**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure two (#58 and #48) of four residents out of 25 sample residents reviewed for abuse were kept free from abuse. Resident #48, with a diagnosis of dementia, had known aggressive and impulsive behaviors to other residents. Resident #48 was walking down the hallway and Resident #58 was walking towards her. Resident #48 pushed Resident #58 and she lost her balance. Resident #58 fell to the ground and fractured her right hip. The facility failed to protect Resident #58 from Resident #48's aggressive behaviors. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/26/23 to 3/2/23, resulting in the deficiency being cited at past non-compliance with a correction date of 1/14/23. I. Facility policy The Abuse policy, revised 7/10/22, was provided by the nursing home administrator (NHA) on 2/27/23 at 2:15 p.m. It read in pertinent part: It was the policy of the facility that each resident would be free from abuse. Abuse could include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. The resident will be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility would strive to educate team members and other applicable individuals in techniques to protect all parties. Every resident was unique and may be subject to 'abuse' based on a variety of circumstances, including community physical plant, environment, the resident's health, behavior or cognitive level. a. Before admission, prospective residents would be screened to help determine suitable placement within the community. b. Upon admission and periodically after that, each resident would have an assessment completed which identified potential vulnerabilities such as cognitive, physical, psychosocial, environment and communication concerns. c. The interdisciplinary team would identify the vulnerabilities and interventions on the resident care plan. II. Resident altercation The 1/14/23 health status note revealed Resident #58 was physically abused by Resident #48 (perpetrator). It reported that at approximately 3:00 p.m. Resident #48 was leaving the shower room and walking down the hall when Resident #58 walked towards her. Resident #48 pushed Resident #58 causing her to fall. Resident #58 sustained a right hip fracture related to the fall. Both residents lived in the memory care neighborhood and were non interviewable. Resident #48 was accompanied by a certified nurse aide at the time of the incident. III. Resident #48 A. Resident status Resident #48, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnoses included Parkinson's disease, unspecified dementia, history of falling, and anxiety. The 12/6/22 minimum data set (MDS) assessment revealed, the resident was unable to complete a brief interview for mental status score (BIMS). She had short and long term memory problems, and her cognitive skills for daily living were severely impaired. She required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene. She required supervision while walking independently in the corridor. She had inattention and disorganized thinking. She had physical symptoms towards others one to three days out of the seven day look back period. She received an antipsychotic and an antidepressant daily. B. Record review The behavior care plan, initiated 8/26/22 and revised 2/27/23, revealed the resident had the potential to be physically aggressive related to her impulsivity and dementia. Interventions included: -Care partners to provide reassurance to the resident when walking. -Care partners would conduct frequent checks to be aware where the resident was for safety. -Resident resided on the west side of the memory care neighborhood related to preference of a lower stimulated environment that assists in the prevention of other residents entering into her proximity and preventing her from reacting in a physically aggressive way towards them. -Motion monitor in her room. -Offer and encourage engagement with personalized sensory box. -Review and monitor psychotropic medication regimen as needed by pharmacy consultant, primary care physician, and psychotropic committee. The activities care plan, initiated 8/26/22 and revised 12/22/22, revealed the resident participated in one to one programming of her desired activities. She was invited to a smaller group of activities of her choosing. Interventions included: -Care partners to offer resident's simple pleasures such as: soda, rice krispies treats, and snacks, especially chocolate. -Encourage resident to go into the living area next to her room where her coloring and drawing table as well as supplies were. -Invite and encourage resident to participate in desired activity as tolerated. The 1/14/23 health status note documented the altercation. The resident was immediately escorted to her room. IV. Resident #58 A. Resident status Resident #58, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2023 CPO, the diagnoses included unspecified dementia, unspecified fracture of the right femur, major depressive disorder, anxiety disorder, unsteadiness on her feet, other abnormalities of gait and mobility, and age-related osteoporosis. The 12/6/22 MDS revealed, the resident was unable to complete a BIMS. She had short and long term memory problems, and her cognitive skills for daily living were severely impaired. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required supervision with transfers and walking in room and corridor. She had inattention and disorganized thinking. She wandered one to three days out of seven look back days. The behavior care plan, initiated 9/2/22 and revised 2/27/23, revealed the resident's behavior may impact others because of her dementia. She had a history of becoming confused, tearful, and believed that others in her room and/or previous roommates were strangers and did not belong in her room. Interventions included: -Resident would not have a roommate at the time. -Encourage resident to express her feelings and validate if needed. -Frequent checks. -Staff would intervene if the resident got upset with other residents. -Stop sign and creative name design placed across the residents door to deter other residents from wandering into her room. The activities care plan, initiated 9/2/22 and revised 1/23/23, revealed the resident loved to read about anything and also enjoyed reading her bible. She liked to listen to music and gospel. She liked to attend social gatherings. Interventions included: -Keep the resident's family involved in discussion about her care. -Participate in meaningful engagements independently (read and watch TV). -Participate in socials, group music events, and movies. The 1/14/23 health status note documented the resident had been walking down the hall independently when she was pushed by another resident and hit the handrail before falling to the ground. The resident was complaining of right hip pain and was unable to move as well as yelling out in pain. The resident was sent to the emergency room for evaluation and treatment. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 3/1/23 at 9:55 a.m. She said Resident #48 was moody and could get angry. She said the resident hit staff and other residents. She said when Resident #48 left her room, staff walked with her to keep other residents safe, since they never knew when she would strike out. She said Resident #48 liked to go into other resident rooms. She said Resident #58 cried a lot for no reason which aggravated other residents. She said when there was an altercation between residents, staff would immediately separate them. CNA #2 was interviewed on 3/1/23 at 10:05 a.m. She said Resident #48 wandered and would not wait for help. She said Resident #48 did not like big groups and liked to be alone. She said Resident #48 would hit others if she did not know them, especially new people, and struck out without warning. She said if she left her room, staff were required to be one-on-one with her. She said Resident #48 had a motion sensor in her room to notify staff she was being active, and also had a door knob safety cover on her door on the outside to prevent residents from wandering into the room. She said Resident #58 cried most of the time and aggravated Resident #48. She said Resident #48 could not handle annoying or loud sounds. She said when there was an altercation between residents, staff would immediately separate them. Licensed practical nurse (LPN) #3 was interviewed on 3/1/23 at 10:47 a.m. She said Resident #48 could be resistive to care. She said when Resident #48 went into the hallway and someone was in her view, she would reach out for them. She said she could lash out and hit without warning. She said she had a motion sensor in her room and when activated staff would immediately check on her. She said staff tried to keep other residents from her hallway. She said if residents did walk down Resident #48's hallway, they would watch to make sure they were kept safe. She said the staff tried to keep the residents in the common area so they could be monitored. She said staff tried to keep the residents engaged so they did not wander. She said Resident #58 did not have any behaviors, but cried a lot, had repetitive words, and wandered. She said Resident #58 no longer resided in the memory care neighborhood. The NHA was interviewed on 3/1/23 at 1:26 p.m. She said Resident #48 was leaving the shower room and walking down the hall with a CNA. She said Resident #58 was coming towards them and Resident #48 reached out and pushed her. She said Resident #58 lost her balance and fell to the ground. She said Resident #48 was immediately taken to her room and Resident #58 was assessed for injuries. She said Resident #58 was sent to the emergency room for evaluation and treatment. VI. Facility interventions On 1/14/23 the facility placed a motion monitor in Resident #48's room and required staff to be with her one-on-one staff supervision when she left her room. Following the incident the facility: -Held an in-service for all staff on dementia and abuse. -The facility completed a full audit of the memory care neighborhood and identified three residents with aggressive behaviors. Individualized interventions were put into place for each of the three identified residents. Resident #58 no longer resided in the memory care neighborhood. When she was readmitted from the hospital, she resided in a different neighborhood within the facility. Resident #48 was not involved in any further resident to resident altercations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide supervision, assistance, services, and implement timely interventions to prevent falls with injuries for two (#29 and #4) of nine residents reviewed for accidents/hazards out of 25 sample residents. Resident #29 had three falls since admission, had severe cognitive impairment, used a wheelchair for ambulation, and required supervision with transfers. Between 9/21/22 and 11/27/22, Resident #29 experienced three falls: one witnessed and two unwitnessed. After the 11/18/22 fall, the resident sustained a left hip fracture. On admission the resident fall risk was 15. The facility failed to initiate a fall care plan with effective interventions to prevent repeated falls. Furthermore, the facility's failure to timely develop appropriate interventions, and effectively anticipate cognitively impaired resident's needs, resulted in two unwitnessed falls within 10 days, contributing to Resident #4's pelvic fracture and decline in activities of daily living. Findings include: I. Facility policy The Fall Prevention policy, revised 12/21/22, was provided by the nursing home administrator (NHA) on 3/1/23 at 3:45 p.m. It read in pertinent part: Each resident will be assessed for the risk of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (resident pushes a resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse indicate in the assessment the resident's fall risk and initiate interventions on the baseline care plan, in accordance with the resident's level of risk. The nurse will refer to the facility's High Risk or Low/Moderate Risk Protocols. