**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#82) of two residents reviewed for falls out of 14 sample residents. The facility failed to timely and appropriately implement interventions including assistance with all activities of daily living as documented in her 1/10/23 minimum data set (MDS) assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she could not initiate staff assistance by using her call light due to severely impaired cognition. Furthermore, the facility failed to ensure adequate supervision and effective interventions were in place to prevent falls for Resident #82, with a fall that resulted in injuries that required transfer to a hospital. Due to the facility's failures, lack of appropriate supervision and effective interventions resulted in three falls within three days since the admission. Fall on 1/10/23 resulted in major injury with bilateral nasal fracture and nasal cavity hemorrhages and required hospitalization for eight days. Findings include: I. Facility policy The Falls -Clinical Protocol policy, revised March 2018, was provided by the director of nursing on 1/25/23 at 1:30 p.m., read in part: The physician will help identify individuals with a history of falls and risk factors for falling. Staff will ask the resident and the caregiver or family about a history of falling. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. II. Resident #82 A. Resident status Resident #82, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 clinical physician orders (CPO), diagnoses included history of falling, vascular dementia, depression, cerebrovascular disease (stroke) and fracture of nasal bones. The 1/10/23 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired. Wandering behavior was noted in one to three days of the seven day assessment period. The resident required extensive assistance of one person with bed mobility, supervision with transfers, extensive assistance with dressing, toilet use and personal hygiene. The resident was independent with eating. Section J indicated the resident had one fall since admission with major injury. The resident received an antipsychotic medication and antibiotic. B. Resident observation and interviews Resident #82 was observed on 1/23/23 at 12:17 p.m. in the dining room, eating her lunch. She had fading bluish and yellowish bruises around her nose and on the forehead. A frequent visitor with knowledge of the facility was interviewed on 1/23/23 at 11:00 a.m. The frequent visitor said she observed a female resident in the dining room during supper on 1/10/23. The resident was leaning to one side in her wheelchair for more than 20 minutes. The frequent visitor said at least four staff walked by her table and no staff repositioned this resident. The frequent visitor said at one moment she had heard other residents calling for staff, yelling loudly and saw the female resident on the floor in a puddle of blood around her head. The frequent visitor said at that moment there were no staff in the dining room; she went to the nurses' office and asked the nurse to come to the dining room. Resident #82's granddaughter was interviewed on 1/24/23 at 1:00 p.m. She said her grandmother had fallen at home prior to her hospitalization and was at high risk for falls due to her declining physically and mentally. She said the facility was aware of her grandmother's fall risk and that was also the reason the family decided to put a camera in her room and someone from the family was watching her in case she had fallen with no staff around, the family member would call the facility. She said when the first fall happened on 1/8/23, her father called the facility staff to get her grandmother off the floor. The resident's daughter was interviewed on 1/24/23 at 4:25 p.m. She said upon her mother's initial admission to the facility on 1/7/23 she repeatedly told all staff, nurses and CNAs (certified nurse aide) that her mother was very high risk for falls. She said that was the reason we placed the camera in her room so we can watch her and in case she tried to get out of bed we could talk to her or call the facility. The daughter said that happened on 1/8/23. She said her husband was watching her mother getting out of the wheelchair and falling. She said there were no staff coming to the room so he dialed the facility's phone number and asked the nurse to go to her mother's room and pick her off the floor. She said the staff was supposed to check on her mother frequently and help her to lie down after meals. She said if the staff paid more attention to her mother, she would not have had a fall with injury on 1/10/23 and would not have had to be hospitalized for eight days. C. Record review The comprehensive care plan revealed the following: - (Resident #82) is at risk for falls. H/O (history of) falls (prior to admission) PTA. Fall Risk evaluation done with admission, score of 20 (high risk for falls). Risk factors include use of psychoactive RX (medication), deconditioning & impaired cognition. The resident experienced a fall on 1/8/23 with attempted self-transfer. Staff are to offer to lay the resident down after meals. Experienced 2 (two) falls 1/10/23. The first fall was in her room when she was attempting to get out of bed. The second fall was from the WC (wheelchair) in the dining room. The second fall resulted in a trip to the ER (emergency room), (and the resident was) subsequently admitted . Hospital staff reported (the resident's) 'nose fractured. When making rounds, verify (the resident's ) position in bed or chair, reposition as needed. Staff to make frequent rounds to check for unmet needs. (dated 1/12/23). On 1/20/23 the following was added to the care plan: Staff to make frequent rounds to check for unmet needs. readmitted [DATE], falls risk score of 22. