**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of the facility's Fall Prevention Program, and review of the facility's Nursing Care Policies, the facility failed to ensure Resident Identifier (RI) #1's comprehensive care plans were implemented on 09/26/2022. RI #1's plan of care for falls had an approach that guided staff to assist with transfer and locomotion. RI #1 also had a BIMS score of 9, indicating moderate cognitive impairment, and was care planned for communication problems and cognition deficits. On 9/26/2022 at approximately 1:00 PM, Employee Identifier (EI) #6, the Dietitian (RD), and EI #15, a Certified Nursing Assistant (CNA), took residents outdoors in wheelchairs while EI #9, a Registered Nurse (RN), held the door open. RI #1 self-propelled out the exit door with them. The RD told RI #1, a cognitively impaired resident with communication deficits and the need for assistance, to wait. The intent was to take the residents down a sloped sidewalk to a patio area. RI #1 wheeled him/her self out the door as the RN held the door open. RI #1 wheeled around the RD, who had another resident in a wheelchair, and down a sloped sidewalk unassisted. RI #1's wheelchair rolled down the slope, the left wheel of the wheelchair rolled off the sidewalk and overturned off the edge of the sidewalk, propelling RI #1 onto the ground face first on his/her left side on the ground. EI #6, the RD who initiated taking residents outside, did not know the level of supervision/assistance required for the residents before taking them outside an exit with a sloped sidewalk. EI #9, the RN who held open the door, said she was new, and she thought the RD was supervising the resident since she was wheeling another resident outside and asked the RN to hold the door open for them as she was returning from her lunch break. RI #1 was pronounced dead on the scene on 09/26/2022 at 1:02 PM, after being assessed by EI #16, the Medical Director, who was present at the facility when the incident occurred. This deficient practice placed RI #1, one of six sampled residents for whom care plans were reviewed, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 11/3/2022 at 3:17 PM, the facility's Administrator (Employee Identifier (EI) #3); the Regional Administrator of the South Central Region for NHC Healthcare and member of the Governing Body (EI #1); the facility's Director of Nursing (DON, EI #4); and a Regional Nurse for NHC Healthcare (EI #2) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the immediate jeopardy findings in the area of Develop/Implement Comprehensive Care Plans, F656. Findings include: Cross reference F689, F837, and F867. The State Agency received a complaint on 10/21/2022 that alleged the complainant was a witness to an accident that caused the death of a resident of the facility, RI #1. RI #1 was witnessed on 9/26/2022, outside, rolling down an incline in a wheelchair. The complainant alleged hearing someone calling out RI #1's name over and over and that was what caught the complainant's attention. The complainant reported that RI #1's wheelchair, while rolling down the incline, went off the edge of the concrete, and RI #1's wheelchair flipped over, throwing RI #1 onto concrete, face down, about three feet from the sidewalk. Review of an undated facility document titled Fall Prevention Program revealed the following: . PURPOSE: To reduce patient's risk of falling. 3. Apply fall risk interventions as appropriate for the patient . The facility provided for review, Patient Care Policies, page 13, which documented . 4.0 NURSING POLICIES . B. The care plan serves as a guide for care decisions and is made available for use by all patient care personnel. RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Epilepsy, Dementia, Osteoarthritis, Kyphosis, Contracture of the Right Hand/Second Finger, Hallux Valgus of the Left and Right foot, Presence of Artificial Eye, and History of Falling. RI #1's Care Plan for being at risk for falls related to balance problems, fall history, visual and hearing impairment, incontinence, weakness, and multiple medical problems, with a start date of 03/15/2021, documented approaches to assist with transfers and locomotion and to observe for unsafe actions and intervene. RI #1's Care Plan for cognitive deficits documented an approach dated 04/02/2021, to allow adequate time to answer and respond. RI #1's Care Plan for being at risk for having difficulty communicating related to a hearing and visual impairment, with a problem start date of 10/25/2021, documented approaches to observe for signs and symptoms of difficulty communicating and anticipate any unmet needs and to speak slowly, clearly, and to face RI #1 when talking, changing the tone of voice or repeating information as needed. Review of RI #1's most recent quarterly Minimum Data Set (MDS) assessment, dated 7/25/2022, revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. RI #1's MDS also documented the resident required extensive, two-person assistance with bed mobility and transfer, one-person physical assistance with locomotion on the unit (his/her room and adjacent corridor on the same floor). Per this assessment, locomotion off the unit did not occur. This assessment also indicated RI #1 used a wheelchair for mobility. Review of a Patient Care Report for RI #1 from Emergency Medical Services (EMS), dated 09/26/2022, revealed EMS arrived on the scene at 1:00 PM. This report documented Cardiac Arrest prior to EMS arrival, patient dead at the scene. The report also indicated a witness at the scene said the resident fell from his/her wheelchair and lost consciousness. Per the EMS report, RI #1 had a formal DNR (Do Not Resuscitate order) and EI #16, the Medical Director, was present. RI #1's progress note dated 9/26/2022 documented . This nurse was notified at 12:55 pm that patient had fallen out of wheelchair in back sitting area. Upon arrival and assessing patient (he/she) was found to be absent of vital signs, . Dr. (EI #16) present . A typed facility statement from EI #6, the RD, dated 9/26/2022 at 4:21 PM documented the following: On 9-26-22, . (RI #6 and another resident) told me, . (EI #6's name), that they wanted to go sit outside. I asked .