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Indicate transfer status on door name plate. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Medication regimen review iv. Low bed v. Alternate call system access vi. Scheduled ambulation or toileting assistance vii. Family/caregiver or resident education viii. Restorative nursing program ix. Therapy services referral 7. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program and the interdisciplinary team will review fall interventions as necessary. 8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete an incident report. c. Notify the physician and family. d. Review the resident's care plan and update as indicated. e. Document all assessments and actions. f. Obtain witness statements in the case of injury. II. Resident #29 A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the February 2023 computerized physicians orders (CPO), the diagnoses included multiple sclerosis, unspecified dementia, anxiety, and a fracture of the ischium (hip). The 12/2/22 minimum data set (MDS) assessment revealed, the resident was unable to complete a brief interview for mental status score (BIMS). She had short and long term memory problems, and her cognitive skills for daily living were severely impaired. She required extensive assistance with toilet use, dressing, and personal hygiene. She required supervision with transfers and walking in the room and corridor. She had impairment to one side of her lower extremities. She used a wheelchair and had a fracture related to a fall. She had two or more falls with injury since admission, and one fall with a major injury. B. Record review Care plan The left ischium fracture care plan, initiated 11/16/22, revealed the resident sustained a hip fracture related to a fall. The interventions included: -Anticipate and meet needs. -Be sure the call light was within reach and respond promptly to all requests for assistance. -Float heels while in bed. -Care team to consider physical therapy (PT) and occupational therapy (OT) evaluation if needed and if resident and family wishes too. -Follow physician orders for weight bearing status. -Modify environment as needed to current needs: non-slip surface for bath/shower, bed in lowest position with wheels locked, floors that are even and free from spills, clutter, and glare free light. -Monitor, document, and report as needed signs and symptoms of hip fracture complications. The fall risk care plan, initiated 3/1/23 (during survey), revealed the resident had a potential for falls related to multiple sclerosis and history of falls. The interventions included: -The resident would frequently ambulate behind her wheelchair and transfer chair to chair throughout the day. -The resident had shoes and may need assistance with putting them on. -The residents' room would be arranged to promote safe mobility with the wheelchair. -The resident transfers independently. -The resident used a wheelchair for mobility. -The resident would like personal items within reach. C. Observations 1. Call light observations The call light in the residents room was not within her reach. The call light cord hung over the call light house attached to the wall which was observed on 2/27/23 at 11:20 a.m., 2/28/23 at 10:58 a.m. and 3/1/23 at 12:34 p.m. Making the call light unavailable if the resident returned to her room. 2. Resident #29 observations On 2/28/23 at 9:56 a.m. Resident #29 was observed sitting in a recliner in the common area watching the bowling activity. She transferred herself from the recliner to her wheelchair to take her turn at bowling. On 2/28/23 at 11:02 a.m. following the bowling activity, Resident #28 transferred herself from her wheelchair into a recliner in the common area. On 3/1/23 Resident #29 was observed continuously from 10:33 a.m. to 11:45 a.m. She self transferred herself from her wheelchair to a recliner and vice versa 13 times. At 11:45 a.m she stood up from a recliner and abandoned her wheelchair. She used an overbed table as a walker and pushed it to a chair across the room and sat down. She declined to go to the dining room for lunch. Lunch was brought to her and placed on the overbed table. With all the resident's transfers, the resident's wheelchair brakes were not engaged and the wheelchair rolled backwards as she sat. Falls The fall investigations were requested from the NHA on 2/28/23. The NHA stated that fall investigations were part of the facility's quality assurance performance improvement (QAPI) process and they were not provided. 1. According to the 9/24/22 health status note, at 4:19 a.m., the resident recalled falling in the shower. She stated she hit her head indicating along the lower hairline behind her ear. There were no reddened areas or tender spots. Her neurological status (neuros) were intact. -No fall care plan was initiated with implemented interventions. 2. According to the 11/18/22 incident note, at 9:14 a.m., the nurse was in the dining room helping another resident and heard yelling. She saw Resident #29 laying on her left side beside the window in the lounge. She attempted to assess the resident but she would not turn over onto her back and continued crying and yelling out. The supervisor asked the resident if she wanted to go to the hospital which she declined. X Rays revealed the resident sustained a left ischium fracture. A left ischium fracture care plan was initiated. However, a fall care plan was not in place with effective interventions. 3. According to the 11/27/22 post fall evaluation, at 2:14 a.m., the resident had an unwitnessed fall at her bedside. Activity at the time of fall was probably the resident transferring between wheelchair and the recliner. There was no injury. -No new interventions were implemented and the fracture care plan was not revised. -There were no IDT review notes for any of the above falls. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 3/1/23 at 9:55 a.m. She said Resident #29 was independent and a stand by assist with transfers, but mostly transferred herself. She said staff did stand by assist with transfers to the toilet, bed, and recliner. She said she did not know what interventions were in place to prevent falls because she worked all of the units. She said staff tried to keep the resident in the common area. She Resident #29 could not remember how to use her call light and yelled out. CNA #2 was interviewed on 3/1/23 at 10:05 a.m. She said Resident #29 was one assist with transfers and could bear weight. She said the resident was not able to recall how to use the call light. She said the resident was on frequent checks since she wandered. She said staff tried to keep her in the common area so they could monitor her. She said Resident #29 frequently transferred herself and would not wait for help. Licensed practical nurse (LPN) #3 was interviewed on 3/1/23 at 10:47 a.m. She said Resident #29 was independent with transfers. She said since the resident's past falls, the resident continued to transfer independently per her choice. She said no interventions were in place to reduce her falls. She said the resident was not able to use her call light. -However, the MDS assessment indicated the resident required supervision from staff for transfers and walking. The NHA was interviewed on 3/1/23 at 1:00 p.m. She said the fall on 9/21/22 was a result of Resident #29's history of trauma and striking out at staff. She said the staff was giving her a shower when she became agitated when the water was turned. The resident stood up from the shower chair and swung at the staff and fell. She said the physician speculated that the resident was having a flare up related to her multiple sclerosis and was having increased spasms and pain. The resident was offered to be sent to the hospital but refused. The NHA said the fall on 11/18/22 was caused by a rolling stool that was next to a chair. She said Resident #29 frequently transferred herself from her wheelchair to a chair. She said the intervention was to remove the stool from the common area. She said the physician said the resident became hypoxic (low blood oxygen level) from refusing to wear her oxygen. She said the resident refused to go to the hospital for x-rays until the family was able to take her. The x-ray resulted in a hip fracture. The NHA said the 11/27/23 fall was unwitnessed in her room. She said as an intervention the facility added purposeful rounding and to offer assistance with toilet use. She said PT/OT was not offered. The restorative nursing program director (RNPD) was interviewed on 3/1/23 at 1:15 p.m. She said Resident #29 should have been a one person assist or stand by assist for transfers. She said the resident was not on a restorative program because she did not retain information. She said she would immediately initiate a fall care plan with an appropriate plan of care. E. Facility follow-up The NHA was interviewed again on 3/2/23 at 11:37 a.m. She said the facility did a root cause and analysis and the falls had declined since October 2022. She said the facility had fall rounds every Thursday. She said going forward the facility would create a profile for each high risk fall resident and put a plan of correction in place. She said the facility pharmacist would do an additional review for residents who were a high fall risk as well. She said starting the following week, in the fall meeting the facility would review falls and the pharmacist would review medications. -However, based on Resident #29's fall risk, falls with injury and observations, the facility did not implement effective measures to prevent falls. III. Resident #4 A. Resident status Resident #4, age above 65, was admitted on [DATE]. According to the February 2023 clinical physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic neuropathy, Alzheimer's disease, osteoarthritis and