**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #32 A. Resident status Resident #32, age of 93, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included unspecified dementia, diabetes and history of falls. The 2/2/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required one-person assistance with transfers, dressing, walking, toilet use, bathing, and personal hygiene. The resident had unsteady balance but could stabilize themselves without assistance. The resident used a cane for ambulation. The MDS assessment marked the resident had no falls in the six months prior to admission. B. Observations Observations made from 8:30 a.m. to 5:30 p.m. on 3/27/23 through 3/30/23 revealed: Resident #32 was not checked on every two hours by staff, the resident's room was the last room on the hallway and the furthest from the nursing station, and the resident kept the door closed the majority of the day. Inside the resident room throughout this timeframe, non-skid strip tape was not observed being used on the floor anywhere in the room and there were no fall mats in the room. C. Record review The comprehensive care plan fall focus initiated on 2/21/23, revealed the resident had a fall with injury. Interventions initiated on 2/22/23 were to continue interventions, and to check and document neurological checks post fall. The activities of daily living focus initiated on 2/10/23 revealed the resident had a self-care deficit due to dementia and joint pain. Interventions initiated 2/21/23 revealed the resident required one-person assistance and a wheelchair or four-wheel walker for mobility. The resident also had impaired vision and required glasses. Falls On 2/20/23 the resident had a witnessed fall in their room. The certified nursing aide (CNA) was providing the resident assistance to go to the dining room. The resident was in their recliner and when the resident stood up, the resident tripped over a pair of shoes in front of their chair resulting in a fall. It was determined the fall was due to clutter, poor lighting, gait imbalance, weakness and poor memory. -The incident report indicated the resident was to use a walker for ambulation. The report failed to identify interventions recommended post fall to prevent further falls. On 2/21/23 the resident had an unwitnessed fall at bedside. The resident's spouse, whom the resident shared the room with, came out of the room and alerted staff that the resident had fallen when trying to get out of their bed. It took two staff to assist the resident from the floor. The resident sustained an abrasion to their knee and the wound was treated. It was determined the fall was due to poor lighting, confusion, gait imbalance, improper footwear and poor memory. -The report failed to identify interventions recommended post fall to prevent further falls. On 3/2/23 the resident had an unwitnessed fall in their room. The resident's spouse came out of the room yelling for help. The resident was found on the floor with blood around their head. The spouse had impaired cognition as well and could not tell staff how the resident fell. The resident told the staff the fall occurred while riding a horse on the way to see mom. The injury was addressed and was documented as a hematoma. It was determined the fall was due to confusion, gait imbalance, weakness, and poor memory. -The report failed to identify interventions recommended post fall to prevent further falls. Nursing progress note dated 3/7/23 revealed the resident had an unwitnessed fall in their room. Their spouse came out of the room yelling for help. The resident was found on the floor and blood was on the floor. It took three staff to assist the resident from the floor. It was determined the resident had hit the back of their head and reopened the hematoma from the 3/2/23 fall. The nurse assessed the resident. -There was no interdisciplinary (IDT) note or incident report located for the fall. On 3/29/23 (during survey) the resident had an unwitnessed fall in their room. Their spouse came out of the room and alerted staff that the resident had fallen. The resident was found by staff sitting on the floor, it took two staff to assist the resident from the floor. Neither the resident nor their spouse could say how the fall occurred. It was determined the fall was due to gait imbalance and ambulating without assistance. -The report failed to identify interventions recommended post fall to prevent further falls. D. Staff interviews The restorative aide (RA) #1 was interviewed on 3/28/23 at 1:58 p.m. She stated she had never seen the resident for restorative therapy for falls. The occupational therapist (OT) was interviewed on 3/28/23 at 2:20 p.m. She stated she did not have records of the resident being seen by physical or occupational therapy or a screen being requested due to falls. Registered nurse (RN) #1 was interviewed on 3/28/23 at 2:50 p.m. She stated the resident had three falls. The interventions for the resident were to keep the bed in the low position, ensure the resident was wearing appropriate socks and shoes, and to remind them to use their call light instead of attempting to transfer or ambulate independently. She said their falls have been a result of advancing dementia and the resident's cognitive inability to