**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure one (#9) of six residents received adequate supervision to prevent accidents out of 18 sample residents reviewed. Specifically, the facility failed to ensure Resident #9, who had been assessed as having a risk for falls upon admission, received the care and services to prevent a fall. The facility failed to ensure the resident was supervised after a fire drill. Record review and interviews showed after a fire drill on 5/31/23 staff failed to ensure resident safety when residents were left without adequate supervision when behind closed fire doors. After a fire drill, Resident #9 was hit by an interior fire door and sustained multiple injuries including a dislocated shoulder, fracture of the right shoulder and multiple fractures of the pubis rami (the inferior and superior pelvic bones). Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 8/15/23 to 8/17/23, resulting in the deficiency being cited as past noncompliance with a correction date of 6/1/23. I. Facility policies and procedures 1. The Fall Management policy, dated 6/4/2020, was requested and received from the nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, Purpose: to promote patient safety and reduce falls by proactively identifying, care planning, and monitoring of patients' fall indicators. Policy: the facility will assess the resident . with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Accident: refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Avoidable accident: means that an accident occurred because the facility failed to: -Identify environmental hazard and/or assess individual risk of an accident, including the need for supervision and/or assistive devices; Evaluate/analyze the hazards and risks and eliminate the, 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; Supervision/adequate supervision: facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required. This determination is based on the individual residents' assessed needs and identified hazards in the resident environment. Hazards: refer to the elements of the resident environment that have the potential to cause injury or illness. Hazards over which the facility has control - are those hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury or illness. Accurate and thorough assessment of the patient is fundamental in determining indicators for potential falls. Patient conditions may vary throughout the day, week, month, or other time period and the identification of patient fall indicators is an ongoing, interdisciplinary assessment process. 2. The Fire policy, dated 9/9/22, was requested and received from the (NHA) on 8/16/23. The policy documented in pertinent part,The facility will ensure that associates are trained and prepared to respond in the event of a fire within the facility, in accordance with current national fire protection association guidelines. Employees are periodically instructed and kept informed with their duties under the plan. The plan addresses the basic response required of staff. -Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Response to alarms -Clear hallways of persons and equipment, in the event a large-scale evacuation is needed; -Remove only those residents in immediate danger from fire and smoke; -Assist resident and visitors to safe areas of the facility, preferably behind a fire door or compartment Educational elements -Associates should be aware of their assigned work stations and duties when the fire alarm sound -All personnel should stand by their departments or work areas for directions after making their own department safe Actions based on job role at the facility -Administrator/incident commander -Once the fire alarm has been activated, determine the location of the activation. -Assess the situation -Supervise emergency operations Nursing staff -Report the location of the alarm activation and assess the situation -Mark doors and rooms as they are cleared of people -Perform a head count of staff and residents -Coordinate with the incident commander and other members of incident command Maintenance -Immediately respond to the area of the fire alarm activation -Coordinate with the incident commander. II. Resident #9 A. Resident status Resident #9, age [AGE], admitted on [DATE] and readmitted to on 6/6/23 from the hospital. According to the August 2023 computerized physician orders (CPO) the diagnoses included fracture of the pubis, fracture of the right ilium, fracture of upper end of right humerus (right shoulder), dislocation of right shoulder joint, Alzheimer's disease and dementia. The 3/21/23 minimum data set (MDS) assessment was cognitively intact with a score of 13 of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance from one staff member for dressing and toilet use. She required supervision from one staff member for bed mobility, transfers, locomotion on and off the unit and personal hygiene. She walked independently in her room and in the hallways. The resident was independent with eating after setup assistance from one staff member. Section J indicated the resident had no falls six months before her admission or falls after her admission to the facility. B. Observation On 8/16/23 at 11:07 a.m., Resident #9 was observed ambulating with a walker and a staff member provided stand by assist. The resident had a steady gait and appeared to tolerate the activity well. C. Record review The fall risk care plan initiated on dated 6/16/22 documented the resident was at risk for falls. The interventions included, in pertinent part, call light within reach encouraging the resident to use the call light when she needed assistance, physical and occupational therapy as ordered. -The care plan failed to identify risks for injury that could arise from environmental hazards. 