric hip fractures and perioperative morbidity and mortality at 1 year. The treatment of geriatric hip fracture patients is a great challenge due to multiple medical comorbidities and serious perioperative complications. Obtaining stable reduction and fixation to permit early mobilization is critical to decreasing the development of perioperative complications. Early surgery is thought to be the best option for HF patients to reduce the risk of perioperative complications and death . Preoperative DVT, which affects 8-34.9% of hip fracture patients and may be as high as 62% in those with delayed operations, plays a critical role in HF patients' preoperative waiting time. [NAME] reported that delayed surgery, hypoproteinemia, three or more comorbidities, and a d-dimer level?>?1.59 mg/l were predictors of preoperative DVT . Preoperative DVT is one of the most common complications after hip fractures because of immobilization and medical problems of patients. Early prevention of preoperative DVT was beneficial in shortening the time from injury to surgery and lowering the incidence of postoperative complications. Medical problems and prolonged time from injury to admission have recently been linked to an increased risk of preoperative DVT . Patients over the age of 90 had a significantly higher rate of preoperative DVT than any other age group, which was linked to a prothrombotic state and decreased vascular function due to aging . In the present study, the mean time from injury to admission and surgery was significantly longer in the DVT group than in the non-DVT group. Three possible reasons may explain this. First, prolonged immobilization could result in venous congestion; second, vascular injury caused by fracture activated the coagulation system; third, the fracture was frequently coupled with dominant and hidden blood loss, especially hidden blood loss for intertrochanteric fractures. Therefore, earlier admission was necessary for intertrochanteric fractures . According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R20 admitted to the facility on [DATE]. Her diagnoses include rheumatoid arthritis, atrial fibrillation, atherosclerotic heart disease, joint disorder, history of falling, weakness, hypertension, sensorineural hearing loss bilaterally, pulmonary hypertension, and age-related osteoporosis. R20's Minimum Data Set (MDS), with Assessment Reference Date (ARD) of [DATE], indicates R20 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. R20's Comprehensive Care Plan, initiated on [DATE], indicates R20 required assistance of 1 for the following: dressing, bathing, bed mobility, and assist of 2 with sit to stand lift for transfers and needs one staff member to propel her in the wheelchair for long distances. R20's Comprehensive Care Plan indicates R20's medications are administered by the nurse. Facility Self Report, dated [DATE], includes: Investigation Summary: . On [DATE], R20 put on her call light because she wanted to be toileted. The assigned CNA (Certified Nursing Assistant) . was in the lunchroom, and CNA L was covering the floor. CNA L transferred R20 with sit to stand lift and took her to the toilet. Shortly thereafter, R20 put on the call light to get off the toilet and go back to bed. CNA L once again used the sit to stand lift without assistance of another staff member and upon raising her up the battery died. R20 was complaining that under her arms (where sling was) was hurting her, so CNA L used the emergency button to lower the lift arm. Apparently, that did not lower initially so CNA L tried to start pushing lift toward R20's bed and after going from the tile bathroom floor to the carpeted bedroom, the lift started to lower with resident still in sling. As the lift arm lowered the resident ended up in a squatting position with her buttocks touching the foot pad of the lift. CNA L decided to try to help the resident by pushing her buttocks and got her high enough to sit in her wheelchair. Shortly after that, CNA M arrived at the unit. CNA L told her she needed help with the transfer from the wheelchair to the bed. After the resident was settled, CNA L told the nurse that the resident was complaining of pain in her leg and that during the transfer with the sit to stand the battery died. She did not mention that this transfer was completed by only herself. LPN G (Licensed Practical Nurse) asked CNA L to write a statement and then she was going to see the resident. CNA L wrote an initial statement on [DATE] that was left for the nurse and not read until after end of day shift. CNA L statement left at nurse station, includes: [DATE] While transfer with the sit to stand. The sit to stand went dead in mid-air. She complained about her arms hurts [sic] so did the force thing to force the sit stand while that was going. [sic] It end sitting her down on the floor. I held her back with my legs so she wouldn't fall back. With her help I was able to get her back in her chair. Then a new sit to stand was used to get her in bed. Nurse was told. Statement was wrote [sic]. UM/RN Q (Unit Manager/Registered Nurse) statement, dated [DATE], includes: R20 had complained of right knee pain after being in the sit to stand. Resident was assessed in bed. Pain to right knee was stated at a 4 out of 10. Floor nurse gave scheduled Tylenol