understand their ADL limitations. A record of the resident's fall would be on an incident report in their medical record. Fall interventions would be in the resident's care plan. The director of nursing (DON) was interviewed on 3/29/23 at 10:27 a.m. The DON stated the resident had come from assisted living due to cognitive and functional decline. The resident had fallen while in assisted living. Fall interventions for the resident had been to provide a hospital bed. The staff conducted frequent checks and the resident was now using a wheelchair for ambulation. CNA #7 was interviewed on 3/29/23 at 1:35 p.m. She stated the resident had been having an ADL decline over the last two weeks. The staff were to check on the resident every two hours but usually they found out about a fall when the spouse told them. Neither resident cognitively remembered to use their call light for help or before trying to perform an ADL on their own. The DON was interviewed on 3/30/23 at 12:55 p.m. She said she would provide the incident report for 3/7/23 and the interventions that had been put in place for the resident after each fall. The DON returned at 1:25 p.m. and revealed she had been unable to find any fall interventions in the resident's record and the care plan had not been updated. She provided the incident report for 3/2/23 but did not have one for 3/7/23. Based on record review and interviews, the facility failed to keep residents safe from accident hazards related to fall prevention for two (#16 and #32) of two residents reviewed for falls, out of 29 sample residents. Resident #16 had a history of fall and was assessed to be at high risk for repeated falls. Facility assessment and medical diagnosis revealed the resident had muscle weakness, poor balance, unsteady gait. Additionally, the resident had severe cognitive impairment that affected the resident judgment and ability to make sound safe decisions. Per the resident's medical records, the resident forgot or was unable to use the call light when she needed assistance to make safe transfer from surface to surface. Despite the resident's care plan having fall prevention interventions in place the resident continued to have repeated falls. The resident record failed to show a review of the effectiveness of the resident's fall interventions or consider more effective interventions to prevent the resident from falling. The facility's failure led to the resident experiencing repeated falls with injury. The resident had 11 falls between 11/4/22 to 3/24/23. The resident experienced several injuries including a fractured hip on 12/21/22, head injuries from the resident hitting her head during falls as evidenced by bruising, swelling, and pain to the head and several other aches, pains and bruises. Additionally, the facility failed to develop person centered care plan and individualized interventions; to assess interventions and to modify the care plan when applicable in order to prevent Resident #16 and #32 form experiencing repeated falls. Findings include: I. Facility policy and procedure The Fall Prevention Program policy and procedure was received from the nursing home administrator (NHA) on 3/29/23 at 1:29 p.m. It read in pertinent part: Each resident will be assessed for fall risk and shall receive care and services according to their level of risk to minimize the likelihood of falls. The objective of this policy is to use a risk assessment to determine a resident's fall risk. The facility uses a high, low and moderate risk using a scoring system on the risk assessment. Upon admission the nurse on duty will complete a fall risk assessment to determine a resident's risk of falls. The nurse will indicate on the resident's door frame with a leaf if the resident is a fall risk. This indicates to follow the fall precautions listed in the resident's care plan. When a resident experiences a fall, the facility will: 1. Assess the resident 2. Complete a post fall assessment 3. Complete an incident report 4. Notify physician and family 5. Review the resident's care plan and update as indicated 6. Document all assessments and actions 7. Document witness statements in case of injury II. Resident #16 A. Resident status Resident #16 age [AGE] was admitted to the facility on [DATE] and readmitted on [DATE]. According to the March 2023 computerized physicians orders (CPO) diagnoses included generalized osteoarthritis, history of falling, unspecified severe dementia with behavioral disturbances, unspecified fracture of right pubis (pubic bone), fracture of left femur (hip), muscle weakness and closed fracture with routine healing. The 1/4/23 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview of mental status (BIMS) score of eight out of 15. The resident required extensive assistance with transfers, bed mobility, dressing, and use of assistive devices with a manual wheelchair. The MDS assessment documented that the resident experienced a fall at least 30 days prior to admission. The resident experienced a fall with fracture in the last six months after admission. Surgery was needed for hip replacement prior to admission. B. Observations On 3/28/23 at 10:00 a.m., Resident #16's room was located five rooms down the hall from the nurse's station. Nursing staff did not have a direct line of