**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate assessment and supervision to prevent an accident for one of three residents (Resident 1) when physical therapy (PT, a healthcare profession that helps you move better or strengthen weakened muscles) did not follow physician's orders to assess Resident 1's functional ability level upon admission and develop a resident-centered plan of care. This resulted in Resident 1's fall, head injuries, multiple fractures, and subsequent death. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), congestive heart failure (heart muscle does not pump blood as well as it should), atrial fibrillation (irregular heartbeat), osteoporosis (condition that causes the bones to become brittle and fragile), long term use of anticoagulant (blood thinner), urinary incontinence (the loss of bladder control), chronic kidney disease (loss of kidney function), and a history of falling. Review of Resident 1's Progress Notes (PN) dated 8/2/23 4:25 p.m., indicated admitted a XXX y.o. (year old) female from IL (Independent Living), via w/c (wheelchair) at 11:30 AM, accompanied by the [family member], . and the Director of IL. With the dx (diagnoses) of Chronic Heart Dis (Chronic Heart Disease, type of heart disease that affects your heart function repeatedly and over time), Chronic kidney disease, stage 4 (severe loss of kidney function), CHF (Congestive Heart Failure, heart does not pump blood as well as it should) Alert/oriented with forgetfulness, reality orientation as needed Handle gently suring (typo during) ADL'S and transfer Extensive assist with ADL's & transfer. Review of Resident 1's Observation Detail List Report with Observation Date: 8/2/23 4:34 p.m., indicated admission Observation, OBSERVATION DETAILS, General admission Information, . Mode of Transfer: Wheelchair . Resident Arrived With: Wheelchair Level of Consciousness: Alert . NERVOUS SYSTEM: Cognition: Attention: Attentive, Orientation: Disoriented (i.e. time, place, situation), Memory: Impaired, Thinking: Disorganized (rambling, incoherent,, impaired judgment), .GASTROINTESTINAL SYSTEM: Gastrointestinal History: Date of Last BM (bowel movement): 08/02/2023, . Resident's Current Bowel Continence Level: Occasionally incontinent, . GENITOURINARY: Genitourinary History: Current Urinary Continence Level: Occasionally incontinent, Incontinence Pattern: Unable to get to toilet in time due to urgency, .Management of Bladder incontinence: Adult briefs/Depends (underwear), . MUSCULOSKELETAL SYSTEM: Musculoskeletal History and Physical Observation: Does the resident present with any of the following (checked): Extremity weakness, History of Joint Replacement, Requires Assistive Devices, . Assistive Devices: Walker, Wheelchair, .Observe extremities for any pain, swelling, weakness, stiffness, warmth, tenderness, loss of sensation, change in color, or impaired function indicate location(s) (checked): Right Lower Extremity - Gen (generalized) weakness, Left Lower Extremity - Gen weakness Review of Resident 1's Physician's Progress Notes with Encounter Date 8/2/23 written by Physician (PHYS), indicated .Pls. see EPIC (a medical record system) reports for evaluations from [name of 3 Physicians] and fellow at [name of clinic] colleagues for care and goals of care discussions leading to current placement in long term care Functionally now at 1-2 person assist with transfer, ADL's Durable medical equipment: 4WWalker (4-wheel walker), Electric Scooter, Walk in tub, Grab bars, adjustable bed with transfer handles, Emergency call devices Review of Resident 1's PN: PN dated 8/6/23 indicated Resident 1 had an unwitnessed fall with subsequent pain on 8/6/23 and was transferred to the hospital that day; PN dated 8/8/23 indicated Resident 1 returned to the facility on hospice (focuses on a person's quality of life as they near the end of life) care on 8/8/23, with diagnosis of subarachnoid bleed (bleeding in the space between the brain and the surrounding membrane); PN dated 8/20/23 indicated Resident 1 passed away in the facility on 8/20/23. Review of Resident 1's acute hospital CT scan (computerized tomography scan, procedure used to view internal components of the body) to head, cervical (neck) and spine dated 8/6/23, indicated Resident 1 had Multicompartment intracranial hemorrhage [bleeding in multiple parts of the head] including a moderately sized intraparenchymal hematoma [a pool of blood in the tissue of the brain] in the right frontal operculum [part of the brain], with associated subarachnoid hemorrhage in the left collateral sulcus [a part of the brain] of the temporal lobe. Findings are most compatible with traumatic subarachnoid hemorrhage. Review of Resident 1's acute hospital X-ray (images of internal tissues, bones, and organs on film or digital media) to shoulders dated 8/6/23, indicated Resident 1 had an Acute [sudden onset] mildly displaced fracture [partial or complete break in the bone] at the surgical neck of the humerus [upper arm bone]. Review of Resident 1 's acute hospital CT scan to chest dated 8/6/23, indicated Resident 1 had Few lateral nondisplaced [aligned] right rib fractures. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 8/14/23, indicated Resident 1 had a brief interview for mental status [BIMS, a tool used to assess cognition (knowing, learning, and understanding things)] score of 6 [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. Review of Resident 1's fall care plan dated 8/3/23, indicated following interventions to prevent falls: - Provide resident an environment free of clutter and floor free of glare, liquids and/or foreign objects. - Keep call light and personal and frequently used items within reach. - Keep bed in lowest position with brakes locked. - Encourage resident to use environmental devices such as hand grips, handrails, etc. - Educate and remind resident to ask for assistance with transfers and ambulation. Review of Resident 1's Physician's orders dated 8/2/23, indicated Occupational therapy (health care profession that help improve the ability to perform activities of daily living) evaluation and treatment (see OT POC [plan of care] for treatment modalities, frequency, and duration). Physical therapy evaluation and treatment (see PT POC for treatment modalities, frequency, and duration). Rehab potential: Fair). During an interview on 1/3/24 at 10:50 a.m. with Certified Nursing Assistant (CNA) A, CNA A stated depending on the resident's condition, PT should have assessed resident's functional level upon admission, and then therapy department would update nursing. She further stated staff would check on residents frequently and place confused residents close to staff who can keep an eye on them to prevent falls. During a concurrent interview and record review on 1/3/24, at 11:08 a.m., with Registered Nurse (RN) B, review of Resident 1's Fall Risk assessment dated [DATE], indicated a score of 17 (0-5 Low Fall Risk, 6-13 Moderate Fall Risk, >13 High Fall Risk), which indicated Resident 1 was high fall risk. RN B stated therapy should have assessed the Resident 1's transfer status (how a person can move from one position to another, example from bed to chair) to determine what level of assistance was required. During an interview on 1/3/24 at 11:43 a.m. with the Director of Rehabilitation Services (DOR), the DOR stated therapy was to assess a resident's functional level if there was a physician order, but it also depended on the resident's payer source, it had to be verified before any treatment. Since walking was not one of Resident 1's goals, PT did not evaluate her. During an interview on 2/7/24, at 2:36 p.m., with the Director of Nursing (DON), the DON stated on the day of the fall, the assigned CNA for Resident 1 changed the resident and got her ready in the morning, helped her to get out of the bed, sat the resident in the wheelchair next to the bed, placed the over bed table in front of the resident, then left the room. When the CNA came back to the room, she found that Resident 1 had fallen in the bathroom with her walker by her side. She further stated Resident 1 possibly stood up on her own, walked to the walker across the room, went to the bathroom then fell in there and hit her head. The resident required extensive assist (individual would not be able to perform or complete the activity of daily living without another person to aid in performing the complete task, by providing weight-bearing assistance) for transfer and no staff was aware that the resident was able to stand up and walk prior to the fall. During an interview on 3/6/24, at 1:20 p.m., with the DON, she stated therapy was verifying Resident 1's payer source, which usually takes several days. However, Resident 1 fell and went to the hospital before the payor source was verified. Resident 1 was then admitted to hospice upon return, so therapy did not pursue to assess her. Review of Resident 1's Certificate of Death dated 8/24/23, indicated Resident 1 passed away in the facility on 8/20/24, the immediate cause of death was A. Multiple blunt force injuries to include multicompartmental intracranial hemorrhage. B. Fall. A review of the facility's policy and procedure (P&P) titled Medicare / Managed Care admission Protocol revised October 2017, the P&P indicated, Supportive Data: It is important to consider Medicare qualifications before the resident is admitted . During the inquiry and admission process, many activities take place simultaneously Physician orders: 2. Upon admission, physician orders for a Medicare A/Managed Care stay include, but are not limited to: An order for Evaluate and Treat for therapy services which proceeds evaluation; . A review of the facility's policy and procedure titled Fall Prevention Protocol revised October 2017, indicated, Purpose: This protocol describes mechanisms for assessing residents at risk for falls and providing interventions to reduce the likelihood of falls Assessment: 1. The John Hopkins Fall Risk Assessment is completed in the electronic medical record within 24 hours of admission for all SN (Skilled Nursing) residents Interventions: The following interventions are considered for residents who are at risk for falls: 1. Resident and/or family/responsible agent are instructed on physical activity strengths and limitations 7. The resident environment is routinely assessed for safety 8. Assistive devices used by the resident are placed within the resident's reach and are in good working order 10. Frequent rounds are made to check the resident 12. Where appropriate, a referral to rehabilitative therapy services is made to obtain interventions or recommendations to reduce fall occurrences. 12.1 If a resident is not a candidate for formal rehabilitative therapy services, consider including in the Restorative Nursing Program, as appropriate 13.1 The resident is also assessed for the appropriateness of the use of bed/chair alarm, personal alarm, and motion sensor systems 15. The resident is placed in a room close to the nursing station, if possible 17. Address any sensory deficits, especially hearing and vision, to minimize the effects of these deficits as much as possible. 18. Instruct resident to rise slowly from a standing or sitting position and to remain in a standing position until they feel balanced enough to begin walking.