(EI #4, DON), if I was allowed to take patients outside by myself. She confirmed that I could take patients outside. after lunch. I took . (RI #6 and the other resident) downstairs via the elevator. I asked a CNA to help me take one of them outside. (RI #1) was sitting inside at the doorway to the exit where the patio is located. (He/She) told me that .(he/she) wanted to go outside as well. I told . (him/her) yes . but we have to wait on someone to help you. I looked back for additional help. A nurse came to the door and offered to help us. The nurse held the door open while I exited the building with .( RI #6). As I rounded the corner about to take .(RI #6) to the patio, .(RI #1) rolled up beside me at a continual roll. I asked . (him/her) to stop and to wait just a second and that I would take . (him/her).(He/She) did not respond to me.(He/She) kept rolling forward. I could not let go of . (RI #6), because .(he/she) would have rolled forward down the hill. I again told . (RI #1) to stop . (He/She) did not respond to me. I told the CNA in front of me that . (he/she) was rolling . She was in the process of moving . (the other resident) and could not reach . (RI #1) . (RI #1) kept rolling forward down the sidewalk. The left side wheel on . (his/her) wheel chair went off the side of the side walk tipping the wheel chair over . (RI #1) fell out of the wheelchair onto . (his/her) knees and then onto . (his/her) front side of . (his/her) body. Nursing immediately came to . (his/her) side at that time. A handwritten statement dated 9/26/2022, signed by EI #9, Registered Nurse (RN), documented the following: Upon arrival back from lunch . (at approximately 12:48 PM, EI #6, RD) . was taking several pts (patients) outside to sit . (RI #1) exited door . (with EI #6) . behind . pushing a . resident . (RI #1) using . (his/her) feet began self propelling down Ramp . (EI #6) instructed pt to stop but at that time pt had fallen. I didn't witness the actual fall. Upon arrival to pt, lying face down angled on .(left) shoulder. Shallow Respirations, Non Responsive. Multiple staff arrived . A handwritten statement dated 9/26/2022, signed by EI #15, CNA, documented the following: I was rolling a patient down to the pavilion outside, and as we got to the pavilion I heard someone scream at me catch .(him/her)! Stop .(him/her)! When I turned around I saw . (RI #1) rolling rapidly down the ramp. I ran as fast as I could . by the time I got to . (him/her) . (his/her) wheelchair had already went off the side walk and lunged . (him/her) forward causing . (him/her) to land hard face first on the ground, and cause . (him/her) to fall on . (his/her) side . A typed facility statement, signed by EI #4, DON, dated 9/26/2022, documented the following: I received a phone call on my cell phone at 12:55pm from downstairs CNA . she stated I needed to hurry and come to back parking lot area . (RI #1) had fallen out of . (his/her) chair and seemed to be unresponsive. I made it downstairs at 12:58 pm, patient was laying on . (his/her) back, Paramedic on scene. I stated patient was DNR. Patient had no pulse or respirations noted . A facility statement, signed by EI #16, the Medical Director, dated 9/26/2022, documented the following: On 9/26/22, I was notified by DON of . (RI #1) being unresponsive and apneic after falling out of wheelchair near back patio . On arrival . (RI #1) was unresponsive no respirations/pulse . patient was noted to be DNR . rhythm checked. Rhythm was PEA . (Pulseless Electrical Activity), no spontaneous respirations, no palpable pulse, and no reflexes elicited. Patient pronounced by me at 1:02pm . A facility POST INVESTIGATION OF INCIDENTS form, with an incident date of 09/26/2022, documented RI #1 was sitting in a wheelchair at the back door leading up to the incident. The document indicated staff were inserviced to use an alternate exit when taking patients to the gazebo/pavilion area. EI #4, the DON, signed the form as complete. RI #1's care plan and approaches not being followed was not identified as a contributing factor in the incident. On 10/25/2022 at 10:29 AM, EI #6, the RD, was asked to explain the incident on 9/26/2022 involving RI #1. EI #6 stated EI #9, RN, was holding the door open while EI #15, CNA, took a resident out the door and EI #6 took RI #6. EI #6 said RI #1 was sitting inside the door looking outside. According to EI #6, the CNA and the other resident went down first and she was pushing RI #6 in a wheelchair. EI #6 said when she got to the area just at the top where it sloped down, RI #1 rolled up beside her and at that point she realized RI #1 was rolling on his/her own. EI #6 said she asked RI #1 to wait until they got the others down to the patio, and continued to call out to RI #1, but RI #1 did not acknowledge her and kept rolling down the sidewalk toward the patio. EI #6 said, she could not let go of RI #6 because RI #6 would have rolled down too. EI #6 said, EI #9 was behind her somewhere, as she was looking forward and did not exactly know where EI #9 was. EI #6 said RI #1 moved the wheelchair with his/her feet. EI #6 said, she called out to EI #15, the CNA ahead of her, but she could not get to RI #1 before the left wheel went off the side of the sidewalk and tipped the wheelchair over to the left and RI #1 fell forward onto the sidewalk, knees hitting first and RI #1 fell forward. A phone interview was conducted on 10/25/2022 at 2:22 PM with EI #9, RN. EI #9 was asked about the incident with RI #1 on 9/26/2022. EI #9 said that she was coming back from her lunch break and opened the door for EI #6 and the residents she was taking to the gazebo. She stated that EI #1 rolled himself/herself out of the door while she held the door open. She stated