sight of the resident's room from the nurses station, as the interdisciplinary team (IDT) recommended in a fall investigation. The resident was in a recliner and was wearing gripper socks. The wheelchair had an anti roll back bar applied. C. Record review 1. Care plan The resident's comprehensive care plan last reviewed on 1/10/23 revealed: Resident #16's care plan documented a care focus for fall prevention. The fall care focus last revised 11/4/22 revealed the resident was a risk for falls related to confusion, deconditioning, gait balance problems and being unaware of safety needs. Interventions included: -Anti rollback device placed on the back of the resident's wheelchair, initiated 12/8/22; -Do not put anything above the resident's reach, initiated on 11/4/22; -Ensure the resident is able to use the call light on command, initiated on 11/4/22; -Ensure Resident #16 is wearing rubber sole shoes or gripper socks for all transfers and ambulation (walking), initiated on 11/4/22; -Follow facility protocol for falls (no explanation of what the fall protocol was), initiated on 11/4/22; -Keep most used items within reach, initiated 11/4/22; -Provide activities that minimize the potential for falls while providing diversion and distraction; initiated 11/4/22; -Move (Resident #16's) wheelchair away from bed so that (the resident) does not attempt to self-transfer, initiated 12/14/22; -Provide a chair with an armrest, initiated: 11/4/22; -Review medications associated with fall risk antidepressants, initiated: 11/4/22; and, -Use a silent alarm to Resident's bed and chair related to Resident not being unable to call for assistance, due to poor safety awareness and dementia/confusion, initiated 11/7/22. The care plan documented a care focus for a facility acquired fracture of the resident femur occuring on 12/20/22. The goal of the intervention read in pertinent part: I (Resident #16) will remain free of complications related to hip fractures. Interventions included Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance initiated 1/3/23. -Resident #26's care plan was not updated with newly proposed interventions suggested in post fall investigations, and there was no documentation that existing interventions were assessed for effectiveness. 2. Resident falls Review of the resident's medical record revealed the resident had 11 falls from 11/8/22 to 3/28/23. Fall 11/8/22 Nursing note dated 11/8/22 at 3:35 p.m. read in part: Upon entering the resident's room, the resident was laying on her back. The resident was alert and able to verbalize that she fell and hit her head on the floor when trying to get up from the recliner. The resident's alarm did sound, gripper socks in place, the call light within reach. Resident was able to move all extremities, but expressed pain on right groin area, noted a large protruding hematoma to the lateral right side of the resident's head, protrusion purple in color and painful. Emergency medical services (EMT) called and the resident was transferred to the hospital for further evaluation and treatment. Nursing note dated 11/8/22 at 11:45 p.m., read in pertinent part: Resident returned to facility about 6:55 p.m. Resident to follow up with physician to recheck head injury in one week. Resident was given a pain pill at 7:03 p.m. for all over pain. Resident did not want to eat. About 11:10 p.m., the resident's bed alarm was sounding and when CNA (certified nurse aide) went to assist the resident, the resident was self-transferring into her wheelchair. The resident was reminded to use the call light for staff to assist as needed. Another pain pill was given at 11:15 p.m. Post fall report dated 11/8/22, read in pertinent part: nurse heard resident's voice from hallway saying help me. Upon entering the residents' room, the resident was on floor laying supine (on the back) diagonal from the recliner chair. Resident was alert and confused per usual, the resident complained of lower back pain and pain at the back of head. Upon observation, resident had a large protruding bump/bruising noted to the left back side of head, no visible bleeding noted, slipper socks and alarm in place, Vitals obtained and neurological check started. Resident voiced 'I hit my head', but was unable to give a full description of the fall. -predisposing factors: resident was confused, memory impairment and had weakness. -There was no documentation that the fall prevention interventions were assessed for effectiveness and no recommendations to add additional interventions. Fall 12/8/22 Nursing note dated 12/8/22 at 5:13 a.m., read in part: Alarm was sounding when this nurse entered the resident's room. The resident was trying to transfer into her wheelchair. The wheelchair rolled a little and the resident slid onto the floor. Non-skid socks in place. The resident said, 'I was trying to go to the bathroom.' Post fall report dated 12/8/22, revealed Resident #16 attempted to self transfer from the bed to the wheelchair without assistance and fell onto the floor when the wheelchair that was not locked rolled out from underneath the resident. There were no initial signs of symptoms of injury. The report documented the resident had poor safety awareness and an unsteady gait. Predisposing factors included poor lighting. Intervention