**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision was provided to one resident (#1) to prevent a fall with injury. The deficient practice resulted in a fall with injury. Findings include: Resident #1 was re-admitted on [DATE] with diagnoses that included epilepsy, personal history of traumatic brain injury (TBI), hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side. A care plan initiated on March 29, 2023 included the resident had ADL (activities of daily living) self-care performance deficit related to TBI and was at risk for falls related to right sided weakness. Interventions included two-staff participation with transfers and wearing of safety helmet, frequent reminder to allow staff to supervise while ambulating, call light be within reach, encourage to call for assistance as needed, wearing appropriate footwear when ambulating or wheeling in wheelchair and keeping needed items such as water in reach. The care plan dated April 7, 2023 included the resident had bowel/bladder incontinence related to impaired mobility. Interventions included to ensure there was an unobstructed path to the bathroom. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. The MDS assessment also indicated that the resident required limited one person assist for transfers, walking, and locomotion and used a walker and/or wheelchair as mobility devices. The discharge note dated July 21, 2023 included the resident left facility and was transported by a family member for a brain surgery. Per the documentation, the resident's vitals were stable with no acute distress and the provider was aware of surgery. A physician order dated July 24, 2023 included for the bed may be placed against the wall to increase living space in room. A fall risk evaluation dated July 24, 2023 revealed a score of 14 indicating the resident was high risk for fall. The assessment included the resident has had a history of 1-2 falls in the past three months, had balance problem while standing/walking, decreased muscular coordination/jerking movements, change in gait pattern when walking, and required use of assistive devise. A physician note dated July 24, 2023 revealed the resident had left-sided cranioplasty on July 21, 2023; and that, during hospitalization, the resident had a seizure-like episode in the recovery room after surgery and was transferred to ICU (Intensive Care Unit) for close monitoring and neurocritical care. Per the documentation, during the physician's examination at the day of discharge, the resident did not require oxygen, denied shortness of breath, chest pain, nausea, vomiting, diarrhea, fevers, or loss of consciousness. Assessment included CCM (Cerebral cavernous malformations) medical management treatment and plan. The plan was to continue seizure precautions per facility, follow up with neuro surgery/neuro as outpatient, and fall precaution. A nursing note dated July 25, 2023 included skin examination for re-admission revealed an incision to left side of head from temple to mid-forehead in a C-shape, approximately 25 centimeters long, with approximately 42 staples in place, was open to air, with no redness, drainage or separation noted along incision. It also included that there were no signs/symptoms of infection, non-tender to touch and the resident denied pain. Further, the documentation included that the resident had non-skid socks in place and bed in low position. The skin care plan dated July 26, 2023 included that the resident had actual impairment to skin integrity related to surgical wound to scalp with staples. Interventions included to follow facility protocols for treatment of injury. The condition follow-up note dated July 26, 2023 revealed resident was monitored for readmission s/p (status post) skull bone flap replacement and postoperative seizure activity. A condition follow-up note dated July 27, 2023 indicated that the resident was monitored for readmission s/p skull bone flap replacement and postoperative seizure activity. Per the documentation, no distress, seizure activity was noted or reported and the staples to scalp were intact with no signs/symptoms of infection. It also included that resident tolerated all medications and the vitals were within normal limits. The physician progress note dated July 31, 2023 included the resident was alert and oriented x2, had surgical scar to the left side of the head and had right hemiparesis. Assessments included history of SDH/SAH (Subdural hemorrhage/subarachnoid hemorrhage) s/s decompressive craniectomy; s/p cranioplasty on July 21; and, generalized weakness. Plan was CCM medical management treatment and plan and fall precautions. Review of the comprehensive care plan did not include any focus of care, goals, desired outcomes, and specific interventions related to the resident's recent cranioplasty from July 25 through August 2, 2023. A physician order dated August 3, 2023 included for an order that the bed may be placed in appropriate position for safety. The comprehensive care plan was revised on August 3, 2023 to include the following interventions initiated: -Anticipate and meet needs; -Bed in appropriate position for safety; -Educate resident/family about safety reminders and what