**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Bsed on interviews, review of Resident Identifier (RI) #1's medical record, a revview of the Hospital Discharge Summary Report, and review of a facility's policy titled, Resident Care Planning, the facility failed to ensure RI #1's ADL Flow Record, which was part of the resident's care plan that provided instructions to direct care staff on how to care for a resident, accurately reflected RI #1's care planned intervention of two-person assistance with bathing, which resulted in RI #1 being hospilized with sustaining serious injuries. On 01/16/2023, RI #1 fell from the bed to the floor during a bed bath, that was provided by Employee Identifier (EI) #4, Certified Nursing Assistant (CNA). EI #4 reported while providing a bed bath by herself to RI #1, she repositioned RI #1 on to his/herside. RI #1 slid off the alternating air mattress on the bed and hit the floor. EI #4 stated she could not prevent RI #1 from falling, because she was on the opposite side of the bed but was unaware that RI #1 required the assistance of two people when performing care. RI #1 complained of pain in his/her legs and was sent to the emergency room by ambulance. As a resulto of the fall, RI #1 was admitted to the hospital and diagnosed with fractures to his/her Tibia and Fibula. This deficient practice placed RI #1; one of three residents sampled for falls, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 03/24/2023 at 5:33 PM, the Administrator, EI #1; the Director of Nursing (DON), EI #2; the Assistant Director of Nursing (ADON), EI #5; Minimum Data Set (MDS)/Care Plan Coordinator, EI #3; Medical Record, EI #8; Corporate Nurse, EI #6, and Corporate Liaison, EI #7; were provided a copy of the Immediate Jeopardy Template and notified of the findings at the immediate jeopardy level in the area of Comprehensive Resident Centered Care Plan, at F656-Develop/Implement Comprehensive Care Plan. The immediate jeopardy began on 01/16/2023 and continued until 03/25/2023, when the facility implemented corrective actions to remove the immediacy and prevent further recurrences. Findings Include: A facility policy titled, Resident Care Planning, dated September 2003, documented, Purpose: To assure each resident has a Resident Care Plan that is current, individualized . Procedure: . 7. Implementation a. Action or nursing intervention is specific . b. Times and actions are stated so that care givers new to resident can carry out care with complete continuity. c. The ADL (Activity of Daily Living) record is a part of the resident's Care Plan. RI #1 was admitted to the facility 03/27/2018 and readmitted on [DATE] with fracture Tibia, Fibula and Osteoarthritis. RI #1's Falls care plan, dated 03/11/2021, documented an intervention of RI #1 requiring the assistance of two people with turning, repositioning, bathing and perineal care. RI #1's ADL Flow Record for December 2022, failed to provide guidance on how many staff members were required to provide RI #1 a bed bath. A review of a Quarterly MDS, with an Assessment Reference Date of 10/20/2022, identified RI #1's BIMS (Brief Interview for Mental Status) of nine (moderately impaired cognition). RI #1's Hospital Discharge Summary Report documented: . Date of admission: [DATE] Date of discharge: [DATE] . Significant Findings . (He/She) was found to have a left acute minimally displaced bicondylar tibial plateau fx (fracture) and proximal fibula fx . On 03/21/2023 at 2:37 PM, an interview was conducted with EI #4, CNA. EI #4 said that she was providing a bath to RI #1 on 01/16/2023 when RI #1 slid off the bed to the floor. EI #4 reported hearing RI #1 saying his/her leg was hurting bad. EI #4 reported RI #1 was a two-person assistance at the time of the fall for transferring, but she did not know that RI #1 required the assistance of two people for bathing. EI #4 reported residents' level of assistance required for ADLs was doucmented on the ADL Flow Record in the ADL books, that are kept at the nurses' station. On 03/21/2023 at 3:44 PM, an interview was conducted with EI #9, Licensed Practical Nurse (LPN). EI #9 reported she responded to RI #1's room on 01/16/2023 after becoming aware of the fall. EI #9 said she observed RI #1 on the floor on his/her left side. EI #9 reported when staff assisted RI #1 