**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to safely transfer one of five residents reviewed for pain (Resident 51) from the bed to the wheelchair, using a gait belt. As a result, Resident 51 sustained a fracture to the left humerus (shoulder). In addition, Resident 51's fistula (a site used for dialysis[a treatment to remove waste products from the blood]) was unusable, requiring Resident 51 to be hospitalized for the placement of a new dialysis access site. Findings: Resident 51 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (a condition in which the kidneys cannot remove waste from the blood), dependence of renal dialysis (a treatment to remove waste products from the blood), according to the facility's admission Record. On 8/19/23 at 12:20 P.M., a concurrent observation and interview was conducted with Resident 51. Resident 51 was in her room, with her lunch tray in front of her. Resident 51 was grimacing and pointing to her left shoulder and stated, Pain. On 8/19/23 at 12:23 P.M., an interview was conducted with Certified Nursing Assistant (CNA)1. CNA 1 stated Resident 51 complained of left shoulder pain after being transferred from her bed to wheelchair that morning. Resident 51 was assisted by two night shift CNAs. CNA 1 stated Resident 51, .is always a two-person transfer with a gait belt . A review of Resident 51's Emergency Department Radiology (x-ray) result, dated 8/20/24 at 12:51 A.M. indicated Resident 51 had a fracture of the left humerus. On 8/20/24 at 8:20 A.M., Resident 51 was observed in her room and noted to have her left arm wrapped from her wrist to her shoulder with an elastic bandage and in a sling. A review of Resident 51's Progress Note, dated 8/20/24 at 1:30 P.M. indicated .Dialysis cancelled .resident has severe pain in left arm due to fracture .per MD send resident to hospital for central line placement for dialysis On 8/21/24 at 6:21 A.M., an interview was conducted with CNA 2. CNA 2 stated he had not been assigned to Resident 51 for a few months. CNA 2 stated months ago, Resident 51 did not need much assistance, and he was not familiar with her current needs for help with transfers. CNA 2 continued, on 8/19/24, he assisted another CNA (CNA 3) to transfer Resident 51 from the bed to the wheelchair. CNA 2 stated he placed his arm under Resident 51's left arm, while CNA 3 placed her arm under Resident 51's right arm. CNA 2 stated while lifting Resident 51 from the bed, she began to slip down. CNA 2 stated he grabbed Resident 51's hand and heard, A pop. CNA 2 stated a gait belt was not used to transfer Resident 51. When asked whether CNA 2 would do anything differently the next time he transferred a resident, CNA 2 stated he would hold on tighter. CNA 2 did not mention the use of a gait belt for safe transfer. A review of Resident 51's Care Plan for ability to perform transfers, dated 3/14/24, indicated the resident required total assistance (all care provided by staff) for transfers. On 8/21/24 at 9:06 A.M., an interview was conducted with Physical Therapist (PT) 1. PT 1 stated Resident 51 required two-person, total staff assist with transfers. PT 1 stated residents who required total assistance needed a gait belt during transfers. PT 1 stated during transfers, staff should have their hands on the gait belt, not under the resident's arms. PT 1 stated Resident 51 was at risk of injury if staff used Resident 51's arms during transfer, instead of using a gait belt. On 8/22/24 at 3:47 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff should have used a gait belt while transferring Resident 51. The DON stated a safe transfer for Resident 51 meant two-person assist with a gait belt. The DON acknowledged by not using a gait belt, Resident 51 was not safely transferred from bed to chair. A review of facility policy titled Gait Belt, Use of, revised November 2012, indicated, .It is the policy that staff will help control and balance (by using a gait belt) residents who require assistance with ambulation and transfer . A review of the facility's policy titled Safe Lifting and Moving of Residents indicated, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . A review of the Facility Assessment Tool, dated 6/17/2024, indicated, Core Competencies include .transfers, using gait belt, using mechanic lifts .