**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#49) of eight residents reviewed for accident hazards out of 34 sample residents. Resident #49 was identified as a high fall risk through facility assessment. Resident #49 needed substantial to maximum assistance rolling from left to right/right to left in bed. Resident #49's care plan was reviewed on 4/4/24 and included an intervention for the assistance of two people with bed mobility (scooting, rolling, or moving from lying to sitting or sitting to lying) and transfers in and out bed. Resident #49 sustained a fall out of bed on 4/11/24 while receiving incontinence care from certified nurse aide (CNA) #1. CNA #1 was providing care for the resident without another staff member in the room for assistance. When CNA #1 rolled the resident toward her, the resident rolled too far over and began to fall off the bed. CNA #1 was unable to catch the resident and Resident #49 fell to the floor. Resident #49's injuries included two forehead lacerations, bruising to her nose and mouth and bleeding in her mouth with a small laceration of the interior upper lip and bruising to the right eye. She was transported to the hospital for further treatment where imaging tests revealed Resident #49 had sustained C1 and C2 vertebrae (top of the neck) fractures from the fall. Due to the facility's failure to ensure two staff members were present to assist Resident #49 with bed mobility during incontinence care, Resident #49 sustained a fall which resulted in a major injury. Findings include: I. Resident status Resident #49, over the age of 65, was admitted on [DATE], readmitted on [DATE] and passed away at the facility on 4/13/24. According to the April 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia, atrial fibrillation , type II diabetes mellitus, chronic kidney disease, spinal stenosis , osteoarthritis, osteoporosis and history of falling. The 4/1/24 minimum data set (MDS) assessment revealed the resident had a memory problem and was severely impaired in her decision making abilities for everyday life based on staff interview for mental status. She was dependent on care with eating, oral hygiene, toileting, showering and bathing, upper and lower body dressing including footwear, personal hygiene, and all transfers. She needed substantial/maximum assistance rolling from left to right/right to left in bed. II. Record review A. Care plan and interventions Resident #49's 4/4/24 care conference summary documented her care plan reflected her current status and she remained needing total care as a resident. The care plan, reviewed 4/4/24, included the following care plan focus areas: The falls care plan, initiated on 12/4/14 and revised on 10/6/21, documented Resident #49 was at high risk for falls due to her previous falls with fracture and surgical repair complicated by her Alzheimer's disease diagnosis and her non-weight bearing status. She utilized a geri chair (padded wheeled chair) and staff assisted the resident with mobility. Resident #49 was unable to stand. Pertinent interventions included the use of a mechanical lift for transfers as the resident was non weight bearing and providing supportive care and assistance as needed with mobility. Resident #49's care plan for self care, initiated on 12/4/14 and revised on 8/28/18, documented she had a deficit related to her diagnosis of advanced dementia and needed assistance with all activities of daily living. Pertinent interventions included the assistance of two people with bed mobility and transfers in and out of bed. The care plan interventions documented she needed assistance with dressing, eating, personal hygiene and toileting as she was completely incontinent of bowel and bladder. B. Fall on 4/11/24 The 4/12/24 progress note, written at 1:36 a.m,. documented Resident #49 suffered a fall from her bed on 4/11/24 while CNA #1 was providing care. CNA #1 and CNA #2 assisted Resident #49 using the mechanical lift to transfer Resident #49 from a chair to her bed. The sling was detached from the mechanical lift and removed from under the resident. CNA #2 left the room to assist another resident while CNA #1 remained with Resident #49 to change the resident in bed. When CNA #1 turned Resident #49 toward her, she was not close enough to the bedside edge to enable her to effectively brace Resident #49 as she was being turned. Resident #49 rolled farther than CNA #1 anticipated and started to fall off the bed. CNA #1 attempted to catch Resident #49 but was unable to do so. Resident #49 was assessed and sustained two lacerations to her forehead, bruising to her nose and mouth with a small laceration on her interior upper lip, and bruising to her right eye. Resident #49 was sent to the emergency department for further evaluation. -The facility failed to ensure two staff members were present to assist Resident #49 with her bed mobility while providing incontinence care as outlined in her care plan. The 4/13/24 physician communication progress note written at 2:39 p.m. documented Resident #49 was admitted to a local hospital on 4/12/24 and diagnosed with fractures of the C1 and C2 vertebrae. She was readmitted back to the facility on 4/12/24 at 7:00 p.m. with diagnoses of fractures to the C1 and C2 vertebrae and bilateral nasal displaced bone fractures. She was wearing a neck collar. C. Facility fall investigation and follow up Resident #49's post fall assessment documented Resident #49's fall occurred on 4/11/24 at 10:00 p.m. in her room. Resident #49 was in bed and was turned for incontinence care by CNA #1. The assessment documented CNA #1 reported she rolled Resident #49 toward her and the resident rolled farther than CNA #1 anticipated to the edge of the bed. Resident #49 started falling off the bed and CNA #1 attempted to catch her. CNA #1 did not have her arms up by Resident #49's shoulders and she was unable to catch her. Resident #49 was unable to provide information regarding what happened due to her advanced dementia. The interdisciplinary department (IDT) risk management review note, written on 4/17/24 at 1:44 p.m., documented the root cause of Resident #49's fall as the momentum of the resident being rolled toward CNA #1 was too fast during incontinence care performed while the resident was on her bed. Interventions put into place after the fall included the following: Resident #49 was sent to the emergency room for evaluation, given a soft neck collar upon return to the facility on 4/12/24 and provided the assistance of two people for care provided in the resident's bed. Education for CNAs and nurses in the facility began on 4/12/24 regarding ongoing proper turning of residents in bed during care. D. Post fall training The Positioning a Resident to Perform Incontinence Care education presented to all of the CNAs and licensed nurses after Resident #49's fall was provided by the division director (DD) on 6/5/24 at 5:54 p.m. The education for staff was initiated on 4/12/24 and documented the following in pertinent part, To maneuver or turn a resident when a slide sheet is not used, is performed in the following steps (make sure all supplies are easily accessible: brief, wipes, barrier cream, trash can). -Raise the bed to at least waist height; -Cross the resident's arms over their chest; -Bend the resident's leg towards you; -Push gently across the hip and the shoulder so that the resident rolls away from you; -Once the resident is in a side-lying position, ensure the knees and the ankles of the resident do not rest on each other; -Place a wedge behind the upper back, support the top leg using a pillow or an appropriate pad and do the same for the top arm; and, -Check for comfort and readjust. The education documented additional things to consider, such as the dependency of the person and the level of assistance they can offer during the task, the size of the person (check the width of the bed to ensure staff were able perform the maneuver safely) and the weight of the person (was the manual force provided by a single person enough to perform the task safely by avoiding leaving the patient stranded midway or having a fall). CNA #1 and CNA #2 signed documentation they completed the training on 4/12/24. III. Staff interviews CNA #3 was interviewed on 6/6/24 at 10:30 a.m. CNA #3 said the level of assistance a resident needed for care, including transfers, was found in the resident's care plan. CNA #3 said he reviewed a resident's electronic medical record (EMR) to see their care needs. CNA #3 said he was unable to view multiple residents records at a time and there was not an easier way to review the level of assistance for multiple residents at one time. He said there were a number of reasons a staff member might need to leave a resident's room while performing care tasks for a resident. CNA #3 said any changes to the amount of care needed by a resident were communicated between facility staff during their shift change with other CNAs. He said the nurses also provided updates or changes to care needs of the