back to bed, he/she was complaining of discomfort in his/her back and within 15 minutes he/she began stated he/she was hurting everywhere. EI #9 stated RI #1 required two-person assistance at the time of the fall. On 03/22/2023 at 12:09 PM, an interview was conducted with EI #3, LPN, MDS and Care Plan Coordinator. EI #3 said her duties included completing the residents' care plans and MDS. EI #3 said prior to the fall on 01/16/2023, RI #1's care plan indicated he/she required the assistance of two people with turning, repositioning, bathing, and perineal care. On 03/22/2023 at 4:23 PM, EI #3 was interviewed. EI #3 reported the direct care staff, CNAs, used the ADL Flow Records to determne what level of assistance was required for each resident. EI #3 stated after RI #1's fall, staff noticed the level of assistance for bathing on the ADL Flow Record and care plan did not match because the care plan reflected RI #1 required two person assist. EI #3 stated it was a danger to a resident when the CNAs did not know a resident was care planned for two person assistance. On 03/24/2023 at 8:41 AM, a follow up interview was conducted with EI #3/MDS and Care Plan Coordinator. EI #3 stated that she did not know when two-person assistance for bathing was added to RI #1's care plan, but knew it was prior to RI #1's fall on 01/16/2023. EI #3 said that she was responsible for ensuring the ADL Flow Record was updated when a care plan was updated. EI #3 was asked when RI #1's care plan for two-person assist with bathing was changed, why was the ADL Flow sheets not updated. EI #3 replied, sometimes interventions did not get carried over like they should. On 03/22/2023 at 4:46 PM, an interview was conducted with EI #2, Registered Nurse, DON. EI #2 reported on 01/16/2023, a CNA was giving RI #1 a bed bath and RI #1 slid off the bed to the floor. EI #2 reported RI #1 was care planned for two-person assistance with bathing at the time of the fall. EI #2 stated the CNAs used the ADL Flow Record to find the level of assistance needed for each resident. EI #2 stated RI #1's ADL Flow Record for January, prior to RI #1's fall, did not have an assistance level for bathing documented. EI #2 said the ADL Flow Record should specify an assistance level for bathing so the CNAs would know which level was required for each resident. EI #2 said it was EI #3's (Care Plan Coordinator) responsibility to ensure the ADL Flow Record and care plan matched. EI #2 stated the concern of the care plan and ADL Flow Record not matching is the correct assistance was not provided, which led to RI #1 rolling out of the bed. EI #2 said RI #1 was a two-person assistance for bathing at the time of the fall, which resulted in RI #1 sustaining a left acute Tibia and Fibula fracture. On 03/22/2023 at 5:25 PM, an interview was conducted with EI #1, Administrator. EI #1 confirmed RI #1's care plan, prior to the fall on 01/16/2023, indicated RI #1 required the assistance of two people for turning, bathing, and positioning. EI #1 was asked how did the CNAs know the level of assistance the residents needed. EI #1 replied, CNAs were to follow the ADL Flow Record. EI #1 said the ADL Flow Record and the care plan should match and have the same instructions for level of assistance. EI #1 stated safety was the concern with RI #1's ADL Flow Record not providing instruction for two-person assistance with bathing as care planned. ****************************************************************************************************** The facility took immediate action to correct the noncompliance by: 1. RI #1's care plan was updated for a two person assistance for ADLs including bathing by the MDS Coordinator and an in-service was completed for staff assigned to care for RI #1 by the Director of Nursing on 01/19/2023. Nursing staff were re-trained on following the plan of care as communicated on the ADL documentation flow sheet when providing ADL care by the Assistant Director of Nursing/Staff Development Coordinator and/or Director of Nursing on 03/25/2023. Nursing staff who are not present on 03/25/2023 will be re-trained at the beginning of their shift on their next scheduled day prior to receiving their assignment. by the Staff Development Coordinator and/or Director of Nursing. EI #4 was re-trained on following the care plan for a two person assist while bathing RI #1 on 01/19/2023 by the Director of Nursing. RI #1's ADL flow sheet was updated for use of the alternating pressure air mattress on 03/24/2023. EI #4 has not worked since 03/18/2023 and is scheduled to be trained on the use of an alternating pressure air mattress by the Assistant Director of Nursing/Staff Development Nurse on her return date 03/27/2023 at 7p prior to accepting her assignment. 