for pain. Resident's right knee was parallel to left knee. Right leg did not have internal rotation when assessed. CNA L second statement, dated [DATE], includes: I answered R20's call light. She was in the bathroom, [sic] as I am lift her up with sit to stand, she complains of pain in her arm pits as I go to lower her the machine died in mid-air, so I press the release button so it can be lower. [sic] wasn't aware that it was going so I tried to get her to her bed as quick as possible but on the way, she had been lower to the ground, so I made sure she didn't hit head and made sure she was sitting upright. With her help, I was able to get her off the floor into her wheelchair, then I use a charged sit to stand to put her in her bed. (Handwritten on the interview is a statement that states per interview did a squat on lift and was able to push up enough to get into wheelchair.) DON B (Director of Nursing) statement, dated [DATE], includes: On [DATE] at around 2:30 PM LPN G reported to me that R20 said she had an issue with an earlier transfer in the sit to stand lift and that her leg was sore. I instructed her to get Unit Manager/RN Q and look at R20 and prepare an incident report. LPN G did complete incident report as other incident. On [DATE] R20 was seen by Nurse Practitioner (NP O and NP P) and she noted there was a leg discrepancy and ordered an x-ray. R20 also had denied any fall at that time and told NP O that she thought it was from being up in the sit to stand too long. I was made aware of the possible change just around 9:00 AM. CNA L was in the facility with a resident . completing one-on-one observation. Around 10:30 AM, I interviewed CNA L and had her complete a new written statement. During that interview I found out that the sit to stand transfer was not completed per policy initially and that only CNA L was in the room. CNA L witnessed the issue with the lift and resident. I felt at that point that the potential injury could be the result of a witnessed fall due to change of plane for the resident. I then went into risk management and changed the reason for the incident report from other to witnessed fall and completed the corresponding assessments for the incident. At about 1:00 PM, the X-ray did reveal a fracture of the right hip, and the resident was being transferred to the emergency room for evaluation. The incident was then reported to the state as an injury of unknown origin because I could not definitively determine cause and investigation was initiated. Facility 24 Hour Communication Board, dated [DATE], includes: R20- Day shift- right knee pain, up long in sit to stand, complained of right knee/leg pain . PM shift- extra strength Tylenol as needed given for 9 out of 10 pain, new order for Flexeril 10mg (milligrams) 1 dose . (It is important to note there is no mention of R20 sitting down on the floor during a sit to stand transfer.) R20 Nurse Notes, Medication Administration Record (MAR), and text messages exchanges with R20's provider include: Nurse Note, Late entry added on [DATE] for [DATE] at 2:00 PM . Writer was notified by LPN G that resident had complaints of pain to her right knee after being in the sit to stand too long. Writer assessed the resident. Right knee appeared equal to left knee. No rotation, redness, or swelling noted. Resident stated she has arthritis in that knee and has pain from time to time. Had pain 4 out of 10 at that time. (It is important to note this is the documentation in R20's medical record of an assessment being completed, but this note was not added to R20's medical record until [DATE], 9 days later. It is also important to note there is no evidence in R20's medical record of vital signs being gathered, including heart rate, blood pressure, or respirations per minute.) Text message, date and time unknown, from facility to provider, includes: resident complained of knee and leg pain after being in sit to stand too long. No injury noted. Will continue to monitor for pain and update with any changes. (It is important to note the facility did not report R20's change of plane, fall, or sudden drop from lift to R20's medical doctor.) Text message dated [DATE] at 2:59 PM, from provider to facility, includes: noted no new orders. Thank you. MAR Note dated [DATE] at 7:33 PM Tylenol Extra Strength Tablet 500 MG. Give 1000 mg by mouth as needed for pain every evening. Text message dated [DATE] at 8:04 PM, from facility to provider, included: R20 is now complaining of 9 out of 10 pain with movement. I did give her as needed Tylenol. Nurse Note, [DATE] at 8:06 PM: Resident is rating hip pain a 9 out of 10, no swelling or discoloration to hip, Pain is with movement. Message sent . to on call Nurse Practitioner. As needed Tylenol given to resident. Will monitor. (It is important to note there is no evidence in R20's medical record of an RN assessment being completed with this new onset of 9 out of 10 pain.) Text message, dated [DATE] at 8:07 PM, from provider to facility, includes: Is there any visible change? (It is important to note R20's medical provider still is unaware of R20's change of plane or that a transfer ended sitting her on the floor.) Text message dated [DATE] at 8:09 PM, from facility to provider, includes: No swelling or skin discoloration but she said it hurt during cares