residents. CNA #3 said all staff received education after Resident #49's fall. He said the training covered resident transfers, understanding when a resident needed assistance from one versus two staff members and how to provide incontinence care. He said the facility was consistent in providing education after a resident's fall. CNA #2 was interviewed on 6/6/24 at 2:20 p.m. CNA #2 said a resident's EMR provided information regarding the level of care assistance a resident needed but the information could also be provided by another CNA at their shift change or a nurse at any time. CNA #2 said he provided care to Resident #49 on 4/11/24. CNA #2 said he and CNA #1 transferred Resident #49 to her bed using a mechanical lift on 4/11/24. CNA #2 said once Resident #49 was on her bed, both he and CNA #1 thought CNA #1 was capable of providing incontinence care to Resident #49 by herself. CNA #2 said after Resident #49 was transferred to her bed he left Resident #49's room. CNA #2 said after Resident #49 fell, he did discuss Resident #49's fall with the facility managers. He said he was aware, after the fall and additional training was provided to the facility staff, that there should have been two people who provided care to Resident #49. CNA #2 said a staff member should not leave a resident's room until the care was complete. He said there was additional training provided to him and other staff after Resident #49's fall that included computer based training, as well as on shift teachings from the nurses. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 6/6/24 on 6/6/24 at 2:50 p.m. The DON said CNA #1 provided incontinence care for Resident #49 while she was on her bed, the resident rolled too fast toward the edge of the bed and started to fall. The DON said CNA #1 stood closer to Resident #49's lower body to provide incontinence care. She said CNA #1 had to move toward the resident's upper body to catch the resident as she started to fall. The DON said CNA #1 was unable to stop the resident from falling. The DON said CNA #1 should have been standing in a different spot at the resident's bedside while providing her incontinence care. The DON said the facility began to review resident's care plans after Resident #49's fall. She said the residents with care needs most similar to Resident #49 were identified first to prevent a similar situation with other residents. The DON said if a resident's care needs changed the MDS assessment was updated. She said the nurse supervisors would then provide the nursing staff education on the changes. The DON said the facility provided CNA #1 additional training related to turning and lifting of residents with the restorative therapy department. The DON said the facility also had regular meetings with residents to discuss what staff could improve on to prevent falls. The DON said the CNA tasks for daily care in the resident's EMR did not include the residents' level of assistance needed. The DON said the CNA tasks were pre-populated. She said she would look into if the facility would be able to make changes to the pre-populated tasks. The DON said, as a best practice, staff should look at the residents' care needs every day. The NHA said Resident #49 fell toward CNA #1 as she provided incontinence care. The NHA said Resident #49 needed two people while using the mechanical lift, however it was not clear to the staff, based on how her care plan was written, that Resident #49 needed two people for her incontinence care immediately prior to her fall on 4/11/24. The NHA said CNA #1 and CNA #2 had transferred Resident #49 into the bed and then CNA #2 left the room. The NHA said CNA #1 tried to clean the resident and move the resident while she provided incontinence care. The NHA said both CNA #1 and CNA #2 thought they were following the facility's policy while providing care for Resident #49. -However, only one staff member stayed to provide incontinence care, this was not in line with Resident #49's care plan which indicated the resident needed the assistance of two staff members for bed mobility (see record review above). The NHA said the restorative therapy department provided the facility staff with ongoing education for lifting, transferring and resident care. The NHA said the restorative therapy department was reviewing resident care plans after Resident #49's fall but the NHA did not think the reviews had been completed. The NHA said the therapy department staff provided education during the different shifts and on different units that included a demonstration of proper transferring techniques. The NHA said a contracted facility provider also attended the facility fall meetings on a regular basis and provided different resources to the facility for fall prevention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to implement appropriate and timely interventions to ensure two (#71 and #46) out of five residents reviewed for pressure ulcers received the necessary care and treatment to prevent the development of a pressure injury (ulcer), out of 37 sample residents. Specially the facility failed to ensure: -Necessary interventions to assist Resident #71, despite the facility being aware of the resident's compromised health and skin condition, contributed to the resident developing a stage three (3) pressure ulcer to the coccyx. -Resident #71 with pressure relief, timely incontinent care and friction reduction, to prevent the development of a moisture induced stage three (3) pressure injury. Interventions to change and reposition the resident were not implemented timely, in order to maintain the resident's skin integrity and promote healing. -Resident #46's fingernails were trimmed to prevent pressure from his fingernails digging into his left palm. Furthermore, the Resident #71 was left to sit up in a moist and wet adult incontinent briefs his wheelchair for long periods of time without being changed or repositioned timely. Preventative assessment did not accurately capture the residents risk for skin breakdown to ensure a proper plan was put in place to address any skin concerns and because of this, the resident sustained moisture associated skin damage. Findings include: I. Facility policy and procedure The Skin Care policy and procedure revised 4/15/19, was provided by the nursing home administrator (NHA) on 2/27/2020 at 2:45 p.m. The policy read in pertinent part: The resident can expect minimized potential for skin breakdown and treatment of existing problems to maximize skin integrity though initiation of appropriate interventions. -Instruct the patient/other according to the Preventing Pressure publication. Including the patient's risk status, the need for intervention, and the importance of the patient's participation in the program. -Skin care standards of the incontinent patient: Assess if the patient is a candidate for bowel/bladder program, or toileting on schedule. Cleanse the skin after each incontinent episode with the system approved skin care cleanser. The Positioning the Resident policy and procedure revised 7/25/02, was provided by the NHA on 2/27/2020 at 2:45 p.m. The policy documented the mechanical steps of positioning a resident and the various positions a resident could be positioned into, but did not document the benefits and reasons for positioning a resident in different positions to offset pressure points. II. Resident status A. Resident #71 Resident #71, age [AGE], was admitted on [DATE]. According to the February 2020 computerized physician orders (CPO) diagnoses included full incontinence of feces and functional urinary incontinence; pressure ulcer of sacral region, stage three (3) (added to diagnoses on 1/7/2020) and Alzheimer's disease. The 1/22/2020 minimum data set (MDS) exam revealed the resident was not able to participate in the brief interview for mental status (BIMS) due to severe cognitive impairment. Staff assessment revealed the resident had significant short and long-term memory impairment with severely impaired cognitive skills for daily decision making. The resident was totally dependent on two staff persons for activities of daily living (ADL) including: transferring between surfaces; going to the bathroom; complete personal hygiene; bathing; dressing; to position safely and comfortably in bed; and to move throughout the community. The resident was identified to be at risk for developing pressure ulcers and as having moisture associated skin damage and a current stage three pressure ulcer which developed in the facility (facility acquired). He was receiving pressure ulcer care and was on a turning/positioning program. B. Resident observation and family interview Resident was observed on 2/25/2020 at 3:17 p.m., lying in bed on his back propped to the left side with a pillow. He was with his family and appeared comfortable and was sleeping. Based on the resident's medical record, staff and family interview the resident had been progressively declining in his level of functioning and activity. On the days of observation