Other·August 5, 2025

F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe practices were followed for Patient 1 when the facility failed to provide two staff's assistance as required during a mechanical lift for Patient 1. As a result, Patient 1 fell from the mechanical lift and sustained the acute spinal processes fractures in the cervical and thoracic spines. This failure resulted in the actual harm for Patient 1. Review of the facility's P&P titled Hoyer Lift (mechanical device used to safely transfer residents who have limited mobility) dated 2001 showed at least two nursing assistants are needed to safely move a patient with a mechanical lift. Prepare the environment: clear an unobstructed path for the lift machine, ensure there is enough room to pivot, position the lift near the receiving surface, and place the lift at the correct height; place the sling under the patient. Visually check the size to ensure it is not too large or too small; lower the sling bar closer to the patient; attach sling straps to sling bar, according to the manufacturer's instructions; make sure the sling is securely attached to the clips and that it is properly balanced; check to make sure the patient's head, neck and back are supported; before the patient is lifted, double check the security of the sling attachment; examine all hooks, clips or fasteners; check the stability of the straps; and ensure the sling bar is securely attached and sound. Medical record review for Patient 1 was initiated on 7/15/25. Patient 1 was readmitted to the facility on 5/18/25 and discharged to an acute care hospital on 6/28/25. Review of Patient 1's Quarterly MDS (Minimum Data Set) assessment under Section GG dated 5/13/25, showed Patient 1 was dependent on the staff's assistance for ADL (activities of daily living) care. Review of Patient 1's Fall Risk Assessment dated 5/19/25, showed Patient 1 was at high risk for falls. Review of Patient 1's Progress Note dated 6/28/25 around 0845 hours, showed the staff was preparing the medications by the medication cart in front of Room A when the staff had witnessed the patient falling from the sling while being transferred to the shower bed via Hoyer lift by one CNA (Certified Nursing Assistant). Review of Patient 1's Progress Note dated 6/28/25 at 1921 hours, showed in subsequent conversation, the CNA reported she had already transferred Patient 1 from the bed to the Hoyer lift sling and was navigating the lift to position the patient to be transferred to the shower bed when through the momentum of the movement, the sling swung enough to tip Patient 1 out of the sling and on to the floor. The LVN (Licensed Vocational Nurse) reported being at the medication cart with her back at the patient's room preparing the medications when a loud noise and CNA's voice alerted her. The LVN turned around and witnessed the patient falling from the sling and landing directly on the floor on her back. Review of Patient 1's IDT (Interdisciplinary Team) note dated 6/30/25, showed on 6/28/25 around 0845 hours, while the CNA was preparing the patient for the shower, the patient fell from the Hoyer lift. Upon the investigation, according to the CNA, while she was checking the hook of the sling attached to the Hoyer lift, Patient 1 made a big wiggle of her shoulder and body. The sling made a big swing, resulting in Patient 1 falling on the floor. Review of Patient 1's Hospitalist Discharge Summary note from the acute care hospital dated 7/7/25, showed Patient 1 was being lifted with a lift and accidentally dropped on her back. Upon the evaluation in the acute care hospital, Patient 1 was discovered to have the acute spinal processes fractures in the cervical and thoracic spines. On 7/15/25 at 0950 hours, an interview and concurrent medical record review for Patient 1 was conducted with the DON (Director of Nursing). The DON was asked about Patient 1's fall from the mechanical lift used during the transfer on 6/28/25. The DON stated CNA 1 was working with the Hoyer lift and had transferred Patient 1 from the bed to the shower bed by herself. The DON stated there must be two people when transferring a Patient using the Hoyer lift. CNA 1 told her that she should have called another staff member for help. On 7/15/25 at 1200 hours, Patient 1 was observed lying on a low air-loss mattress and appeared to be overweight. Patient 1 stated she was back from the acute care hospital. Patient 1 stated she fell from the mechanical lift. Patient 1 was asked if the staff were transferring her with a mechanical lift. Patient 1 stated one staff member was trying to transfer her from the bed to the shower bed with the lift and she fell on her back. On 7/15/25 at 1215 hours, an interview was conducted with LVN 1. LVN 1 stated the patient was bedbound and totally dependent on the staff's assistance for care, including transfers. On 7/15/25 at 1240 hours, an interview and concurrent medical record review for Patient 1 was conducted with the MDS Coordinator. The MDS Coordinator stated Patient 1 was totally dependent on the staff's assistance for care and needed two or more people's assistance for transfers. The MDS Coordinator further stated for Patient 1 using a mechanical lift for transfers, there should have had two people transfer the patient. On 7/15/25 at 1530 hours, an interview and concurrent medical record review for Patient 1 was conducted with CNA 1. CNA 1 was asked about Patient 1's fall. CNA 1 stated Patient 1 requested to have a shower, and CNA 1 transferred Patient 1 from the bed to the shower bed using a mechanical lift. CNA 1 stated Patient 1 made a shaking movement when she was lifted and the sling was moving, then the patient was out of the sling. CNA 1 also stated Patient 1 was big and fell on the ground. CNA 1 further stated she did not ask another nurse to help because she thought LVN 3 was in the room. When asked if LVN 3 assisted CNA 1 with the mechanical lift, CNA 1 stated LVN 3 was working with Patient 1's roommate. In addition, CNA 1 stated she was aware Patient 1 needed two people to transfer using a mechanical lift. On 7/15/25 at 1645 hours, an interview and concurrent medical record review for Patient 1 was conducted with the DON. The DON was asked for a care plan to address the assistance needed for Patient 1's transfers and bed mobility and if there was a plan of care developed status post fall on 6/28/25. The DON was not able to provide any documentation. The DON verified the findings. This violation had a direct or immediate relationship to the health, safety or security of the patients.