**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to provide supervision, assistance, services, and implement effective person centered interventions to prevent falls with injuries for one (#26) of four residents reviewed for accidents/hazards out of 29 sample residents. Resident #26 had a history of falls upon admission on [DATE], was cognitively intact, used a cane and needed limited assistance with transfer, supervision with ambulation within the room and was independent with ambulation outside of the room. Between 4/16/22 and 4/26/23, Resident #26 experienced fifteen falls: fourteen unwitnessed and one witnessed. The facility failed to consistently implement fall interventions after each fall and when fall interventions were implemented they were often ineffective due to the resident's declining cognition. The facility failed to assess Resident #26's significant change in cognition as part of the root cause analysis for implementation of person centered fall interventions according to the 7/29/22 Neuropsychological report. The facility failed to conduct consistent interdisciplinary team (IDT) review of Resident #26's falls. Due to the facility's failures to implement effective fall prevention measures, the resident fell on 4/26/23, the resident sustained a subdural hematoma (brain bleed). After the subdural hematoma, the resident's cognition score was alert and oriented to self only and the resident became non-verbal. The resident required extensive assistance from staff for all activities of daily living and was no longer able to walk. Findings include: I. Facility policy and procedure The Fall Management policy, undated, was provided by the nursing home administrator (NHA) on 5/8/23 at 4:07 p.m. It read in pertinent part, Upon admission, the nurse will complete a fall risk assessment to determine the resident's level of fall risk. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. If the resident is determined to be at high risk, then the resident is referred to rehabilitation services as applicable. The resident and the resident's representative are provided education on fall risk and interventions in place to reduce the potential for falls. After a fall event- The IDT reviews all resident falls within 24-72 hours to evaluate circumstances and probable cause for the fall. The Care Plan will be reviewed and/or revised as indicated. Fall trending and analysis information is reported to the Quality Assurance and Performance Improvement (QAPI) Committee. Residents who have experienced actual falls will be reviewed each week during the At-Risk Review Meeting.The At-Risk Review committee members will review residents with falls for documentation, compliance, and interventions on a weekly basis. The DON or designee will ensure communication to staff members regarding changes to interventions related to fall risk is completed. II. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO) diagnoses included stroke, traumatic subdural hemorrhage, repeated falls and vascular dementia. The 5/6/23 minimum data set (MDS) assessment was incomplete at the time of survey. A brief interview of mental status (BIMS) assessment dated [DATE] revealed the resident had significant cognitive impairments with a BIMS score of zero out of 15. No behaviors were indicated. The 3/6/23 MDS assessment revealed the resident had significant cognitive impairments with a BIMS score of four out of 15. The resident required extensive assistance with bed mobility, transfers, toileting, dressing, walking, and personal hygiene. The fall section was incomplete. B. Observations Resident #26 was observed on 5/3/23 at 9:30 a.m. in his bed in room. There was a transfer pole next to his bed, skid strips on the floor and the bed was in a low position. There was no fall mat and the resident was not wearing non-skid socks. There were no one-on-one staff present for supervision. The resident was unresponsive to questions and was unable to track movement in front of him with his eyes. The resident had stitches on face next to right eye. Resident #26 was observed on 5/3/23 at 3:10 p.m. in his bed.There were no one-on-one staff present. The resident was unresponsive to questions and was unable to track movement in front of him with his eyes. Resident #26 was observed on 5/4/23 at 2:00 p.m. in his bed in room. The resident was sleeping. There were no one-on-one staff present. C. Record review The fall care plan, revised on 4/28/23, revealed the resident had actual falls related to poor balance, unsteady gait, and unaware of safety. Interventions were to provide physical and occupational therapy, encourage the resident to ask for assistance, determine causative factors for falls, increase supervision (added after survey began), low bed (added after survey began), offer assistance to toilet, commonly used articles within reach, ensure call light is within reach, anticipate needs, follow facility fall protocol, review information on past falls and attempt to determine cause of falls, transfer pole in place for safe transfer, non-skid strips next to bed, range of motion and reposition/ambulate as tolerated at least every two hours. The May 2023 CPO revealed the following physician orders as follows: -Three orders for speech therapy (ST) to evaluate and treat the resident from 6/9/22 to 5/3/23; -Five orders for physical therapy (PT) to evaluate and treat the resident from 6/9/22 to 5/3/23; -Four orders for occupational therapy (OT) to evaluate and treat the resident from 7/20/22 to 5/3/23; -Patient will benefit from a transfer pole next to his bed to improve ease of transfers and reduce fall risk. He is able to demonstrate safe