between 2/24/2020 through 2/27/2020 the resident was not responsive and was unable to complete an interview. The resident's medical power of attorney (MPOA) was interviewed on 2/25/2020 at 3:17 p.m. The MPOA said the resident was actively passing (dying) and was put on comfort care this week. The MPOA said the resident developed a bedsore on his backside just after the New Year and after that he could no longer stay up in his wheelchair or get around like he used to. The facility informed the MPOA when the pressure ulcer was identified. He said it was initially quarter sized. He said he thought it was getting better since they put him on bedrest. The MPOA said he understood the pressure ulcer was caused by sitting up too long in his wheelchair in the same position without being moved. There was too much pressure on his backside. The staff tried their best, but they get busy and are not always able to take care of things as quickly as they can at other times. He said they had difficulty transferring Resident #71 out of the chair to get him changed because he was afraid of the mechanical lift and would cry when they went to lift him. It took some time for him to learn that they were not trying to punish him with the lift. Weight loss may have contributed to the pressure ulcer developing, as well. Today he seems comfortable and we have asked them not to get him up, he does not need to be uncomfortable and they can reposition him better in bed. C. Record review The comprehensive care plan dated 2/4/2020 revealed the resident needed the following: Care focus - Potential for impaired skin integrity: requires assistance with some ADLs and incontinence of bowel and bladder pressure ulcers noted. The goal initiated 7/7/19, was: Resident to have no complications related to moisture associated skin damage of the buttocks and cleft/coccyx. The interventions included: -Keep skin clean and dry, initiated 4/6/19 and Frequent position changes while in bed at night and in chair, initiated 4/13/16. Care focus - Altered elimination: resident has functional bowel and bladder incontinence. The goal initiated 6/22/15, was The resident will remain free form skin breakdown due to incontinence and brief use. The interventions included: -Clean the perineal area and apply barrier cream with each incontinence episode, initiated 6/22/15. Care focus -Self-care deficit: resident has an ADL self-care deficit related to limited mobility. The goal initiated 6/22/15 was The resident will maintain a neat and clean appearance. The interventions included: -Bed mobility: requires assistance by staff to turn and reposition in bed, initiated 6/22/15. -Toilet use: containment program initiated 6/22/15. -Transfers: at times use sit and stand lift. At times needs sling lift, initiated 6/22/15. Nursing: weekly skin observation notes dated 12/15/19 at 2:20 p.m. and 12/25/19 at 10:35 a.m. revealed the resident had redness to the groin, posterior scrotum area. The skin of the sacrum /coccyx/ischial pressure areas were intact. Concern: prevention of moisture associated skin damage to the buttocks. Nursing: weekly skin observation note dated 1/5/2020 at 10:41 a.m. revealed the resident had redness to his groin, posterior scrotum area, and a stage three pressure ulcer on the coccyx area. Nursing note dated 1/6/2020 at 11:17 a.m., read in pertinent part: Skin/wound note: Resident #71 has a stage three (3) coccyx wound more than likely related to position in his chair and sitting in it for long periods of time. Physician progress note dated 1/7/2020 at 12:07 p.m., read in pertinent part: -Problem #2: pressure ulcer -coccyx - stage three (3). Subjective: wound care nurse reports stage three pressure ulcer to coccyx related to positioning in his chair. Please offload area in bed and limit Resident #71 to be in a chair for meals. Ensure he remains in the chair 30-45 minutes to prevent gastric reflux (GERD), then to bed and left open to air. Coccyx has a seven-day skin protector in place. Do not cover the wound. Continue with vinegar/water wash. -Objective: A thin elderly male reclining in his wheelchair for assessment. He is calm, cooperative, in no apparent distress. -Skin is warm and dry, some evidence of flaking and seborrhea scattered around his face and upper chest. I did not visualize his coccyx, however, it is under surveillance by nursing and the wound care nurse. Physician: wound care note dated 1/9/2020 at 3:59 p.m. revealed the resident had a stage three pressure wound on the coccyx area measuring one centimeter (cm) by one cm no depth measurement. The wound bed was clean with no drainage. Braden scale for predicting pressure sore risk assessment dated [DATE] at 3:18 p.m., revealed the resident was at a moderate risk for skin breakdown with a score of 13 out of 18. However, the assessment was inaccurately documented for the following reason: at the date of the assessment the resident had a stage three pressure ulcer on his coccyx and the assessment choice contradict with the resident's medical records and staff interviews in the areas of nutrition and friction/shear. The Braden scale documented, the resident's nutrition/food intake pattern was adequate: eats over half of most meals which is partly in line with the nutrition dietary note documenting the resident eats on average 75 percent of his meals; however, the resident had a recent significant unplanned weight loss which would indicate that his dietary intake was not adequate. The nutrition note read in pertinent part: -Nutrition/dietary note dated 1/22/2020 at 1:14 p.m.: Resident #71, seen for weight loss and wounds. Current body weight 161 pounds body mass index (BMI) 24.5 within normal limits, weight is down 5.2 percent over 30 days. - He is on a pureed diet, receives assistance with meals. Oral food intakes vary, average 75% of meals. He accepts fortified shakes twice a day and med pass supplement 90 milliliters (ml) twice a day well. Due to wound and weight loss, recommend increasing med pass to 90 ml three times a day. The Braden scale also checked that the resident only had potential problems with friction and shearing: moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chairs, restraints or other devices. Maintains a relatively good position in chair or bed most of the time but occasionally slides down. In contrast the MDS assessment dated [DATE] revealed the resident was totally dependent on two staff persons for most ADLs including: transferring between surfaces; going to the bathroom; complete personal hygiene; bathing; dressing; to position safely and comfortably in bed; and to move throughout the community. The ADL-tracking-30 day look back for peri care provided-after every incontinent episode reveal the resident received peri care approximately three to four times a day, and not every two hours, as ordered. Dates and times recorded was as follows: -1/27/2020 at 12:09 a.m., 8:51 a.m. and 3:05 p.m. -1/28/2020 at 1:58 a.m., 8:45 a.m., 7:55 p.m. and 11:51 p.m. -1/29/2020 at 9:31 a.m. and 4:19 p.m. -1/30/2020 at 12:00 a.m., 9:34 a.m. and 3:48 p.m. -1/31/2020 at 6:29 a.m., 8:40 a.m. and 4:17 p.m. -2/1/2020 at 12:09 a.m., 9:16 a.m. and 9:47 p.m. -2/2/2020 at 1:42 a.m., 8:05 a.m., and 7:35 p.m. -2/3/2020 at 12:36 a.m., 9:40 a.m., 3:13 p.m. and 11:52 p.m. -2/4/2020 at 8:27 a.m., 5:23 p.m., and 10:42 p.m. -2/5/2020 at 9:29 a.m. and 5:04 p.m. -2/6/2020 at 1:11 a.m., 8:43 a.m., 9:35 p.m., and 10:52 p.m. -2/7/2020 at 9:00 a.m. and 9:41p.m. -2/8/2020 at 12:02 a.m., 8:15 a.m., and 9:46 p.m. -2/9/2020 at 12:38 a.m., 8:40 a.m., and 3:39 p.m. -2/10/2020 at 5:35 a.m., 8:26 a.m. and 3:47 p.m. -2/11/2020 at 2:02 a.m., 2:22 p.m., and 5:20 p.m. -2/12/2020 at 2:39 a.m., 9:46 a.m., 3:25 p.m., and 10:39 p.m. -2/13/2020 at 8:53 a.m., 3:52 p.m., and 10:38 p.m. -2/14/2020 at 2:03 p.m., 7:57 p.m., and 10:57 p.m. -2/15/2020 at 10:44 a.m., 8:02 p.m., and 11:20 p.m. -2/16/2020 at 9:22 a.m. and 3:57 p.m. -2/17/2020 at 1:27 a.m., 8:22 a.m., 7:42 p.m., and 11:54 p.m. -2/18/2020 at 10:06 a.m. and 5:23 p.m. -2/19/2020 at 12:00 a.m., 9:11 a.m. and 9:05 p.m. -2/20/2020 at 12:15 a.m., 9:54 a.m., 9:20 p.m. and 10:49 p.m. -2/21/2020 at 9:11 a.m., 3:53 p.m. and 11:15 p.m. -2/22/2020 at 7:45 a.m., 7:15 p.m. and 11:13 p.m. -2/23/2020 at 7:08 a.m., 5:52 p.m. and 10:38 p.m. -2/24/2020 at 9:56 a.m. and 3:15 p.m. -2/25/2020 at 12:45 a.m. and 8:54 a.m. D. Staff interview Registered nurse (RN) #11 was interviewed on 2/25/2020 at 3:29 p.m. RN #11 said Resident #71's wound was being managed by the facility wound nurse, he was currently on palliative care with comfort measures. RN #11 said the family asked for the resident to remain in bed for his comfort and the CNAs were repositioning and changing him every two hours. Certified nurse aide (CNA) #12 was observed and interviewed on 2/25/2020 at 3:47 p.m. CNA #12 was observed changing and repositioning Resident #71. CNA #12 said they have been turning, changing and doing oral care for the resident every two hours. The resident's pressure ulcer was observed, the pressure ulcer