history of falling. The diagnosis of fracture of left pubis was added on 2/16/23. The 12/14/22 MDS assessment revealed the resident had impaired cognition including short and long-term memory problems. No behaviors or rejection of care were noted. She required limited assistance with bed mobility and transfers, extensive assistance with dressing, toilet use and personal hygiene, and supervision with eating. No falls or falls history were noted. B. Record review The comprehensive care plan revealed the following: -Fall: The resident is moderate risk for falls r/t (related to) use of walker, hx (history of) of tremor and poor vision (dated 9/26/22). Interventions included: Assist of 2 (two) and gait belt for transfers (dated 3/1/23). (Resident) will remain free of injury. Start: 4/19/21. Neighbor has floor lamp next to bed to use when the room is dark due to poor eyesight. Restorative program in place for AROM (active range of motion), strength, ambulation. (Resident) will be provided with non-skid socks at night d/t (due to) fall. (Resident) uses a w/c (wheelchair) for mobility. Purposeful rounding during the day, evening, and night. Start: 11/30/21. Has push pad call light. Start: 12/13/21. Motion monitor in room to alert staff when (resident) is getting up. Start: 12/27/21 (revision on 2/20/23). -ADL (activities of daily living): The resident has an ADL self-care performance deficit r/t (related to) dementia, fatigue. New pelvic fx (fracture) 2/16/23 (dated 2/17/23). Interventions included: Encourage the resident to use bell to call for assistance (dated 9/26/22). -Cognition: (Resident) has impaired cognitive function/dementia or impaired thought processes r/t (related to) dementia, impaired decision making, long term memory loss (dated 9/26/22). -Risk for Falls (dated 2/5/23). Interventions included: If fall occurs, alert provider. If resident is a fall risk, initiate fall risk precautions. -The fall care plan did not specify frequency of purposeful rounding. -The cognition care plan did not address resident's ability to use a call light. -The facility failed to monitor the effectiveness of Resident #4's care planned interventions and implement effective interventions. C. Nursing notes On 2/5/23 a nurse documented: This writer heard neighbor (referred to as resident) calling for help and when writer walked into room, writer noticed neighbor was on her knees leaning against bed (like praying) and blankets were on the floor. This writer asked neighbor what happened and neighbor states 'I slid out of bed.' Neighbor does complain of knees and legs hurting. The bed was lower and staff used sling to assist neighbor to bed. Notified (name/son) at 2043 (8:43 p.m.) and informed him of incident. Fax was sent to (physician). Fall protocol started. Neighbor was given routine Tramadol (pain medication) around 2100 (9:00 p.m.). Neighbor has been resting in bed and has not had any further complaints of pain. On 2/16/23 at 5:10 p.m. a nurse documented: This nurse was informed at 1710 (5:10 p.m.) that the neighbor was on the floor in between the bathroom and bedroom doorway with her walker in front of her. 'My hip hurt.' Head-to-toe assessment done with complaints of pain to the left hip, stopped moving neighbor and sent to (hospital) via ambulance at 1749 (5:49 p.m.), son (name) was notified at 1726 (5:26 p.m.), called 911 at 1728 (5:28 p.m.) and EMTs (emergency medical technicians) arrived at 1735 (5:35 p.m.). Neuro (neurological) checks were initiated with elevated blood pressure, and blood sugar 162. On 2/16/23 at 8:51 p.m. a nurse documented: Called son and updated him that (Resident) will be returning from (emergency room) with a closed pelvic fracture that is non-surgical and non-displaced, was given Morphine 2 mg at 1842 (6:42 p.m.). The 2/16/23 hospital record, x-ray report revealed the following: Nondisplaced fractures of the superior and inferior ramus of the left ischium (two fractures in the pelvic ring bone). On 2/16/23 a nurse documented: The neighbor returned from ER (emergency room) at 2134 (9:34 p.m.) with new orders . may ambulate and weight bear light toe touch on her left leg, and assist as needed with transfers and weight bearing. Diagnosis of closed pelvic non-surgical, non-displaced left hip fracture. Son (name) has been notified and updated. The neighbor is eating a snack in the dining room and the fall protocol continues. On 2/17/23 a nurse documented: Neighbor in w/c (wheelchair) in DR (dining room) eating snack at the beginning of the night. Neighbor assisted to bathroom and then to bed x 2 (with two) staff. Neighbor c/o (complaint of) pain to inner left groin/hip area, insisted she wanted to go to BR (bedroom). Positioned on her right side in bed. Continue on neuros. Neighbor able to move all extremities, lifts left leg well only c/o of pain with extra movements . On 2/17/23 restorative program manager documented: Assessed transfer with stand pivot transfers and neighbor is not able to maintain toe touch weight bearing. Discussed with therapy and we both agreed total lift is most appropriate for transfers. D. Staff interviews CNA #4 was interviewed on 3/1/23 at 5:02 p.m. He said the resident was most of the time independent with all transfers, sometimes required supervision. He said when staff were busy with a resident it was not possible to respond immediately to an alarm from another resident's room. CNA #3 was interviewed on 3/2/23 at 11:10 a.m. She said Resident #4 was not able to use her call light. She said prior to her falls, the resident transferred with staff supervision, however she did not wait for staff. She said the resident had a monitor in her room that would sound on the hallway when she tried to transfer herself from the bed and put her feet on the floor. She said when staff were busy with another resident they did not come right away. She said she was not aware the resident's assessment (MDS assessment 12/14/22) documented required limited assistance with transfers and extensive assistance with toilet use. LPN #1 was interviewed on 3/2/23 at 11:20 a.m. He said he was aware Resident #4 required frequent staff checks as she did not remember to use the call light and always transferred herself. The restorative nursing program director was interviewed on 3/2/23 at 12:33 p.m. She said the resident's care included purposeful rounding, and after the fall on 2/16/23, was added in the task and nursing aides have to chart on it in the resident's record. She said the care plan should specify rounding every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for two (#54 and #2) of six residents reviewed for falls, out of 32 sample residents. Specifically, the facility failed to ensure adequate supervision and effective interventions were in place to prevent multiple falls for Resident #54 and Resident #2, and falls that resulted in multiple injuries to Resident #54. The lack of supervision and effective interventions resulted in seven unwitnessed falls and one witnessed fall since 1/5/21 that caused multiple fractures and injuries to Resident #54's pelvis, right wrist, left hip, left elbow, left hand and head that caused her extreme pain, required trips to the emergency department and resulted in limited mobility. Findings include: I. Facility policy The Fall Prevention policy and procedure, dated 12/16/19, provided by the nursing home administrator (NHA) on 11/18/21 at 11:38 a.m. read in part: -Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. -A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. -The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. -High risk protocols include: Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status and provide additional interventions as directed by the resident's assessment, including but not limited to: Assistive devices, increased frequency of rounds, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education, restorative nursing program, therapy services referral. -When any resident experiences a fall, the facility will: Assess the resident, complete an incident report, notify physician and family, review the resident's care plan and update as indicated, document all assessments and actions, obtain witness statements in the case of injury. II. Resident #54 A. Resident status Resident #54, age [AGE], was admitted [DATE] and readmitted [DATE]. According to the November 2021 computerized physician orders (CPO) diagnoses included unspecified fracture of left acetabulum (hip socket), muscle weakness, difficulty in walking, unspecified fracture of pubis (pelvis), abnormalities of gait and mobility, history of falling and unspecified fracture on the lower end of the right radius (wrist). The 8/31/21 minimum data set (MDS) assessment indicated Resident #54 had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. She was positive for wandering and required limited assistance of one staff member for bed mobility, dressing and personal hygiene. She required limited assistance of two staff members for transfers. She was not steady and was only able to stabilize with staff assistance when moving from seated to a standing position, when walking, when moving on and off the toilet and with surface to surface transfers. She had impairment of one side of her lower extremity. She was occasionally incontinent of bladder, always continent of bowel and was not on a toileting program. She received scheduled pain medication. She was positive for falls with injury and one with major injury. B. Daughter interview and observations Resident #54's daughter was interviewed on 11/15/21 at 11:29 a.m. She said the resident was admitted to the memory care unit in January 2021. She fell while on that unit and broke her pelvis. She moved off the memory care unit and to her current room in March 2021. She has fallen multiple times since moving and has broken multiple bones. She has broken her pelvis twice and her right wrist. She said there was a motion sensor near her bathroom door that was supposed to alert staff if she was up and moving around but she was not sure it was working because when I am here and walking near it no one comes to see if everything is ok. At this time the motion sensor was positioned at the bottom of the door frame on the outside of the bathroom door. The resident was seated on the side of her bed, which had a lipped mattress. She was able to position herself to the edge of the bed with her feet touching the floor. No staff entered the room when the resident or her daughter moved within range of the motion sensor. Her bed was not in its lowest position. On 11/16/21 at 2:50 p.m. Resident #54 was seen seated alone at a table in the dining area on [NAME] hall. On 11/17/21 at 12:00 p.m. the door to Resident #54's room was closed and she was not in the common area. On 11/18/21 at 8:10 a.m. Resident #54 was in her room with the door closed. Upon entry to the room, the motion sensor that had been by the bathroom door, had been moved to underneath