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for one of one resident reviewed for falls (Resident 25), the facility failed to ensure: 1. Adequate supervision and close monitoring were provided; and 2. Effectiveness of interventions were evaluated, and new interventions were implemented to address resident's behavior of getting up unassisted and prevent further falls. These failures resulted to Resident 25 to have five repeated falls in 2022 while at the facility. The resident's 5th incident of fall on September 20, 2022, resulted in Resident 25 sustaining left hip fracture (broken bones), and was transferred out to acute hospital for further evaluation and surgery. Findings: On September 20, 2022, at approximately 1:05 p.m., Resident 25 was observed standing near the foot of her bed and was trying to ambulate. Resident 25 was observed to have difficulty standing and keeping her balance. There were no staff observed near Resident 25's room nor the hallway to monitor Resident 25. On September 20, 2022, at 1:10 p.m., the Administrator (ADM) was informed of Resident 25 needing assistance. The ADM was observed to walk to Resident 25's room and found the resident on the floor. Resident 25 was observed on the floor laying on her left side with both arms and legs flexed. On September 20, 2022, Resident 25's record was reviewed. The admission Record, indicated Resident 25 was admitted to the facility on [DATE], with diagnoses which included disorders of bone density and structure (bone disease), unsteadiness on feet, Alzheimer's disease (mental health condition with memory loss), and dementia with behavioral disturbance (mental health condition with memory loss). A review of the untitled care plan, dated December 16, 2018, indicated, . (name of resident) has impaired cognitive function/dementia or impaired thought process r/t (related to) Alzheimer's (sic), Dementia, Difficulty making decisions .Interventions .Engage the resident in simple, structured activities that avoid overly demanding tasks . A review of Resident 25's record indicated a bowel toileting program was initiated since April 4, 2019, and indicated the resident to be assisted to the bathroom before and after meals and at bedtime. A review of the untitled care plan, initiated January 20, 2022, indicated, (Resident's name) is risk for falls r/t poor safety awareness .fall risk assessment 26 (high) .dementia .Alzheimer's disease . A review of the document titled, Progress Notes, dated January 20, 2022, at 4:20 p.m., indicated, .Around 4PM (4 p.m.) CNA (Certified Nursing Assistant) called the writer that (resident's name) found on the floor, face down and nose bleeding .According to her she's trying to gets-up (sic) by herself, tries to transfer herself to bed without calling for assistance, was out of balance and landed on the floor .Noted L (left) forehead bump, bruising and swollen, L (left) eye is red and nose stops bleeding with redness/bruising also. Resident verbalized pain on the affected area (L forehead bump) .Noticed vomits when incident happens. Noted resident confused, trying to get up most of the time, thinking she can be able to walk without assistance and saying wanna (want to) go home to Mexico .Called (physician's name) to send to ER (emergency room) for further eval . A review of the document titled, Progress Notes, dated January 20, 2022, at 4:10 p.m., indicated the following interventions were placed after the fall incident on January 20, 2022: - Landing mat (a soft mat placed at the side of the bed used when the resident falls out of bed); - Call light within reach; - Closely monitoring for safety and comfort; and - Keep resident clean and dry. A review of the document titled, admission Record, indicated Resident 25 was readmitted back to the facility from the acute hospital on January 23, 2022. A review of the document titled, Fall Risk Assessment, dated January 23, 2022, indicated, .History of Falls within last six months .Multiple Falls .Agitated Behavior in Last Seven Days .Behavior occurred daily or more .Gait Analysis .Unable to independently come to a standing position .Exhibits loss of balance while standing .Strays off the straight path of walking .Requires hands-on assistance to move from place to place . A review of the document titled, Progress Notes, dated February 2, 2022, at 10:09 p.m., indicated, .Resident had unwitnessed fall. Staff found resident sitting on the floor mat by bedside . A review of the document titled, FSI-Fall Scene Investigation Report, dated February 2, 2022, indicated lowering and locking the bed as new intervention recommended. A review of the Minimum Data Set (MDS- an assessment tool), dated July 12, 2022, indicated the following information on Resident 25: - BIMS (Brief Interview for Mental Status) score of 2 (severely impaired); - Required one-person extensive assistance with transfer; - With unsteady balance requiring staff assistance with moving from seated to standing position and transferring between bed and wheelchair; - Always incontinence (involuntary leakage) of the bladder and frequent incontinence of the bowel; and - On a toileting program to address bowel continence. A