was dressed with a clear barrier film. The clear bandage was intact. The skin underneath was deep pink and the top layer of skin was not intact. RN (#3) was interviewed on 2/25/2020 at 4:15 p.m. RN#3 said as soon as the CNA notified her of the resident's pressure ulcer she assessed the wound and notified the resident's physician for orders to treat the wound. Resident #71's stage three pressure ulcer was on his coccyx and started as moisture associated dermatitis and shearing. He had a history of being incontinent paired with cluster areas of breakdown (impaired breakdown). He did not have much adipose tissue on his buttocks and he was sitting on that portion of his coccyx all the time that he was up in his wheelchair, sometimes for the majority of the day shift. The RN said letting resident sit up in his wheelchair for extended periods of time most likely contributed to his skin breakdown. His posture was not good and he was not able to hold himself up properly, he was sinking into himself (RN #3 modeled her words by crunching her abdomen and rolling her shoulder in ward). Anything could be prevented, it is hard to say what was the cause of his pressure ulcer; I really think he was sitting up in his chair too long, and sitting in the same position without being changed. The RN #3 said they were currently using Cavilon Advanced Skin Protectant over the resident's pressure ulcer. Cavilon is a heavy lacquer like substance that seals the wound and provides seven (7) days of coverage to protect against moisture dermatitis and shearing. His health condition changed this week and he is declining rapidly. The wound care doctor will not be looking at his wound this week during wound rounds because of his declining health. We are making the resident comfortable and he is being changed and repositioned every hour. If he does get up in his wheelchair he was to be repositioned every hour. If he gets up to eat he will remain up for a maximum of 45 minutes after the meal to promote digestion and prevent acid reflux he was not to be up in his wheelchair longer than two hours at a time. After that he needs to be back in bed to off load pressure from his coccyx. His pressure ulcer had been improving, I looked at it this past Sunday and applied a new layer of Cavilon. The wound was pretty much gone. CNA #1 was interviewed on 2/27/2020 at 12:00 p.m. CNA #1 said she just started to work with the resident so she was not familiar with his care prior to his developing the pressure sore. Her usual practice of care for incontinent residents was to keep them dry, clean their skin after an incontinent episode, and apply lotion to protect the skin. Since working with Resident #71 she has been directed that he was to be up for only short time periods and be back to bed and repositioned at least every two hours alternating from side to side to keep him off his buttocks, so his sore could heal. CNA #2 was interviewed on 2/27/20 12:28 p.m. CNA #2 said she had been working in the facility since mid-January and since that time they were directed that the resident can be up for only two hours at time and then had to be put to bed. If he was up to eat, he had to be put back in bed within 45 minutes after eating and turned frequently. CNA #2 said since she had been working with Resident #71 his pressure ulcer looked much the same as it did when she started. It was currently about the size of a thumb nail or a dime and was pink in color. The nurses were applying a special clear barrier gel and there was no gauze bandage over the wound. CNA # 3 was interviewed on 2/27/2020 at 12:35 p.m. CNA #3 said she had been working with Resident #71 for over a year and she had never known the resident to be resistive to care. She said Resident #71 was always willing to lay down to get off of his buttocks. CNA #3 said the resident needed assistance to lay down. The director of nursing (DON) was interviewed on 2/27/2020 at 5:27 p.m. The DON said Resident #71 had moisture associated dermatitis and the staff should have encouraged him to offset and get out of his wheelchair to relieve pressure off his coccyx and buttocks to help prevent pressure ulcers from developing. The resident was currently in bed and staff have been instructed that he was not to be left up in his chair for more than two hours at a time. III. Nail care 1. Resident #46 A. Resident status Resident #46, was admitted on [DATE]. The February 2020 computerized physician orders (CPO) diagnoses included type II diabetes mellitus, left hand contracture, and hemiplegia. According to the 12/27/19 minimum data set (MDS) assessment he had moderate cognitive deficits with a brief interview for mental status (BIMS) score of 11 out of 15. He required extensive assistance of one person for hygiene and he had one sided impairment of his upper extremities. B. Resident interview Resident #46 was interviewed on 2/25/2020 at 11:26 a.m. He said his fingernails were digging a hole in his left palm, which was causing him to have pain in his left palm, and the pain in his left palm affected his ability to enjoy his day. He could barely lift the fingers off of his left palm, to keep his finger nails from digging into it, to relieve the pain. He said he had requested more than once to have his nails trimmed, however the task was not completed. He said he He could not cut his own fingernails because his left hand was affected by a stroke. He said it continuously remained in a closed fist position, and to open it required a surgical procedure to release the tendons which kept it in a fist. Resident #46 was interviewed on 2/26/2020 at 10:07 a.m. He said yesterday he asked registered nurse (RN) #1 to cut the fingernails of his left hand because they were causing him to have pain in his left palm; she told him she would get someone to do it and nobody did it for him. The resident said the pain in his left hand was no longer bearable because the fingernails are so long. Resident #46 was interviewed on 2/26/2020 at 1:25 p.m. He said licensed practical nurse (LPN) #1 trimmed some of the fingernails of his left hand today and he felt better she trimmed them. He looked forward to having the rest of his fingernails trimmed today and trimmed more often. LPN #1 told him she would trim the other fingernails later today. The left palm pain he felt before his fingernails were trimmed C. Observation 2/25/2020 - At 11:46 a.m., Resident #46's left hand was observed in a closed fist position. The resident's hand did not have anything protecting his left palm. The fingers of his left hand overlapped his left thumb. The fingernails of his left hand fingers pressed into his left palm. These fingernails caused his palm to be reddened. He used his right hand to lift the fingers of his left hand off of his left palm to show the indentation the left hand fingernails continually made in his left palm. He was observed to attempt to independently open his left hand, to get his fingernails off of his left palm, however, he could not lift his fingers off of his left palm without using his right hand. 2/26/2020 -At 10:45 a.m., with the presence of the nursing home administrator (NHA) and the assistant director of nursing (ADON), the resident's left hand was observed in a closed fist, with no palm protector in place. He showed the NHA and the ADON his left palm and how the fingernails of his left hand dug into his palm which caused him pain. He told them that last night he requested RN #1 to trim the fingernails of his left hand because they dug into his left palm because it hurt. He told them that RN #1 said she would have someone trim the fingernails of his left hand and none of the nurses, not even RN #1, trimmed them last night. He told them his left palm hurt and wanted the fingernails of his left hand trimmed so they would no longer dig into his left palm so he would no longer be in pain. 2/27/2020 -At 2:00 p.m., the resident's fingernails of three fingers of his left hand appeared to be trimmed and no longer digging into his left palm. There was nothing protecting his left palm. D. Record review The care plan, initiated on 9/1/2015 and revised on 4/19/18, identified he had a potential for impairment of skin integrity due to diagnoses of vascular disease and type II diabetes. Interventions included to keep his finger nails short, to place a wash cloth or hand brace on left hand to prevent contraction of his left hand and prevent fingers from digging into the palm of his left hand at night, and to keep his skin clean and dry. According to the review of the February 2020 progress notes, retrieved on 2/26/2020 at 10:30 a.m., they reflected there was no documentation RN #1 nor any nurse trimmed Resident #46's fingernails of his left hand. According to a review of the February 2020 skin assessments, retrieved on 2/26/2020 at 10:30 a.m., they reflected there was no documentation RN #1, nor any other nurse, assessed the skin of Resident #46's left palm. According to the February 2020 treatment administration record (TAR), retrieved on 2/26/2020 