her bed facing toward the bathroom door. She had the box call light system, that was normally mounted to the wall, lying on her overbed table next to her bed. C. Record review The care plan initiated 1/8/21, revised 1/20, 2/24, 3/8, 4/9, 8/22, 8/24, 9/9, 10/13, 10/24 and 11/16/21 indicated Resident #54 had a potential for falls related to confusion with a history of falls and a recent fall with fracture of her pelvis. Staff were to assist her routinely, conduct purposeful rounding every two hours. If she was unable to get up they were to check and change her and do bed checks at night. She used a bedside commode for toileting. On 1/20/21 staff were to offer routine assistance to the bathroom as she did not always use her call light. She used a wheelchair for mobility and required the assistance of two staff members for non weight bearing transfers. She needed verbal cueing for weight bearing restrictions due to poor cognition. She was to wear non-skid footwear when out of bed. Her bed was to be locked and kept in the lowest position. On 3/8/21 Resident #54 was to transfer with stand by assistance with a front wheeled walker and she used a wheelchair for long distance mobility. However, the care plan also indicated she transferred independently. A lipped mattress was applied to her bed. She had the potential for pain related to a left pelvic fracture. Staff were to provide analgesics as ordered and report uncontrolled pain to provider. On 4/9/21 Resident #54 was to have a touch call bell. However, throughout the survey she did not have the touch call bell. On 8/22/21 staff were to monitor for pain related to a fractured right wrist and encourage Resident #54 to keep a splint on her right wrist. No new interventions were added. On 8/24/21 staff were to rest Resident #54's right arm on a pillow to help relieve discomfort, two days after the fracture. On 9/9/21 a motion monitor was placed in Resident #54's room, related to recent falls with fractures, to alert staff when she was getting out of bed. Staff were to encourage her to sit in the living area so they could keep a better eye on her. On 10/13/21 Resident #54 had a fall with a laceration to the back of her head with a hematoma. Staff were to assess for pain and monitor for healing. No new interventions were added. On 10/24/21 Resident #54 had a fall in the hallway and fractured her pelvis again. Staff were to orient to room features, bed function, call light use and remind the resident to use call light for assistance with transfers and toileting. Pain medication was ordered for three days. No new interventions were added. On 11/16/21 the care plan indicated Resident #54 was non-compliant with non-weight bearing status and she had a touch call bell, however throughout the survey she did not have the touch call bell at her bedside. Review of the fall risk assessments, that indicated a score greater than 10 was considered a high fall risk, revealed the following: -1/8/21-a score of 14, high risk -4/15/21-a score of 15, high risk -7/2/21-a score of 9, low risk -11/8/21-a score of 19, high risk No new fall risk assessments were completed after the falls in August, September and October 2021. All pain assessments were requested and the NHA said there had been no quarterly pain assessments completed since her admission to the secure unit in January 2021. Medication administration record (MAR) documentation for routine nursing pain assessments was also requested but was not provided. Therapy documentation was requested for all falls and the only documentation received was related to the fall on 1/5/21 and 10/24/21. The incident reports for each fall were requested but were not provided. D. Falls Fall #1, 1/5/21 unwitnessed fall: The 1/5/21 nursing event note documented by licensed practical nurse (LPN) #4 at 8:04 a.m. read: Resident had been up all night walking. At 5:00 a.m., heard resident hollering and found on floor at room doorway, laying on left side and complaining of pain to left side. Also sustained 1 centimeter (cm) U shaped skin tear to elbow. Dressed skin tear with steri strips. Neuro (neurologic) checks were started and vital signs (VS). About 7:00 a.m., physician was here doing rounds and saw resident and gave orders to send to emergency room (ER) for x-rays. Left in ambulance at 7:50 a.m. Family was notified of fall and being sent to hospital.Was also on 15 minute checks due to altercation with another resident. -No documentation was provided for the 15 minute checks staff were to have conducted prior to this fall. The 8:13 a.m. nursing note documented by registered nurse (RN) #2 read in part: Was notified by charge nurse that resident had fall this am at 5:00 and at 7:24 a.m. resident having severe pain to left hip/pelvic area. Physician here informed her that resident having severe pain to left hip/pelvic area received telephone order (T.O.) to send resident to ER for evaluation. At 7:50 a.m. left via ambulance. The 1:30 p.m. nursing note documented by RN #2 read: Was informed by RN at hospital that resident fractured left hip, that she will be admitted . All departments notified. The 1/5/21 ER computed tomography (CT) pelvis scan indicated Resident #54 had a fall with a comminuted (bone broken into more than two pieces) fracture of the left acetabulum (socket of the hip bone) consistent with impaction injury. Adjacent pelvic sidewall hematoma is present. The 1/5/21 ER physician documentation at 8:25 a.m. indicated the patient had an unwitnessed ground-level fall at the nursing home. At baseline the patient ambulates with a walker. Patient brought in unable to bear weight on the left leg. Only complaint is pain in the left leg. Pain is moderate. Patient needs 3 months of touchdown weight bearing on the left lower extremity. Acute pain control as needed. At this time the patient has a catheter inserted because of her inability to move without severe pain. -The 12:52 p.m. physician history and physical documentation read in part: She presented to the emergency room after a fall with severe pain and could not ambulate or move. She was brought by emergency medical services (EMS) to the emergency room department where she was found to have a comminuted minimally displaced acetabular fracture to the left hip. After discussions with the orthopedic team in the emergency room it was felt that this was a nonsurgical injury and that the patient was going to need to be treated for pain and then started on a program of minimal weight bearing or toe-touch weightbearing. In my estimation this patient is going to require greater than 48 hours of hospitalization for the appropriate management and care of the presented issues. Patient has significant pain to the left hip region whenever she moves at all. I have inadequate pain control at this juncture she is going to require intravenous (IV) opioid therapy. The oral opioids that she was given in the emergency room have done nothing to really help her when she tries to move. The 1/7/21 physician progress note read in part: I anticipate this patient being able to be discharged back to the nursing home tomorrow where it is going to be a very long arduous path back to a baseline because of this acetabular fracture. The 1/8/21 hospital discharge summary read in part: The patient was placed on toe-touch weight bearing only. Because of patient's severe dementia she is unable to grasp the concept of limited weightbearing and physical therapy (PT) occupational therapy (OT) have recommended that this patient be in a wheelchair for locomotion purposes until there is some more healing. She still has significant pain when trying to lift the left lower extremity. She is unable to do so yet. -No pain assessment was completed after this fall and the intervention for the staff to offer routine assistance to the bathroom was not added to the care plan until 1/20/21. The 1/6/21 OT evaluation documented the following: Per patient's (pt's) daughter report, the pt has been a resident of the nursing home for a period of time. The daughter states that the pt had been ambulating with a front wheeled walker (FWW), but did need occasional cues for safety. The patient was also able to dress herself, but needed cues to do so. She also needed cues to toilet. Not oriented to place, not oriented to situation, not oriented to time. Due to pt's decreased short term memory (STM), pt requires consistent cueing to maintain toe touch weight bearing (TTWBing) at this point in time as she does not have the ability to remember her weight bearing precautions. Due to her impaired STM, she will continue to require extensive physical assist with mobility in order to maintain TTWBing and to allow for healing of her acetabular fracture. The 1/8/21 therapy evaluation documented the following: Upon PT arrival to client's room, she is seated edge of bed (EOB) and very impulsive and displays moderate confusion. During rest, client denies pain throughout the left lower extremity (LLE) and hip; upon standing and attempted transfers with FWW, client reports ouch!, though is unable to rate her pain level numerically. RN reports that client has been very confused and impulsive. RN present during evaluation. PT recommends to RN for nursing staff to use assist x 2 for transfer from bed to chair so additional staff can assist with client maintaining LLE TTWB status. PT does not recommend use of stand aide as it is unlikely that LLE TTWB can be maintained with the use of standing aide. Client has significant dementia and displays decrease in functional safety awareness. Fall #2, #3 and #4, 8/21, 8/22/21-(two falls) all unwitnessed The 8/21/21 nursing documentation completed by LPN #5 at 5:26 a.m. read: 4:00 a.m. neighbor (resident) yelled out for help, sitting on floor by side of bed, sheet to bed on floor. No injury noted, neighbor is able to move all extremities, no complaints of pain or discomfort. Neighbor was getting up from floor by herself, did not want to wait for lift. Staff x 2 assisted neighbor with sitting on side of bed. When neighbor went to stand up with walker she complained of right wrist pain. Neighbor is moving wrist with full range of motion (ROM), refused ice pack, did accept as needed (PRN) Tylenol. 