Three Links Care Center

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

9/12/25, had 2 sets of black loops (one set on the top of the sling and one set on third set of loops), however, she was not aware this type of sling had two sets of black loops and could cause a risk for placing

the incorrect length when attaching the sling. ADON stated, The loops of the sling do not just slip off and

during the re-recreation of the transfer when using two different lengths of black loops, we noted a tension release and caused the sling to come off the arm of the lift. ADON further stated, She was 99% sure the incorrect loops were used by NA-A and NA-B and this is why Resident R1 fell out of the sling to the ground. During

an interview on 9/18/25 at 2:56 p.m., Resident R1's medical doctor (MD)-C stated if any resident fell from a lift at two feet would put that resident at risk for serious injury or harm. During an interview on 9/19/25 at 11:37 a.m., orthopedic surgeon medical doctor (OS-MD) stated Resident R1 had been seen on 9/16/25, for a scheduled follow-up and had been informed Resident R1 had a fall from a total mechanical lift four days prior. Resident R1 had imaging done of right hip and right femur and was found to have a new transverse (according to the Cleveland Clinic

a transverse fracture are a type of broken bones, usually caused by falls or car accidents) fracture of the femur. OS-MD further stated, most definitely the fall from the lift caused the fracture of Resident R1's femur and put him at risk for serious risk for harm and did cause serious harm for Resident R1 due to needing surgery. Review of

the facility's Mechanical Lift Policy dated 5/28/25, identified facility staff would use appropriate techniques and processes when utilizing mechanical lift devices to lift and move residents, to protect the safety and well-being of staff and residents, to promote quality care, and to follow applicable laws regarding use of power-driven mechanical lifts. Review of the facility's Fall Prevention and Management Policy dated 6/5/23, identified The interdisciplinary team (IDT) would evaluate the fall by reviewing the fall incident report to determine a Root Cause Analysis (RCA) of the fall and further interventions may be put into place according to the determined cause of the fall, to help prevent further falls. Any further interventions that were developed would be documented. The immediate jeopardy was issued at PNC after it was verified the facility implemented the following prior to survey: -Resident R1 was sent to ER for evaluation following fall on 9/12/25, and will be reassessed on return from the hospital for proper sling size and care plan updated. -Sling and lift used for Resident R1's transfer was removed from use until inspected and found to be free of malfunction. -NA-A and NA-B had return demonstration competency testing done on 9/12/25, for safe lifting using the mechanical lift. -The facility reviewed their policy and procedure for safe mechanical lift transfers and developed a plan to ensure identification via color coding the sling loops to ensure the correct one being used. Policy will be adjusted after mechanical lift representative reviews policy on 9/23/25, if needed. -All residents utilizing similar slings like Resident R1 have had the proper sling to use marked with the colored tape to identify the same loops.-All residents who utilized the mechanical lifts had slings inspected, care plans reviewed to ensure the proper sling size in the care plan. -The facility began re-education with return demonstration, to nursing staff on manufacturer's recommendations of using the full body mechanical lift to include checking the straps for tension and using proper sling size according to the care plan beginning on 9/12/25, and will be having mechanical lift representative provide education on 9/23/25, to all of the nursing staff.

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