with movement. (It is important to note R20's medical record did not contain evidence of a thorough RN assessment being performed. The above data of no swelling and no discoloration was gathered by an LPN.) Text message, dated [DATE] at 8:10 PM, from provider to facility, includes: It was just from being in the sit to stand? Text message, dated [DATE] at 8:13 PM, from facility to provider, includes: Are you able to see the incident report in point click care? Text message dated [DATE] at 8:16 PM, from facility to provider, includes: Apparently she was in the sit to stand for a while according to her and now is having the right hip pain. She says it feels like she pulled a muscle. MAR Note dated [DATE] at 8:30 PM, includes: Tylenol Extra Strength Tablet 500 MG. Give 1000 mg by mouth as needed for pain every evening. Administration was ineffective . Follow up pain scale: 8. Text message, dated [DATE] at 8:35 PM, from facility to provider, includes: any new orders? Text message dated [DATE] at 8:41 PM, from facility to provider, includes: She now rates the hip pain 8 out of 10, this is one hour after taking the extra strength Tylenol. Text message dated [DATE] at 8:49 PM, from provider to facility, includes: We can try a one time dose of Flexeril 10 milligrams to see if it helps. Text message dated [DATE] at 9:15 PM, from facility to provider, includes: Thank you. Noted. Will continue to monitor for pain and update with any changes. Nurse Note dated [DATE] at 9:29 PM, includes: Physician Assistant from . aware and new order for one time dose of Flexeril 10mg muscle relaxer. Resident aware. Will monitor. Nurse Note, [DATE] at 10:13 PM, includes: One time dose of Flexeril given and effective. Resident reports less pain to right hip, 2 out of 10. Facility 24 Hour Communication Board, dated [DATE], includes: Night Shift- R20- complained of pain to right knee/leg . Day Shift- New order stat x-ray related to right hip, right knee, Flexeril 5mg as needed three times a day for pain . Advanced Practice Nurse Practitioner (APNP) Note, dated [DATE] at 10:30 AM, includes: Chief complaint- right knee and leg pain . Patient was an acute add on today presenting today with right knee and leg pain after being transferred via sit to stand overnight last night per RN report . vital signs- [DATE]: blood pressure- 122/64, oxygen saturation- 96%, pain- 0, temperature- 97.6 degrees, respirations-18, heart rate 74, weight 140 . vitals [DATE] blood pressure- 110/62, oxygen saturation- 95%, pain-0, temperature 97.3 degrees, respirations-17, heart rate- 65 . vitals [DATE] pain 8 . vitals [DATE] pain-0 .Muscoskeletal- no joint tenderness or deformity. Right lower extremity with minimal range of motion. Unable to flex, extend, abduct, adduct, or externally rotate hip without extreme pain. Right lower extremity internally rotated while resting in bed and unable to straighten. Pedal pulses plus 2 bilaterally, warm to touch, and sensation intact. No bruising or swelling noted. (It is important to note the incident took place on [DATE] between 1:00 PM and 2:30 PM according to the resident's statement, CNA L's statement, CNA M's statement, LPN G's statement, and UM/RN Q's statement and this APNP's note reflects the most recent vitals recorded in R20's medical record. These vitals are from [DATE] and [DATE]. The facility did not record R20's blood pressure, heart rate, respiratory rate, or temperature on [DATE] or after the change in condition was noted.) R20's Radiology Report, dated [DATE] at 12:25 PM, includes: . Hip . Right . Results: Intertrochanteric right femoral fracture with mild angulation. Mild soft tissue swelling . Conclusion: Acute Intertrochanteric right femoral fracture as noted . Knee . Right . No acute fracture or dislocation. The osseous structures appear intact. Modest joint space narrowing. Soft tissues are unremarkable. Conclusion: No acute osseous findings. Recommend a repeat multi-view imaging in 1 week or sooner if clinically warranted especially if symptoms continue or persist or progress. R20's SBAR Communication Form, dated [DATE], includes: this started on [DATE] . Since it started it has stayed the same. The condition, symptom, sign has occurred before: No . Medication Changes in the last week: Flexeril . Vital Signs: 139/79, Pulse: 81, Respirations: 18, Temperature: 97.8 . Functional Status: No changes observed. Skin Evaluation: not clinically applicable to the change in condition being reported . Pain: New Intensity of pain: 9 . Appearance- Summarize your observations and evaluations: (blank) . Review and Notify: Primary Care Clinician Notified: Yes- date and time: [DATE] at 1:00 PM. Recommendations of Primary Clinicians: Send to emergency room for evaluation and treatment of right hip fracture. Check all that apply: X-ray . Nursing Note for additional information on change in condition: (blank) . Signed by RN/UM Q . R20's Emergency Department Note, dated [DATE], includes: X-ray today shows a broken hip. Given that you are not ambulatory, there is no clear indication for surgery and based on your wishes and discussion with family, it is safe to go back to your facility. You will need care with movement to try to avoid significant displacement of the right leg especially. You should at least take Tylenol, up to 1 gram, every 6 hours, as needed; if