4:45 a.m. neighbor walked out of room with walker, then standing in hall holding on to walker with only left hand, went to use left hand to adjust hair and almost fell backwards, this nurse was within reach and caught neighbor. Assisted neighbor back to room and to recliner. Fall protocol started, neuro's remain within normal limits (WNL). Physician faxed, will notify oncoming shift to call daughter in the morning. The 9:26 a.m. nursing note documented by LPN #2 read: Called and spoke to daughter regarding fall at 4:00 a.m., updated her that neighbor is moving all extremities, also informed daughter that neighbor has stated that she ' broke her right wrist. ' Right wrist has no swelling, no signs of pain or discomfort and is able to move wrist with no problems. Daughter stated to let her know if anything changes. The 8/22/21 nursing note documented by RN #4 at 12:32 p.m. read in part: Called from nurse on unit, neighbor had fallen at 11:00 a.m., right wrist swollen and painful, neighbor not able to bend wrist. Neighbor agreed to go to ER (emergency room). Called on call physician and spoke directly to the nurse practitioner (NP) received new orders to send to ER for x-ray of right wrist evaluate and treatment for possible fracture. Notified on call transportation for pick up. Called ER nurse to give report but no answer. Neighbor sent out with a staff member. The 1:54 p.m. nursing note documented by LPN #2 read: Neighbor had just been weighed, when certified nurse aide (CNA) left the room and then neighbor had fallen. When this nurse got to the room neighbor was naked from the waist down with a pair of pants lying on neighbor's legs, back and head were against the wall across from the closet. Neighbor stated ' I fell and my head hurts ' head to toe assessment done, no bleeding or a bump to the back of head, right wrist was swollen, red, warm and tender to the touch. Assisted neighbor to get up and in wheelchair and CNA helped neighbor get dressed. Neuro checks started and sent neighbor to hospital ER for evaluation and treatment with an x-ray. Physician notified via fax and spoke with daughter. Received call from the ER that right wrist is fractured and a splint was placed on the right wrist, with orders to follow up with primary doctor. The 10:20 p.m. nursing documentation completed by RN #5 read in part: Resident on fall protocol. She slept much of the evening, ate in her room, took the right wrist splint off, states her right wrist hurts. The 8/22/21 ER physician documentation at 1:02 p.m. read in part: Chief complaint right wrist pain after fall this am. Wrist x-ray findings: Distal radius does show a fracture. She was placed in a prefabricated wrist splint. The 8/24/21 physician note read in part: Over the weekend patient fell and sustained a right distal radial fracture. She was sent home in a brace which she keeps removing it because of her dementia. She keeps removing her splint so it is difficult to immobilize the joint so that the fracture can heal correctly. The 8/25/21 orthopedic consultation note read in part: Patient has dementia and decided she did not want to cooperate with any type of casting. She felt that she did not need to have anything done. -Staff were to check on the resident more throughout the day and anticipate her needs but there was no documentation of more frequent checks after this fall. Purposeful rounding (every two hours) was not started until 8/24/21. Fall #5, 9/8/21 unwitnessed fall On 9/8/21 at 11:29 p.m. nursing note documented by RN #6 read in part: At approximately 7:47 p.m. neighbor was shouting ' someone help ' and I had found her on the floor near her bed. Neighbor states she had gone to the restroom and when finished she decided she was too weak to get up so she crawled to her bed. Neighbor states when she got near her bed she was too weak to get up on her own so she started to yell for help. Upon assessment findings include a skin tear on left arm below elbow measuring 0.5 cm x 0.5 cm, red/purple in color, scant blood, surrounding skin intact. Skin condition was treated per standing order, cleaned with normal saline and applied steri-strip. Neighbor states ' I don't hurt any different than what I did before ' . Neuros were started and indicate no abnormal findings. Family was notified about the incident and had no questions but did ask to reach out with any changes. Towards the end of my shift neighbor transferred self from her bed to the recliner and was encouraged to use call light. All personal items and call light are within reach. -The motion sensor was added on 9/9/21 after this fall, but only after she had sustained three prior falls with two fractures. Staff were to try and keep the resident in the lounge area so they could watch her. Fall #6, 10/5/21 unwitnessed fall The 10/5/21 nursing note, documented by RN #7 at 11:57 p.m., read: At approximately 7:00 p.m. CNA on duty notified this nurse that neighbor was sitting on the floor in front of her recliner. Transferred to bed x2 assist and gait belt. Denies pain. No injuries noted. ROM to all extremities per her normal. Denies hitting head. Alert and oriented x3. Fall protocol started. Neuro checks WNL. Refused vital signs being taken multiple times. Stated ' I'm fine I'm fine. ' Remained in bed watching TV for the rest of the evening. -No new interventions were put in place after this fall. Staff were to be educated again on motion monitor, to make sure it was not being turned off. Fall #7, 10/13/21 unwitnessed fall The 10/13/21 nursing note, documented by LPN #2 at 9:08 a.m., read: This nurse was informed by CNA that neighbor had told her that she had fallen this morning and had hit her head. ' I fell this morning and hit my head, I think that I stumbled and hit my head on the floor. I seem to be doing that a lot, must be because I am getting old. ' Head to toe assessment done and found a 0.25 cm cut with a hematoma to the back of head. Cleaned and left open to air. Neighbor got self up off of the floor and was back in bed when neighbor told CNA of the fall, Neuro checks started. Physician and power of attorney (POA) notified and updated. -No new interventions were added after this fall. Fall #8, 10/24/21 witnessed fall The 10/24/21 nursing note documented by RN #2 at 12:22 p.m., read: At 11:45 notified by charge nurse that resident had tripped over vital sign kart by CNA station and that the CNA had caught her and eased her to the floor. At 11:48 a.m. resident laying in bed supine position with legs in bent position. Asked resident if she could extend her legs and she did slowly without any difficulty. No abnormal internal or external rotation noted, no shortening of left leg noted. Complains of left groin pain 10/10. Paged on call physician. NP returned call informed him that resident had tripped was caught and eased to the floor and that she complains of left groin pain 10/10. Informed him no abnormal external, internal or shortening of leg noted. Told him resident is requesting X-ray to be done. Received T.O. (telephone order) for resident to go to ER for evaluation via facility bus. Called hospital spoke with ER nurse informed her of above information and that resident will be transported by facility bus. The 10/24/21 nursing note documented by LPN #6 as a late entry at 1:23 p.m, read: Incident time: 10:05 a.m. CNA called writer to CNA station, noted resident laying on floor on left side. CNA stated resident had tripped over the vital signs cart, she caught resident and lowered her to the floor. States resident did not hit her head. Resident stated she had tripped. Resident checked for injuries, noted skin tear left hand 1.2 cm. ROM WNL. No complaints of pain or discomfort at this time. Resident assisted up off floor with 2 staff assist and put into wheelchair and taken to room. Put into recliner per request. Skin tear cleansed with normal saline and approximated with steri strips. The 10/24/21 hip/pelvis x-ray report revealed the following: Interval fracture of the left ischium (lower and back part of the hip bone) with mild displacement. Fracture lines appear acute. The 10/24/21 ER physician note documented at 1:03 p.m. indicated the following: She has mild tenderness in the left hip but more with palpation of the left ischial tuberosity (curved bone that makes up the bottom of the pelvis). X-ray of left hip and pelvis shows a nondisplaced pubic rami (at the front of the pelvis) and ischial tuberosity fracture. CT scan confirms the above findings with minimal hematoma. Previously noted acetabular fracture line still present. The 10/28/21 therapy notes documented the following: Patient has bedrest orders from the physician, however, nursing staff report patient is getting herself out of bed and ambulating with a FWW to dining room independently several times per day. It was determined she is not appropriate for skilled PT services at this time and has limited to no rehab potential due to her advanced dementia affecting her ability to participate in or carry over any education or training provided by therapist to facilitate independence and mobility. After this fall she was placed on routine pain medication and staff were to check on her frequently. -However, there was no documentation provided that frequent checks were completed. She was to have a push-pad call light on her bed so staff would be alerted if she was getting up. However, she did not have a push-pad call light on her bed throughout the survey. E. Staff interviews CNA #11 was interviewed on 11/18/21 at 8:20 a.m. She said she had worked at the facility for 10 months and she was familiar with Resident #54. She said the resident would get up on her own and often did not remember to use the call light. She said the motion sensor under her bed would send an alert vibration to a box the CNAs carried in their pocket to let them know the resident had placed her feet on the floor. She said if she would go on a break she would give the nurse the box so she would know if the resident was getting up. She said when she worked she tried to check on the resident often, roughly every 30 minutes or so but those checks were not documented. She said Resident #54 was not supposed to be walking because of a recent fracture but she would still get up on her own and walk. She said the resident had not had one-to-one supervision after any of the falls. LPN #2 was interviewed on 11/18/21 at 8:35 a.m. She said she had worked with Resident #54 since March 2021 and was aware of the many falls she had had. She said the motion sensor was added to her care plan on 9/9/21. She said when the resident pushed her call light the nurses and CNAs would be alerted through a pager that she needed help. She said the resident often did not understand and would forget to use her call light when she needed help. She said she did not carry one of the boxes that was connected to the motion sensor. She said the resident had not had one to one supervision after any fall occurrence. The restorative manager (RM) was interviewed on 11/18/21 at 12:01 p.m. She said she was involved in all fall occurrences. She said she would meet during the morning meetings with the NHA and the director of nurses (DON) and every Friday they discussed any residents that had falls and they would try to come up with different interventions to prevent falls. She said Resident #54 had been impulsive and would get up on her own, unfortunately resulting in multiple falls with injuries. She said the motion sensor was added as an intervention in September 2021 but there have been no new interventions added since then although the resident had fallen three more times in October (2021). F. DON interview The DON was interviewed on 11/18/21 at 11:36 a.m. She said Resident #54 usually would not call for assistance prior to getting herself up. She said she was supposed to have a soft call light that activated with a mild touch. However, she was unaware the call light the resident had at her bedside was the hard box type that was removed from the wall and placed on her bedside table. The resident would have to push a blue button in the center of the box to activate the call light. She said she had also placed a sign within the resident's sight that reminded her to use the call light. She said the sign had an arrow pointing to the call light next to her. However, she was unaware there was no sign in the resident's room. She said they had not used one-to-one supervision as an intervention after any of her falls. She said when she fell in January 2021on the secure unit they allowed her daughter to stay with her for a while but no one has stayed with her after any of the falls since January 2021. She did not offer any recommendations on how to prevent future falls for Resident #54. III. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), depression, anemia and chronic kidney disease (CKD). The 11/1/21 minimum data set (MDS) assessment revealed severely impaired cognition with a brief interview for mental status (BIMS) score five out of 15. No rejection of care was documented. The resident was independent with bed mobility, transfers, dressing, toilet use and personal hygiene. He required supervision with eating. He received an antidepressant and opioid medications daily. B. Record review 1. Care plan: -Cognitive loss/dementia: (Resident) has difficulty with comprehension. BIMS score 5. Approaches included: remind, supervise or assist as needed. -Falls: (Resident) has potential for falls related to weakness, balance problems. Approaches included: floors free from spills and clutter. Provide adequate, glare free lighting. Personal items within reach. Assist to wear non-skid footwear. (Dated 4/28/21); Rolater walker, independently ambulate and assist prn (as needed). Transfers independently. (Dated 5/10/21). Non-skid strips by bed. Provided (Resident) a pendant call bell. (Dated 9/2/21). Provided (Resident) with a reacher. Encourage (Resident) to use walker instead of cane due to 2 (two) recent falls. (Dated 11/1/21). 2. Falls Nursing notes review and provided by the nursing home administrator (NHA) records revealed the following: -9/1/21, Neighbor was found sitting on the floor with his back against the bed frame with no injuries noted. He said he was getting up to go to the bathroom and slipped. He said he did not hit his head. Head to toe assessment done, he was able to move all extremities, no signs of injuries or bruising noted. POA (power of attorney) and MD (physician) notified. Restorative put nonskid strips on floor beside bed and provides him with a pendant call bell. -9/27/21, Noted a decline in strength, endurance and ambulation and also memory issues. PT (physical therapy), ST (speech therapy), OT (occupational therapy) evaluation and treatment standing orders written. -10/30/21, Nurse saw a bruise on neighbor's R (right) elbow and neighbor said he fell before lunch. He said he was coming out of the bathroom and lost his balance. Assessed neighbor for injuries and found 10x5cm dark purple bruise to R (right) elbow. Able to move all extremities. Denies pain. Neuros WNL (within normal limits) for neighbor. Neighbor refused VS (vital signs) to be checked. Neighbor was encouraged to use walker instead of cane. Blood pressure is dropping when standing. MD (physician) notified. -10/31/21, CNA (certified nurse aide) reported to this nurse that neighbor was on the floor in his room. He was lying on the floor next to his bed near the closet wearing his slippers. His cane beside him. He said he just fell but did not remember what he was doing. Nurse found a 3x1.7cm rectangular skin tear to L (left) elbow. Able to move all extremities. Denies pain. Neuros WNL (within normal limits) for neighbor. He was provided a reacher. -11/12/21, CNA (certified nurse aide) found neighbor lying on the floor leaned up against the chair. He stated he was coming out of the restroom and went to sit in his chair[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure that one (#66) of five residents reviewed out of 32 sample residents were free from unnecessary psychotropic medications. The facility's failed to document and evaluate the effectiveness of non pharmacological behavioral interventions for Resident #66, a person with dementia; alternatively psychotropic medications were prescribed which lead to over-sedation of the resident. The resident resided in a secured memory care unit with other residents and had an alarm system on her door to alert staff when the door opened. The facility failed to demonstrate how non-pharmacological interventions were attempted and failed prior to initiating medication changes and prescribing psychotropic medications which posed risk to the resident's health, safety and highest practicable physical, mental and psychosocial well-being. The resident was prescribed duplicate medication therapies to target behavioral symptoms of dementia with psychosis which had sedative effects. (cross-reference to F744 failed to ensure resident with dementia received appropriate treatment and care) Findings include: I. Facility policy The Use of Psychotropic Drugs policy, dated 1/1/18, was provided by the nursing home administrator (NHA) on 11/28/21 at 11:28 a.m. It read in pertinent part, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. The indications for initiating, withdrawing, or withholding medications(s), as well as the use of non-pharmacological approaches, will be determined by assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. II. Observations of side effects of duplicate medication therapy Numerous observations were made of Resident #66 between 11/14/21 and 11/18/21. The following observations were made: -On 11/15/21 at 12:25 p.m., the resident was observed laying in bed. She did not lift her head or respond to her name. Her lunch meal tray sat on her bed, uneaten. -On 11/15/21 at 5:05 p.m.the resident was observed laying in bed. -On 11/16/21 at 9:16 a.m. the resident was observed laying in bed. -On 11/16/21 at 12:47 p.m., the resident was observed laying in bed. Her lunch meal tray was next to her on a bedside tray table, mostly uneaten. A cooked brussel sprout was tucked under the pillow she was resting her head on. The resident slightly shook her head yes when asked if she was hungry. She then attempted to lift her head and then laid back down. -On 11/16/21 at 4:10 p.m. the resident was observed to be laying in bed. -On 11/17/21 at 9:22 a.m., the resident was observed laying in bed. -On 11/17/21 at 4:45 p.m. the resident was observed to be out of her room and coming down the hallway with the assistance of three staff people: one staff person supporting each of her arms with weight bearing assistance and one staff person behind her. Staff escorted the resident to the shower room. -On 11/18/21 at 9:15 a.m. the resident was observed in her bed with her breakfast meal tray on the bedside table. III. Psychiatrist interview The facility psychiatrist (PSY) was interviewed 11/17/21 at 10:38 a.m. He said he was concerned about the resident's psychotropic medication regimen and he felt the facility staff were quick to ask for medication adjustments without attempting non-pharmacological interventions. He said the resident would respond to internal stimuli and could act out unprovoked. He said a different environment better suited to the resident's needs would be more appropriate, however, the resident representative was not in favor of moving the resident. He said he did not feel the current regimen was safe and if others could not be safe around her when she was not sedated; it was not an appropriate placement. He said that he would want to know what was attempted prior and what circumstances could have contributed to behaviors prior to making medication changes. He said requests for consultation on medication adjustments came from facility staff and not from the resident's physician. He said the primary care physician (PCP) would receive recommendations but ultimately make the decision of which medications were prescribed. He said that he was concerned that medications were being requested and added as a convenience for staff. He said the resident was in a controlled environment living on a secured unit and the facility staff were alerted when the resident left the room. He said he felt the request of the facility for additional medication was for the purpose of sedating the resident. He said over-sedating a resident posed risks to their safety and impacted their quality of life. IV. Resident #66 A. Resident status Resident #66, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), pertinent diagnoses included dementia with behavioral disturbance and psychosis, Parkinson's disease, anxiety disorder and dementia. The 10/8/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and a brief interview for mental status (BIMS) could not be conducted because the resident was rarely/never understood. The resident required extensive assistance from two staff members to perform bed mobility, personal hygiene, toilet use and dressing. She required limited assistance from one staff member to perform bathing. She required supervision with eating, transfers and walking in her room and on the unit. The resident had one instance of exhibiting aggressive behavior during the seven day assessment period. V. Record review Intake documentation from an outside facility dated 6/13/18 indicated that the resident history/previous diagnosis of paranoid schizophrenia with visual hallucinations and unspecified psychosis not due to a substance or known physiological condition. The psychotropic medication review committee, which included the facility pharmacist (PH), medical director, NHA, director of nursing (DON), social services director (SSD), social worker (SW) and other members of the resident care team, met monthly or as needed and documented recommendations of the committee. The facility psychiatrist (PSY) provided recommendations to the committee. The committee met on 4/11/2021 after the resident returned from an outside behavioral health facility. She returned with prescriptions for Abilify 10 milligrams (mg) once daily, Seroquel 100 mg in the morning, 50 mg at noon and 100 mg at hour of sleep related to diagnosis of dementia with psychosis Zoloft 100 mg in the morning related to major neurocognitive disorder with behavioral disturbance and Oxcarbazine 150 mg twice daily related to dementia with psychosis. A physician order dated 4/11/21 ordered that every shift, staff document behaviors of hallucinations that cause anxiety, fear or distress and offer interventions including; one to one staff assistance, provide an activity, time alone, provide needed care, assess cause, change