recommendations included a directive for staff to increase rounds to check on the resident more often and for staff to anticipate the resident's needs during rounding times. Nurses note dated 12/9/22 at 2:31 p.m., revealed the resident was being monitored for witnessed fall on 12/8/22 with no apparent injuries. The resident had chronic pain to the right hip and right lower extremity with ibuprofen given with positive results to relieve pain. Fall 12/13/23 Nursing note 12/13/22 at 10:05 p.m., read in pertinent part: Late entry: Alarm sounding when nurse went into resident's room. Resident was sitting on the floor on a fall matt with back to bed, the bed alarm was on the resident's bed, but was towards (where the resident's) lower back (would have been an not at the shoulder where it was to be placed), non-skid socks in place, and the call light on the bed by where the resident's torso would have been. Wheelchair was within arm's reach which the resident tried to get to. Resident stated she was ready to get up. Assisted resident to standing position with resident able to bear weight. Resident reported discomfort to the hip but was continuing to heal from a prior fracture of the pubic (bone)with noted with chronic pain. Resident states pain is the same as usual. Abrasion to right of spine noted without pain or discomfort to site. Education received to staff regarding placement of bed alarm at shoulder height, not low back staff acknowledged (understanding). Resident with dementia and often forgetful to use call light. Post fall report dated 12/13/22 revealed, Resident #16 was attempting to get into her wheelchair without assistance and she fell onto the floor. -There was no documentation that the fall prevention interventions were assessed for effectiveness and no recommendations to add additional interventions. Staff were educated on the proper placement of the resident bed alarm; however, it was unknown hitch staff were educated because the training document was not provided. Fall 12/20/22 Nursing note dated 12/20/22 at 6:49 p.m., read in pertinent part: Resident #16 had an unwitnessed fall at 5:15 p.m. Resident (was found) lying supine approximately eight feet from the bed beside a reclining chair. Non slip socks on feet, legs were pointing in the direction of the bed, knees pulled up. (the resident ) verbalizing complaints of severe pain in the left hip. The resident was A&O (alert and oriented) to self, place, event, and readily conversing with nurse staff. (The resident said) 'I think I broke my hip.' Resident was unable to move, flex or extend the left leg or move the left knee medial without pain. The resident left the facility at 5:34 p.m. for hospital treatment assessment. Post fall report dated 12/20/22 at 5:15 p.m. revealed Resident #16 tried to ambulate from the bed to a chair without staff assistance. The resident fell before getting to the chair, which was approximately three feet away. The resident complained of severe hip pain immediately following the fall and was sent to the emergency room. Predisposing factors included recent illness, gait imbalance, impaired memory and a recent change in medications. Other information: the bed pressure alarm did not activate, as intended. -There was no documentation that the fall prevention interventions were assessed for effectiveness and no recommendations to add additional interventions. Hospital records dated 12/28/22 documented Resident #16 had fallen at the facility and complained of weakness in her legs and extreme pain in the left hip area.The resident was transferred to the emergency room; X-ray results concluded the resident had sustained a left hip fracture as a result of the fall. The resident underwent surgical intervention, on 12/21/22, to repair the hip fracture. Discharge instructions included making a follow up appointment with the resident's primary care physician, getting enough rest and eating healthy foods to help recover quickly. Nurses note dated 12/28/22 at 5:49 p.m., read in pertinent part: Resident readmitted from the hospital with arrival at 3:15 p.m., after left femur fracture with surgery done on 12/21/22. Observed three separate incision sites to the left lower extremity with steri-strips and sutures intact. Orders received to clean incision sites to left lower extremity, apply xeroform to sutures/steri-strips and cover with ABD (absorbent) pad. The resident is weight bearing as tolerated with sit-to-stand used for admission weight with resident tolerating well. PT (physical therapy) and OT (occupational therapy) to evaluate the resident. The resident is alert to self only with confusion to time, place and situation. Resident verbally reports pain to left leg with facial grimacing. Fall 1/17/23 Nursing note dated 1/17/23 at 11:10 p.m. read in pertinent part: Late entry: Called to resident room due to a fall. CNA heard the resident's bed alarm sound and went to the resident's room, as the CNA walked into the resident's room the resident fell to the floor. Resident was wearing gripper socks but they were no longer gripping due to the tread was mostly worn off, also the fall mat was not in place. Removed the old gripper socks and put on different ones and disposed of the other ones. Fall mat was placed at the bedside. CNA was