you have stronger pain, it is reasonable to try hydrocodone. The medication prescribed for pain today will make you sleepy; . X-ray pelvis AP and hip right final results: Impression: Impacted and displaced intertrochanteric right femur fracture . Reason for exam: fall, deformity . additional relevant history: fall, deformity . Findings: The osseous structures appear demineralized. There is a mildly impacted and displaced fracture of the proximal right femur involving the base of the femoral neck extending into the intertrochanteric region. Increased varus angulation. The femoral head remains normally aligned with the acetabulum. The pelvic ring appears intact. Left hip alignment is normal . On [DATE] at 10:42 AM during a phone interview, CNA M indicated when she entered the room R20 was in her wheelchair and CNA L told her the sit to stand lift malfunctioned and R20 was on the floor. CNA M indicated she did not report this change of plane to the nurse on the floor or to the oncoming shift, because she figured CNA L would report it. CNA M indicated when a resident has a change of plane, is on the floor, or has a sudden fall from a lift she goes to get the nurse immediately and does not move the resident until the nurse is done with an assessment and tells her it is ok to move the resident. CNA M indicated 2 staff are to be present when staff use any mechanical lift per facility policy. On [DATE] at 11:24 AM during interview, LPN G stated, Originally I was told by CNA L that R20 was complaining of pain to her leg and there was an issue with the sit to stand. I had asked her to write a statement. I ended up finding the statement later on. It was very unclear, and I was looking for clarification. LPN G indicated she did not see any changes in R20 when she looked but asked UM/RN Q to assess her. LPN G indicated she did not remember gathering a set of vitals on R20. LPN G stated, I would like to have had more accurate information and more information by the CNA L. She should not have picked R20 up off of the floor. She should have grabbed a nurse. LPN G indicated education was given after the incident to be sure staff are using sit to stand lifts with two staff. LPN G indicated education that was given did not include what to do post fall or reporting accurate information. On [DATE] at 11:47 AM during a phone interview, CNA K indicated he came in on [DATE] at 2:30 PM and in report they said there was an incident with R20 and the sit to stand lift. CNA K stated, During first rounds, I could tell something was wrong with R20. I said to LPN N I think you need to get an x-ray, her leg does not look quite right. The position of her leg was not right. She was laying in the bed. Didn't look normal. CNA K indicated if a resident has a fall, he is to report the fall immediately and he does not move resident until after an RN has completed an assessment. CNA K indicated staff are to have two staff present when running any mechanical lifts in house per facility policy and he received education on this. CNA K indicated the typed summary of his interview in the Facility Self Report does not reflect what he reported to the facility. On [DATE] at 1:54 PM during interview, DON B indicated CNA L reported to LPN G that the lift battery died during transfer and now R20 is complaining of pain. Then CNA L slipped a written statement containing more information on the nurses' desk before exiting the building for the day. LPN G found the statement around 2:30 PM and brought it to DON B. DON B told LPN G to start an incident report, grab UM/RN Q for an assessment, and to report incident and findings to R20's provider. DON B and Surveyor reviewed CNA L's first statement. DON B and Surveyor reviewed contact with R20's provider. DON B indicated the provider was not made aware R20 was sitting on the ground. DON B stated, I was going to get a second statement from her to make sure there was a fall. DON B indicated CNAs are to report falls immediately to the floor nurse and give as many details as possible. Surveyor asked DON B what the process is for witnessed falls and unwitnessed falls. DON B indicated the process is for an RN to complete an assessment and notify the resident's provider. DON B indicated a thorough assessment contains a full set of vitals, a description of the affected area including any deformities, any discoloration, any changes in temperature, any shortening, or any rotation. DON B indicated she does not see any vitals recorded for [DATE] in R20's medical record. DON B indicated a fall is an unintended change of plane. DON B indicated staff are to have two staff present for all mechanical lift transfers per facility policy and CNA L transferred R20 two times alone, once to the toilet and once out of the bathroom. DON B indicated LPN N called her on [DATE] around 8:15 PM to let her know R20 was experiencing 9 out of 10 pain. DON B indicated she planned to assess R20 when she came in on [DATE] in the morning. Surveyor asked DON B if she would be willing to do an enactment of a staff member using the mechanical lift. DON B indicated she and Corporate Consultant EE would volunteer to demonstrate how to activate the emergency button so Surveyor could see how long it takes to lower a resident completely using the emergency button. (It is important to note