environment, distraction, offer a PRN (as needed) medication, offer snack, toilet resident or walk with with the resident. Interventions were numbered and should be documented as to which intervention was offered when behaviors were present. A physician order dated 4/11/21 prescribed 150 mg of Oxcarbazepine (an anti-seizure medication) twice daily at 8:00 a.m. and 8:00 p.m. related to dementia with psychosis. The resident was admitted to the facility with this prescription. The resident care plan initiated on 4/11/21, included the resident had the potential for pushing or hitting others if they get too close to her/invading her personal space. The resident had a history of pushing or hitting others if they were in her way. Interventions included: -Staff were to assist the resident to sit in a recliner when in the living room (not the couch) so other residents won't sit beside her; and -Staff to monitor and intervene if other residents got too close to the resident. The psychotropic medications review committee met on 4/23/21; the note read that the resident attempted to pull another resident out the resident's bed. The nurse was able to stop this. The PSY recommended prescribing Trazodone 12.5 mg three times daily related to neurocognitive with behavior disorder. The committee notes indicated that staff should observe for over sedation or changes in her vitals. A physician order dated 4/23/21 prescribed Trazadone (an antidepressant medication) 12.5 mg three times daily at 8:00 a.m., 12:00 p.m. and 8:00 p.m. A consent for the use of Trazadone was signed by the resident's representative on 4/27/21. The consent included, There are many potential risks associated with the use of psychotropic medications. These potential risks include risk of falls, altered level of consciousness, increased confusion, loss of balance and various other side effects which can differ depending on the medications. In addition, the Food and Drug Administration (FDA) gave a 'Black Box' warning that 'Elderly patients with dementia are at increased risk of death, heart failure or sudden death. The consent also included that non-pharmacological interventions attempted had been one-to-one visits with the resident, aroma therapy, chaplin services, massage, music and to go outdoors. On 4/29/21 the care plan was updated to include that the Resident's emotional well-being is impacted by her dementia with psychosis, paranoia, being over-stimulated by others around her and her physical aggression towards others. The resident will have improved emotional well-being as observed by behaviors that indicate she is comfortable in her environment. The resident will color or do puzzles in her room. Her family stated she used to do puzzles a lot; she does not always get the puzzle right but she enjoys it. The psychotropic medication committee met on 5/26/21; the note read the resident had continued to exhibit aggressive behaviors. Recommendation was made that Trazodone 12.5 mg could also be used as an as needed medication. The PSY did not feel one day with incidents required a large medication change from him. He did not feel comfortable making adjustments. The committee note indicated that the resident would benefit from a small neighborhood, however, the resident representative was not in favor of having the resident moved. The note read the psychiatrist stated it was in the best interest of the resident not to snow her (over sedate). On 5/29/21 additional interventions were implemented on the care plan to include: -A sign with the resident's name in large letters placed on her door to help the resident find her room; -Staff perform safety checks every 15 minutes to be aware of her location; -Staff to encourage the resident to eat in the living room or her room where there is less stimulation. If she insists in eating in the dining room, staff will escort her out when she is done; -Staff to help the resident find her room after supper. On 6/28/21 a nurses note read that the resident slapped another resident. No injuries occurred; Resident #66 was redirected and walked back to her room by staff. On 6/30/21 the committee met for review; the note read that the resident was exhibiting a baseline of difficulty with redirection when disinhibited and having agitation towards others which for the most part were unanticipated per staff. It was reported that the resident was having episodes of exhibiting aggression. Given physical agitation and reports of requiring frequent redirection from entering other residents' rooms; the team recommended increasing Trazodone dosage from 12.5 mg to 25 mg. On 9/14/21 a nurse's note read that the resident had taken a rice crispy treat away from another resident and ate it. Staff redirected her away from the other resident and back into her room. On 9/24/21 additional interventions implemented to the resident's care plan which included: -To offer weighted blanket or baby doll for comfort; -Chaplin to deliver large print devotional books; -Offer audio books. On 9/16/21 a nurses note read that the resident had grabbed onto another resident's forearm and then released and went down the hallway. No injuries were documented. On 9/28/21 the psychotropic medications committee reviewed the resident's medications and behaviors; the committee note read that it had reported by another resident on the memory care unit that the resident may have hit a peer, but it was not witnessed. Resident #66 was reported to be restless, agitated and hard to redirect. Her Trazodone was increased by her primary care physician (PCP) from 25 mg to 50 mg three times daily. -Trazedone was increased three times in three months; from 12.5 mg three times daily to 25 mg three times daily to 50 mg three times daily, however, documentation of behaviors and intervention offered every shift was not completed as ordered by the physician on 4/11/21. The September 2021 medication administration record (MAR) had no documented behaviors or non-pharmacological interventions offered. A physician order dated 9/29/21 increased prescribed Trazedone to 50 mg three times daily related to behavioral disturbance. On 10/4/21 the committee met for review; the note read that they reviewed use of Seroquel and if it's use had been beneficial to reducing behaviors. Seroquel was increased from 100 mg in the morning, 50 mg in the afternoon and 100 mg at hour of sleep to 100 mg in the morning, 200 mg in the afternoon and 100 mg at hour of sleep. The committee note read that more behaviors were occurring in the afternoon. Her Seroquel was reduced a total of 50 mg to 100 mg in the morning and 200 mg in the afternoon and 100 mg at hour of sleep. The note indicated the committee would review use of Oxcarbazepine. -This was an increase in Seroquel not a reduction. A physician order dated 10/4/21 ordered Seroquel (an antipsychotic medication) be administered three times daily: 100 milligrams (mg) at 8:00 a.m., 200 mg at 2:00 p.m. and 100 mg at hour of sleep related to dementia with psychosis. On 10/8/21 a nurses note read that the resident was trying to get into another resident's room and they were both in the doorway. The resident shoved the other resident to try to get by. She was taken back to her room. On 10/8/21, the psychotropic medication committee met for review; the note read that it was recommended that Abilify be increased to 15 mg daily, initiate Prazosin one mg daily (the resident should be observed for increased fall risk and blood pressure monitored), Zoloft be increased to 100 mg (this change to be held for one week after other medication changes were made). -The care plan was not updated with new interventions. The facility decided to increase the residents' medication instead. A physician order dated 10/8/21 prescribed 15 mg of Abilify (an antipsychotic medication) daily in the morning related to neurocognitive with behavior disorder. A physician order dated 10/8/21 prescribed Prazosin (an [NAME]-hypertensive medication) one mg twice daily related to dementia with psychosis. A consent for the use of Seroquel was signed by the resident representative on 10/11/21. The consent included, There are many potential risks associated with the use of psychotropic medications. These potential risks include risk of falls, altered level of consciousness, increased confusion, loss of balance and various other side effects which can differ depending on the medications. In addition, the Food and Drug Administration (FDA) gave a 'Black Box' warning that 'Elderly patients with dementia are at increased risk of death, heart failure or sudden death. The consent also included that non-pharmacological interventions attempted had been one-to-one visits with the resident, aroma therapy, chaplin services, massage, music and to go outdoors. A consent for the use of Prosazin was signed by the resident representative on 10/11/21. The consent included, There are many potential risks associated with the use of psychotropic medications. These potential risks include risk of falls, altered level of consciousness, increased confusion, loss of balance and various other side effects which can differ depending on the medications. In addition, the FDA gives a 'Black Box' warning that 'Elderly patients with dementia are at increased risk of death, heart failure or sudden death. The consent also included that non-pharmacological interventions attempted had been one to one visits with the resident, offer simple pleasures, anticipate needs, activity and change the environment. The care plan was updated on 10/12/21 to include that the resident had sensory impairment secondary to dementia with psychosis. Interventions included: -To assist the resident in daily decision making. Staff were to identify/eliminate factors causing acute confusional state; -Avoid frustrating the resident by quizzing with orientation questions that cannot be answered; and, -Provide a low-stimulation environment and when speaking to her, give her time to respond. On 10/13/21 the care plan was updated to include a door alert system placed on her door to alert staff when the door to her room was opened. On 10/15/21, the psychotropic medication committee met. The resident's prescription to Zoloft was increased from 150 mg to 200 mg per day for depression as recommended by the psychiatrist and ordered by the PCP. Daily charting for behaviors was completed by facility staff. Review of the behavior charting from 10/17/21 to 11/17/21 revealed that the resident had documented behavioral symptoms of aggression on 10/19/21 and 10/20/21. -There was no corresponding narrative documentation of what the behavior exhibited was, where it took place and if a non pharmacological intervention was attempted and whether it was effective. No other behaviors were documented during this period. A physician order dated 10/27/21 ordered the resident's doorbell alarm to be checked every shift to ensure it was working. Place a work order if not functioning after troubleshooting. Assign