review of the document titled, Progress Notes, dated July 27, 2022, at 2 p.m., indicated, .At 0915 (9:15 a.m.) Resident found sitting on the floor with both flexed and right hand holding on the sink and left hand holding the toilet seat . A review of the document titled, FSI-Fall Scene Investigation Report, dated July 27, 2022, indicated Resident 25 was left alone in the bathroom and was trying to get up. A review of the untitled care plan, initiated on July 28, 2022, indicated, .IDT (Interdisciplinary Team - a group of healthcare professionals) Fall Review: Recommending staff remain with patient for direct supervision during toileting program to reduce risk for falls . A review of the document titled, Progress Notes, dated August 7, 2022, at 2:39 p.m., indicated .At 13:25 (1:25 p.m.) Resident found sitting on the floor, leaning backward against the wheelchair, both foot rest on axilla (underarm), both legs are extended with soiled adult brief . A review of the document titled, FSI-Fall Scene Investigation Report, dated August 8, 2022, indicated Resident 25 was trying to stand up prior to the fall and was last toileted at 9 a.m. (Resident 25 should have been toileted before and after lunch according to the toileting program initiated on April 4, 2019). The document also included interventions to implement toileting schedule, and ensure the resident was placed in high visibility area when out of bed. OT (occupational therapy) was also recommended to assess for fall preventions to maximize safety and decrease risk of falls. A review of the physician's order, dated August 9, 2022, indicated, .Patient will receive skilled OT services 3x/wk (three times a week) for 4 (four) weeks for self-care, there (therapeutic) ex (exercise), there act (activities), wheel chair management, group therapy, and patient/caregiver education in order to maximize safety and decrease risk for falls .related to UNSTEADINESS ON FEET .for 30 days. A review of the document titled, OT Evaluation & Plan of Treatment, dated August 9, 2022, indicated, .Clinical Impressions: Pt (patient) .with decreased safety awareness and cognitive deficits, decreased strength, balance and endurance that raise a concerns (sic) for safety with functional transfers, mobility and ADLs (Activities of Daily Living) . A review of the document titled, Occupational Therapy Discharge Summary, dated September 13, 2022, indicated Resident 25 received OT services from August 9 to September 13, 2022. The document included the following: - Short term goal for Resident 25 was to complete toilet/commode transfers with minimal assist and occasional verbal cues for safety awareness. Resident 25 required maximum assistance and 90% of verbal cuing upon discharge from OT services (goal not met); - Long term goal to decrease risk for falls as evidence by scoring of more than 6 (six); Resident 25 scored 1 (one) upon discharge from OT services (goal not met); and - Recommendation to continue with restorative nursing program. There were no further interventions initiated to address Resident 25's behavior of getting up unassisted after completing OT services on September 13, 2022. A review of the document titled, Progress Notes, dated September 20, 2022, at 3:56 p.m., indicated .Around 1310 (1:10 p.m.) CN (charge nurse) was notified by business personnel patient had an (sic) fall. CN then went to the room and found patient lying on the floor on her left side. Both feet legs flexed and both arms on her side .Patient complained of pain on L (left) hip and L (left) lower leg, unable to move .MD (physician) was notified with order to send to ER (emergency room) for eval (evaluation) . A review of the document titled, FSI-Fall Scene Investigation Report, dated September 20, 2022, indicated Resident 25 was trying to stand up prior to the fall. There were no new interventions recommended after this fall incident. A review of the document titled, Progress Notes, dated September 21, 2022, at 8:54 a.m., indicated F/U (follow up) call (name of hospital) .Resident is admitted for left hip fracture and going for surgery today at 11AM (11 a.m.) . There were no documented evidence specific interventions were implemented to provide close supervision and monitoring for Resident 25 to address the resident's behavior of getting up unassisted after each fall incident on January 20, February 2, July 27, August 7, and September 20, 2022. On September 22, 2022, at 11:51 a.m., Registered Nurse (RN) 3 was interviewed. She stated Resident 25 had the tendency to get up from her wheelchair unassisted. She stated Resident 25 was confused at most times and required redirections. On September 22, 2022, at 12 p.m., an interview with CNA 1 was conducted. She stated Resident 