**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to assess and monitor an existing pressure injury for one (#50) of seven residents reviewed for wounds out of 32 sample residents and failed to take steps to prevent the resident's development of pressure injuries. Resident #50 who required hands on assisance from staff to complete activities of daily living such as toileting, bed mobility, dressing and personal hygiene and who was at high risk for developing pressure injuries developed facility acquired pressure injury. The resident's pressure injury was first discovered on 4/27/23 and started as a redness spread over the bony part of the resident's left hip. The wound care physician classified the wound as a trauma wound. There was no documentation in the resident's chart to identify what type of trauma caused the wound to develop other than the resident lying on the hip creating skin damage for pressure to the wound site. A note written by the facility's occupational therapist (OT) documented that the pressure injury was discovered on 4/27/23 after the resident had been sitting up in her wheelchair for an extended period. The injury was linked to the resident seating system and position in the wheelchair from the wheelchair components and the cushion putting pressure on the resident's left hip. Following the observation, the OT adjusted the resident's wheelchair seating system and the wound improved by 5/24/23 but emerged again a month later. On 6/28/23 the resident medical record revealed the wound to the resident left hip emerged again as an open wound measuring 1.3 centimeters (cm) in length by 2 cm in width by 2 cm in depth. The wound bed was covered with 100% slough (stringy yellowish dead skin). The facility physical therapist (PT) assessed the resident and recommended the resident lay off of her left side to facilitate wound healing to the left hip. Following this recommendation, the resident developed a pressure injury to the right hip (on 9/4/23). The wound was assessed as an unstageable pressure injury on the resident's right posterior (back) hip with full-thickness of the skin (extending beyond two layers of skin tissue) and tissue loss. The wound measured 0.5 cm in length by 0.7 cm in width with no measurable depth. The PT reassessed the resident's seating system following the progression of the facility acquired pressure injuries and documented that the resident had had an inappropriate wheelchair and positioning program causing poor posture and skin related issues. The assessment documented that the resident required more frequent repositioning assistance to offload pressure from the left him with added side and back laying positions. The assessment documented that the resident had been tolerating the recommended repositioning; however, observations revealed the resident was not being respositioned as recommended (see observations below). The wound care physician (WCP) assessment of the pressure injuries reviewed the WCP believed the wounds were avoidable (see the WCP interview below). Interventions were not implemented consistently and observation of the resident's care revealed a lack of timely repositioning and staff not following the PT's recommendations to assist resident to offload pressure alternating from side to side and back lying on a frequent basis in order to promote healing the left hip wound and improved skin integrity. The facility failed to promote full healing of the wound and failed to prevent the formation of a second wound from worsening. The facility's failure to develop and implement timely and effective interventions led to the development of two unhealed pressure injury wounds one of which caused the resident severe pain. On 11/22/23, the pressure injury to the resident's left hip while healing persisted and measured 0.7 cm, in length by 0.7 cm in width by 0.1 cm in depth. However, the pressure injury wound to the right rear hip, first observed 9/4/23, worsened from intact skin to an unstageable pressure injury measuring 1.2 cm in length by 1.2 cm in width by 0.1cm depth with a build-up of dead tissue and severe pain at the wound site. The wound required surgical debridement to remove dead tissue and progressed to a stage 4 pressure ulcer measured 1.2 cm in length by 1.2 cm that began to spread under the surface of the skin at the wound edges. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 12/7/23, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dark dead skin) may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy The Skin Integrity and Pressure Ulcer/Injury Prevention and Skin Management policy, reviewed 3/31/23, was provided by the nursing home administrator (NHA) on 11/30/23 at 1:26 p.m. It revealed in pertinent part, Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure, ulcer injury, complete, wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury, Advisory Panel) and WOCN (Wound, Ostomy, Continent, Nurse Society). A comprehensive skin inspection/assessment on admission and readmission to the center may identify pre-existing signs of possible deep tissue damage already present. These signs include purple or very dark areas, surrounded by edema; profound, redness, or induration; bogginess; and or discoloration. These signs possibly indicate an unavoidable stage three or four with slough, drainage, or even eschar within a few days. A risk assessment to Braden Scale, or Norton Scale determines the resident's. Risk of pressure injury development. The score is documented on the tool and placed in the resident's medical record using the appropriate form. Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Examples include, but are not limited to; impaired/decreased mobility and decreased functional ability. Morbid conditions, such as end-stage, renal disease, thyroid disease, diabetes mellitus, or other end-of-life concerns. Drugs such as steroids that may affect wound healing. Impaired diffuse, or localized blood flow. A patient's refusal of some aspects of care treatment especially in multi-system organ failure, or end-of-life conditions. Exposure of skin to urinary and fecal incontinence. Under nutrition, malnutrition, and hydration deficit, edema and history of a healed injury. Measures to maintain and improve resident's tissue tolerance to pressure and implemented in the plan of care. All residents upon admission are considered to be at risk of pressure injury development due to medical issues requiring nursing care and related disease processes and illness or need for rehabilitation services. Upon admission and throughout stay at minimum distribution surface is in use with her and repositioning as needed with ADL care/assistance in care, if needed to include skin barriers, application as needed, preventative, wheelchair cushions, if indicated, etc. Skin inspections with particular attention to bony prominences. Skin cleansing with appropriate cleanser at the time of swelling and at routine intervals. Minimize skin exposure to incontinence using devices and skin barriers. Minimize injury due to shear friction through proper positioning, transfers, and turning schedules. Encourage PO food and fluid intake and improve residence, mobility and activity when potential exists. Measures to protect the resident against the adverse effect of external mechanical forces, such as pressure friction, and are implemented in the plan of care; reposition, at least every 2 to 4 hours, as consistent with overall patient goal and medical condition. Utilize positioning devices to keep prominences from direct contact and ensure proper body alignment protection/suspension if indicated. A distribution mattress surface is placed under the resident. When positioned in the wheelchair, the resident is to be placed on a pressure reduction device and repositioned. When positioned in a wheelchair consideration is given to postural alignment, distribution, weight, balance, and stability. When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. III. Resident #50 A. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included Parkinson's, dementia with behavioral disturbances and major depressive disorder. According to the 11/10/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired and was unable to complete a brief interview for mental status (BIMS). She was dependent on one person with transferring and dressing. She required substantial assistance from one person with toileting, bed mobility, dressing, personal hygiene and eating. The resident was dependent on a wheelchair and needed moderate assistance with locomotion. The resident was at risk for developing pressure ulcers. The resident had unhealed pressure ulcers. The resident had one unstageable pressure ulcer. The pressure ulcers were not present at admission. B. Observations On n 11/27/23 Resident #50 was observed and revealed: -At 9:00 a.m. the resident was in her bed lying on her right side. -At 10:00 a.m. the resident was in her bed lying on her right side. -At 11:58 a.m. the resident was in her bed lying on her right side. On 11/28/23 Resident #50 was observed and revealed: -At 10:26 a.m. the resident was in her bed lying on her right side. -At 10:40 a.m. an unknown CNA went into the Resident #50's room but did not reposition her and the resident remained lying on her right side. -At 12:30 a.m. a unknown CNA went into Resident #50's room to help her roommate, but did not assist Resident #50 with any care. Resident #50 remained on her right side. -At 1:30 p.m. the Resident #50 remained on her right side. On 11/30/23 Resident #50 was observed and revealed: -At 9:00 a.m. the resident was in her wheelchair in the hallway. -At 12:00 p.m. an unknown staff member transported the resident, who was still up in her wheelchair to the dining room for lunch. -At 12:45 p.m. after the resident finished lunch, an unknown staff member transported the resident to her room and transferred her to bed using a hoyer (mechanical) lift. The staff laid her down on her right side. C. Record review According to the Braden scale (a scale to measure risk of developing pressure ulcers) dated 5/11/23 Resident #50 was at mild risk of developing pressure ulcers. According to the health status note dated 5/1/23 at 11 a.m., the resident had a new skin issue discovered on 4/27/23. The resident had redness spread over her left hip. The registered nurse (RN) on duty cleansed the skin and placed prophylactic (preventative) foam dressing on the left hip. A seating cushion that was previously placed for positioning the resident in the wheelchair was removed and OT had been working with the resident on positioning. OT removed a rigid lateral support (lateral trunk support) and adjusted lateral support so it would not rest on the bony prominence of her hip. According to a care management note dated 5/4/23 OT was discontinued due to the resident meeting all her wheelchair goals. According to the OT Discharge summary dated [DATE] the resident received therapy between 3/15/23 and 5/6/23. The