utilization ordered 11/18/22 and discontinued on 2/1/23; and, -Neuropsychology evaluation ordered 7/29/22. According to post fall reviews, nursing progress notes with At-Risk Review committee meeting notes dated 4/16/22 to 4/26/23, the resident had fifteen falls in 12 months. -According to the IDT post fall review on 4/16/22 at 7:00 p.m. the resident had an unwitnessed fall in his room after slipping when coming out of his bathroom. The resident was wearing non-skid socks. The staff were waiting for a new medication started for urinary frequency to become therapeutic. The resident was reminded to use his call light when needing to get up and was continuing to see OT/PT. According to the At-Risk Review committee notes dated 4/20/22, current interventions in place were bed by door, non-skid socks, transfer pole, raised toilet seat, and new medication for urinary frequency. There were pending orders for PT. -According to IDT post fall review on 5/7/22 at 1:12 a.m. the resident had an unwitnessed fall in his room after slipping out of his bed onto the floor. The fall resulted in abrasion to his right thigh and bruise to his right knee. Staff to continue to educate the resident on use of call light and his walker. The resident was to continue to see OT/PT. According to the At-Risk Review committee notes dated 5/11/22, no changes to current interventions from 4/20/22 and no new interventions. -According to IDT post fall review on 6/6/22 at 7:50 p.m. the resident had an unwitnessed fall in his room after slipping out of his bed onto the floor. There were no new interventions after the fall. According to the At-Risk Review committee notes dated 6/8/22, no changes to current interventions from 4/20/22 and no new interventions. -According to IDT post fall review on 6/18/22 at 7:50 p.m. the resident had an witnessed fall in his room after standing, pulling on his room curtain and losing his balance. The resident had just discontinued PT and was on a restorative therapy program (maintenance program of current functioning). The resident was also on frequent observations, but the review did not clarify how frequent. According to the At-Risk Review committee notes dated 6/22/22, no changes to current intervention of restorative therapy. Neuropsychological evaluation for cognitive function scheduled for 8/10/22. -According to IDT post fall review on 7/6/22 at 7:00 p.m. the resident had an unwitnessed fall in his room after attempting to ambulate. The resident was wearing non-slid socks. There were no new interventions. There was no At-Risk Review committee meeting following fall. -According to IDT post fall review on 7/9/22 at 7:45 a.m. the resident had an unwitnessed fall in his room after attempting to ambulate. The resident was wearing non-slid socks. New interventions were to toilet the resident every two hours and educate the staff to provide more frequent visual checks by checking in his room when they walk by. According to the At-Risk Review committee notes dated 7/13/22, no changes to current intervention of restorative therapy. New intervention of increased observations, but it did not clarify frequency. -According to the At-Risk Review committee notes dated 7/20/22 the resident was to have one-on-one supervision when out of bed. The notes did not clarify if he would have a one-on-one while in his room or when out of his room or what times of day. -According to IDT post fall review on 7/21/22 at 9:25 a.m. the resident had an unwitnessed fall in a common area and was found on the floor. The fall resulted in a skin tear below his right knee. The resident smelt like he had a bowel movement. Staff were to anticipate needs and toilet the resident after lunch despite fall happening after breakfast. There was no At-Risk Review committee meeting following fall. -A nursing note dated 7/24/22 revealed the resident was found on the floor at 7:30 p.m. There was no IDT post fall review completed and no further details. -According to IDT post fall review on 7/25/22 at 1:25 a.m. the resident had an unwitnessed fall in his room attempting to transfer himself. The review documented the resident was currently working with PT/OT. There were no new interventions after the fall. According to the At-Risk Review committee notes dated 7/27/22, no changes to current intervention of restorative therapy and one-on-one supervision when up out of bed, however the resident had an unwitnessed fall 7/21/22 while on one-on-one supervision. -According to IDT post fall review on 9/5/22 at 3:30 a.m. the resident had an unwitnessed fall in a common area room when he was reaching for a snack off of a tray table. The staff were to continue to anticipate the resident's needs and check on the resident frequently. The fall review did not indicate the resident was still on one-on-one supervision. An OT evaluation was to be ordered. According to the At-Risk Review committee notes dated 9/7/22, OT to evaluate the resident, continue with restorative therapy. No other interventions were listed. -According to IDT post fall review on 10/22/22 at 11:15 a.m. the resident had an unwitnessed fall in his room. The fall resulted in two abrasions to his upper and lower back. The resident was attempting to get into his wheelchair. No new interventions. According to the At-Risk Review committee notes dated 10/26/22, the resident had abrasions to his back. No current or new interventions were listed. -According to IDT post fall review on 11/3/22 at 8:50 a.m. the resident had an unwitnessed fall in his room. He was found by a therapist walking past his room. It was determined the fall was due to a recent room move. No current or new interventions