that she turned and went into the facility and heard EI #6 say RI #1's name and stop and she stated that was when he/she fell out of the wheelchair. RI #9 was asked, when did EI #6 ask her to assist with the residents. EI #9 stated, EI #6 did not ask her to help, EI #6 just asked her to hold the door. EI #9 was asked, who assisted RI #1 out the door. EI #9 replied, no one. EI #9 was asked, what should have happened. EI #9 replied, RI #1 should have been assisted. EI #9 was asked, what was the risk of a resident wheeling themselves down an inclined sidewalk. EI #9 replied, the risk of falls. A follow-up interview was conducted with EI #6, the RD, on 10/25/2022 at 5:35 PM. EI #6 was asked, when she was taking the residents outside did she know she would need assistance. EI #6 replied, yes that is why she asked for assistance. EI #6 was asked, why would she need assistance. EI #6 replied, to get the residents to the patio because she would not want to leave one resident on the patio by themselves and go back and get another resident. EI #6 was asked, how would other staff assist her. EI #6 replied, to help safely push them down to the patio area until she could get down there to them. EI #6 was asked, what was the risk of someone wheeling themselves down a sidewalk slope. EI #6 replied, losing control of their wheelchair. EI #6 was asked, should RI #1 have been wheeling himself/herself down the sidewalk slope by himself/herself. EI #6 replied, she did not know RI #1's abilities. On 10/25/2022 at 6:28 PM EI #15, CNA, was asked about the incident on 9/26/2022 with RI #1. EI #15 said, EI #6 was pushing a resident and juggling her laptop in her other hand, and she offered to help. EI #15 said EI #6 told her they were going to the patio. EI #15 said, RI #1 was sitting at the door when she went through the door outside with another resident. EI #15 said EI #9 opened the door, and she went down to the patio. EI #15 said she then heard catch him/her, catch him/her, stop him/her, stop him/her, and she looked around toward the door and saw RI #1 coming down the ramp rapidly. EI #15 said, she ran as fast as she could, but the left wheel went off of the sidewalk, and RI #1 fell face first on his/her side. On 10/27/2022 at 9:41 AM, EI #6, RD, was interviewed with follow-up questions. EI #6 was asked how she determined the risk factors for each of the residents she was taking outside. EI #6 said she did not determine individual risk factors, but more overall risk factors and she needed three staff members to get all three of them to the patio. EI #6 said she did not know the supervision requirement for RI #1 but knew the three residents she was taking outside would need supervision to go outside. EI #6 was asked when she asked EI #9 to assist RI #1 down the sloped sidewalk. EI #6 said, she never directly asked EI #9 to assist RI #1 down the slope. EI #6 also said she did not ask anyone if she could take RI #1 outside, but the nurse manager, EI #9, assisted with the door, and she knew RI #1 was going outside. When asked who she communicated with about the level of supervision required for them to go outside, EI #6 said, no one really told her a level of supervision that they needed. On 10/30/2022 at 1:12 PM, EI #16, the attending physician for RI #1, was interviewed. When asked what his understanding was of what RI #1 was doing in that area on 9/26/2022 just prior to the incident, EI #16 said, something out on the patio because it was a really nice day. EI #16 did not know who was responsible for the resident in that area at that time. EI #16 said, what could have been done differently to prevent the accident was to not use that particular exit door and to have a better way of identifying residents' assistance needs. On 11/01/2022 at 12:58 PM, a follow-up interview was conducted with EI #16. EI #16 said if RI #1 was not left unattended the fall could have been avoided. EI #16 also stated if someone was controlling the wheelchair or if someone had locked RI #1's wheelchair wheels, RI #1 would not have rolled down the sidewalk alone. When asked what should have been done differently for RI #1 in this incident, EI #16 said, clarity of communication, better organization, and dietary should be clear on the status of assistance the residents need before taking them outside. On 11/03/2022 at 8:10 AM, EI #6, the RD, was asked how she knew what assistance RI #1 needed for locomotion. EI #6 said, from general daily observations that she had observed throughout the facility. EI #6 reviewed RI #1's care plan and said, RI #1 was limited to extensive assistance with Activities of Daily Living (ADLs) related to balance problems. EI #6 said, RI #1 was assist with transfers and locomotion with assistance of one person and that meant RI #1 would need someone to assist with locomotion. EI #6 said the risk of not following the care plan to assist with locomotion was the lack of maintaining RI #1's safety at all times. On 10/31/2022 at 10:15 AM, EI #4, DON, was asked what should have been done differently when taking residents out the east exit door. EI #4 said, they should have ensured that they had the proper number of staff needed to ensure resident safety. EI #4 said, before going out the door, they should have had a staff member assisting each resident when exiting the building. EI #4 clarified that each resident should have had someone holding onto their wheelchairs. When asked what she thought caused the incident, EI #4 said, the level of assistance RI #1 required was not provided. A follow up interview was conducted with EI #4 on 11/02/2022 at 5:41 PM. EI #4 was asked, what was the assistance level on the care plan for RI #1. EI #4 replied, limited to extensive assist. EI #4 was asked, what did limited to extensive assistance mean. EI #4 replied, assistance times one at the minimum. EI #4 was asked, why was the care plan not followed that stated to assist RI #1 with locomotion on 09/26/2022. EI #4 replied, miscommunication