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Bed in a lowered position when in bed. Encourage the resident to wear appropriate footwear when transferring, toileting, ambulating. Extensive assistance with bed mobility & transfers. Gait belt as needed for transfers. (1/9/23). Staff to make frequent rounds to check for unmet needs. When making rounds, verify position in bed or chair, reposition as needed (1/12/23). -(Resident #82) has an alteration in musculoskeletal status; after the fall with nasal fractures (dated 1/19/23) -The facility failed to monitor the effectiveness of Resident #82's care planned interventions and implement effective interventions. The 1/8/23 Fall Risk Data Collection revealed the resident had a history of falls, her balance was impaired and she was able to stabilize with physical assistance. Score was 20 (high risk for falls). The 1/10/23 Fall Risk Data Collection score was 22 (high risk for falls). D. Nursing notes: On 1/8/23 a nurse documented: Pt (patient) was in the main area with nursing staff at change of shift. At approximately 6:30 (a.m.) she wheeled herself into her room and attempted to transfer to the bed unaided. Family called the nurse's station at 6:30 (a.m.) to report that the patient had fallen. Staff found the patient sitting on the floor with legs outstretched and her arms behind her. Pt reported pain in the lower back. Follow up phone call was made with the family who reported that she slipped when trying to transfer to the bed and landed on her buttocks. Neuro (neurological) checks initiated, VS (vital signs) taken, pain assessed and pt (patient) placed back in wheelchair and within sight of nursing staff. Pt (patient) given Tylenol for the pain. Provider notified. On 1/9/23 a nurse documented: Patient admitted for skilled services with dx (diagnoses) of: atherosclerotic heart disease of native coronary artery without angina pectoris. She has two surgical incisions to left groin, on antibiotics due to infection in one of the sites. Patient has hx (history) of dementia and is confused. She has a wanderguard in place and the family provided security cameras with sound in the patient's room. Patient has non-skid socks on, falls mats in place, bed in low position and a call light within reach. She has poor safety awareness. Pleasant and cooperative with cares. The patient can be continent at times, incontinence care being managed by staff. PT/OT (physical therapy/occupational therapy) as ordered. Call light within reach, will monitor. On 1/10/23 SBAR revealed: Altered mental status Bleeding (other than GI (gastrointestinal)) Falls Fever Trauma (fall related or other) . Nursing observations, evaluation, and recommendations are: Resident #82 fell at 1620 (4:20 p.m.), this writer and (name) RN (registered nurse) assessed the resident. Resident stated 'I was trying to get out of bed and I fell.' No injury noted. Neuro (neurological assessment) WNL (within normal limits). Neuros started. Resident was in chair with nurse and was talking with nurse. Resident was taken to the dining room. Resident was noted by another family member leaning left side. Then resident suddenly fell forward and hit her face at 1740 (5:40 p.m.). Resident (#82) started bleeding from the nose. (name) LPN (licensed practical nurse) put pressure on residents nose per RN request. RN called 911.' On 1/10/23 at 6:54 p.m. a nurse documented: Resident after being evaluated by paramedics was taken to (name) Hospital. Daughter and MD (physician) were notified. On 1/23/23 a nurse documented: Patient readmitted for skilled services s/p (status post) fall with nasal fx (fracture). Patient has hx (history) of dementia and is confused and forgetful. Family provided security cameras with sound in the patient's room. Patient has non-skid socks on, falls mats in place, bed in low position and the call light within reach. She has poor safety awareness, frequently reminded to use call light for assistance. Pleasant and cooperative with cares, does refuse at times, usually in the evening/bedtime but can be easily redirected. The patient was mostly incontinent, being managed by staff. PT/OT as ordered. Call light within reach, will monitor. On 1/24/23 a nurse documented: Patient son in law called the nurse's station during shift change and stated that the patient had pressed her call light six times, that she needed to use the bathroom and no one was coming to help her. (This was most likely observed through their security cameras that the family had set up in the patient's room.) This nurse went directly to the patient's room and her call light was not on and two CNAs were in the patient's room asking her if she needed to use the toilet to which she responded, 'No, I want to go to bed.' Call light was within reach, patient reminded to use call light for assistance but quickly forgets and has poor safety awareness. Bed in low position, fall mats in place. Will monitor. E. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/25/23 at 11:30 a.m. CNA #1 said the nursing staff could find all of the assigned resident information, including risk for falls, on the [NAME]. The DON was interviewed on 1/25/23 at 12:25 p.m. The DON said Resident #82 had three falls in the facility. After the fall on 1/8/23 at approximately 6:30 a.m. the facility implemented frequent checks. She said usually the staff were to check on the residents every two hours, however she expected nursing staff would check on residents who are at risk for falls more often. She said fall mats were placed on each side of the resident's bed to prevent injuries if the resident fell from the bed. She said the resident had a fall on 1/10/23 at 4:40 p.m. in her room with no injuries, and the staff brought the resident to the common area, lobby, so she would be close to a nurse. She said there was no investigation completed after this fall because an hour later the resident had fallen again, in the dining room. She said the dietary staff was present in the dining room and witnessed the resident's fall. She said she was not aware the resident was left in the dining room without nursing staff present. The DON said she was not aware the frequent visitor had to find a nurse when the resident was on the floor. She said she would provide extensive training with all staff in the facility on falls prevention within the next few days. CNA #2 who was assigned on the unit where Resident #82 resided, was interviewed on 1/25/23 at 12:55 p.m. She said she was not informed Resident #82 was a high risk for falls. She said she did not work with this resident before, however she concluded the resident may be at risk for falls because of the camera in her room. She said sometimes there was a lack of communication, sharing information about residents between nursing staff during shift changes. She said the standard was to check on residents every two hours for repositioning or provide incontinence care. She said if she was aware of a resident's risk for falls, she would try to check on that resident every 15 minutes. CNA #3 was interviewed on 1/25/23 at 2:46 p.m. She said the CNAs could check all of the information about assigned residents on their tablet, in the electronic charting system, under care plan in [NAME] ( a condensed version of the resident care plan). She opened Resident #82's [NAME] and read the CNAs should check on the resident frequently. She said the [NAME] did not specify how often. She said the staff checks on residents approximately every two hours, however for residents who were at a high risk for falls should be checked more frequently, every 15 minutes and the [NAME] should specify that exact time. LPN #1 was interviewed on 1/25/23 at 3:05 p.m. She said she worked on 1/10/23 the afternoon shift. She said Resident #82 fell in her room before supper, was transferred to her wheelchair and she was taken to the dining room. She said she did not observe the resident leaning to one side during the meal. She said after the supper meal the frequent visitor called her to the dining room and said a female resident had fallen and was on the floor. She observed Resident #82 on the floor with her face down and in a puddle of blood. She said she called the RN and they were trying to stop the bleeding. She said the RN went to the nursing office and called for an ambulance and the operator told her not to move the resident. She said the ambulance arrived before 7:00 p.m. so the resident was on the floor, in the dining room, for approximately one hour. -The facility failed to provide staff education and increase resident's supervision to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide adequate supervision and an environment as free from accident hazards as possible for two (#84 and #2) of six residents reviewed for accidents out of 21 sample residents. Resident #84 required two staff assistance with transfers and staff dependent for toileting. The facility failed to ensure Resident #84 had two staff assistance when she was provided incontinence care on 8/2/21 when she rolled off the bed. Due to the facility failures, the resident sustained a closed fracture of neck of left humerus (upper arm) and refracture of her rib (see hospital records). In addition, the facility failed to ensure Resident #2's appropriate interventions were implemented to prevent two falls, the interdisciplinary team conducted a thorough falls investigation, and the primary care clinicians were aware of the resident's falls. Findings include: I. Facility policy The Falls and Fall Risk policy, was received via email on 11/9/21, from the director of nursing (DON). The policy read in pertinent part, the staff along with the attending physician will implement a resident-centered fall prevention plan for each resident risk factor. II. Resident #84 A. Resident status Resident #84 was admitted on [DATE] with diagnoses of traumatic hemorrhage of cerebrum, chronic obstructive pulmonary disease, diabetes mellitus, COVID-19, morbid obesity and end stage renal disease