to do if a fall occurs; -Follow facility fall protocol; -Maintain a clear pathway, free of obstacles; -May place bed against wall to increase living space in room; -Encourage to use bell to call for assistance; -Converse with resident while providing care; and, -Explain all procedures/task before starting. A Nurse Practitioner (NP) progress note dated August 8, 2023 included that the resident was up in chair, ambulated independently and denied pain/headache. Physical exam of the skin noted surgical scar to left side of head. Another NP progress note dated August 15, 2023 revealed the resident was up and ambulating on unit and was talking more clearly; and that, the nurse reported that he resident's pulse was sometimes low due to propranolol. Physical exam of skin noted surgical scar to left side of head. Assessment was CCM medical management treatment and plan. Plan included to continue seizure precautions-per facility and fall precaution. Review of the fall risk evaluation dated August 18, 2023 revealed a fall risk score of 9 indicating medium risk for falls. The assessment also included the resident had a history of 1-2 falls in the past three months, had balance problem while standing/walking, decreased muscular coordination/jerking movements, and change in gait pattern when walking. A nursing note dated August 18, 2023 included that the nurse heard a loud noise in resident's room and upon entering found the resident on the bathroom floor with head against the wall with significant amount of bleeding. Per the documentation, the resident reported that he tripped on commode that was in the bathroom; and that, 911 was called because resident had recent surgery to the head. A physician order dated August 18, 2023 revealed an order to send the resident to the ED (Emergency Department) for evaluation and treatment regarding fall. The nursing home to hospital transfer form dated August 18, 2023 included the resident was transferred to the hospital for a fall with injury. Under relevant information, there was no mention that the resident had a recent cranioplasty. Review of the fire department incident report revealed that on August 18, 2023 revealed the resident was found on the floor in the bathroom with head dressed and bandaged. Per the documentation, resident had moderate amount of blood on his head and face, would occasionally moan but was unresponsive to verbal stimulus. Detailed findings included bleeding, deformity, laceration and swelling to the head. The documentation also included that the laceration was approximately 6 inches long was full thickness with brain matter protruding from the wound. The report also included that the resident's initial acuity was Critical /Immediate; and that, after assessment and treatment, the resident's final acuity was unchanged. It also included that the resident was transported to the hospital emergency department. An undated graphic photo provided by the complainant revealed that the resident was lying down with leads on his chest, nasal cannula on his nose and blood-stained gauze was lying beside the resident's head. The photo revealed the resident had dried blood stain on his forehead and deep laceration extending from the top of his forehead just by the hairline to almost the length of the top of his head with the wound opened and something white was protruding from the open wound on the top of the head. The facility's incident report with a locked date of August 21, 2023 included that on August 18, 2023 a loud noise was heard in the resident's room and the resident was found in the bathroom floor with his head against the wall and had significant amount of bleeding. The report included that the resident described that he tripped over a commode that was in the bathroom. Further review of the fall risk care plan revealed that the intervention of frequent safety checks and frequent reminder to allow staff to supervise while ambulating was not initiated until August 18, 2023. An IDT (interdisciplinary team) fall committee note dated August 21, 2023 revealed the resident had a fall incident on August 18, 2023, was found on the floor in his bathroom and had a laceration to his head. Per the documentation, 911 was called due to recent craniotomy and resident was admitted to the hospital. The documentation also included that resident reported that he tripped on his commode while getting off the toilet and fell forward. Per the documentation, the commode was in place to raise the toilet seat to an appropriate height for the resident. Further, the note revealed that the resident was ambulatory with supervision with no assistance, had a recent left craniotomy and had history of TBI with decompressive craniotomy, seizure disorder; and, worked with therapy for strengthening. It also included that resident will often get up alone and walk around his room and staff provided frequent safety reminders and redirection. However, review of the clinical record revealed no documentation that resident #1 was provided safety reminders, redirection, or education regarding ambulating without supervision/assistance. During an interview with a licensed practical nurse (LPN/staff #5) conducted on August 25, 2023 at 1:35 pm, the