**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide adequate supervision and an environment as free from accidents hazards as possible for one (#7) of three residents reviewed for accidents out of 27 sample residents. The facility failed to ensure proper transfer procedure was completed by staff to prevent a fall with injury for Resident #7. Resident #7, who had a diagnosis of medically complex conditions, was admitted to the facility on [DATE]. The facility failed to follow safety measures during resident transfers. The facility failed to provide two person assistance with transfers as documented in the 3/2/23 baseline care plan dated and the 3/7/23 minimum data set (MDS) assessment. Due to facility's failure to provide two person assistance with transfers and adequate supervision for transfers for Resident #7, she had a fall on 3/6/23 when transferring from the bed to wheelchair resulting in her being sent to the hospital for a head laceration requiring two sutures. Furthermore, the facility did not provide proper transfer education with staff after the incident on 3/6/23. Findings include: I. Facility policy The Fall Prevention policy, revised on 9/28/22, received from the nursing home administrator (NHA) on 5/9/23 at 11:52 a.m. It revealed in pertinent part, to ensure optimal patient safety, safety interventions will be implemented and monitored with appropriate documentation. The admitting nurse/nurse manager will be responsible for ensuring that interventions were initiated and communicated with staff to follow through. II. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnosis included pneumonia (lung infection), sepsis (systemic infection), urinary tract infection (infection in the bladder), type two diabetes (abnormal insulin levels), lymphedema (abnormal drainage on lymph nodes resulting in swelling) and hypertension (high blood pressure). The 3/7/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive two person physical assistance for transfers and bed mobility. One person extensive assistance with toileting and personal hygiene. She required set up assistance with eating. B. Resident and representative interview Resident #7 was interviewed on 5/4/23 at 10:20 a.m. She said she fell in the facility and hit her head on the bedside table or wall, which cracked her head open. The facility sent her to the emergency room and they stitched my head up. She said she was admitted to the hospital for her head injury along with pneumonia they found during testing. She said she was in the hospital for three weeks before coming back to the facility. Resident #7 was interviewed again on 5/9/23 at 2:00 p.m. She said she had only been in the facility a few days when she fell. She stated there was only one certified nurse aide (CNA) in the room transferring her from one place to another. When transferring from the bed to the wheel chair when she lost her balance and fell hitting her head. There was only one CNA in the room and there was not a gait belt on. Resident #7 stated her head was covered with blood and they sent her to the hospital via ambulance. Resident #7 said she needed two people for transfers because she was weak and scared to fall. Resident #7's son was interviewed on 5/9/23 at 2:30 p.m. He said the facility informed him of his mother's fall the day it happened. He was told she was transferring from the bed to the wheel chair with one person's assistance when she lost her balance and fell. He was told the CNA was standing in front of Resident #7 at the time of fall. He stated his mother required two person assistance at the time of the fall related to weakness. She was transported to the hospital due to the head injury she sustained during the fall. She stayed in the hospital for a few weeks because when they were conducting testing they also found her to have pneumonia. C. Record review The admission nursing observation dated 3/2/23 revealed Resident #7 had faint pedal pulses, bilateral lower extremity pitting edema, urinary incontinence due to the inability to reach the toilet timely related her to decreased mobility. The fall risk section of observation tool revealed Resident #7 had decreased muscular coordination, requiring use of assistive devices. The baseline person centered care plan dated 3/2/23 received from the NHA on 5/8/23 at 11:23 a.m. revealed Resident #7 required two person assistance with transfers, weight bearing as tolerated and no other safety measures were implemented on admission. The care plan dated 4/3/23 identified potential for complications related to recent fall with scalp laceration. Goal was to decrease the potential risk for falls during the duration of the residents stay. Interventions placed per care plan effective date 4/3/23 were to educate the patient on: high low bed to decrease risk of injury, notify physician, physical and occupational therapy. Resident #7 needs identified were gait training and strengthening with physical therapy (PT) and occupational therapy (OT). The PT evaluation note from 3/3/23 revealed Resident #7 was a modified assistance with staff performing 50% assistance with transfers. The OT evaluation dated 3/3/23 revealed resident was minimum to maximum assistance with transfers. On 3/6/23 at 10:22 a.m. a registered nurse (RN) documented she went to assist a certified nurse aide (CNA) who requested assistance with Resident #7 as she was slipping out of her recliner. The resident almost had a fall on the floor when the CNA, the RN and a physical therapy assistant (PTA) assisted the resident back into the recliner. The resident was unable to provide any assistance to get her back in the chair. The resident reported she was sitting in the recliner and began sliding forward to grab something causing the foot rest to tip the recliner chair forward. On 3/6/23 at 8:03 p.m. the RN documented Resident #7 had a witnessed fall in her room. The nurse assessment revealed the resident sustained a laceration to the back of the head. The resident was alert, vitals signs and all extremities found to be baseline. The resident denied pain. The resident was sent out to the emergency room for evaluation. On 3/6/23 at 10:12 p.m. the licensed practical nurse (LPN) note revealed around 7:20 p.m. the resident had a witnessed fall. The CNA stated the resident fell while she was transferring from the bed to the wheelchair, the resident lost her balance and fell backwards. The LPN requested an RN for assessment. The resident sustained a head laceration