with hemodialysis. The resident was discharged to hospital on 8/2/21. The 8/2/21 minimum data set (MDS) assessment revealed the resident had clear speech, made self-understood and was able to understand others. Her cognitive skills were moderately impaired with a brief interview for mental status (BIMS) score nine out of 15. She required extensive assistance of one person with bed mobility, two persons extensive assistance with transfers, limited assistance with dressing, and supervision with eating and personal hygiene. She was totally dependent on staff with toilet use. The resident was always incontinent of urine and bowel. B. Care plan -(Resident) is at risk for falls. Fall risk eval(uation) done with admit(ion), score of 16 (score 10 and above indicated high risk). Risk factors include deconditioning .Experienced a fall from bed during incontinence care. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Check for incontinence on rounds. Provide incontinent care as needed. Dependent 2 (two) staff for Hoyer lift transfers. Turn and reposition as needed, extensive assist 2 (two) staff. Date initiated 8/1/21. When making rounds, ensure that she is in the middle of the mattress. Ensure when being positioned for pericare that she is in the middle of the mattress. Revised 8/2/21. C. Nursing notes -On 8/2/21 at 2:35 a.m. a registered nurse (RN) documented: This nurse called to patient room by CNA (certified nurse aide) at 0005 (12:05 a.m.), patient was being changed and was turned onto right side, flung her leg over the bed and rolled onto the floor, landing on her left side. Resident stated, 'I rolled on over to the floor.' This nurse and CNA assisted patient back to bed via Hoyer lift. Assessed for injuries, resident had no c/o pain at this time, neuros WNL (within normal limits). At 0105 (1:05 a.m.), called to room by CNA as resident was now having c/o (complained) pain. '12 out of 10 in left shoulder.' Resident has AV fistula in left arm and bruising up and down arm prior to incident. Resident asked to be transferred to hospital. Called (provider), transfer non-emergent to hospital . Patient left with (ambulance) with glasses and cell phone at 0135 (1:35 a.m.) . The IDT (interdisciplinary team) post-fall report documented: IDT reviewed circumstances regarding resident's fall. Staff instructed to ensure resident is in the middle of the bed prior to and during all cares. Staff to also anticipate resident's needs to decrease the need of resident reaching and repositioning herself. D. Hospital records The 8/2/21 emergency department discharge to hospital summary revealed Resident #84 was admitted with medical diagnosis of closed fracture of neck of left humerus. The 8/2/21 radiology pertinent diagnostic results revealed: 1. Current findings demonstrate refracture rib previously healing comminuted spiral fracture of the mid humeral shaft now with significant angulation and mild to moderate displacement. 2. Interval comminuted fracture of the humeral head/neck junction mildly displaced and mildly angulated. The resident's care plan addressed two staff with turning and repositioning. The facility failed to prevent resident's fall with major injuries, refractured rib and humeral bone fracture. E. Staff interview Registered nurse (RN) #1 was interviewed on 11/4/21 at 11:58 a.m. She said she was working the night shift that started on 8/1/21 at 6:00 p.m. until 6:00 a.m. on 8/2/21. She said there was one CNA on the skilled rehab unit. She said shortly after midnight the CNA called her for help when Resident #84 fall of her bed during incontinence care. She said the resident did not complain of pain immediately after the fall. She said an hour later Resident #84 started complaining of excruciating pain in her left shoulder. She said the resident was transferred to a hospital by an ambulance. She said the CNA did not anticipate the resident would roll off the bed and was not aware that two staff were needed with repositioning. III. Resident #2 A. Resident status Resident #2, age [AGE] was admitted on [DATE] with diagnoses of cerebral infarction, metabolic encephalopathy, anoxic brain damage, polyneuropathy, anxiety and insomnia. The 8/18/21 MDS assessment revealed moderate cognitive impairment with a brief interview for mental status (BIMS) score eight out of 15. She required extensive assistance of two staff with bed mobility and transfers, extensive assistance of one person with dressing, toilet use and personal hygiene, and limited assistance with eating. B. Resident and family interviews Resident #2 was interviewed on 11/4/21 at 8:40 a.m. She said she remembered she fell two times from her bed. She said she did not remember what caused the falls. Resident's daughter was interviewed on 11/4/21 at 12:30 p.m. She said she was aware of one fall. She said her mother was very independent prior to her stroke. She said it was hard for her mother to adjust to the new situation and her illness. She said it would prevent the falls if the facility staff checked on her mother more often during the first month of her stay in the facility. C. Care plan The resident's comprehensive care plan was reviewed and revealed: -(Resident) is at risk for falls. Falls risk eval(uation) done with admit(ion), score of 18 (score 10 