LPN stated that interventions for residents at risk for fall included frequent checks and lots of education if the resident were alert and oriented. The LPN said that an incident report is completed following a fall; and, if the fall was unwitnessed then neuro checks were also completed. The LPN said that even when the fall was witnessed but if the resident hits their head, neuro checks and assessments were completed. Regarding resident #1, the LPN said that he was familiar with resident #1 who was new at the facility for rehabilitation and was moved to North station. The LPN said that resident #1 was a very pleasant man who was making great strides with rehab, was improving his vocabulary and making daily improvements with regards to being able to do things for himself; and that, the resident was highly motivated. The LPN said that resident #1 had a surgery in which part of the resident's skull removed and replaced; and that, the suture line was healing. He stated that the resident's room was close to the nurse's station; and that, there were no orders for mat on the floor. He said sometimes, the resident would call for help and sometimes would not call for help and those were the times that he had to be reminded. The LPN said that resident #1 was a standby assist; and that, resident #1 normally listens when told not to get up and wait. However, the LPN said that the resident does try to get up. He also said that maybe if he had gotten to the room to give the resident his medications 10 seconds prior or if somebody saw him getting up, then resident #1 would have been reminded and he would not have gotten up and fell. The LPN said that certified nursing assistants (CNAs) and the nurses conduct rounds on the resident but staff was him frequently and so were the nurses. He stated that resident #1 was not on a specific rounding timeframe. However, since resident #1's roommate was actively passing, there were always people there. Regarding the fall incident, the LPN said that the interventions in place at the time of the resident's fall included frequent reminders and education since the resident needed constant reminder, call for help (resident would acknowledge that it was important) and bed was in low position. At the time of the fall, the LPN said that he was in the process of preparing the resident's medication when he heard a loud noise and he went to the resident's room and found that the resident was not in bed. The LPN said that he tapped on the door and when he opened the door, the resident was on the floor leading to the restroom; and that, the resident was putting 2-3 words together. The LPN stated that he then applied pressure to the wound and asked the resident what happened; and that, the resident kept mixing his words and kept pointing to the commode, was not sensible, and spoke in a lower tone compared to his normal voice. Further, the LPN stated that prior to the resident's fall, the suture line to the resident's wound was healed and nothing was open, the staples had been removed. However, after the fall, it looked like there was a significant wound and there was a lot of bleeding so he yelled for 911 to be called. The LPN said that the resident's wound was right in the frontal area about a centimeter from the healed suture line and that skin on the head being pulled back a little. The LPN stated he could not tell how deep the wound was but that it had some thickness to it and was a pretty good laceration. Further, the LPN said that he applied pressure and waited for 911 since the wound looked beyond his scope of care. The LPN said that he was not aware that the resident was not back yet; and that, he thought the resident was coming back the same day. He said that he last spoke to the resident's family who told him that they were waiting for the test results then the resident would come back to the facility. However, the LPN said that when another nurse called the hospital on Tuesday, August 22, 2023, the nurse was told that the resident was on life support and there were brain matter coming out of his skull. The LPN said that this information was not confirmed. An interview with a CNA (staff #10) was conducted on August 25, 2023 at 2:09 p.m. Staff #10 stated that interventions for fall risk resident usually consisted of: redirecting and assisting them, letting them know how to use the call light and ask for assistance, help them get into bed, and ensure call light was within reach. The CNA noted that some residents are care planned to have mat on the floor and/or bed lowered to the floor. Staff #10 stated that she was familiar with resident #1 and that he was a pleasant man who had to be redirected several times. She said resident #1 is supposed to use his wheelchair to ambulate. However, resident #1 walks around without his wheelchair. Since resident #1 is unstable, he has to be told not to get up without using a wheelchair so he does not fall. Staff #10 stated that when resident #1 is left alone, he then gets up without the wheelchair and walks instead. She said that resident had a fall; and, when the fall occurred, she was across the hall and heard a bump and a nurse yelling for help and she took the resident's vitals. The