reminded to always use the fall mat when the resident was in bed. Resident did have pain in the left leg. Percocet (pain medication) given with positive results. Post fall report dated 1/17/23, revealed CNA heard resident bed alarm sound and went to the resident's room where the resident was found seated on the bed feet on the floor, as the staff entered the room the resident slid off the bed onto the floor. When asked what happened the resident stated, I was playing. Staff assisted the resident back onto bed. Resident refused the offer to use the bathroom. The resident was noticed to be wearing gripper socks but the socks were no longer gripping due to the tread being mostly worn off the bottom of the socks. Predisposing factors included poor lighting. -There was no documentation that the fall prevention interventions were assessed for effectiveness and no recommendations to add additional interventions. Fall 2/15/23 Nure note dated 2/15/23 at 3:15 a.m. read in pertinent part: Resident was observed laying on her floor on her back. The wheelchair was in the bathroom doorway laying down with the front wheels up. The wheelchair breaks were locked. Noted to have a hematoma (pooling of blood under the skin) to the back of her head with no other complaints of pain or discomfort. Post fall report dated 2/15/23 revealed a loud crashing noise was heard form Resident #16 room the resident yelled out ohh. Upon entering the resident's room the resident was found lying on her back, on the floor. The wheelchair was in the bathroom doorway laying down with the front wheels up in the air. The wheelchair breaks were locked. The resident was wearing gripper socks. Resident had been previously lying in bed with the wheelchair next to the bed with breaks on. Resident was assessed and was noted to have a hematoma to the back of her head. The resident description of the fall: 'I fell and hit my head.' Predisposing factors included poor lighting, gait imbalance, impaired memory, and getting up without assistance. -There was no documentation that the fall prevention interventions were assessed for effectiveness and no recommendations to add additional interventions. Nurse note dated 2/17/23 at 12:03 p.m. read in pertinent part: Resident is being monitored for unwitnessed fall on 2/15/23. Observed slightly raised, dark purple colored hematoma to left side of back of head measuring approximately 8 centimeters (cm) in length by 6 cm in width. Non-raised light purple colored bruising to middle of back of head measuring approximately 5 cm in length by 5 cm in width. Resident denies any head or neck discomfort with range of motion to the neck within normal limits. Resident denies headaches Unchanged mental status with the resident being alert to self only and confused to time, place and situation. The resident continued to bear weight and transfer with sit-to-stand lift without difficulties (with staff assistance). The resident with poor safety awareness due to dementia with frequent self-transfers and inability to comprehend use of call light. Personal alarms on to alert staff. Continue to anticipate resident's needs to help prevent falls. Bed in lowest position when in bed and fall mat in place. Fall 2/24/23 Nursing note dated 2:40 p.m. read in pertinent part: CNA responded to resident (position change) alarm to find resident on the floor at the end of the bed. with back against the dresser, legs straight out, call light at bedside, floor mat in place and slipper (gripper) socks on appropriately. Resident was pleasantly confused which is her baseline. No head, neck or back pain upon assessment. Post fall report dated 2/24/23, documented the same information as the progress note with the following additional information. The resident description: I was trying to get to my wheelchair. Predisposing factors included confusion and impaired memory. Interventions following the fall were for staff to encourage the resident to use the call light, continue current interventions and check on the resident every hour while in bed. Fall 2/24/23 Nursing note dated 2/25/23 at 5:17 a.m. read in pertinent part: This nurse was called to the resident's room. Resident was found sitting on the floor between the window and bed. Resident had a hematoma 6 cm in diameter with a small abrasion was noted on the resident's head left side above the ear. Also on the outside of the resident's left wrist there were three small blood blisters. Will continue with the plan of care. Post fall report dated 2/258/23 revealed the resident was found sitting on the floor between the window and the bed. Resident description of the fall: Resident said she was trying to go to the restroom. Predisposing factors included: impaired memory and getting up without assistance. -There was no documentation that the fall prevention interventions were assessed for effectiveness and no recommendations to add additional interventions. Fall 3/7/23 Nursing note dated 3/7/23 1:34 p.m, read in pertinent part: CNA notified nurse that resident had fallen. Nurse and DON entered the resident's room to find the resident's bed at its lowest position and fall matt in place. Resident was kneeling on the floor facing towards the doorway with the left arm on bed and right arm on the wheelchair. It appeared