and above indicated high risk). Risk factors include recent CVA (cerebrovascular accident) with LT (left) sided weakness, use of hypnotic RX (prescribed medication). Experienced a fall from bed. (Revised 8/29/21) -(Resident) has LT (left) sided Hemiplegia/Hemiparesis r/t (related to) recent CVA. Is Left hand dominant. (Date 8/12/21) -(Resident) has a potential for a communication problem. S/P CVA (status post cerebrovascular accident) with aphasia. Has difficulty at times with word finding. Communication is improving. (Date 8/31/21) -(Resident) is on anticoagulant therapy (Apixaban). (Date 8/12/21) -(Resident) is on sedative/hypnotic therapy (Zolpidem) for sleeplessness. (Date 8/12/21) -(Resident) uses antipsychotic medications (Zyprexa) for anxiety. (Date 8/24/21) D. Nursing notes 1. Fall #1 -On 8/27/21 at 10:02 p.m. a nurse documented: She is A/O (alert and oriented) x 2-3 tonight. Needs are anticipated by staff .Ambien (a sedative, hypnotic medication) and Zyprexa (an antipsychotic medication) given at HS (night), appears to be working well. Resident had 1 (one) hour yelling out tonight, but then calmed down. Resident is resting well at this time. Call light is positioned so she can use it with her right hand. Turned and repositioned Q 2 (every two) hours and PRN (as needed) by staff. Bed in low position, fall mat in place. She is on isolation as she is unvaccinated and a new admit. -On 8/29/21 at 12:15 a.m. a nurse documented (SBAR): This nurse found resident on floor between bed and window, on fall mat. Bed was in low position and her call light was still attached to her gown. When asked what happened, resident stated she was trying to reach for her bible. Resident assisted back into bed by this nurse and CNA. Resident states she did not hit her head. No injuries noted at this time. Vitals/Neuros initiated as fall was unwitnessed. Will monitor patient. -On 8/29/21 a nurse documented: Daily skilled charting for (Resident): She is A/O (alert and oriented) x 1-2. Needs are anticipated by staff d/t (due to) a CVA (cerebrovascular accident) and left sided weakness and is here for skilled services and rehab. Boot on left lower extremity. She is NWB (non-weight bearing) and is a Hoyer lift (for transfers). Her speech is a little unclear. Resident resting with eyes closed, have not observed her calling out this evening. She did have c/o left arm and left foot pain, PRN (as needed) Tramadol (pain medication) given .No c/o pain from fall last night. Resident turned and repositioned Q 2 (every two) hours and PRN (as needed) by staff. Bed in low position, fall mat in place, call light within reach but resident does not remember how to call for assistance - frequent checks for safety, will monitor. -On 8/30/21 a nurse practitioner documented in the skilled visit progress note: No falls -On 9/2/21 the IDT (interdisciplinary team) post-fall report documented: After IDT review, staff reminded to ensure resident is in the center of the bed prior to, during, and after cares. Staff to also anticipate resident's needs. The facility failed to implement appropriate approaches to prevent Resident #2's fall. The facility failed to thoroughly investigate resident's fall. The facility failed to communicate resident's fall with her primary care clinician. 2. Fall #2 -On 9/17/21 at 9:35 a.m., a nurse documented: Daily skilled charting for (Resident): Resident alert and oriented x 3 able to make needs known, but sometimes with difficulty expressing herself, L. (left) sided weakness post CVA, maintaining O2 (oxygen) saturation at 90% on RA (room air). Resident had an unwitnessed fall this shift w/o (without) any injuries, neurocheck initiated and all at resident's baseline so far, resident educated to use call light to call for assistance, bed in low position and call light within reach. -On 9/18/21 SBAR (situation, background, assessment and recommendation) revealed: Resident was found lying on the fall mat next to her bed on her L. (left) side. Resident stated that her son was coming to visit and she was trying to get up out of bed to go see him when she fell. Resident was assessed and noted with no injuries. Resident stated she did not hit her head, resident was assisted off the floor and back to bed by staff, call light was placed within reach and bed in low position. -There was no incident report and investigation in resident's medical record. -On 9/23/21 resident's physician documented in the skilled visit progress note: Patient feeling badly as her L (left) leg and her L (left) foot were hurting badly .No falls The facility failed to implement appropriate approaches to prevent Resident #2's second fall. The facility failed to thoroughly investigate resident's fall. The facility failed to communicate resident's fall with her primary care clinician. IV. Staff interviews The director of nursing (DON) was interviewed on 11/4/21 at 11:50 a.m. She said she has been the DON in this facility for just a couple weeks. She said she had learned there was a lot of documentation not completed after residents' falls. She said she will implement a thorough investigation after each resident's fall and provide all staff education on how to prevent falls with appropriate interventions and how to complete a post fall investigation.