at 10:30 a.m., it reflected there was no documentation Resident #46 had the fingernails of his left hand trimmed on a regular basis. E. Interviews LPN #1 was interviewed on 2/26/2020 at 10:11 a.m. LPN #1 identified she worked the day shift today and said when she came to work her shift today, the night nurse did not report any care concerns to her about Resident #46. The certified nurse aide (CNA) #11 was interviewed on 2/26/2020 at 1:06 p.m. CNA #11 said she was unable to thoroughly clean Resident #46's left hand when she showered him as his hand was in a closed fist position. She said it hurt him when she tried to clean under or between the fingers of his left hand. She said his left hand was in a closed fist positon when he came to the facility. LPN #1 was interviewed a second time on 2/26/2020 at 12:57 p.m. LPN #1 said Resident #46's left hand was contracted. She did not know he needed his nails trimmed. She said nails were trimmed and assessed on shower days. She trimmed his nails after she was instructed by the ADON to trim his nails. She said two fingernails of his left hand and planned to trim the remaining fingernails in after a while because it caused him pain when she tried to cut the fingernails of his left hand. Resident #46 could not open his left hand; it remained in a fist with the thumb trapped under his fingers. She had never documented when she trimmed his nails before today. She said Resident #46 had to have his nails trimmed by a licensed nurse due to his diagnosis of type II diabetes. She said there was no documentation that RN #1 or another nurse trimmed the fingernails of his left hand last night. When she trimmed the fingernails of his left hand today she said his left hand smelled. His left hand was contracted when he was admitted into the facility. RN #1 was interviewed on 2/27/2020 at 4:52 p.m. She said RN #3 (the wound nurse) and the other nurses trimmed Resident #46's fingernails because he was a diabetic. His nails were to be assessed and trimmed on his shower days or whenever they needed to be trimmed.RN #1 said his nails needed to be trimmed to maintain hand hygiene and prevent skin injury from scratching, and to prevent the formation of skin sores sustained due to poor healing of skin injuries from untrimmed nails. The ADON was interviewed on 2/26/2020 at 10:29 a.m. The ADON said she was not aware of the resident's nail situation until after the observation (see above). She said she had not been informed the resident was in pain from the nails on his left hand. She said the licensed nurses should have informed her of it all because it would have allowed her to: assess his left hand and fingernails, take immediate action to protect his skin, provide safe nail care, and treat his pain. In addition she needed to ensure the staff notified the physician and resident representative. The ADON was interviewed a second time on 2/26/2020 at 10:54 a.m. The ADON said Resident #46 told her he could not have a rolled washcloth in his left hand. She said she saw an indentation in his left palm (caused by his long fingernail) and he told her that his left palm was sore in that area; she did not observe the area to be an open area. The NHA was interviewed on 2/26/2020 at 10:54 a.m. The NHA said she saw how his left hand was in a fist and how the fingernail of his left ring finger was long enough to press into his left palm. Resident #46 told her that the fingernail of his left hand grew faster than fingernails of his right hand. She compared the fingernail length of the left hand ring finger to that of the right hand ring finger. She saw that what Resident #46 said was accurate, namely, that the fingernail of his left hand ring finger was longer than that of the right hand ring finger. RN #1 should have honored Resident #46's request of her to trim the fingernails of his left hand because they caused him left hand pain. The facility should have a system in place (which it currently did not) to keep the fingernails of his left hand trimmed as often as needed; to keep him comfortable. Resident #46 told her it was too painful to have a rolled washcloth in his left hand. She would follow up to ensure the fingernails of his left hand were trimmed and the left hand pain from the fingernails was reduced or relieved. The director of nursing (DON) was interviewed on 2/27/2020 at 5:15 p.m. The DON said nurses, not CNAs, trimmed the fingernails of residents with a diagnosis of diabetes to prevent injury and prevent infection, F. Follow up The NHA was interviewed on 2/26/2020 at 1:32 p.m. The NHA said the nail trimming was added to the treatment administration record. She said the facility ordered wash cloths to place in Resident #46's left hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews the facility failed to reduce the risk of all known or foreseeable accident hazards that cannot be eliminated and ensure that each resident received adequate supervision and assistance devices to prevent accidents, for two (#29 and #53) of three residents reviewed for falls out of 37 sample residents. Specifically, the facility failed to ensure Residents #29 and #53 were free from continued falls. The facility failed to: -Ensure each resident (#29 and #53) were fully assessed following each fall episode for all possible accidents/hazards factors which might result in a fall. -Ensure each resident (#29 and #53) were provided consistent oversight, supervision and monitoring while engaged in known impulsive and unsafe behaviors. -Ensure each resident (#29 and #53) received prescribed fall interventions consistently and effectively. -Ensure a thorough assessment to consider all possible causes of the residents' falls. -Ensure that all staff were fully trained on use of interventions to prevent Resident #53's falls. The facility was aware of Resident #29's history of falls, high risk for additional falls due to his impulsiveness, poor safety awareness and poor balance and the facility still failed to prevent the resident from falling and fracturing his humerus three days after his admission to the facility. Findings include: I. Facility policy and procedure The Fall Management Program policy, revised 8/2/19, was provided by registered nurse (RN) #2 on 2/26/2020 at 3:33 p.m. The policy read in pertinent part: Purpose: Residents having a high potential for falls shall have a care plan formulated, which shall identify approaches to be used to minimize the risk of falls and/or injuries. A resident fall risk shall also be identified from the minimum data set (MDS) information and appropriate plan of care implemented. -Policy: The goal is to modify some of the risk factors for falls and adjust the resident's environment to minimize the risk of injury due to falls. -If a resident is at high risk for falls, the restorative department will evaluate interventions and implement these interventions to minimize fall occurrences. -All members of the restorative/rehab/fall committee will review falls routinely and conduct a thorough root cause analysis and implement further strategies to minimize a residents incidence of falls. II. Resident #29 A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the February 2020 computerized physician orders (CPO), diagnosis included hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting right non-dominant side, spinal stenosis and intervertebral disc degeneration, and lumbar region. The 12/6/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He had fluctuating inattention; had difficulty focusing on conversations; and he said he had trouble concentrating on activities such as when reading or watching television. The resident required extensive assistance from staff with bed mobility; transferring from surface to surface; using the toilet; personal hygiene; bathing; and dressing. He was not steady and only able to stabilize with human assistance when moving from a seated to standing position, walking and transferring from place to place. He had two falls since the prior MDS assessment dated [DATE] one with injury. B. Resident interview and observation Resident #29 was interviewed on 2/24/2020 at 2:49 p.m. Resident #29 said I fell and broke my arm, pointing to his left arm, he said it still hurts. Staff let me fall and I fell slamming my arm into the wall. Resident #29 was observed and interviewed again on 2/27/2020 at 4:45 p.m. Resident #29 was in the hall just outside of his room. He was trying to get into his room but was having difficulty navigating his wheelchair in the doorway due to his leg rest being extended to elevate his foot. He said he was trying to get into his room to call staff so he could get into his comfortable recliner chair. He was wearing a black strap seat belt clipped off slightly to his side. He said if he took it off it would alarm and it would be really loud. C. Record review The admission MDS dated [DATE] revealed the resident had a history of falling and had falls in the month before his admission, as well as additional falls in the previous six