between two staff members. EI #4 was asked, how staff should have assisted RI #1 with locomotion on 09/26/2022. EI #4 replied, assist times one. When asked what would have assisting RI #1 with the wheelchair prevented, EI #4 said, possibly going off the sidewalk and the tipping of his/her wheelchair. EI #4 was asked, what was the risk of not following the care plan to assist with locomotion. EI #4 replied, falling. On 11/02/2022 at 4:26 PM, EI #3, the Administrator, was asked what might have gone differently if staff had followed RI #1's care plan. EI #3 said, RI #1's wheelchair might not have tipped over. EI #3 said, RI #1's care plan was not followed and there was a miscommunication between two staff members on 09/26/2022. This deficient practice was cited as a result of the investigation of complaint/report number AL00042123. **************************************************************** On 11/04/2022 at 6:55 PM, the facility submitted the following acceptable Removal Plan addressing F656: F656-Care plan 10/30/22 MDS Coordinator began in-servicing all nursing partners on how to access the care plan and to utilize it for level of assistance required for patients. 11/3/22 RN trained MDS coordinator to ensure she was competent to train partners on how to access the care plan and to utilize it for level of assistance required for patients comprehensive care plan. 11/3/22 MDS Coordinator/designee all nursing partners in-service on how to access the care plan and to utilize it for level of assistance required for patients. This in-service was provided by the MDS Coordinator . 11/3/22 Regional Nurse in-serviced DON on Patient communication tool process and identified this system to communicate individualized patient requirements related to comprehensive plan of care to ensure staff provides needed assistance/supervision to patients. 11/3/22 4pm DON trained the following designees ( DHIM, WCC, UM, ADON, RN) on Patient communication tool process this is a system to communicate individualized patient requirements related to comprehensive plan of care to ensure staff provides needed assistance/supervision to patients. The DON and designees (DHIM WCC, UM, ADON, RN) immediately began in-servicing all partners on utilizing PCT/Care plan to provide care based on patients' requirements - person centered care. This training will be provided by the next worked shift for all partners prior to the next shift worked. Inservice included: The PCT should contain the following information ACL, developmental age comparison, BATF, preferred name, interests, care approaches, and abilities considering activities from all disciplines i.e. feeding, dressing, ambulation, transfers, communication. All partners have access to the patient communication tool. This tool provides all partners with the ability to know what type of assistance, cognitive abilities, and equipment the patient requires. Be sure to utilize this tool to assist patients or to notify the nurse should you notice a change in the patient. If you have questions, please see the nurse. If you do not know or have questions about the needs of a patient, ask the nurse prior to assisting any patient. 11/3/22 Reviewed/revised all patient care plans to ensure patients locomotion and transfer assistance was reflected in care plan. This was completed by Regional Nurse and Assistant Regional nurse by 10pm (11/3/22). 11/3/22 Administrator designated nursing leadership to review/update all patients' PCTs according to the PCT process . completed 11/3/22 10pm Contents will be completed and immediacy will be removed on 11/3/22 After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F656 was lowered to a D level on 11/03/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, review of the facility's investigative file related to a fall involving Resident Identifier (RI) #1, review of Patient Care Policies and review of the facility's policy titled SUBJECT: Incident and Accident Process, the facility failed to provide needed assistance and/or supervision to RI #1, a resident in a wheelchair, to prevent an accident outdoors at the facility on 09/26/2022. RI #1's plan of care for falls had an approach that guided staff to assist with transfer and locomotion. RI #1 also had a BIMS score of 9, indicating moderate cognitive impairment, and was care planned for communication problems and cognition deficits. On 9/26/2022 at approximately 1:00 PM, Employee Identifier (EI) #6, the Dietitian (RD), and EI #15, a Certified Nursing Assistant (CNA), took residents outdoors in wheelchairs while EI #9, a Registered Nurse (RN), held the door open. RI #1 self-propelled out the exit door with them. The RD told RI #1, a cognitively impaired resident with communication deficits and the need for assistance, to wait. The intent was to take the residents down a sloped sidewalk to a patio area. RI #1 wheeled him/her self out the door as the RN held the door open. RI #1 wheeled around the RD, who had another resident in a wheelchair, and down a sloped sidewalk unassisted. RI #1's wheelchair rolled down the slope, the left wheel of the wheelchair rolled off the sidewalk and overturned off the edge of the sidewalk, propelling RI #1 onto the ground face first on his/her left side on the ground. EI #6, the RD who initiated taking residents outside, did not know the level of supervision/assistance required for the residents before taking them outside an exit with a sloped sidewalk. EI #9, the RN who held open the door, said she was new, and she thought the RD was supervising the resident since she was wheeling another resident outside and asked the RN to hold the door open for them as she was returning from her lunch break. RI #1 was pronounced dead on the scene on 09/26/2022 at 1:02 PM, after being assessed by EI #16, the Medical Director, who was present at the facility when the incident occurred. This deficient practice placed RI #1, one of three sampled residents reviewed for