resident had been assessed by OT due to the resident being at risk for falling out of her wheelchair due to inability to sit up in the chair without leading to the left. The initial intervention for positioning was causing additional rubbing and pressure on the residents left hip. As a part of the assessment and treatment the OT made adjustments to preventing the support from rubbing against the resident's hip. According to an event note dated 6/28/23 the resident had an open area to her left hip on the bony prominence. The affected area had been padded with mepilex dressing for the past four weeks due to non blanchable redness (when the skin is unable to return to a normal pigment when pressed) that developed from using equipment to help her sit upright in her wheelchair. The resident was evaluated by the wound team. According to the wound observation tool dated 6/28/23 the resident acquired a new skin impairment on 6/28/23, on her left hip. The first observation revealed the resident's skin had epithelial tissue (normal healthy skin) present and granulation tissue (beefy red tissue an indicator that skin was healing) the wound had a small amount of serous drainage (normal clear yellow fluid an indicator of a healing wound). The wound measured 1.3 cm in length, 2.2 cm in width and 0.2 cm in depth. According to the wound note dated 7/5/23 the resident's left hip was identified as a trauma wound with a status of not healed. The wound measurements were 1.3 cm in length by 1.9 cm in width with no measurable depth with 100% slough. There was a small amount of serous drainage noted. The physician performed surgical debridement (procedure to remove dead tissue). Post debridement measurements were 1.3 cm in length by 1.9 cm in width by 0.1 cm in depth. According to the wound note dated 7/12/23 the resident had an unhealed left hip trauma wound. The wound measurements were 1.3 cm in length by 2.2 cm in width with no measurable depth.There was a small amount of sero-sanguineous (watery bloody) drainage noted. The wound bed had 95% eschar and 5% slough. There was no change noted in the wound progression. The left hip wound was still developing but not enough to allow for debridement. According to wound notes dated 7/19/23 the resident's left hip trauma wound and had received a status of not healed. The wound measured 1.5 cm length by 2.5 cm in width with no measurable depth. There was a small amount of serous drainage noted. Wound bed had 100% slough. There was no change noted in the wound progression. The wound was surgically debridement; post debridement measurements were 1.5 cm in length by 2.5 cm in width by 0.3 cm in depth. According to the PT evaluation and treatment plan dated 7/19/23 the resident had a pressure wound. The resident had poor posture, adverse effects to skin integrity and there was inconsistent use of hoyer lift. The resident's goal was to be able to sit in an upright position and transfer safely in the hoyer lift to decrease further risk of skin trauma. The PT assessment recommended making changes to the resident's wheelchair cushion. According to the wound note dated 8/2/23 the resident's left hip wound measured 1.7 cm in length by 2.4 cm in width with no measurable depth, muscle was exposed. There was a moderate amount of serous drainage noted. Wound bed had 100% slough. The wound was surgically debrided with post debridement measurements of 1.7 cm length by 2.4 cm width by 0.3 cm. According to the August 2023 treatment administration record (TAR) treatment orders included instructions for staff to reposition resident every two hours and ensure offload of the left hip at all times every shift for wound on left hip, ensuring the resident was not laying on left hip until wound was resolved. Order dated 8/2/23 and discontinued 9/24/23. According to the wound note dated 8/9/23 the resident's left hip wound measurements were 2.5 cm in length by 1.3 cm in width with no measurable depth. Muscle was exposed and tunneling (occurs when a chronic wound has progressed to form an opening underneath the surface of the wound's edge) was present at a distance of 1.4 cm. There was a moderate amount of serous drainage noted. Wound bed had 100% slough. The wound was surgically debrided. The post debridement measurements were 2.5 cm in length by 1.3 in cm width by 0.1 cm in depth. According to the PT evaluation and treatment plan dated 8/30/23 the resident's wheelchair was modified but continued to require monitoring for adverse effects. The assessment recommended that the resident be encouraged to lay on her side while in bed to alleviate pressure to aid with left wound healing but this resulted in a non-blanchable redness on the resident's right hip. The resident continued to require education on participants in a rotating program reposition and promote overall skin integrity. According to the comprehensive care plan focus for impaired skin integrity dated 8/24/23 the resident had a trauma injury wound. Interventions included providing treatment as ordered. Weekly skin checks in wound rounds. Air pressure mattress. Clean and dry skin after each incontinent episode. Encourage the residents to wear geri-gloves (non-compression, seamless knit material that contours to the body to protect thin, sensitive skin from tears, abrasions, and light bruising) as tolerated, to avoid skin tears on hands. Staff should make certain nails are trimmed. Added padding to the resident's wheelchair arms. Ensure the resident's hands on her lap when