were listed. There was no At-Risk Review committee meeting following fall. -According to IDT post fall review on 11/22/22 with no time indicated, the resident had an unwitnessed fall in his room after trying to ambulate. The review documented the resident was currently working with PT, with no new interventions. According to the At-Risk Review committee notes dated 11/23/22 the resident had slid out of his bed and was to be referred to therapy. There was no reference to the resident currently being on therapy already. No new order for therapy was in the resident's chart. -According to IDT post fall review on 2/24/23 at 5:10 p.m. the resident had an unwitnessed fall in his room after trying to get out of bed. The review documented the resident was on restorative therapy and PT. No other current interventions listed and no new interventions. There was no At-Risk Review committee meeting following fall until 3/15/23. -According to IDT post fall review on 4/26/23 at 7:47 p.m. The resident had an unwitnessed fall in his room and was found on the floor bleeding from the right eye area. The resident was sent to the hospital. It documented to re-evaluate the necessity for the transfer pole, access room for openness and furniture placement. Orders were PT/OT/ST upon his return from hospital. There was no At-Risk Review committee meeting following fall. The hospital discharge summary post fall dated 4/26/23 document resident suffered from three to four millimeter (mm) subdural hematoma. A Neuropsychological (a form of psychology focussed on how injuries or illnesses of the brain affect cognitive and behavioral functions) report dated 7/29/22 was scanned into the resident's chart on 8/26/22. It read in pertinent part, Performance on a measure of problem solving for daily health and safety behaviors was suggestive of substantial functional difficulties. Current cognitive and functional difficulties will likely persist and progress. Given his nurse's report of a relatively abrupt change in cognitive status following a fall approximately six weeks ago, an MRI (non-invasive imagining technology) may be beneficial to rule out other potential contributors. The facility nurse noted difficulties in decision making, sustained attention, spatial judgment, organization, multitasking, and impulsivity. Test results show impaired visuospatial abilities (visual-spatial processing is the ability to tell where objects are in space. That includes your own body parts. It also involves being able to tell how far objects are from you and from each other), impaired attention, impaired executive functioning (executive function refers to a set of skills. These skills underlie the capacity to plan ahead and meet goals, display self-control, follow multiple-step directions even when interrupted, and stay focused despite distractions, among others), and memory and recognition performances below expectation. His response to questions pertaining to home safety were in the low range suggestive of substantial difficulty with judgment regarding issues and situations to be encountered in daily life. -No physician notes or progress notes were located in the resident's medical record indicating the neuropsychological report was reviewed and his results included in fall prevention planning. -There was no record of follow-up regarding an MRI as recommended by the report. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/3/23 at 3:15 p.m. She said she was the resident's CNA but stated she did not know what the resident's fall interventions were or were to find them in the resident's chart. She stated she checked in on him every time she walked past his room but did not say how frequently that was and there was no room rounding sheet. CNA #1 said the resident tried to get out of bed twice the previous day. CNA #5 was interviewed on 5/3/23 at 3:25 p.m. She said the resident had changed in his vision since he returned from the hospital on 5/2/23 and continued to try to get out of the bed by himself. She stated the resident needed a sitter but did not currently have one. She said there was no room rounding sheet to document how many times the staff were to check on the resident. Restorative nursing assistant (RNA) was interviewed on 5/3/23 at 3:31 p.m. She said she had worked with the resident on and off on hand eye coordination and independent motor skills. She said she had worked with him since December 2022 and he had not had any falls until now. She did not know what the resident's fall interventions were. Registered nurse (RN) #4 was interviewed on 5/3/23 at 3:38 p.m. He said the staff checked on the resident every time they walked past his door. He said there was no specific timeframe and there was no room rounding sheet. The resident was to have his bed in the lowest position but he did not know any other fall interventions for the resident. He said when IDT put new interventions into place, the nurse managers would verbally tell the floor staff. The RN had been out for a week and a half and since returning and no one in IDT had told him about new fall interventions for the resident. The NHA was interviewed on 5/4/23 at 4:10 p.m. She was unaware that Resident #26 was still attempting to get out of his bed since returning from the hospital. She said that she would work on a plan to keep him safe right away. CNA #1 was interviewed on 5/7/23 at 3:38 p.m. CNA #1 stated the fall interventions in place for the resident were non-slip strips, transfer pole, low bed, call light within reach, grip socks, every 15 minute checks if on neurological checks and right now he had a one-on-one sitter for supervision. If new interventions