accidents, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 11/3/2022 at 3:17 PM, the facility's Administrator (Employee Identifier (EI) #3); the Regional Administrator of the South Central Region for NHC Healthcare and member of the Governing Body (EI #1); the facility's Director of Nursing (DON, EI #4); and a Regional Nurse for NHC Healthcare (EI #2) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the findings of substandard quality of care at the IJ level in the area of Accident Hazards/Supervision/Devices, F689. Findings include: Cross reference F656, F837, and F867. The State Agency received a complaint on 10/21/2022 that alleged the complainant was a witness to an accident that caused the death of a resident of the facility, RI #1. RI #1 was witnessed on 9/26/2022, outside, rolling down an incline in a wheelchair. The complainant alleged hearing someone calling out RI #1's name over and over and that was what caught the complainant's attention. The complainant reported that RI #1's wheelchair, while rolling down the incline, went off the edge of the concrete, and RI #1's wheelchair flipped over, throwing RI #1 onto concrete, face down, about three feet from the sidewalk. Review of an undated facility document titled Fall Prevention Program revealed the following: . PURPOSE: To reduce patient's risk of falling. 3. Apply fall risk interventions as appropriate for the patient . The facility provided for review, Patient Care Policies, page 13, which documented . 4.0 NURSING POLICIES . B. The care plan serves as a guide for care decisions and is made available for use by all patient care personnel. RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Epilepsy, Dementia, Osteoarthritis, Kyphosis, Contracture of the Right Hand/Second Finger, Hallux Valgus of the Left and Right foot, Presence of Artificial Eye, and History of Falling. RI #1's Care Plan for being at risk for falls related to balance problems, fall history, visual and hearing impairment, incontinence, weakness, and multiple medical problems, with a start date of 03/15/2021, documented approaches to assist with transfers and locomotion and to observe for unsafe actions and intervene. RI #1's Care Plan for cognitive deficits documented an approach dated 04/02/2021, to allow adequate time to answer and respond. RI #1's Care Plan for being at risk for having difficulty communicating related to a hearing and visual impairment, with a problem start date of 10/25/2021, documented approaches to observe for signs and symptoms of difficulty communicating and anticipate any unmet needs and to speak slowly, clearly, and to face RI #1 when talking, changing the tone of voice or repeating information as needed. Review of RI #1's most recent quarterly Minimum Data Set (MDS) assessment, dated 7/25/2022, revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. RI #1's MDS also documented the resident required extensive, two-person assistance with bed mobility and transfer, one-person physical assistance with locomotion on the unit (his/her room and adjacent corridor on the same floor). Per this assessment, locomotion off the unit did not occur. This assessment also indicated RI #1 used a wheelchair for mobility. Review of a Patient Care Report for RI #1 from Emergency Medical Services (EMS), dated 09/26/2022, revealed EMS arrived on the scene at 1:00 PM. This report documented Cardiac Arrest prior to EMS arrival, patient dead at the scene. The report also indicated a witness at the scene said the resident fell from his/her wheelchair and lost consciousness. Per the EMS report, RI #1 had a formal DNR (Do Not Resuscitate order) and EI #16, the Medical Director, was present. RI #1's progress note dated 9/26/2022 documented . This nurse was notified at 12:55 pm that patient had fallen out of wheelchair in back sitting area. Upon arrival and assessing patient (he/she) was found to be absent of vital signs, . Dr. (EI #16) present . A typed facility statement from EI #6, the RD, dated 9/26/2022 at 4:21 PM documented the following: On 9-26-22, . (RI #6 and another resident) told me, . (EI #6's name), that they wanted to go sit outside. I asked .(EI #4, DON), if I was allowed to take patients outside by myself. She confirmed that I could take patients outside. after lunch. I took . (RI #6 and the other resident) downstairs via the elevator. I asked a CNA to help me take one of them outside. (RI #1) was sitting inside at the doorway to the exit where the patio is located. (He/She) told me that .(he/she) wanted to go outside as well. I told . (him/her) yes . but we have to wait on someone to help you. I looked back for additional help. A nurse came to the door and offered to help us. The nurse held the door open while I exited the building with .( RI #6). As I rounded the corner about to take .(RI #6) to the patio, .(RI #1) rolled up beside me at a continual roll. I asked . (him/her) to stop and to wait just a second and that I would take . (him/her).(He/She) did not respond to me.(He/She) kept rolling forward. I could not let go of . (RI #6), because .(he/she) would have rolled forward down the hill. I again told . (RI #1) to stop . (He/She) did not respond to me. I told the CNA in front of me that . (he/she) was rolling . She was in the process of moving . (the other resident) and could not reach . (RI #1) . (RI #1) kept rolling forward down the sidewalk. The left side wheel on . (his/her) wheel chair went off the side of the side walk tipping the wheel chair over . (RI #1) fell out of the wheelchair onto . (his/her) knees and then onto . (his/her) front side of . (his/her) body. Nursing immediately came to . (his/her) side at that time. A handwritten statement dated 9/26/2022, signed by EI #9, Registered Nurse (RN), documented the following: Upon arrival back from lunch . (at approximately 12:48 PM, EI #6, RD) . was taking several pts (patients) outside to sit . (RI #1) exited door . (with EI #6) . behind . pushing a . resident . (RI #1) using . (his/her) feet began self propelling down Ramp . (EI #6) instructed pt to stop but at that time pt had fallen. I didn't witness the actual fall. Upon arrival to pt, lying face down angled on .