assisting her with ambulation. According to the altered skin integrity care focus dated 9/11/23 interventions included assisting the resident to reposition when in bed off of her back with the use of wedges, as tolerated, to prevent skin breakdown. According to an event note dated 9/4/23, the resident had a non-blanchable wound to the right hip bony prominence. The affected area was maroon in color. The resident had been laying mostly on her right side due to the wound on her left hip. The resident did not like to lay on her back to relieve pressure from both bony prominences. Affected area was cleansed with normal saline, skin prep and covered with mepilex dressing. According to wound notes dated 9/6/23, the resident developed an unstageable pressure injury on her right posterior hip with full-thickness skin and tissue loss. The pressure ulcer had received a status of not healed. The wound measured 0.5 cm in length by 0.7 cm in width with no measurable depth. The wound bed had 100% epithelialization with obscured full-thickness skin and tissue loss. According to wound note dated 9/6/23 the resident's left hip wound measured 1.2 cm in length by1.5 in cm width by 1 cm in depth with undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) with a maximum distance of 2.3 cm. According to event note dated on 9/11/23,the resident had a non blanchable wound. The resident was sleeping and resting on an air mattress with order for staff to provide repositioning assistance and wound care treatment and dressing changes. According to the wound observation tool dated 9/13/23 the resident had an unstageable pressure ulcer facility acquired on 9/4/23, on her right hip. The wound was worsening and had slough tissue. The wound measurements were 3.0 cm in length and 5.0 cm in width According to the PT evaluation and treatment plan dated 9/20/23 the resident tolerated the position throughout the day with no adverse effects to the left hip wound. The resident tolerated a rotating positioning program in supine (on back) to promote overall skin integrity. The resident currently had an inappropriate wheelchair and positioning program. The resident needed a smaller wheelchair and to be repositioned more frequently. According to the September 2023 treatment administration record (TAR) treatment orders included instructions for staff to reposition the resident and offload bilateral hip as allowed every shift for skin management order dated 9/24/23 and discontinued 10/19/23. According to the PT Discharge summary dated [DATE] the resident was discharged with a good seated and supine positioning with no worsening wounds. According to the pressure ulcer care focus dated 11/13/23 the resident had an unstageable pressure ulcer on her right hip. Interventions included administer medications and treatments, as ordered. Provide enhanced barrier precautions. Inform the resident and family of any new skin breakdown. Perform lab and other diagnostic work as ordered, report the results to the medical doctor and follow up as indicated. Observe and report changes in skin status; appearance, color, wound healing, sign of infection, wound size and stage of wound. Serve diet as ordered and monitor intake and record. According to the wound note dated 11/15/23 The resident had an unstageable pressure injury on her right, posterior hip with obscured full-thickness skin and tissue loss and had received a status of not healed. The wound measured 1.2 cm in length by 1.2 cm in width with no measurable depth, with undermining at a distance of 2.6 cm. There was a large amount of serous drainage noted. The patient reports a wound pain of level 0/10. The wound bed had 80%, granulation, 20% slough. The wound was surgically debrided, post debridement measurements were 1.2 cm in length by 1.2 cm in width by 0.1cm depth. According to the wound observation tool dated 11/22/23 the resident acquired a skin impairment on her left hip, due to trauma of equipment use on 6/28/23 (seating and transferring devices, see above). The left pressure wound was assessed to have been healing with granulation tissue (beefy red) the wound had serous and scan drainage. measurements were 0.7 cm, in length by 0.7 cm in width by 0.1 cm in depth. According to the wound observation tool dated 11/22/23 the resident had a stage 4 pressure ulcer facility acquired on 9/4/23, on her right hip. The wound was worsening and had granulation and slough tissue . The wound measurements were, 1.2 cm in length and 1.2 cm in width with tunneling. IV. Staff interviews The wound care physician (WCP) was interviewed and observed on 11/29/23 at 1:20 p.m. while performing wound care on Resident #50's left hip. The WCP said the resident was admitted to the facility on [DATE], with a left hip trauma injury. The wound had been unstable. The wound had worsened and was now classified as a stage 4 pressure injury with tunneling and had a large amount of drainage. The WCP said the wound likely had severe colonization and was possibly an infection but he was unable to determine the severity of the infection because he was unable to see the bottom of the wound. The WCP said if the resident acquired the left hip wound at the facility then the wound on her right hip was avoidable. The wound doctor said the resident would not have acquired the right hip wound if she did not have the left wound. The WCP said the resident was positioned on the right hip because it was painful to lay on her left hip. The WCP said the resident should be repositioned