the resident was trying to transfer to the wheelchair without assistance. Personal (position change) alarm was on the bed but (placed) low in bed. (the alarm) Sounded when the resident tried to self-transfer. The DON (director of nursing) and nurse assisted the resident into a wheelchair. Resident without bruising skin tears or redness. CNA assisted residents to the bathroom. The resident denied complaints of pain or discomfort. Able to move all extremities without pain/discomfort. Staff received education regarding proper placement of (position change) alarms required to be by residents shoulders and not beneath the resident's glutes (the buttocks). Post fall report dated 3/7/23, revealed the resident was found on the floor after a fall. Interventions including bed at lowest position and use of a fall matt were in place. The position change alarm was not placed properly. Resident description of the fall: I was just trying to get up. -There was no documentation that the fall prevention interventions were assessed for effectiveness and no recommendations to add additional interventions. Nursing note dated 3/8/23 at 11:23 a.m. read in pertinent part: Unchanged mental status with resident being alert to self only and confused to time, place and situation. Resident continues to bear weight and transfer with sit-to-stand lift without difficulties. The resident with poor safety awareness due to dementia with frequent self-transfers and inability to comprehend use of call light. Personal alarms on to alert staff. Alarm on bed positioned at shoulders/back. Nursing note dated 3/9/23 at 8:48 a.m., read in pertinent part: Night nurse reported that resident's bed (position change) alarm was not working. Noted that the alarm was working but delayed (in alarming). This nurse changed out the bed alarm to number 40. Staff updated on new bed alarm (number). Fall 3/11/23 Nursing note dated 3/11/23 at 2:59 p.m., read in pertinent part: Resident's alarm (position change) sounded with nurse rushing to room. Resident was on hands and knees on fall matt about to crawl towards the wheelchair. Alarm was in place but had moved down when the resident shifted. Fall matt in place and under resident. Low bed in place and all the way to the floor. Wheelchair was against the wall about a foot away from the resident. New intervention is for Dycem (non slip pad) under personal alarm to prevent alarm from falling down and keep wheelchair close to resident. Resident's call light was within reach but the resident has poor safety awareness and does not use it. Also in place fall matt remains in place, hi/Low bed and anti roll back to wheelchair. Post fall reported dated 3/11/23, document the same as the progress note above. Additional information included: Resident description of the fall: I need to go to the damn bathroom that's what I am doing. I will crawl there myself. -There was no documentation that the fall prevention interventions were assessed for effectiveness and no recommendations to add additional interventions. Fall 3/24/23 Nursing note dated 3/24/23 at 4:17 p.m. read in pertinent part: resident's bed silent alarm went off, CNA went to resident's room and observed the resident kneeling on floor mat in front of bed, CNA notified this nurse, this nurse went into see resident, sitting on floor mat in front of bed with feet in front of her, slipper socks in place, call light in reach. Resident pleasantly confused per usual baseline, smiling, alert and oriented to self only no distress noted, general aches and pains in legs-chronic pain, no visible injuries, Resident able to move all extremities w/o difficulty. When asked what happened the resident said 'I wanted to be down here, I was trying to get up.' The resident taken to the nurse's station for one to one monitoring. Post fall report dated 3/24/23 at 2:00 p.m. documented the same information as in the nursing note above. Additional information predisposing factors included confusion, weakness, gait imbalance, and impaired memory. -There was no documentation that the fall prevention interventions were assessed for effectiveness and no recommendations to add additional interventions. Therapy assessment Physical therapy and plan of treatment certification period 1/29/22 to 1/27/23 revealed Resident #16 was evaluated for physical therapy. Short term goals included: Goal #1- the patient will improve the ability to safely transfer from sitting to the side of the bed to lying flat on the bed with supervision or touching assistance. Goal #2- The patient will improve the ability to safely transfer from lying on the back to sitting on the side of the bed, feet flat on the floor with supervision or touching assistance in order to get out of bed. Goal #3[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a fall with injuries during facility transportation of one (#28) of three out of 23 sample residents. The facility failed to ensure Resident #28 was provided safe transportation. Due to the facility ' s failures Resident #28 was loaded into the van and was not secured properly before being left unattended while the transportation driver left the residents side to open the door on the other side of the vehicle. Because of this failure the resident's wheelchair was unstable and rolled forward