(left) shoulder. Shallow Respirations, Non Responsive. Multiple staff arrived . A handwritten statement dated 9/26/2022, signed by EI #15, CNA, documented the following: I was rolling a patient down to the pavilion outside, and as we got to the pavilion I heard someone scream at me catch .(him/her)! Stop .(him/her)! When I turned around I saw . (RI #1) rolling rapidly down the ramp. I ran as fast as I could . by the time I got to . (him/her) . (his/her) wheelchair had already went off the side walk and lunged . (him/her) forward causing . (him/her) to land hard face first on the ground, and cause . (him/her) to fall on . (his/her) side . A typed facility statement, signed by EI #4, DON, dated 9/26/2022, documented the following: I received a phone call on my cell phone at 12:55pm from downstairs CNA . she stated I needed to hurry and come to back parking lot area . (RI #1) had fallen out of . (his/her) chair and seemed to be unresponsive. I made it downstairs at 12:58 pm, patient was laying on . (his/her) back, Paramedic on scene. I stated patient was DNR. Patient had no pulse or respirations noted . A facility statement, signed by EI #16, the Medical Director, dated 9/26/2022, documented the following: On 9/26/22, I was notified by DON of . (RI #1) being unresponsive and apneic after falling out of wheelchair near back patio . On arrival . (RI #1) was unresponsive no respirations/pulse . patient was noted to be DNR . rhythm checked. Rhythm was PEA . (Pulseless Electrical Activity), no spontaneous respirations, no palpable pulse, and no reflexes elicited. Patient pronounced by me at 1:02pm . A facility POST INVESTIGATION OF INCIDENTS form, with an incident date of 09/26/2022, documented RI #1 was sitting in a wheelchair at the back door leading up to the incident. The document indicated staff were inserviced to use an alternate exit when taking patients to the gazebo/pavillion area. EI #4, the DON, signed the form as complete. RI #1's care plan and approaches not being followed was not identified as a contributing factor in the incident. On 10/25/2022 at 10:29 AM, EI #6, the RD, was asked to explain the incident on 9/26/2022 involving RI #1. EI #6 stated EI #9, RN, was holding the door open while EI #15, CNA, took a resident out the door and EI #6 took RI #6. EI #6 said RI #1 was sitting inside the door looking outside. According to EI #6, the CNA and the other resident went down first and she was pushing RI #6 in a wheelchair. EI #6 said when she got to the area just at the top where it sloped down, RI #1 rolled up beside her and at that point she realized RI #1 was rolling on his/her own. EI #6 said she asked RI #1 to wait until they got the others down to the patio, and continued to call out to RI #1, but RI #1 did not acknowledge her and kept rolling down the sidewalk toward the patio. EI #6 said, she could not let go of RI #6 because RI #6 would have rolled down too. EI #6 said, EI #9 was behind her somewhere, as she was looking forward and did not exactly know where EI #9 was. EI #6 said RI #1 moved the wheelchair with his/her feet. EI #6 said, she called out to EI #15, the CNA ahead of her, but she could not get to RI #1 before the left wheel went off the side of the sidewalk and tipped the wheelchair over to the left and RI #1 fell forward onto the sidewalk, knees hitting first and RI #1 fell forward. A phone interview was conducted on 10/25/2022 at 2:22 PM with EI #9, RN. EI #9 was asked about the incident with RI #1 on 9/26/2022. EI #9 said that she was coming back from her lunch break and opened the door for EI #6 and the residents she was taking to the gazebo. She stated that EI #1 rolled himself/herself out of the door while she held the door open. She stated that she turned and went into the facility and heard EI #6 say RI #1's name and stop and she stated that was when he/she fell out of the wheelchair. RI #9 was asked, when did EI #6 ask her to assist with the residents. EI #9 stated, EI #6 did not ask her to help, EI #6 just asked her to hold the door. EI #9 was asked, who assisted RI #1 out the door. EI #9 replied, no one. EI #9 was asked, what should have happened. EI #9 replied, RI #1 should have been assisted. EI #9 was asked, what was the risk of a resident wheeling themselves down an inclined sidewalk. EI #9 replied, the risk of falls. A follow-up interview was conducted with EI #6, the RD, on 10/25/2022 at 5:35 PM. EI #6 was asked, when she was taking the residents outside did she know she would need assistance. EI #6 replied, yes that is why she asked for assistance. EI #6 was asked, why would she need assistance. EI #6 replied, to get the residents to the patio because she would not want to leave one resident on the patio by themselves and go back and get another resident. EI #6 was asked, how would other staff assist her. EI #6 replied, to help safely push them down to the patio area until she could get down there to them. EI #6 was asked, what was the risk of someone wheeling themselves down a sidewalk slope. EI #6 replied, losing control of their wheelchair. EI #6 was asked, should RI #1 have been wheeling himself/herself down the sidewalk slope by himself/herself. EI #6 replied, she did not know RI #1's abilities. On 10/25/2022 at 6:28 PM EI #15, CNA, was asked about the incident on 9/26/2022 with RI #1. EI #15 said, EI #6 was pushing a resident and juggling her laptop in her other hand, and she offered to help. EI #15 said EI #6 told her they were going to the patio. EI #15 said, RI #1 was sitting at the door when she went through the door outside with another resident. EI #15 said EI #9 opened the door, and she went down to the patio. EI #15 said she then heard catch him/her, catch him/her, stop him/her, stop him/her, and she looked around toward the door and saw RI #1 coming down the ramp rapidly. EI #15 