CNA said that the nurse asked resident #1 what happened and resident said he got up, tripped on the commode and hit his head. The CNA said there was blood everywhere and they put pressure on the resident's head and called 911. She stated that one person was taking vitals, and another nurse and another CNA were helping. The CNA said that she heard the resident say that he tripped and hit himself on the wall which was contradicting what the LPN (staff #5) had said regarding resident's ability to say what happened. The CNA stated that the interventions in place for resident #1 at the time of the incident included call light in place, mat on the floor, lowered bed, ensure that things resident needs were within reach to prevent him from doing things he was not supposed to, and redirect if resident does things that are not safe. The CNA further stated that she does not think there was anything that could have been done to prevent the resident from falling. A phone interview with another LPN (staff #15) was conducted on August 28, 2023 at 8:59 a.m. She stated that upon admission residents are assessed for fall risk and based on this, they determine if there are orders for safety. She said that safety education is provided if resident is coherent enough to agree; and that, they also do a toilet schedule and fall risk management. Staff #15 stated that she only took care of resident #1 twice; and that, resident #1 just sat at the side of the bed and listened to music and seemed to respond better in Spanish. She stated that during the night shift, resident #1 asks for help before getting up and would turn on his call light. Staff #15 stated that resident #1 suffered a fall the morning before she returned to shift. Staff #15 said that at the time of the fall, the fall interventions in place for resident #1 included toilet schedule, might have had a mat on the floor but she was not sure, and was care planned for safety. She stated that since she was always in the hall, when she worked with him, she checked on him approximately every 45 minutes. Staff #15 stated that for the night shift, resident #1 was pretty compliant. However, she was not sure if it was the same for the day shift. Staff #15 stated that when she cared for him, resident #1 had a large incision on his head, but it was healing, there was no drainage or anything open. During an interview with the Director of Nursing (DON/staff #50) conducted on August 28, 2023 at 2:03 p.m., the DON stated that her expectation was for staff to identify residents' risk for falls and implement interventions that are ordered and care planned. She stated that the interventions for fall risk residents depends on the resident and the evaluation. The DON said that her expectation was for staff to identify who the high-risk residents are and follow physician's orders for interventions, conduct frequent checks for safety, ensure items are within reach and to toilet resident frequently. Furthermore, the DON said that if an intervention was not working, they meet as IDT (interdisciplinary team) to create new interventions and that if a resident wants to lay on the floor, that would be included in the care plan. The DON said that it also her expectation a risk management is completed in the electronic record following a fall incident; and that, there are IDT notes in the electronic record, the team reviews information during standup, talk about interventions, and discuss during weekly fall meeting on Friday for opportunities and trends. She also said that it is expected that new interventions are put in place after a fall incident and the interventions are based on the assessed needs of the resident. She stated that if a resident fell and goes to the ER (Emergency Room) then that was an intervention and they would reevaluate the interventions when the resident returns. Regarding resident #1, the DON stated that she was not too familiar with resident #1 without looking at his clinical record; however, she stated that she knew the resident and that the resident was working with therapy. Further, the DON stated that resident #1 was encouraged to use call light but gets up on his own and had to be redirected. The facility policy titled Fall Management System reviewed June 2023 indicated that it was their policy to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Furthermore, residents with a fall risk eval score of 10 or above are considered high risk and will have an individualized care plan developed which includes measurable objectives and timeframes. The policy also included that the care plan interventions will be developed to manage falls and will consider the particular elements of the assessment that put the resident as risk. Review of the facility policy titled Documentation and Charting revised July 2022 revealed that it is their policy to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, etc., as well as the progress of the resident's care. The facility policy on Comprehensive Person-Centered Care Planning reviewed October 2022 stated that comprehensive care plan will include resident's needs identified in the comprehensive assessment and any specialized services, resident's goals, and desired outcomes.