month period before he moved into the facility. Following admission he had a fall in the facility with a major injury. The physical therapy care plan dated 3/7/19 read in part: Referral: the resident comes to us from home after recent falls and overall disability. He is at high risk for falls, debility (right upper extremity hemiplegia and left extremity hemiparesis), fall risk, and no access to his home and socialization without physical therapy intervention. Resident goal: To return to prior level of functioning being safe and independent with wheelchair mobility, ability, transfers and good balance at home with his wife and home health services as needed. Therapy necessity: Skilled PT is necessary to improve balance and fall recovery skills in order to decrease risk for falls. Skilled PT is necessary to improve strength/coordination in order to improve mobility and return to prior level of functioning. Therapy focuses were documented as therapeutic exercise, neuromuscular reeducation, gait training and other therapeutic activities. The occupational therapy care plan dated 3/10/19 read in part: Therapy necessity: Skilled OT is necessary to increase strength, balance and safety education in order to maximize activities of daily living (ADL) and mobility skills. Medical records revealed Resident #29 fell on 3/9/19 and sustained a humeral fracture to the right upper extremity with mild displacement and bruising of the upper right arm into the chest. The fracture was inoperable and his arm was placed in a sling and treated with ice packs and pain medication. The Nursing: Falls Documentation form dated 3/9/19 at 9:11 a.m., documented the resident had an unwitnessed fall on 3/9/19 at 8:30 a.m. The resident was found in the hall, on the floor with his right arm behind his back. Upon initial assessment the nurse noted no injuries to the resident's person. The resident said he was trying to pick up a napkin off the floor and he fell out of his wheelchair. The resident was described to have poor safety awareness. Immediate nursing intervention for safety was documented as resident asked to notify staff when something needs to be picked up from the floor. The neurological flowsheet entry dated 3/9/2020 at 4:15 p.m., revealed the resident started to complain of pain to his right shoulder and arm that was unrelieved by Tylenol medication provided to him. He was sent to the emergency room for x-ray and assessment. Orthopedic clinic note dated 3-13-19 revealed the resident was seen for an orthopedic surgical consult due to a fracture of the humeral neck, right side. The report read in part: The incident occurred at a nursing home. The right shoulder is affected. Incident onset: 3/9/19. The injury mechanism was a fall. The quality of the pain is described as aching. The pain is at a severity of 6/10. Pertinent negatives include no chest pain. He had tried ice, acetaminophen and immobilization for the symptoms. The treatment provided mild relief. Imaging studies: shoulder x-rays show proximal humerus fracture, mild displaced. The treatment options were discussed at length with the patient. It was decided to proceed with current modalities (therapeutic response), rest and elevation and sling with a one month follow up visit. Restorative Nursing: Fall Risk assessment dated [DATE] at 8:54 a.m. revealed the resident was assessed to be a high risk for falls. He had intermittent confusion; a recent injury from a fall; impaired vision; was wheelchair dependent and required assistance with elimination; unable to stand on his own, had decreased muscular coordination; had a history of stroke; a recent fractured bone; took two high risk medications; and had a recent mediation change. The Nursing: Falls Documentation form dated 3/21/19 at 4:15 p.m., documented the resident had an unwitnessed fall in his room on 3/21/19 at 4:14 p.m. The resident was found by staff lying on his back on the floor. The resident said that he had been reaching for his call light when his wheelchair moved and he fell out of the chair. The resident was assessed to be impulsive. Immediate nursing intervention for safety was documented as increase resident room checks. The fall documentation did not explain the location of the call light or go into any detail of why and how the fall occurred (see the interview below with RN #2 for more detail on the staff failure leading to this fall). Nursing: Weekly Skin Observation note dated Date: 2/25/2020 at 9:26 a.m., revealed the resident had no current wounds, was making multiple attempts at trying to transfer self and continues to complain of right shoulder pain earlier fall and fracture. The comprehensive care plan last updated 12/12/19, revealed the following: -Care focus: Altered mobility and is a high fall risk: stroke during carotid surgery with right side hemiparesis. Resident #29 has limited physical mobility. Very poor safety awareness and has had multiple falls at home and at other facilities prior to admission. He remains at very high risk due to mental and physical limitations and impulsive actions. -Goal: Resident #29 to remain free from fall related injury. -Interventions in pertinent part: -Low Bed, initiated 3/6/19, and -Do not leave unattended in the bathroom, initiated 7/17/19, -Sit to stand lift, as needed. May use lift recliner; keep controls stored in bottom drawer of night stand, initiated 10/21/19 and revised 12/12/19, -Sit to stand lift, as needed for transfers. Two staff and gait belt for all pivot transfers. Keep the right arm free of any resistance or weight bearing. Anti-slip mat in front of the recliner. Anti Thrust cushion (a padded cushion to prevent a person from sliding forward). Encourage the resident to wait for staff to assist with transfers. Bilateral assist bars on bed to help with safer mobility with transfers, Revised 11/7/19. The CPO documented the following orders: -Low bed. Start date 3/6/19. - Physical therapy (PT)/occupational therapy (OT) evaluation and treatment. PT five times a week for two weeks, then three times a week for 10 weeks for therapeutic activities and exercise, Neurological reeducation and gait (balance) training, for diagnosis for unsteadiness on feet and muscle wasting. Start date 3/7/19. -Anti-thrust cushion in wheelchair. No directions specified for fall prevention. Start date 4/27/2019. -Seat belt with alarm when in wheelchair. No directions specified for fall prevention. Start date 4/24/2019. -PT/OT evaluation and treatment. Weight bearing as tolerated to right upper extremity with progressive range of motion (ROM). State date 5/16/19. -Functional maintenance program six times a week indefinitely. Start date 7/5/19. -Sit to stand lift as needed for transfers. Start date 10/21/19. -Non-skid rug in front of recliner every morning and at bedside. No directions specified for fall prevention. Start date 11/6/19. -May have a lift recliner. Keep controls in the bottom drawer of the night stand, for fall prevention. Start date 11/15/2019. -Functional maintenance program six times a week for eight weeks for increased safety with transfers and bed mobility. Start date 1/20/2020. Based on the care plan and the CPO the only interventions in place prior to the resident fall which lead to his fractured humerus was PT/OT and a low bed. There were no interventions to address his poor safety awareness and impulsiveness. The resident had four additional falls: -On 4/23/19 around 11:15 a.m., the resident had an unwitnessed fall in his room while trying to transfer from his wheelchair to bed on his own. According to the Nursing: Falls Documentation form dated 4/23/19 at 11:15 a.m., A CNA took the resident to his room; he wanted to go to bed, she went to get help. When the CNA returned she found the resident lying on the floor on his right side in front of bed. The wheelchair was by the sink and the wheels were not locked. The resident told staff he tried to get up by himself and the wheelchair went backwards and he fell. The report read in part: Safety interventions in place included a grab bar at bedside, low bed, non-slip shoes were on, there was a non-slip mat at the bedside, and the resident had a wheelchair seatbelt (he was capable of removing it). The resident was wearing a sling on his right arm due to a fractured humerus and had contractures and limited ROM. He has cognitive deficit and no safety awareness. The resident was assessed for injury and had a small red mark on his right elbow the size of a dime, most likely from rubbing in his arm sling. New safety interventions/precautions taken after the fall: placed alarm on seat belt, elbow protector to right arm. -On 7/11/19 at 10:10 a.m., the resident had an unwitnessed fall in the bathroom while trying to wipe himself after going to the bathroom. The Nursing: Falls Documentation form dated 7/11/19 at 10:15 a.m., read in part: The resident was left alone in the bathroom and was trying to clean himself after going to the bathroom. He was found on the floor between the toilet and grab pole. The resident was