said, she ran as fast as she could, but the left wheel went off of the sidewalk, and RI #1 fell face first on his/her side. On 10/27/2022 at 9:41 AM, EI #6, RD, was interviewed with follow-up questions. EI #6 was asked how she determined the risk factors for each of the residents she was taking outside. EI #6 said she did not determine individual risk factors, but more overall risk factors and she needed three staff members to get all three of them to the patio. EI #6 said she did not know the supervision requirement for RI #1 but knew the three residents she was taking outside would need supervision to go outside. When asked why she chose to use that particular exit, EI #6 said, it was the only exit she had used to get to the patio. EI #6 was asked when she asked EI #9 to assist RI #1 down the sloped sidewalk. EI #6 said, she never directly asked EI #9 to assist RI #1 down the slope. EI #6 also said she did not ask anyone if she could take RI #1 outside, but the nurse manager, EI #9, assisted with the door, and she knew RI #1 was going outside. When asked who she communicated with about the level of supervision required for them to go outside, EI #6 said, no one really told her a level of supervision that they needed. On 10/28/2022 at 3:00 PM, observations and measurements were made outside of the East exit door that was used at the time of the incident. From the exit door to the right side, where the sidewalk began to slope was measured to be nine feet. The sloped section of the sidewalk was measured to be 288 inches long, with a drop in elevation of 10.5 inches over that distance. On 10/30/2022 at 1:12 PM, EI #16, the attending physician for RI #1, was interviewed. When asked what his understanding was of what RI #1 was doing in that area on 9/26/2022 just prior to the incident, EI #16 said, something out on the patio because it was a really nice day. EI #16 did not know who was responsible for the resident in that area at that time. EI #16 said, what could have been done differently to prevent the accident was to not use that particular exit door and to have a better way of identifying residents' assistance needs. On 11/01/2022 at 12:58 PM, a follow-up interview was conducted with EI #16. EI #16 said if RI #1 was not left unattended the fall could have been avoided. EI #16 also stated if someone was controlling the wheelchair or if someone had locked RI #1's wheelchair wheels, RI #1 would not have rolled down the sidewalk alone. When asked what should have been done differently for RI #1 in this incident, EI #16 said, clarity of communication, better organization, and dietary should be clear on the status of assistance the residents need before taking them outside. On 11/03/2022 at 8:10 AM, EI #6, the RD, was asked how she knew what assistance RI #1 needed for locomotion. EI #6 said, from general daily observations that she had observed throughout the facility. EI #6 reviewed RI #1's care plan and said, RI #1 was limited to extensive assistance with Activities of Daily Living (ADLs) related to balance problems. EI #6 said, RI #1 was assist with transfers and locomotion with assistance of one person and that meant RI #1 would need someone to assist with locomotion. EI #6 said the risk of not following the care plan to assist with locomotion was the lack of maintaining RI #1's safety at all times. On 10/31/2022 at 10:15 AM, EI #4, DON, was asked what should have been done differently when taking residents out the east exit door, EI #4 said, they should have ensured that they had the proper number of staff needed to ensure resident safety. EI #4 said, before going out the door, they should have had a staff member assisting each resident when exiting the building. EI #4 clarified that each resident should have had someone holding onto their wheelchairs. EI #4 said, the difference in East and South exits was that the East exit had an incline in the sidewalk and South did not have an incline. When asked what should have been done to keep RI #1 from rolling down the sidewalk, EI #4 said, someone holding the wheelchair. When asked what she thought caused the incident, EI #4 said, the level of assistance RI #1 required was not provided. A follow up interview was conducted with EI #4 on 11/02/2022 at 5:41 PM. EI #4 was asked, what was the assistance level on the care plan for RI #1. EI #4 replied, limited to extensive assist. EI #4 was asked, what did limited to extensive assistance mean. EI #4 replied, assistance times one at the minimum. EI #4 was asked, why was the care plan not followed that stated to assist RI #1 with locomotion on 09/26/2022. EI #4 replied, miscommunication between two staff members. EI #4 was asked, how staff should have assisted RI #1 with locomotion on 09/26/2022. EI #4 replied, assist times one. When asked what would have assisting RI #1 with the wheelchair prevented, EI #4 said, possibly going off the sidewalk and the tipping of his/her wheelchair. EI #4 was asked, what was the risk of not following the care plan to assist with locomotion. EI #4 replied, falling. On 11/02/2022 at 5:59 PM, EI #4 was asked to clarify what she meant by miscommunication between two staff members. EI #4 said, EI #9 thought EI #6 was assisting RI #1, and EI #6 assumed RI #9 was assisting RI #1 on 9/26/2022 at the time they went outside. On 11/02/2022 at 4:26 PM, EI #3, the Administrator, was asked what might have gone differently if staff had followed the care plan to assist RI #1 with locomotion. EI #3 said, RI #1's wheelchair might not have tipped over. EI #3 said, RI #1's care plan was not followed and there was a miscommunication between two staff members on 09/26/2022. This deficient practice was cited as a result of the investigation of complaint/report number AL00042123. **************************************************************** On 11/04/2022 at 6:55 PM, the facility submitted the following acceptable Removal Plan addressing F689: F689 9/26/22 Incident occurred at 12:55pm 9/26/22 Administrator assessed the East Hall exit to begin the investigation into what happened. Administrator immediately stopped use of east hall exit for patient use. Administrator notified all partners in building at the time not to use door on east hall downstairs. 