injury and was alert till she was transferred to hospital. Fall incident event, risk observation and care plan update dated 3/6/23 provided by the NHA on 5/9/23 at 11:23 a.m. revealed Resident #7 had a witnessed fall in her room while transferring with CNA present. She lost her balance and fell backwards. The resident hit her head on the wall and sustained a laceration to her head. She was transferred to the hospital. Fall observation post fall revealed the resident was alert and oriented to person, place and time. Indicated the resident had one to two falls in the past three months, adequate visions, regularly continent, balance problems with standing/walking, taking antihypertensive medication, predisposing diseases of hypotension. Evaluation concluded resident fall risk score of seven which placed resident in the low fall risk category. Care plan update two person assist for all transfers was selected. -Two person assist with transfers was already indicated staff failed to implement a new intervention for fall prevention post fall. admission records dated 3/6/23 from the hospital indicated Resident #7 was admitted to the hospital for a fall with head laceration. The resident presented in the emergency department with significant scalp bleeding. The resident required two nylon sutures to control bleeding. CNA task documentation in point of care (POC) revealed the following for staff assistance with transferring: On 3/3/23 transfers were one to two person physical assistance; On 3/4/23 transfer were one person physical assistance; On 3/5/23 transfers were one person physical assistance; On 3/6/23 transfers were one person physical assistance; On 3/27/23 readmission transfers were two person physical assistance; and, On 3/28/23 transfers were one to two person physical assistance. -The documentation on 3/6/23 when the resident had a fall (see below) indicated the staff only had one person assisting the resident. III. Staff interviews The transition nurse (TR) was interviewed on 5/9/23 at 11:08 a.m. She said she assisted Resident #7 on 3/6/23 when she was slipping out of the recliner after reaching for something. She said Resident #7 was only given verbal education on recliner function/safety and no other interventions were implemented since she physically did not reach the floor. The director of nursing (DON), assistant director of nursing (ADON) and the regional director of nursing (RDON) were interviewed on 5/9/23 at 11:10 a.m. They acknowledged that the 3/6/23 MDS assessment indicated Resident #7 was a two person physical assistance with transfers. The DON verbalized the following for proper transfer technique for staff: a gait belt should be placed on the resident, the CNA should be standing behind the resident to support them once the resident was standing with balance and have a hold of the gait belt. She acknowledged Resident #7 fell backwards indicating the CNA was not behind the Resident #7 at the time of the fall. The DON provided documentation on 5/9/23 at 1:26 p.m. for a disciplinary action the CNA received from the facility post Resident #7 fall for failure to provide care with a secondary staff member for a resident who required two person assistance with transfers since admission. The statement provided by the CNA revealed she was assisting Resident #7 with a transfer from the bed to the wheel chair to go to the restroom. The CNA stated she was standing behind the resident during the transfer. -However, nursing documentation revealed Resident #7 fell backwards indicating CNA was not behind the resident. The DON was interviewed on 5/9/23 at 2:39 p.m. She said Resident #7's initial admission fall assessment on 3/2/23 fall score was four indicating she was at low fall risk and no interventions were initiated. Resident #7's fall score on readmission on [DATE] was seven, still low fall risk. The DON acknowledged the baseline care plan dated 3/2/23 safety section did not indicate any fall interventions set in place. The baseline care plan had one and two person assistance for transfers selected. The DON said the staff error on the side of more assistance so a two person assistance was preferred for most residents. CNA #1 was interviewed on 5/9/23 at 2:28 p.m. He said he checked the white board in the resident's room to see if the resident was a one or two person transfer. He said the physical therapist would let the staff know if needed whether the resident was a one person or two person transfer. He said he always wore a gait belt as part of his uniform and always used a gait belt to transfer. He said he would stand behind a resident when transferring, depending on the resident's transfer status. He said some residents required both staff members for transfers and may need to stand beside the resident. He said if he needed a second staff member to do a two person transfer he would call them on the headset. CNA #2 was interviewed on 5/9/23 at 2:51 p.m. He had worked at the facility for two years and on the evening shift. He said he learned about how to transfer a resident by the daily resident sheet, talking with the CNAs at shift change and talking with the resident. There was a white board in the resident's room and under transfers it listed how many people to use and the equipment to use. He said he did use a gait belt to help prevent falls. He said each resident that was a fall risk wore a wristband. He said using a gait belt assisting the resident, he stood in front of the resident to help get them out of a chair and then he would stand to the side as he assisted them to walk. The wall mounted computerized clinical kiosk was observed and there was no place to review the resident's transfer status. CNA #3 was interviewed on 5/9/23 at 3:13 p.m. She said she did not receive training on how to complete a resident transfer nor did she receive any kind of inservice. She was not sure if it (not receiving the training) was because she had been a CNA for so long. The DON was interviewed on 5/9/23 at 3:25 p.m. She said the facility did not complete a facility wide transfer education for nursing staff after Resident #7's fall with an injury. The physical therapist assistant (PTA) was interviewed on 5/9/23 at 3:26 pm. She said a resident who was maximum assistance was considered a two person assist with transferring. Once a transfer status was verified by PT it was written on the communication boards in the resident's room and verbally told to the resident's nurse at time of determination.