not injured. New safety interventions and new precautions taken after fall: have the staff stand by while the resident is on the toilet. -On 9/9/19 at 7:15 p.m., the resident had a witnessed fall at the bedside. The Nursing: Falls Documentation form dated 9/9/19 at 7:15 a.m., read in part: Staff was assisting the resident into bed, he was sitting on the edge of the bed and leaned to the right causing him to fall to the floor. He landed on his right side, hitting his head on the floor. He sustained a five centimeter (cm) laceration to the right temple at the eyebrow. The nurse cleansed the wound and attempted to stop the bleeding; the resident was sent to the emergency room for assessment and treatment. The resident returned with sutures to the right side eyebrow area. A CAT scan assessment was negative with no signs or symptoms of brain trauma. The fall documentation did not document if the CNA was interviewed or retrained on positioning of a resident when assisting them to bed so they are not sitting on the edge or in an unsafe position. -On 9/15/19 at 3:00 p.m., the resident had a witnessed fall in the shower room. The Nursing: Falls Documentation form dated 9/15/19 at 3:00 p.m., read in part: the resident was dressed, shoes on, and ready to transfer back into his wheelchair. He did not wait for the CNA to assist him, he reached for the bar in shower room, and stood up on his own, and fell onto his right side. New safety interventions and new precautions taken after fall: the resident was reminded to wait for help before trying to stand on his own. The resident complained of right elbow pain after the fall. The report failed to document where or what staff was doing when the resident was trying to get up on his own. Nursing: Resident Assessment - Weekly Skin note dated 9/15/19 at 12:44 p.m., revealed: After multiple attempts at trying to transfer himself and falling resident's pupil response was slow, but he had two past cataract surgeries. Now he had a wheelchair seat belt in place. He is complaining of right shoulder/arm pain as he was from an earlier fracture in March 2019. He has four new sutures to his right forehead, black right eye, and abrasion to his right cheek, following a fall on 9/9/19, and an unrelated skin tear to his right inner wrist. Sutures to be removed on 9/16/19. D. Fall investigation review RN #2 was interviewed on 2/27/2020 at 1:46 p.m. RN #2 said the resident had recently arrived three days prior when he had his first fall fracturing his humerus. He had been admitted to the facility to work on building independence and strengthening his ability to perform his own ADLs and self-transfer. He had been assessed for PT services for treatment to strengthen his muscles, improve balance and ability to transfer on his own. They found him to be very impulsive and at high risk for falling. The contributing risk factors to his falling had been his loss of ability to self-transfer and his continued attempts at independent transfers. Therapy services had been focused on coaching him to request assistance with transfers but he was asking for assistance. RN #2 was reluctant to show the fall investigation reports but summarized the information in the fall resorts. RN #2 said the resident's initial fall on 3/9/19 occurred out of impulsiveness and the fall committees recommended intervention was to educate the resident to ask for assistance with transfers and picking items up off the floor. RN #2 said the fall report and fall committee notes did not give any other detail regarding the specifics of the resident's fall and fracture. RN #2 said the fall report regarding on 3 /21/19 Resident #29 fell right after completing his physical therapy session with a fill-in temporary physical therapist who was working with the resident when the regular facility physical therapist was on vacation. RN #2 said the investigative findings revealed the physical therapist had finished the PT session and failed to put the resident's wheelchair seat belt back on and did not lock the wheels of the resident's wheelchair when he left the resident. After the therapist left, the resident was reaching for his call light and the resident fell. It was unclear by the fall investigative report where the call light was located (on the floor or other location) or why the physical therapist did not know the resident had been ordered to wear a seat belt when in his wheelchair. RN #2 said the investigative report documented the intervention was provided by the floor nurse. The floor nurse talked to the therapist and educated him on the resident's care plan and fall safety interventions. According to the report the therapist was not aware of the care planned fall interventions and did not know about the resident's wheelchair seat belt. RN #2 said he did not know why the therapist did not know about the resident's care planned interventions, as the care plan would have been available for his review. RN #2 said the regular facility physical therapist may have more information. The 3/21/19 fall investigative report did not document or detail any other factors about the residents fall to show if the call light was in an accessible location, why the resident was trying to call for staff assistance, if anyone had talked further to the therapist about why he was unaware of the resident's care plan interventions or if he even knew where to access the information. RN #2 was not able to give further detail on new safety interventions following the resident's 3/21/19 fall, only that the fall investigative report showed no further interventions were developed following this fall. The report did not explain how future visiting/temporary providers would be educated about the details of a resident's care plan before working with that therapist. RN #2 recommended that I speak with the facilities physical therapist for more information. RN #2 acknowledged that the fall investigation reports did not provide detailed documented information based on the interdisciplinary teams (IDT) discussion of the falls. It was unclear based on the fall reports reviewed, if the IDT fully discussed and investigated all of the fall factors because the fall reports were vague and did not contain a lot of detail. E. Other staff interviews The facility physical therapist (PT) was interviewed on 2/27/2020 at 6:02 p.m. The PT said he was aware that Resident #29 was impulsive and tried to transfer on his own without staff assistance; and that he had fallen and fractured his humerus shortly after admission. He was not aware of the resident's fall following therapy with the temporary therapist during his vacation absence, and said he was very surprised to learn that the therapist was not aware of the resident's need to wear a seatbelt while in his wheelchair. The PT reviewed the fall investigative report and IDT findings but said he was left wondering the details of the fall as the investigation report did not give much detail as to where the resident was before and after the therapy session, had the resident had been wearing the seat belt before the therapy session started. He had so many questions and said he would look into the fall in more detail. He acknowledged the fall investigative reports need more detail and said he would talk with the IDT fall committee about documenting the investigation into a resident fall in more detail, for tracking, trending and prevention purposes. III. Resident #53 A. Resident status Resident #53, over the age of 95, was admitted on [DATE]. According to the February 2020 CPO, age-related osteoporosis, personal history of (healed) traumatic fracture with disorders of bone density and structure left lower leg, and Alzheimers disease. The 12/6/19 MDS assessment revealed the resident was not able to participate in the BIMS due to severe cognitive impairment. Staff assessment revealed the resident had significant short and long-term memory impairment with moderately impaired cognitive skills for daily decision making. The resident required extensive assistance from staff with bed mobility; transferring from surface to surface; using the toilet; personal hygiene; bathing; and dressing. He was not steady and only able to stabilize with human assistance when moving from a seated to standing position and transferring from place to place. He did not walk and needed the help of staff to move around the community in his manual wheelchair. He had two or more falls since the prior MDS assessment dated [DATE]. B. Resident interview and observation Resident #53 was observed on 2/24/2020 at 12:09 p.m. The resident was in his manual wheelchair pushing his trash can and oxygen concentrator around heading in the direction of his bathroom. He was very angry and pointed to his crotch area which was wet and urine soaked there was a faint smell of urine in the room and said I can't live like this He was not able to say if he pressed his call light for help or if he know where his call light was located (the call light was draped over his bed hanging on the