25 should be taken to the restroom before and after each meal (breakfast and lunch during morning shift). She further stated Resident 25 had tendency to get out of bed unassisted. On September 22, 2022, at 1:27 p.m., during an interview with CNA 2, he stated Resident 25 had to be closely monitored for episodes of getting out of bed without asking staff for help. He stated Resident 25 was often confused and have poor safety awareness. He stated he usually would bring Resident 25 to the nursing station or the receptionist area after the resident went to the bathroom before and after meals for close monitoring. On September 22, at 1:42 p.m., during an interview, CNA 3 stated she was the CNA assigned to Resident 25 on September 20, 2022. She stated she assisted Resident 25 to the bathroom at around 1 p.m. and put resident back to bed. She stated she left Resident 25 in the room and went to pick up meal trays. On September 22, 2022, at 3:40 p.m., the Occupational Therapy Program Manager (OTPM) was interviewed. She stated Resident 25 received OT services from August 9 to September 13, 2022. She stated they mostly worked on the resident's safety and muscle strengthening to improve balance and prevent fall. She stated Resident 25's response to OT treatment varied depending on her cognitive status. She stated OT services were discontinued as Resident 25 had reached the maximum potential based on her cognitive status. On September 22, 2022, at 6:45 p.m., an interview with the Director of Nursing (DON) was conducted. She stated Resident 25 had multiple falls prior to the last fall on September 20, 2022 (which resulted in a left hip fracture). The DON stated Resident 25 was confused and required redirections. She stated Resident 25 required close supervision and monitoring from staff due to her episodes of getting out of bed unassisted. She stated if the nursing staff were not able to monitor Resident 25, the resident would be brought either at the nursing station, receptionist area, or to the activities to be monitored closely by the staff. During the interview with the DON, she stated she was not sure why Resident 25 was in bed after being toileted during the last fall incident on September 20, 2022. She stated Resident 25 should have been brought to the activities or at the nursing station after toilet use. She stated Resident 25 should always be within eye sight from staff. The DON also stated Resident 25 continued to get out of bed due to her current cognitive status and sustained multiple falls despite interventions implemented for the resident. The DON stated she was not sure as to why Resident 25's behavior of getting out of bed was not evaluated or addressed after each fall incident. She was also not sure as to why effectiveness of the interventions were not evaluated after each fall incident for Resident 25. The DON stated the fall incidents in July and August of 2022 were due to Resident 25 getting out of bed to use the restroom. She stated OT referral was initiated after Resident 25 fell on August 7, 2022, to help the resident gain strength and balance while standing. She was not sure as to why OT therapy was not initiated or evaluated earlier for Resident 25 after the fall incident on July 27, 2022. The DON further stated starting OT services earlier than August 9, 2022, would have been beneficial for Resident 25. In addition, the DON further stated a fall alarm could have helped to prevent falls for Resident 25. She stated the facility currently discouraged the use of fall alarm on residents who were high risk for fall. The facility policy and procedure titled, Falls Management, dated November 2012, was reviewed. The policy indicated, .It is the policy of this facility that our physical environment remains as free of accident hazards as possible .Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls .Resident who have sustained a fall, will be placed on the facility's heightened awareness program, which includes visual identifier, (i.e. Falling Star), designed to alert staff of a resident who has actively fallen in the presence of standard fall prevention interventions that have been outline on the care plan .Recent falls will be reviewed daily by the designated fall team, to evaluate cause, determine additional strategies as needed to prevent recurrence for each resident and further revise the care plan if needed .General incident and accident trending will be complied and reviewed no less often than quarterly by the Quality Assessment and Assurance Committee. The review will include identification of trends, educational needs, common casual factors, (i.e., toileting needs, staffing patterns, etc.), and will develop strategies for systemic correction and resolution .