were put into place, the nurses told the CNAs in the change of shift report. RN #1 was interviewed on 5/7/23 at 3:43 p.m. RN #1 stated the resident had a one-on-one sitter since 5/4/23 because he kept trying to get up and ambulate independently. When a resident fell, the RN did an assessment for injuries and did risk management report. The nurse immediately put interventions in place. The IDT met following the fall and discussed what further interventions should be put into place. If new interventions were put into place, the nurse managers informed the nursing staff and had training if needed. The resident had not had a fall since being readmitted [DATE]. CNA #3 was interviewed on 5/7/23 at 3:48 p.m. CNA #3 stated the resident had fall strips, a transfer pole, low bed, and one-on-one sitter. She said the nursing staff was told by management which fall interventions were in place. Resident aide (RA) #1 was interviewed on 5/8/23 at 1:20 p.m. She said she has been providing one-on-one supervision to the resident since he returned from the hospital 5/2/23. She stated the resident had improved since he had returned. She attempted to speak to the resident but his gaze remained fixed, his eyes did not track and he was unresponsive to her. She stated she was mistaken, she actually just started providing him one-on-one supervision 5/4/23. The director of nursing (DON) was interviewed on 5/8/23 at 1:57 p.m. After a resident had a fall, the IDT will complete an IDT post fall review and include new interventions. The MDS coordinator used to update the care plans after a resident fell but it was now her responsibility. She communicated new fall interventions to the floor staff with on the spot education or went to the staff and told them directly. The MDS coordinator used to update the CNA tasks but she did not think that happened anymore. The DON attempted to go through the resident's medical record to provide the fall interventions after each fall but was unsure where the interventions were in the resident's medical record. She said she thought the resident had an one-on-one sitter at the end of July to August 2022 but the sitter was only for when the resident was out of his room. She acknowledged the majority of his falls were inside of his room. She said with the resident's cognition, it was difficult to prevent his falls; the staff tried to anticipate his needs when he was in his room. Certified occupational therapist assistant (COTA) was interviewed on 5/9/23 at 8:57 a.m. She pulled the resident's therapy notes from November 2022 to current. Therapy had worked with the resident on standing balance, transferring, ambulating with a walker, sequencing tasks and expressive language. The resident was able to complete goals each time he worked with therapies but once he completed and was discharged each time and he did not have the same supervision and support, he would regress and fall again. When therapy was working with the resident in February 2023, he had declined in his abilities and therapy had to work with him on ambulating shorter distances and transferring with staff assistance. He has declined further since his fall in April 2023 and his current goals with PT/OT/ST were to increase upper body strength, bed mobility for sequencing hand and foot placement, communicate yes/no response for basic wants and needs, consumption of oral intact and alternate use of liquids and solids, maintain eye contact with conversation and fine motor coordination. His baseline currently was substantial-maximum assist for all goals. The NHA was interviewed on 5/9/23 at 10:21 a.m. The NHA stated Resident #26 was currently receiving one-on-one 24 hour supervision until he no longer needed it. A review of his medications was done after he returned from the hospital after his 4/26/23 fall. His room was evaluated for hazards and his transfer pole would be reviewed for effectiveness. She was waiting to see what his new cognitive and functional baseline would be before determining interventions that would be effective. She was not sure if his frequent falls were discussed in the facility's monthly QAPI meeting. The NHA would provide the fall interventions for the resident from 4/16/22 to 4/26/23. The NHA and DON were interviewed again on 5/9/23 at 12:07 p.m. The NHA said she was still working on collecting the fall interventions. She said the intervention should be indicated in the IDT post fall review. The NHA was not employed at the facility in July 2022 but DON was at that time. The DON said she did not recall a neuropsychology evaluation being ordered for resident post any falls. The DON and NHA were unaware the resident had a neuropsychology evaluation performed and were unaware of the results. The NHA was aware the evaluation provided detailed cognitive deficit information in numerous areas of functioning. She stated the results of a neuropsychology evaluation ordered for a resident post fall would be included in intervention discussions. She said those results should be provided to the therapy department to tailor the residents interventions based on his abilities. She acknowledged the resident continued to go to therapy and was able to complete goals with therapy but once he was no longer in therapy he was unable to retain the interventions he had learned and then fell again. III. Facility follow-up On 5/9/23 at 12:12 p.m. the NHA provided the same IDT post fall reviews and nursing progress notes with At-Risk Review committee meeting notes previously reviewed in the resident's medical record during the survey. No new interventions, staff education or documented on the spot education were provided.