supine (on her back) to avoid the wound's progression. The WCP said both wounds were stage 4. Registered nurse (RN) #1 was interviewed on 11/29/23 at 2:20 p.m. RN #1 said the resident's left hip trauma wound developed because the resident would propel herself in her wheelchair and would lean to the left side. RN #1 said the pressure ulcer on the right side developed because the resident was in pain and preferred to only lay on her right side. RN #1 said the resident should be positioned on her back to relieve pressure on both hips. RN #1 said the resident had wedge cushions on her bed to help the resident stay positioned on her back. Certified nursing aide (CNA) #1 was interviewed on 11/30/23 at 8:59 a.m. CNA #1 said if there was a change in skin condition the CNAs would report to the nurse and the nurses would report it to the resident's physician. CNA #1 said residents should be repositioned every two hours. CNA #1 said the residents in the facility should not have pressure ulcers if they were repositioned. CNA #1 said Resident #50 acquired pressure ulcers because she was not repositioned properly. CNA #1 said the resident initially had skin issues due to poor positioning in the wheelchair and because the resident was consistently laying on her left side due to not wanting to face the wall while in bed it made her wounds worse. CNA #1 said the resident's bed was facing the other way so now the resident was willing to lay on her right side. CNA #1 said the resident had bed wedges to keep her laying on her back and off her hips. CNA #1 said the other staff did not reposition the resident correctly; she knew this because she observed the other CNAs position the resident consistently on to her right side because the resident moved around when she was on her back. The director of nursing (DON) was interviewed on 11/30/23 at 12:06 p.m. The DON said if a change in the resident's skin was found the CNAs were to notify a nurse and the nurse would notify DON and start the risk management assessment documentation. The DON said residents who could not reposition themselves should be repositioned every two hours. The DON said Resident #50 had first developed a skin tear because she was not seated properly in her wheelchair and was leaning to the left causing friction. The DON said therapy staff put a wedge positioning cushion in place to prevent further skin issues but the resident did not tolerate laying on her back to offload pressure on her hips. The DON said the resident was not eating enough so she was at high risk of pressure ulcers. V. Facility follow-up On 12/1/23, the nursing home administrator (NHA) provided an addendum to the physician's 11/17/23. The addendum note dated 12/1/23 (after exit), documented the wound progress note demonstrates that the wound was unavoidable. The resident was combative during care and repositioning. -The note provided no other rationale about why the wound development was now determined to be unavoidable. Additionally, the WCP said during the interview that the resident's right hip wound was avoidable and would not be there if not for the left wound causing the resident pain and making her reluctant to off load pressure from the right hip and lay on her back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to ensure two (#54 and #4) of four residents reviewed for accident hazards out of 34 sample residents, were provided adequate supervision and a safe environment to prevent accidents and the re-occurrence of accidents. Resident #54 was admitted to the facility on [DATE] with a diagnosis and history of falls. The resident had four falls from 8/23/21 through 4/7/22. The facility failed to implement effective fall precautions with her risk of falling. On 4/7/22 the resident sustained a head injury following a fall which required hospital treatment. The interventions included educating the resident but also documented the resident was not always able to communicate her needs and that she forgot conversations held after a few minutes. The resident had a care plan to wear non-skid socks. During the survey from 8/8/22 to 8/11/22, the resident was observed walking the hallway in nylon material socks that were not non-skid. In addition, the facility failed to: -Transfer Resident #4 in an appropriate manner; -Ensure a tube feeding device was plugged into a medical electrical outlet power strip; and, -Ensure electric cord was clear of a water source. Findings include: I. Resident #54 A. Facility policy The Fall Management policy, revised 4/7/22, was provided on 8/16/22 at 3:53 p.m. via email from the nursing home administrator (NHA). It revealed in pertinent part, Purpose To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. Policy The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Avoidable Accident means that an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. Unavoidable accident means that an accident occurred despite sufficient and comprehensive facility systems designed and implemented to: Identify environmental hazards and individual resident risk of an accident, including the need for supervision. Evaluate/analyze the hazards and risks and eliminate them, if possible and, if not possible, reduce them as much as possible. Implement interventions, including adequate supervision, consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice. All patients have fall indicators. Fall indicators are patient specific information that, when alone or combined with other fall indicators, create a potential for a patient to fall. B. Resident status Resident #54, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physical orders (CPO), the diagnoses included Alzheimer's disease, adult failure to thrive, hypertension (high blood pressure), disorientation, dysphagia (difficulty swallowing), history of falls, and dementia with behavioral disturbances. The 7/16/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15. The resident did not reject care from staff. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required limited assistance with transfers, and walking in the corridors. She was not steading moving from a seated to standing position. C. Record review A review of the facility fall investigations provided by the nursing home administrator (NHA) on 8/1/22 at 1:27 p.m. revealed Resident #54 fell four times. The resident had an injury during the fourth fall which required the resident to be sent to the hospital. A review of the four falls revealed in pertinent part: -The 8/23/21 fall report revealed the resident was found lying in the bathroom on her back, wearing only one non-skid sock. The report did not document any predisposing environmental, physiological, or situational factors that were documented on the fall investigation. The report did not contain any interventions that were put in place. The fall was unwitnessed. The resident was unable to give a description of the fall event. -The 12/18/21 fall report revealed a registered nurse (RN) assessed the fall but only revealed the resident was found on her right side. The report did not document where she was found at the time of the fall, what was the reason she fell, and no other predisposing environmental, physiological, or situational factors were documented on the fall investigation. The report did not contain any interventions that were put in place. The fall was unwitnessed. The resident was combative with staff during the fall assessment by the RN. The resident was unable to give a description of the fall event. -The 12/21/21 fall report revealed the resident was found on her left side on the floor. The report did not document where she was found at the time of the fall, what was the reason she fell, and no other predisposing environmental, physiological, or situational factors were documented on the fall investigation. The report did not contain any interventions that were put in place. The fall was unwitnessed. The resident was unable to give a description of the fall event. -The 4/7/22 fall report revealed Resident found lying face down with a chair on top of her, resident is alert but unable to tell what happened, small abrasion on forehead some bleeding noted. Resident was rubbing left hip and crying.The facility called an ambulance to transport the resident to the hospital. The report did not contain the location where the injury took place. The report documented there were no predisposing factors about the fall with injury. The resident was unable to give a description of the fall. -A follow up fall investigation report for the 4/7/22 fall, written on 4/14/22 (seven days after the fall) was provided by the facility nurse consultant (FNC) on 8/11/22 at 11:49 a.m. revealed in pertinent part, The event time was 3:00 a.m. The resident ambulates without assistance, able to transfer herself, has a history of falls. Resident was on the floor flat on her back, bleeding from the back of her head. Resident was then assisted to a sitting position, notice a deep laceration on her occipital (back of the head). Pressure dressing applied to stop bleeding. At 3:45 a.m. the resident started vomiting. Ambulance called and arrived at 3:53 a.m. The current interventions that were put in place at the time of the 4/7/22 fall were to Anticipate and meet the resident's needs. Assist with activities of daily living (ADLs) as needed, call light within reach. Educate the resident about safety reminders and what to do if a fall occurs. Provide activities that minimize the potential for falls while providing diversion and distraction. Provide appropriate footwear when ambulating non-skid socks provided. The 4/14/22 follow-up investigation had blank pages to the following questions: -Resident/family interviews and an interview of the resident who experienced the event with a list of questions and the resident's responses to be documented was left blank. The 4/14/22 follow-up investigation listed the falls for the past six months which were not included on the fall investigations revealed: -8/23/21 resident was face on floor in bathroom. The section documenting what new intervention was implemented after the fall was left blank. -12/18/21 resident was face of floor beside roommates bed. The section documenting what new intervention was implemented after the fall was left blank. -12/21/21 resident was found on (the) floor. The section documenting what new intervention was implemented after the fall was left blank. The fall care plan revealed the resident was at risk for falls related to diagnosis Alzheimer's dementia with decreased safety awareness, history of urinating in inappropriate places, history of falls. Interventions included: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurred (4/11/22). Provide activities that minimize the potential for falls while providing diversion and distraction (added 7/16/21). Provide appropriate footwear when ambulating non skid-socks provided (added 3/28/21). Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (added 7/16/21). An additional care plan revised on 1/27/22 revealed due to the resident's severe cognitive impairment, education would require specific strategies. -The resident's fall care plan had not been updated when the resident fell on 8/3/21, 12/18/21 and 12/21/21. There was no documentation that the family was educated about safety reminders. The resident was not provided with activities (see activity director interview below). The resident to spend her day walking back and forth throughout the hallways unassisted with no staff reminders of safety/mobility device. The resident was observed not wearing non-skid-socks (see observations below). D. Observations On 8/8/22 and 8/9/22 from 9:00 a.m. until 4:30 p.m. Resident #54 was not wearing shoes. She was wearing red nylon socks which were not non-skid socks. She walked almost continuously from one end of the upstairs hallway to the other. She stopped to talk to residents, walked into her bedroom, and continued to walk without staff assistance. She did not use a walker, cane, or wheelchair while she walked. On 8/10/22 and 8/11/22 from 9:00 a.m. until 5:30 p.m the resident was lying on her bed, and she sat up for meals. Per staff interviews below, the resident often was up at night pacing and would sleep during the day. E. Interviews Licensed practical nurse (LPN) #1 was interviewed on 8/11/22 at 10:35 a.m. She said Resident #54 was up all night on 8/9/22. She said the resident often stayed up all night pacing and walking back and forth on the second floor and then she slept all day. She said the staff would offer her snacks to keep her occupied when she paced up and down the halls. She said the resident had on non-skid socks today. She said the resident had two pairs of socks in her closet. She said one pair of socks was non-skid and one pair of socks was not. She said she did not know if the red socks the resident wore yesterday were non-skid and she said those socks were not in the resident's closet. She said the resident was unable to put on her own socks. She said staff put socks on the resident daily. She said the resident did not prefer to wear shoes. She said the resident did not understand how to utilize her call light. She said due to the resident's mental status she did not understand directions very well. Certified nurse aide (CNA) #4 was interviewed on 8/11/22 at 11:20 a.m. She said Resident #54 was up again all night on 8/10/22. She said when the resident was up all night she paced the hallways and was in bed all the following day. She said Resident #54 walked the halls on the second floor almost everyday and all day. The activity director (AD) was interviewed on 8/11/22 at 11:30 a.m. She said Resident #54 did not attend activities. She said the activity department tried one time to give the resident a one-to-one visit but she declined. She said no other one-to-one attempts were made or given since the resident declined personal visits. She said the resident did not attend group activities often because it was hard for her to pay attention. She said the activity department did not put supplies in the resident's room to help the night staff utilize items when the resident was up all night. She said she would get supplies and put in the resident's room for the evening staff to use with Resident #54. The NHA was interviewed on 8/11/22 at 4:40 p.m. She said from what she remembered about Resident #54's fall on 4/7/22 and from reading the notes, the resident was up wandering most of the night. She said the resident was a fall risk. She said the resident was in her room, fell flat on her back on the floor, and had lacerations to the back of her head. She said the resident had Alzheimer's and dementia and had not declined in health. She said she was unaware of the resident wearing or having regular socks instead of non-skid socks. She said the interventions put in place for falls for Resident #54 would need to be reviewed and updated after the survey (the exit was on 8/11/22). II. Resident #4 A. Facility policy The Mechanical Lift policy, revised 7/22/21, was provided by the director of nursing (DON) on 8/10/22 at 6:23 p.m. It read in pertinent part: The purpose of the policy was to provide guidance when transferring a resident with a mechanical lift.It is important to train staff regarding resident assessment about the importance of safe transfers when using a mechanical lift to transfer a resident. Residents who become frightened during a transfer in a mechanical lift may exhibit resistance movements that can result in avoidable accidents. Communication with the resident during the transfer may help to reduce the resident ' s fear and avoid an accident. The facility will provide this kind of lift for the residents who are determined to need this type of transfer to meet their needs.The facility will ensure that two associates are present during the time of the transfer and that one of the associates is over the age of 18.The facility will use the Lippincott procedure for hoyer lifts and sit-to stand transfers. B. Resident status Resident #4, age [AGE], was admitted on [DATE]. The August 2022 computerized physicians orders (CPO) included a diagnosis of type 2 diabetes, chronic kidney disease, history of falling, localized edema and difficulty in walking. The 7/21/22 minimum data set (MDS) indicated the resident was cognitively impaired with a brief interview of mental status (BIMS) with a score of five out of 15. The resident required extensive assistance with toileting, sitting to