2. Interdisciplinary Team members were re-trained by the Corporate Nurse Consultant on 03/25/2023 on conducting care plan meetings to include a review of the MDS Assessment, ADL Care Plans and ADL documentation flow sheets to ensure that the level of assistance the resident requires is communicated on the ADL Care Plan and ADL documentation flow sheets. Attending Interdisciplinary Team members were the Director of Nursing, Assistant Director of Nursing/Staff Development Coordinator, Treatment Nurse, MDS Coordinator, Clinical Dietary/Restorative Nurse and Administrator. 3. All resident care plans, MDS assessments and fall risk assessments were audited and compared to the ADL documentation flow sheets on 03/25/2023 by the Interdisciplinary Team to verify that the level of assistance on the ADL documentation flow sheet matches the ADL care plans, MDS Assessments and fall risk assessments. Any concerns noted during the audits were immediately addressed by the Interdisciplinary Team member conducting the audit. The audits were turned in to the Director of Nursing for review. 4. Direct Care staff were re-trained on following the Plan of Care by the Assistant Director of Nursing/Staff Development Coordinator on 03/25/2023. The Assistant Director of Nursing/Staff Development Coordinator will train direct care staff who were not present on 03/25/2023 on their next scheduled workday prior to them receiving their assignment. 5. RI #1's care plan was updated and implemented on 01/19/2023. RI #1 has not had any further falls since 01/19/2023. ************************************************** 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 03/25/2023, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00043075.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of medical records, facility policies titled, Incident and Accident Reporting and Fall Assessment Worksheet and Progress Notes, hospital records, and the Alabama State Agency Online Report, it was determined the facility failed to ensure Resident Identifier (RI) #1 was provided two-person assistance with bathing, which resulted in RI #1 being admitted to the hospital with serious injuries. On 01/16/2023, Employee Identifier (EI) #4, CNA provided a bed bath RI #1 without assistance. EI #4 rolled RI #1 onto his/her side and RI #1's legs began sliding off the alternating air pressure mattress. EI #4 stated she could not prevent RI #1 from sliding off the bed onto the floor. RI #1 complained of pain in his/her legs and was sent to the emergency room (ER) by ambulance. RI #1 was admitted to the hospital with a diagnosis of fractures to his/her Tibia and Fibula. Further, through an interview with EI #4, it was determined the facility failed to provide accurate instructions on how to provide a bath to RI #1. EI #4 stated she only had access to RI #1's Activity of Daily Living (ADL) Flow Record, not the resident's care plan, that directed staff to utilize two people when bathing this resident. A review of RI #4, ADL Flow Record revealed it inaccurately directed staff that RI #1 only required the assistance of one person when providing a bath. This deficient practice placed RI #1; one of three residents sampled for falls, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 03/24/2023 at 5:33 PM, the Administrator, EI #1; the Director of Nursing (DON), EI #2; the Assistant Director of Nursing (ADON), EI #5; MDS/Care plan Coordinator, EI #3; Medical Record, EI #8; Corporate Nurse, EI #6, and Corporate Liaison, EI #7; were provided a copy of the Immediate Jeopardy Templates and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, at F-689-Free of Accident Hazards/Supervision/Devices. The immediate jeopardy began on 01/16/2023 and continued until 03/25/2023, when the facility implemented corrective actions to remove the immediacy and prevent further recurrences. Findings Include: On 01/18/2023, the State