floor). He said If you can't help me get out! Staff overheard the resident and came in to assist. C. Record Review The comprehensive care plan dated 1/7/2020, revealed the following: Care focus: Altered/mobility/risk for falls: Resident #53 had a recent fall (1/1/19 in the facility) with a fracture of left hip then surgical repair. He no longer walks and uses a sit to stand lift for transfers at times. Revised 4/16/19. Goal: Resident #53 will remain free of fall related injury from falls. Revised 1/31/19. Interventions in patient part: -Low Bed, return to a low position after transferring him out (to decrease the risk of injury with self-transfers). Revised 7/13/19. -Non-skid socks at night. Initiated 12/12/18. -Anti-slip mat at bedside. Initiated 12/12/18. -Safety and alarm to bed, wheelchair and alarm and bathroom door, revised 1/7/2020, -Assist bars on bed. Initiated 7/2/19. -Typically prefers bedtime before 7:00 p.m. Initiated 1/7/2020. -Locomotion: changed after January 2019 hospitalization. Uses manual wheelchair with extensive assistance to total dependence. Initiated 1/7/2020. -Self-propels wheelchair short distances slowly on occasion. Revised 1/7/2020. -Provide supportive care, assistance with mobility as needed. Initiated 11/20/17. Care focus: Altered elimination: Resident #53 has functional bowel and bladder incontinence related to end of life care and advancing dementia, following hip fracture. Moisture associated skin damage resolving. Revised 10/6/19. Goal: Resident #53 will remain free from skin breakdown due to incontinence and brief use through the review date. Revised 1/22/2020. Interventions in patient part: -Brief use: Provide adult incontinent disposable briefs. Frequent checks and change. OK to use the bathroom or bedside commode as he is able. Revised 3/12/19. Care focus: Altered communication: Resident #53 has a communication problem. Initiated 7/8/19. Goal: Resident #53 will be able to make basic needs known on a daily basis. Intervention in pertinent part: -Anticipate and meet needs. The CPO documented the following orders: -Non slip socks. No directions specified for fall prevention. Start date 11/22/18. -Alarm to wheelchair, recliner, and bed due to history of falls, history of left hip fracture with surgical repair, impulsiveness, and lack of safety awareness. No directions specified for fall prevention. Start date 1/28/19. -Sit to stand lift as needed for transfers (post left hip fracture). No directions specified for fall prevention. Start date 1/27/19. -Non slip mat. No directions specified for fall prevention. Start date 4/5/19. The Restorative Nursing: Fall Risk Assessment - quarterly dated 10/2/19 at 7:54 a.m., revealed the resident was at high risk for falls. He had intermittent confusion; two falls in the prior 30 days; was wheelchair dependent; required assistance with elimination; was unable to stand on his own; had decreased muscular coordination; jerking or unstable when turning; was unsteady or shuffling gait; and had a past fractured bone. The Mobility Assessment form dated 10/2/19 at 7:54 a.m. revealed the resident had full to moderate ability to restore or maintain normal alignment, moderate to poor muscle strength and poor mobility and balance. He was not steady, only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet, and participating in surface-to-surface transfer. He required transfer assistance from two staff and or a sit to stand lift. He did not walk. He was able to bear weight but not on his own. The physical therapy plan of care dated 8/29/19 read in pertinent part: -Reason for referral: This gentleman was referred to us by nursing and his physician due to a recent fall and significant decline in gross motor mobility skills and safety. He is at high-risk for falls, debility, pressure sores, contractors, and lots of access to socialization without physical therapy intervention. -Therapy necessity: Skilled PT is necessary to improve balance and fall recovery skills in order to decrease risk for falls. Skilled PT is necessary to improve strength/coordination in order to improve mobility and return to prior level of functioning. -Since January 2019 he had required maximum to total assistance to complete all mobility tasks. His participation with restorative nursing was inconsistent at best, but we are hopeful that he will at least participate in working on contracture prevention by increasing his range of motion of bilateral knees and ankles. -Precautions: Fall risk. Fall report -On 6/27/19 around 6:00 p.m., the resident had an unwitnessed fall at his bedside. The Nursing: Falls Documentation form dated 6/27/19 at 6:00 p.m., read in part: The resident was found on the floor with his back up against his night stand, lying slightly on his right side. He sustained a small four cm abrasion to his right upper back. Active ROM in all extremities, he denied pain, and denied hitting his head, vital signs and neurotically checked within baseline. New safety interventions and new precautions taken after fall: The resident was educated to use call light to call staff for assistance and to wait for staff to arrive. The nurses fall report failed to document crucial information including if the call light was accessible or if the resident had on non-slip footwear, and the report documented the resident did not hit his head even though the fall was unwitnessed. This and other questions on the nurses fall documentation were left blank. Fall report -On 8/26/19 around 3:45 p.m., the resident had an unwitnessed fall in his bathroom room. The Nursing: Falls Documentation form dated 8/26/19 at 4:05 p.m., read in part: The resident was found sitting on the floor in the bathroom at a 45 degree angle from the commode, next to the wheelchair. It appeared that he slid off of his wheelchair and landed on the floor. The wheelchair was in a locked position next to the toilet. The chair alarm was still on resident and did not activate because the string was long enough to accommodate position on floor without being pulled off. The bathroom door was closed but a staff member passing by his room heard his calls for help. The resident sustained an abrasion to his right back that was 12 inches by 1.25 inches. The resident was not able to explain what happened. New safety interventions and new precautions taken after fall: readjusted alarm location. Fall report -On 12/10/19 around 10:20 p.m., the resident had an unwitnessed fall in the recreation room. The Nursing: Falls Documentation form dated 12/10/19 at 10:20 p.m., read in part: The resident was found on the floor of the recreation room lying on his left side with his head on a chair cushion. The resident's chair alarm was sounding. His shoes were removed and placed on a chair in the recreation room. The resident was smiling and talking to staff with no complaints of pain or discomfort. He was unable to explain how he came to be on the floor. New safety interventions and new precautions taken after fall: the nurse held a staff huddle meeting and instructed that all staff were to respond to an alarm including non-nursing staff. Any staff member can prevent a fall or report to the nurse immediately if a fall does occur. Fall report -On 12/28/19 at 2:15 p.m., the resident had an unwitnessed fall in his bathroom. The Nursing: Falls Documentation form dated 12/28/19 at 2:45 p.m., read in part: The resident was found lying on the floor in the bathroom between the commode and his wheelchair. A CNA passing by his room heard him yelling out. His body/chair alarm was not attached to the resident. There was no documentation detail to tell the actual location of the body/chair alarm. New safety interventions and new precautions taken after fall: The nurse held a huddle meeting with staff to ensure body alarm application when the resident is in his wheelchair and that is applied in the appropriate location. A structured follow-up nurse note dated 12/29/19 at 11:00 a.m. revealed the staff found a three cm by one cm red/purple bruise on Resident #53's left wrist. The resident denied pain and had full ROM. A restorative nurse note: titled Restraint Quarterly Evaluation dated 1/1/2020 at 11:42 p.m. revealed in pertinent part: The resident had a wheelchair, bed and recliner alarms in place with the first use being 1/28/19. -Reason for the alarms: Alarms were implemented due to the resident's frequent falls; sliding out of his chair/wheelchair; frequent attempts to self-transfer; climb out of bed; and a history of falling with at least on fall with a significant injury (fractured hip). -Restraint Reduction strategies and alternatives attempted: one to one activities, high-low bed and scheduled rest times. -Why these alternatives did not work, prompting continued need for restraint: The resident had no awareness of safety needs or functional limitations, due to late stage dementia and other comorbidities. -Attempts to reduce restraint use over the past quarter: None, alarms do not restrain him. He continues to attempt self-transfers in and out