R20's medical record does not contain a thorough assessment by DON B.) On [DATE] at 2:18 PM, Surveyor observed DON B and CNA FF maneuvering the lift while Corporate Consultant EE was seated with the sling in place around her. DON B, CNA FF, and Corporate Consultant EE could not get the emergency button to engage and lower the lift all at once. Surveyor observed a turn button on the hydraulic boom of the shift and when DON B turned that button it would only go one turn at a time. When the button made one full turn, the lift would lower a little bit and stop. Then DON B or CNA FF would turn button another full turn and lift would lower a small amount and stop. Surveyor observed staff were unable to drop the lift in one smooth motion using the red emergency buttons. DON B indicated she did not perform any re-enactments with CNA L or other staff after the incident, but she wished she would have. On [DATE] at 3:36 PM during interview, LPN N stated, When I got here for second shift, I was told R20 was on the sit -to - stand lift too long and now her knee hurts. R20 told me she pulled a muscle. I did look at her before dinner time and gave her a Tylenol at 8:30 PM. She said the pain was in her knee. Her leg goes in a little at baseline. I didn't think too much about it. CNA K thought it was an issue. I wasn't so sure. I had R20 move her leg, and it was her knee that she reported hurt. LPN N indicated R20 reported her pain was 9 out of 10 at one point, but she thought it was a strained muscle. LPN N indicated after Tylenol, R20 rated pain 8 out of 10 so she sent another message to R20's provider and eventually she was given a new order for a muscle relaxer. LPN N indicated she did not report R20 had a change of plane, a sudden drop from the lift, a witnessed fall, or ended up sitting on the ground during a transfer to R20's medical provider. LPN N stated, I was not given correct information in report. I would have monitored her differently through my shift if I knew she fell. CNA K and I looked at her leg and it was turned in a little. I thought that was normal. LPN N indicated her and CNA K thought an x-ray would have been ordered. LPN N indicated she did not remember gathering vitals and did not record information about R20's leg being internally rotated in R20's medical record. LPN N indicated she called DON B to report the resident's pain levels 9 out of 10 and 8 out of 10 and DON B indicated she would be in to look at her in the morning. On [DATE] at 3:46 PM, CNA K was interviewed in person this time and stated, I noticed before I did any cares on her (R20) that something was wrong. Her foot did not sit correctly. It was rotated in. I thought there was swelling above her knee. CNA K demonstrated for Surveyor by pointing the toes of his right foot towards his left foot. CNA K stated, I told the nurse. She contacted the doctor, and I was surprised she (the doctor) did not order an x-ray. I reported the pain and the leg to LPN N. I don't know what LPN N reported to the doctor. Surveyor and CNA K reviewed the facility's summary of CNA K's interview of the incident. CNA K indicated the typed statement from the Facility Self Report does not reflect the interview he gave to the facility. CNA K indicated again he knew something was wrong before he performed any cares with R20 and he was unsure if he should even move R20. On [DATE] at 4:33 PM, NP P (Nurse Practitioner) and Surveyor reviewed communication between the facility and the clinic. NP P indicated the clinic was not made aware that R20 had a change of plane, ended up sitting on the ground during a transfer with a mechanical lift, or was dropped suddenly from the lift. NP P stated, If I knew there was a fall I would have probably ordered x-ray then and there, on [DATE] at 8:04 PM. NP P indicated she was present in the facility on [DATE] in the morning and she did the exam in R20's appointment with NP O. NP P stated, R20 had severe bony tenderness and her foot looked like it had inward rotation. I could barely touch her. She was unable to flex, extend, abduct, or adduct. We did not know of a fall. X-ray was ordered stat because when I saw her it was internally rotated, and she was in so much pain. On [DATE] at 7:46 AM during interview, RN/UM Q (Registered Nurse/Unit Manager) indicated she never saw CNA L's first written statement and what she was told was the lift's battery died and the lift dropped her suddenly. RN/UM Q stated CNA L did not know how to activate the emergency button. CNA L pushed it and it didn't work. Then it did. CNA L tried to move R20 in the lift quickly so she wouldn't be on the floor. I did not see the note. I was told about it. Surveyor asked what the definition of fall is. RN/OM Q indicated a fall is a change of plane. Surveyor asked if dropped her suddenly was a fall? RN/UM stated, I don't know if it was a fall. RN/UM Q indicated she does not remember taking a set of vitals on R20 and if she did it would be recorded in R20's medical record. UM/RN Q indicated she did not report R20 had a fall to R20's provider. Surveyor asked, Are aides observed using lifts before they are using them with residents and does the facility perform competency checks? RN/UM Q stated, No they are not part of a skills checklist before they start. That is a good idea. UM/RN Q stated, She (CNA L)