Agency received an online report from the facility documenting, . (representative name) from the State of Alabama Department of Human Resources Adult Protection Services came to (facility) to get information about a fall that a resident, (RI #1), had on 1/16/23 . (RI #1) had some bruising to (his/her) back and left hip area. (RI #1) was assisted back to bed by staff. (RI #1) told (EI #9, Licensed Practical Nurse) that (he/she) was getting a bath and fell off the bed. (RI #1) complained of hip pain and orders were received to send (him/her) to the ER for evaluation post fall. (RI #1) was admitted to the hospital with a diagnosis of bilateral fractures to (his/her) tibia and fibula . A facility policy titled, Incident and Accident Reporting, revised on June 2016, documented, Purpose: To ensure that all incidents are accurately documented, investigated and preventative measures are implemented to ensure resident . safety. Investigation: . 6. Based on the investigation's findings the resident's care plan will be updated with appropriate preventative interventions if applicable by the Care Plan Coordinator. 7. Employees responsible for implementing new interventions will be in serviced on the new interventions by the Care Plan Coordinator and/or the Charge Nurse/Clinical Coordinator. 8. The completed investigation will be turned in to the Quality Assurance Nurse and/or designee for review. A facility policy titled, Fall Assessment Worksheet and Progress Notes, dated August 2000, documented, Purpose: To identify contributing factors surrounding resident falls and to reduce the risk of subsequent falls. Policy: At the time of fall, the Staff/Charge Nurse or Supervisor will complete the Fall Assessment Worksheet and Progress Note to identify possible factors contributing to the fall. Procedure: . 3. The nurse will document immediate steps taken to prevent a recurrence. 5. The Fall Assessment Worksheet/Progress Note will be forwarded to the Assessment Coordinator for continued follow-up and revamping of the resident's plan of care. 7. The resident's Care Plan will be updated by the Assessment Coordinator following each fall assessment, as indicated. 8. Each fall will be reviewed by the Interdisciplinary Care Plan Team (IDT) within seventy- two (72) hours of fall. 9. The MDS Assessment Coordinator and the Resident Care Manager are responsible for ensuring interventions are in place and implemented. RI #1 was admitted to the facility 03/27/2018 and readmitted on [DATE] with diagnosis of Unspecified Fracture Upper end of Tibia, Osteoarthritis. RI #1's Fall care plan documented an intervention of two person assistance with turning, repositioning, bathing and perineal with a start date of 03/11/2021. A review of a Quarterly MDS, with an Assessment Reference Date of 10/20/2022, identified RI #1's BIMS (Brief Interview for Mental Status) of nine (moderately impaired cognition). RI #1's ADL Flow Record for December 2022, documented, BED BATH 3X (times) WEEK INSPECT SKIN & REPORT PROBLEMS M (Monday) /W (Wednesday) /F (Friday) . SPONGE BATH ON ALTERNATING DAYS OF BED BATH MON /WED /FRI . RI #1's,IDT Post Fall Review, completed on 01/19/2023 by EI #2, Director of Nursing (DON), documented, . Description of Event: Resident was being assisted with a bed bath. Resident was on (his/her) side and the CNA was doing (his/her) back. Resident started sliding off the bed CNA was unable to catch resident. Resident Statement: my legs are hurting . RI #1's Hospital Discharge Summary Report documented: . Date of admission: [DATE] Date of discharge: [DATE] . Significant Findings . Per patient reports (he/she) was being turned and subsequently rolled off the bed. After (his/her) fall (he/she) had a significant amount of lower extremity pain prompting (his/her) ER arrival. (He/she) was found to have a left acute minimally displaced bicondylar tibial plateau fx (fracture) and proximal fibula fx . An interview was conducted with RI #1 on 03/21/2023 at 10:06 AM. RI #1 stated he/she rolled off the bed recently and his/her leg was fractured. RI #1 said, he/she had to go to hospital, and they put a cast on his/her leg. An interview was conducted with EI #4, Certified Nursing Assistant (CNA) on 03/21/2023 at 2:37 PM. EI #4 stated she was bathing RI #1 on 01/16/2023. EI #4 stated she rolled RI #1 over facing