9/26/22, RN- RD, CNA sent home at 2:18pm pending an investigation by the Administrator after discussion with the Regional Administrator and Regional Nurse. 9/26/22 POC was written by DON to include supervision of patients with cognitive impairments with a BIMS below 12. As DON/administrators immediate investigation indicated that this patient's BIMS was a risk. Identified patient had not been supervised and implemented immediate action to prevent patients requiring supervision to be left unattended. DON began inservicing all partners regarding patients with cognitive impairments are to be supervised when taken outside. 9/26/22 4pm DON (director of nursing) completed in-servicing with partners regarding patients with cognitive impairments are to be supervised when taken outside. 100% of partners in-serviced regarding cognitive impaired patients being supervised while outdoors and not utilizing East Hall exit door by 10/3/22. 9/27/22 Untoward event completed by DON to initiate the QAPI process for root cause analysis related to the incident. 9/27/22- RN-, RD, & CNA from incident, were individually in-serviced before start of next shift by the DON regarding supervising patients with cognitive impairments when assisting them outside. 9/28/22 DON initiated QA monitors on partners that had completed the training since 9/26/22 to ensure they knew what patients needed assistance to go outside. This began weekly starting 9/28/22 to 10/18/2022 this QA monitor was completed to ensure training on 9/26 (ended 10/3) was effective and was part of the POC to monitor 2 partners per week for 4 weeks. 10/18/22 100% of partners monitored were able to verbalize correct procedure regarding cognitively impaired patients being supervised outside and not using the east hall door. 10/20/22 QAPI meeting held. Discussion included incident and presented plan of correction. 10/30/22 began to 11/3/22 (completed) MDS Coordinator began an in-service for all nursing partners on how to access the care plan and to utilize it to provide the level of assistance required. 11/3/22 MDS Coordinator & DON completed all nursing partners in-services on how to access the care plan and to utilize it to provide the level of assistance required . 11/3/22 Regional Nurse in-serviced DON on Patient communication tool process and identified this system to communicate individualized patient requirements related to comprehensive plan of care to ensure facility staff provides needed assistance/supervision to residents. 11/3/22 All patients will be reviewed by DON or designee to ensure they have a PCT that accurately states level of assistance/supervision and locomotion including but not limited to when in hazardous areas of the facility premises 11/3/22. 11/3/22 4pm DON/designee(DHIM, WCC, UM, ADON, RN) began in-servicing all partners/all disciplines on utilizing PCT/care plan to provide care based on patient requirements - person centered care. This training will be provided for all facility staff before the start of the next scheduled shift. The inservice provides the partners information to provide patient centered care including what level of cognition and assistance the patient requires to prevent incidents of this nature from occurring again. This included training on regarding ensuring needs are communicated properly and thoroughly to other staff when working together to provide care for patients. Ensure that every patient has adequate supervision to accomplish needs tasks through thorough communication. Patient needs and supervision levels can be found on the care plan, PCT or by asking their nurse. This was completed 11/3/22 100% of all disciplines received this training. Inservice included: The PCT should contain the following information ACL, developmental age comparison, BATF, preferred name, interests, care approaches, and abilities considering activities from all disciplines i.e. feeding, dressing, ambulation, transfers, communication. All partners have access to the patient communication tool. This tool provides all partners with the ability to know what type of assistance, cognitive abilities, and equipment the patient requires. Be sure to utilize this tool to assist patients or to notify the nurse should you notice a change in the patient. If you have questions, please see the nurse. If you do not know or have questions about the needs of a patient, ask the nurse prior to assisting any patient. 11/3/22 RD was inserviced by administrator regarding ensuring needs are communicated properly and thoroughly to other staff when working together to provide care for patients. Ensure that every patient has adequate supervision to accomplish needs tasks through thorough communication. Patient needs and supervision levels can be found on the care plan, PCT or by asking their nurse. 11/4/22 10am bright yellow sign posted on East Hall exit door at standing eye level as well as seated eye level by Administrator that patients do not use this door. 11/4/22 2:30pm Administrator or designee (ADON, RD, ICP, UM) providing education to all patients regarding not using East Hall downstairs exit. 11/4/22 ADON, RD, UM, ICP called all family members of patients who are not cognitively intact to notify them that the East hall door should not be used for patients and to use the south hall entrance. A copy of the sign and map showing what door not to use and what door to use to enter downstairs was placed in all patient rooms. Ongoing purposes this will be placed in admission packet starting 11/4/22 Contents will be completed and immediacy will be removed on 11/4/2022 After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F689 was lowered to a D level on 11/04/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.