one to one staff supervision of the resident. Every shift staff keeps the resident's door closed at all times while she is in her room and the doorbell will function properly. When the resident is out of her room; staff were to accompany her at all times for safety. A risk versus benefit analysis document dated 11/1/21 for the use of Trazodone read that no changes were recommended by the psychotropic medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the resident was doing well on the medication. A risk versus benefit analysis document dated 11/1/21 for the use of Zoloft read that no changes were recommended by the psychotropic medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the resident was doing well on the medication. A risk versus benefit analysis document dated 11/1/21 for the use of Oxcarbazepine read that no changes were recommended by the psychotropic medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the resident was doing well on the medication. A risk versus benefit analysis document dated 11/1/21 for the use of Seroquel read that no changes were recommended by the psychotropic medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the patient was doing well on the medication. A risk versus benefit analysis document dated 11/9/21 for the use of Abilify read that no changes were recommended by the psychotropic medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the patient was doing well on the medication. -No clarification was documented as to what resident/patient doing well on medication meant; the response was vague and did not elaborate on the justification for the use of duplicate medication therapies. The facility completed and documented checks of the resident every 15 minutes. Review of the recorded checks on the resident from 11/9/21 to 11/16/21 revealed she was documented to be in bed, sleeping or in her room at all hours of the day and night: -On 11/9/21 at 8:15 a.m. the resident was documented as being out of her room and was back to her room by 8:30 a.m. The resident was in bed from 1:00 p.m. until midnight. -On 11/10/21, the resident was documented to be in her bed or room all day. -On 11/11/21, the resident was documented to be eating lunch at 12:00 p.m. and was out of her room at 4:15 p.m.; the remainder of the day she was documented as being in her bed/room. -On 11/12/21, the resident was documented as being in her room the entire day. At 6:15 p.m. the documentation indicated that she was eating in her room. -On 11/13/21, the resident was documented as being in her room/ bed until she was sent to the emergency at 1:30 p.m. and returned at 3:45 p.m. where she was documented as being in her bed for the rest of the day. -On 11/14/21, the resident was documented as being in her room the entire day. She ate breakfast at 4:45 a.m. and ate lunch at 12:00 p.m. and was otherwise documented as laying in bed. -On 11/15/21, the resident was documented as being in her bed or room every 15 minutes with the exception of 4:45 p.m. to 5:15 p.m. when she was sitting in her chair in her room. -On 11/16/21, the resident was documented as wandering from 12:00 p.m. to 12:30 p.m. She was documented as being in her room or bed for the rest of the day. Review of the record did not reveal what non-pharmacological interventions were attempted or implemented when the resident exhibited behaviors. VI. Staff interviews The NHA was interviewed on 11/17/21 at 8:39 a.m. She said that Resident #66 had exhibited aggressive behaviorstowards staff and other residents at the facility. She said the resident had not had behaviors in a while. She said the resident had been sent to an outside behavioral health facility in April of 2021 where she had done well with a lower staff to resident ratio. She said that the resident returned to the facility and her provider team felt she would be better served in a more supervised setting with less people and where she could get behavioral supports; she said the resident's representative did not want the resident to move and preferred that she be sedated if it meant having her remain in the facility rather than be moved to another facility. Certified nurse aide (CNA) #9 was interviewed on 11/17/21 at 9:44 a.m. She said that the resident was in her room most of the time but would wander into other resident rooms and had a history of acting aggressive towards others. She said she would make sure the resident was clean and her hair was brushed. She said that the resident had an alarm on her door that would go off at the nurse's station to alert staff if she was leaving her room or if someone else was entering her room. She said staff would observe the resident when she was out of her room. She said the resident would not often sit at the table or close to other residents but staff knew to observe for behaviors if she was in common spaces. She said the resident was not typically aggressive but could swing her arms or act out unprovoked and in a way that was hard to predict. Licenced practical nurse (LPN) #2 was interviewed on 11/17/21 at 9:53 a.m. She said Resident #66 was often sleepy and often preferred to be in bed. She said the resident was not prescribed medications that caused sedation. She then reviewed the resident's electronic medical record and after reviewing the resident's physician orders; she said the resident was on multiple medications that caused sedation. She said the resident had a silent door alarm which alerted the staff at the nursing station when her door opened. She said that the purpose of the alarm was alert staff should keep an eye out for her and make sure she and other residents were safe. She said the psychotropic medication committee met regularly and would make changes to the resident's medications as needed. The SW was interviewed on 11/17/21 at 2:26 p.m. She said she had been involved in the psychotropic medication committee that reviewed the resident's medication regimen monthly. She said the resident had exhibited aggressive behaviors towards staff and other residents and her medications had been adjusted to reduce behaviors. She said the committee had identified the use of audio books such as the bible, a weighted blanket and aromatherapy as non pharmacological interventions for the resident. She said the interventions were individual to the resident, however, could not recall whether the effectiveness of interventions were discussed. The resident's PCP was interviewed on 11/18/21 at 8:53 a.m. She said the resident's medications were recommended by a psychiatrist, though her name was on the medication orders. She said, due to the resident's history of wandering and aggressive behaviors, medication changes had been made numerous times to target behaviors. She said that the resident had a silent alarm on her door to alert staff when the door to her room opened as a preventive intervention. She said due to the resident's size, she had the potential to harm others if she were to become aggressive. She said that she felt the resident's medication regimen did have cause for concern due to the potential negative side effects for the resident. The DON was interviewed on 11/18/21 at 11:44 a.m. She said Resident #66 did not communicate verbally, but staff would try to anticipate her needs. She said sometimes the staff would attempt to do activities with her. She said the facility had implemented calming person centered interventions such as playing bible scripture on audio books for her. She said the resident had paranoia and fear in her eyes at times and may be responding to internal stimuli. She said that the resident was prescribed medications for behaviors and psychiatric symptoms which had a sedating effect. She said it was unethical to overly sedate a resident but that it was also the responsibility of the facility to ensure the safety of other residents and that was a fine line at times. She said having the silent alarm on the resident's door was helpful because staff could know to be aware and provide supervision if she left her room. She said the resident used to constantly be exiting her room and attempting to go into the rooms of other residents. She said there were times when staff were busy with other residents that they would not be able to be as attentive to Resident #66. She said she felt it was time the committee looked at reducing her medications since she was not coming out of her room as often and was sleeping more. The SSD was interviewed on 11/22/21 at 12:04 p.m. She said the psychotropic medication committee reviewed all residents prescribed psychotropic medications monthly as well as quarterly. She said the consulting psychiatrist (CP) would make recommendations to the facility and the PCP. She said the CP would provide options to the PCP and she would then make medication changes. She said the facility would take into consideration the risk versus benefit of prescribing psychotropic medications. She said the PSY had recommended a smaller situation. She said the alarm on the resident's door was helpful to alert staff when she may be leaving her room or others may be entering her room. She said the PSY had previously prescribed medication but had transitioned to consulting and making recommendations as needed. She said she could not recall what interventions had been attempted with the resident, however, due to the history of aggressive behaviors and the potential of aggression; her medications had been adjusted numerous times. The PH was interviewed on 11/22/21 at 12:16 p.m. He said that nursing home residents should be on the lowest possible amount of psychotropic medications due to the risks associated with their use. He said psychotropic medications should be monitored closely and evaluated for effectiveness because different individuals had different reactions to medications and some may not be as effective for some than others. He said the facility had a psychotic medication review committee that met on a regular basis (at least monthly). He said that Resident #66 had been prescribed Oxcarbazine, an anti seizure medication, which potentially had a sedative effect for behaviors. He said that the resident was prescribed Prosazin, an antihypertensive medication, because it was found to help control behaviors due to blocking the body's alpha one receptor which boosts arousal. He said that Seroquel, Trazadone and Abilify had sedative effects. He said he felt the next step should be to try a reduction of either Seroquel or Abilify. He said that the resident had a medication regimen which could include risk to the resident. He said that the facility initiated a reduction of the resident's prescription to Trazedone from 50 mg three times daily to 25 mg on 11/18/21. VI. Facility follow-up A new physician order was entered on 11/18/21 which reduced the resident's Trazadone from 50 mg three times to 25 mg in the morning and 50 mg at noon and hour of sleep. -This would be a reduction of one medication by 25 mg per day.