the door to put sheets on the bed when he/she slid out the bed onto the floor. EI #4 stated she guess the air mattress went down. EI #4 stated she did her best to keep RI #1 from hitting the floor too hard. EI #4 stated RI #1 was holding on to the rails, so she went to the other side to hold RI #1's head to keep him/her from hitting head on the nightstand. EI #4 stated she did not know RI #1 required two people to assist him/her with bathing. In a follow-up interview with EI #4 on 03/23/2023 at 11:05 AM, EI #4 stated in looking at the ADL Flow record it does not have an assistance level listed for bathing. EI #4 stated she assumed RI #1 required assistance of one person for bed baths. An interview was conducted with EI #9, Licensed Practical Nurse (LPN) on 03/21/2023 at 3:44 PM. EI #9 stated when she went into RI #1's room resident was laying in the floor more so on his/her left side. She stated resident was assessed and then put back in bed. EI #9 stated RI #1complained of discomfort all over his/her body and that everything was hurting him/her within 15 minutes of being assessed. EI #9 said she notified the doctor of the fall, and he gave an order to send him/her out. An interview was conducted with EI #3, Care Plan/MDS Coordinator on 03/22/2023 at 12:09 PM. EI #3 stated RI #1's care plan indicated he/she was a two-person assistance with bathing. EI #3 stated RI #1 needed physical assistance with part of his/her bathing activity. A follow-up interview was conducted with EI #3 on 03/22/2023 at 4:23 PM. EI #3 stated the facility was unable to locate RI #1's ADL Flow Record for January prior to the fall, however based on December's Flow Record she thought RI #1 was documented as requiring the assistance of one person for bathing. A follow-up interview was conducted with EI #3 on 03/24/2023 at 8:41 AM. EI #3 stated she was responsible for updating the ADL Flow Record and admitted sometimes changes are not transcribed from care plan to ADL Flow Record as they should. EI #3 said she was responsible for making sure the ADL sheets are updated correctly along with care plans. An interview was conducted with EI #2 (DON) on 03/22/2023 at 4:46 PM. EI #2 stated on 01/16/2023, CNA was giving RI #1 a bed bath and he/she rolled too far to the edge of the bed causing RI #1 to slide to the floor. EI #2 stated the CNAs are made aware of the resident's level of assistance by looking at the ADL Flow Records that are kept at the nurses' station. EI #2 admitted that the facility could not locate RI #1's January's ADL Flow Record prior to the fall, however he stated RI #1's level of assistance was the same as the December ADL Flow record. EI #2 admitted , RI #1 did not have an assistance level for bathing on his/her ADL Flow Record. EI #2 stated the concern of the care plan and ADL Flow Record not matching was the correct assistance was not provided, which led to RI #1 rolling out of the bed. EI #2 stated RI #1 sustained a fractured Tibia and Fibula from the fall. An interview was conducted with EI #1, Administrator on 03/23/2023 at 5:25 PM. EI #1 stated it was her understanding of the incident on 01/16/2023, RI #1 was receiving a bed bath when he/she slid off the bed. When EI #4 turned RI #1 on his/her side to dry his/her back, RI #1's leg came off the bed, and he/she slid to the floor. EI #1 stated RI #1's care plan stated he/she was a two person assist for turning, bathing, and positioning. EI #1 stated RI#1's ADL Flow Record for January 2023, prior to the fall could not be located, therefore she assumed that it would be the same as December 2022 ADL Flow Record. EI #1 admitted she did not see an assistance level for bathing on RI #1's December ADL Flow Record. EI #1 stated since no level of assistance was documented for bathing, the CNAs would probably assume RI #1 was a one person assistance for bathing. EI #1 admitted there were discrepancies between the care plan and ADL Flow Record, and they should match. She stated the concern of them not matching is safety. EI #1 stated RI #1 sustained broken bones of the leg from the fall on 01/16/2023. ****************************************************************************************************** The facility took immediate action to correct the noncompliance by: 1. RI #1's fall investigation that revealed resident had a fall with