1. Fall incident on 5/31/23 The 5/31/23 at 2:10 p.m. incident report documented, After facility fire drill staff was opening fire door, resident was standing behind door and fell when door was opened. Staff states resident was noted hitting head when falling. Resident lying on back when nursed assessed. Range of motion to extremities equal and strong. Right arm strong. Resident grabs left arm when assessed but denies pain when asked. Range of motion strong. Resident assisted by two staff members and gait belt into standing position and then sat in chair. Orthopedic assessments were initiated. No injuries noted. New intervention: Staff education on opening doors after fire drills. The report documented immediate action taken was education to all staff on opening fire doors after fire drills. Signs were placed on doors to remind staff to open doors slowly and for residents to ask for assistance. On 5/31/23 at 3:45 p.m. The nurse note read, After fall resident did ambulate down to the sun room for an activity, used walker and stand by assistance of staff member, no complaints of pain at this time. After activity resident was unable to get self out of the chair. Staff assistance was needed. Gait belt placed and she was unable to take any steps. She was placed in a wheelchair and taken to her room Physician was called, a verbal order was received to send the resident to hospital for treatment and evaluation. Call placed to husband, no answer and unable to leave voice mailbox full. Vital signs: temperature 98.7 (sic) 130/62. The nurses note dated 5/31/23 at 4:12 p.m. documented, the resident was transported to the hospital for evaluation and treatment related to the fall. The fall risk care plan was updated upon the residents return to the facility on 6/7/23. The care plan documented, the resident was at risk for falls with injury related to weakness and limited mobility secondary to a recent fall with diagnoses of right arm fracture and right superior and inferior pubic rami (pelvis) fractures. She currently requires staff assistance of two to complete her activities of daily living (ADL) and transfers. Resident uses a wheelchair as her primary mode of locomotion. The interventions included, in pertinent parts, encourage and assist with repositioning as tolerated,. encourage not to sit on edge of bed as tolerated, required an assist of two with ADLs and transfers. Physical and occupational therapy as ordered. 2. Hospital records The resident required six nights in the hospital from [DATE] to 6/6/23 for evaluation and treatment. Hospital records revealed the resident sustained multiple injuries, dislocation of right shoulder with proximal humerus and glenoid fracture (shoulder) and multiple closed fracture of the right pubic rami (pelvis). III. Facility response to incident A record review revealed the facility completed a root cause analysis of the incident on 6/1/23. The analysis revealed a need to educate all staff members to open the fire doors very carefully, and to check behind the doors for people on the other side. New signs were ordered and placed on every fire to remind everyone to be careful when opening the doors. The root cause analysis read, Fire drill was held and after the fire drill staff was huddled by the nurse's station. After the huddle, the doors to the Resident's doors (sic) were still shut. Staff member pushed open the door and hit the resident as she was trying to come thru the doors. The root cause analysis documented the resident ambulated independently with a walker prior to the incident. Facility staff were educated on 5/31/23 and 6/1/23 to open the fire doors carefully. The education included instruction the fire doors can close during fire or tornado drills. The Quality Assurance and Process Improvement (QAPI) plan included Fire Door Safety. On 5/31/23 the facility identified action items to improve and monitor included: -All staff was educated on the fire doors and opening slowly. -Fire doors were labeled with signs to remind staff to open doors slowly. Follow up fire drills were held on 6/29/23 at 11:00 p.m. and 7/31/23 at 12:00 p.m. The notes documented for each drill the fire doors were reset and the doors were held open prior to staff post-drill huddle meetings. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/16/23 at 4:03 p.m. CNA #1 said he was familiar with Resident #9. He said prior to the fall the resident ambulated independently, however after the fall, she needed increased assistance from staff because of her fractures. He said the since the fall, the resident had shown improvement and was now able to transfer and ambulate with her walker requiring only stand by assistance of one staff member. The CNA said when he was hired he participated in training during orientation for fire drills. He said his duties during a fire drill were to assist residents to a safe area away from the fire and to clear the hallways. He would then respond as told and said that might be to find a fire extinguisher or monitor residents if an evacuation was necessary. The CNA said he received training to open the fire doors slowly and carefully after the resident fell but did not remember specific training before then. The director of nursing (DON) was interviewed on 8/17/23 at 10:23 a.m The DON said she had scheduled a fire drill on 5/31/23. The DON said during a fire drill a staff member was to always remain on each hallway to help residents to their rooms, close door, clear hallways and monitor for additional necessary responses. The DON said that when the fire alarm sounded, the fire doors closed automatically. After the fire alarm was deactivated, the fire door controls must be manually reset before the doors would remain open. She said on 5/31/23 the fire drill was finished and staff from the hallway attended the staff huddle (staff meeting) at the nurses desk. The fire doors had not been reset and closed behind staff as they proceeded to the nurses desk. When staff gathered at the huddle, Resident #9 was in her room, which was behind the closed fire doors. The resident left her room and ambulated towards the nurses desk. The DON said when the huddle ended, a staff member pushed the fire door open and hit the resident which caused the resident to fall to the floor. The corporate vice president (CVP) was interviewed on 8/17/23 at 10:35 p.m. She said the injury was an accident. The staff member was unable to see anyone behind the fire doors.