stand, chair to bed transfer, dressing and bathing. C. Record review Transfer training documentation was received from the director of nursing (DON) one 8/10/22 at 6:23 p.m. It read: any mechanical lift requires two staff members when transferring a resident.The training sign off sheet contained 28 staff signatures, half of which took the training on 7/19/22 and the other half took the training on 7/21/22. The MDS functional status review dated 7/21/22 indicated the resident was totally dependent on the hoyer (mechanical) lift and needed a two person assistance with transferring, from sitting to a lying position and the resident was dependent on her wheelchair for mobility. The care plan detail was updated on 7/29/22. Resident #4 has an activity of daily living (ADL) self-care performance deficit. She has bilateral upper and lower extremity contractures.The resident has non weight-bearing status. A two person hoyer lift should be used for all transfers. D. Observations On 8/10/22 at 1:43 p.m., the resident was sitting in her recliner chair. Certified nurse aide (CNA) #5 and CNA #9 placed the hoyer mechanical lift sling around the resident. The sling criss crossed between her legs. When the CNA began to raise the lift. At 1:50 p.m., the director of rehabilitation (DOR) arrived into the room, after CNA #5 had requested her to come into the room. The DOR told the CNAs that a sit-to-stand lift would be used. She failed to look at the sling which was placed on the resident prior to changing the mechanical lift from a full hoyer lift to a sit to stand. CNA #9 said the sling for the sit-to stand lift was on top of the resident ' s closet. The sling was removed and placed behind the resident. The straps crisscrossed across her breasts. The straps were tight. CNA #5 began to use the lift and the resident was assisted into the standing position. The resident did not have her hands on the lift, and her arms hung down, as she was lifted. The resident called out that it hurt. The CNAs continued using the lift with the incorrect sling after the resident called out that it hurt and she was placed on the bed. The sling was removed. CNA #5 said the sling needs to be an extra large sling. CNA #5 looked at the sling which was used, and it was a medium. She said she would locate a large sling. At 2:06 p.m the DOR told the charge nurse that the sit-to-stand lift was the lift to use with her transfers from the bed to chair and vice versa, although she needed an extra large sling. E. Interviews The director of nursing (DON) was interviewed on 8/10/22 at 4:32 p.m. She said Resident #4 was supposed to be transferred by two staff in the hoyer lift instead the staff used a sit-to-stand lift. She said the staff used a medium sling when they should have used an extra large one. She said it resulted in extreme discomfort to the resident since the sling was too small. The director of rehabilitation (DOR) was interviewed on 8/11/22 at 5:30 p.m. The DOR, who was an occupational therapist assistant, said when she arrived at the room, the resident was complaining that the full mechanical lift sling was hurting her legs, so she said she made the decision to use the sit-to-stand lift. She said that in the past the sit-to stand lift was utilized for this resident. She did confirm that she did not assess the hoyer mechanical lift sling. She said the resident had been assessed for the sit-to-stand lift at an earlier date. She confirmed, she had not checked the sling which was in the room. The DOR said an extra-large sit-to-stand sling would be obtained. She said when the transfer happened, it was tight and squeezed her breasts. The DOR said having the right sling for the resident was important. III. Ensure tube feeding device was plugged into a medical grade power surge protector A. Observations On 8/8/22 at 10:36 a.m., room [ROOM NUMBER] had a tube feeding device, which was plugged into a regular power strip. It was not a medical grade power surge. On 8/10/22 at approximately 4:00 p.m., the tube feeding device continued to be plugged into the non-medical power surge. B. Staff Interview The nursing home administrator (NHA) was interviewed on 8/11/22 at 7:00 p.m. The NHA said environmental plant rounds were completed weekly. She said it was to ensure the environment was safe. She said they had not identified the medical equipment that was not plugged into a medical grade power strip. She said the facility did have medical grade power strips and would replace it immediately. IV. Ensure electrical cord was clear of water source A. Observations On 8/8/22 at 2:30 p.m., room [ROOM NUMBER] had an electrical cord from the television which was observed hanging over the sink. The cord was plugged into a power surge protector, which was plugged in over the wardrobe closet. The power surge protector was not plugged into a ground fault circuit interrupter (GFCI). On 8/8/22 at 4:00 p.m., the cord was observed in the same position. B. Staff Interview On 8/8/2022 at 5:30 p.m., the nursing home administrator (NHA) was shown the electrical cord hanging over the sink. The NHA said, I missed that on my earlier round. The NHA asked the resident if she could unplug the television for a minute while she rerouted the electrical cord. The NHA immediately removed the cord from the power strip protector and plugged it into the GFCI outlet. The cord length still had the capability of hanging into the sink. The NHA said she would get some clips to ensure the cord was not close to the water source.