injuries from (his/her) bed during ADL care from an air mattress deflating while receiving a bed bath from EI#4. EI #4 was re-trained by the Director of Nursing on 01/19/2023 to use two persons assist when giving a bed bath to RI #1. The service representative from (name of company) Medical was contacted on 03/23/2023 and came to the facility to provide training to dayshift nursing staff and therapy staff present on 03/23/2023 including the Director of Nursing and Assistant Director of Nursing/Staff Development Coordinator, on the use of alternating pressure air mattresses including the Prius Salute RDX 3-1 Alternating Anti-Decubitus System on how to turn the mattress to a firm setting during ADL care and transfers. A video recording of the in-service was done on 03/23/2023 to assist in the training of staff who were not present at this time for the in-service provided by the STAT Medical service representative. 16 staff members attended the in-service by the STAT Medical service representative. 18 staff members were trained by the Assistant Director of Nursing and the Director of Nursing on 03/23/2023, 03/24/2023 and 03/25/2023. The Assistant Director of Nursing/Staff Development Coordinator will use the video to train staff. Check offs were completed with return demonstration by the STAT Medical service representative on 03/23/2023 and by the Director of Nursing and Assistant Director of Nursing/Staff Development Coordinator on 03/23/2023, 03/24/2023 and 03/25/2023. The Administrator was trained and checked off by the Assistant Director of Nursing/Staff Development Coordinator on 03/25/2023. 2. The Director of Nursing and Staff Development Coordinator trained nursing staff and therapy staff working on 03/23/2023, 03/24/2023 and 03/25/2023 on the use of alternating pressure air mattresses including the Prius Salute RDX 3-1 Alternating Anti-Decubitus System during ADL care and transfers on 03/23/2023 and 03/24/2023 with return demonstration required at the beginning of their shift. There are 11 staff members who have not been trained and are scheduled to be trained by the Assistant Director of Nursing/Staff Development Coordinator Nursing at the beginning of their next scheduled shift prior to providing resident care. 3. The ADL care plans and ADL documentation flow sheets for all residents who currently are on an alternating pressure air mattress were reviewed and updated to reflect that alternating pressure air mattresses are placed on the appropriate setting during ADL care and transfers and that staff assistance needed during ADL care is consistent on the ADL care plan and the ADL documentation flow sheets by the Director of Nursing and Assistant Director of Nursing on 03/25/2023. 4. The Corporate Nurse Consultant reviewed the manufacturer's manuals for alternating pressure air mattresses used in the facility and generated a policy and procedure for proper use of alternating pressure air mattresses on 03/25/2023 and in-serviced the Administrator, Director of Nursing and Staff Development Coordinator and QA committee on the new policy and procedure. Nursing staff will be in-serviced on the new policy and procedure by the Staff Development Coordinator and/or the Director of Nursing on 03/25/2023. Nursing and/or therapy staff who were not trained on 03/25/2023 will be trained at the beginning of their next scheduled shift prior to performing resident care by the Assistant Director of Nursing/Staff Development Coordinator. 5. The QA Committee had an ad hoc meeting on 03/25/2023 to review for approval the new policy and procedure for the use of alternating pressure air mattresses. The Medical Director was provided the new policy and procedure and approved it on 03/25/2023. QA Committee members who attended the meeting were the Administrator, the Director of Nursing, Assistant Director of Nursing/Staff Development Coordinator, MDS Coordinator, Infection Prevention Nurse, Clinical Dietary/Restorative Nurse, Treatment Nurse, Medical Records Clerk and Corporate Nurse Consultant. The Director of Nursing reviewed the QA Committee meeting with the Medical Director via phone for approval on 03/25/2023. ************************************************** 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 03/25/2023, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00043075.