out of an open door and out of the van causing the resident to fall approximately three feet down out of the van, face-forward onto the asphalt. As a result of the fall, the resident was seen in the emergency room for assessment and treatment. The resident sustained the following injuries resulting in pain to both upper extremities, both lower extremities, back, hip, trunk and head; bruising to both upper extremities, both lower extremities, and face; and skin tears to the head and body (see skin assessment below). Resident #28 was wheelchair bound and totally dependent on staff for mobility and positioning. She had functional limitations in range of motion for upper and lower extremities and was not able to use her arms to prevent the wheelchair from rolling forward. Resident #23 reported feeling unsure what was happening and when her wheelchair rolled forward in the van it caused her to squeal (to make a long, high-pitched cry to tell someone in authority about something wrong). She had originally requested a certified nursing aide to go with her but the aide was not there. Furthermore, the failure occurred because the transportation driver did not fully engage both brakes of the wheelchair, before walking away and leaving a fully dependent resident without the proper safety precautions to prevent injuries. Findings include: I. Facility policy and procedure The Transportation Safety policy and procedure, dated effective 12/13/21, was provided by the nursing home administrator (NHA) on 12/14/21 at 10:32 a.m. It read in pertinent part, Policy purpose to ensure safe transport of resident(s) in facility vehicle .Driver will only accept a resident to transport when necessary resources were available .Driver will review resources necessary and assist resident into vehicle appropriate for their medical status .Driver will secure resident into vehicle using proper safety equipment including, ramp, wheelchair brakes, seat belt, and floor straps per vehicle and equipment safety guidelines .Driver will perform a safety pause to ensure all equipment is secured properly and brakes are placed, as necessary. Driver will also physically perform an equipment check to see if any adjustments need to be made prior to departing. II. Resident #28 A. Resident status Resident #28, age [AGE], was admitted on [DATE], with reentry 11/21/21. According to the December 2021 computerized physician orders (CPO), diagnoses included fracture of the right lower leg, atrial fibrillation, and post-polio syndrome. The 11/28/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required total assistance with two persons for bed mobility, transfers, locomotion on and off the unit, bathing, dressing, toilet use, and extensive assistance of one person for personal hygiene. Functional limitations in range of motion for upper and lower extremities on one side. Use of wheelchair for mobility. B. Resident interview and observation Resident #28 was interviewed on 12/13/21 at 12:11 p.m. She said she had a fall from the facility's van after the transportation driver had taken her up the ramp in her wheelchair and into the van. Resident #28 said she was in a wheelchair (WC) in the van and the driver was trying to adjust and situate her because her right foot was elevated, the driver left her to go around to the driver ' s side of the van to open the drivers side passenger door to accommodate her foot rests to move her into a safe position. Resident #28 said after the driver opened the driver's side passenger door and left to walk back to the ramp side of the van, her WC rolled forward out of the driver's side passenger door and she fell forward out of the wheelchair landing onto the asphalt below. The WC was still hanging out of the van and she was face-forward on the parking lot asphalt. Resident #28 said she hit the left side of her head on the ground. The resident ' s left forehead and eye was observed to be black and blue in color. Resident #28 ' s left elbow, and upper arm were bruised and had thick large, black scabs over the left elbow and upper arm. Left forearm was bruised and Resident #28 said her left leg was also injured. Resident #28 said after the fall the ambulance came and took her to the hospital. Resident #28 was not sure why she fell, remembered falling out of the van, and could not recall if the driver put on her brakes or secured her prior to leaving her to go to the other door. C. Record review 1. Progress notes 12/1/2021 at 1:14 p.m. nursing note: Nurse notified that during transport resident fell out of wheelchair and was on floor. Observed resident lying supine in parking lot with right foot/leg externally rotated more than normal while in boot. Resident complained of hip, back, and leg pain. Emergency medical services (EMS) were called for transport to the emergency room (ER) at 12:50 p.m. Blood pressure 175/88 right arm, heart rate 61, oxygen saturation on two liters per minute (LPM) at 83% with increase to four LPM with 92%, equal unlabored respiratory rate of 18 breaths/min. Contusion and bruise to left eye and cheek bone observed. Skin tear to left arm with bleeding with inability to see extent due to shirt that resident did not want to be cut. Transportation verbally reported to the nurse that the resident was laying face down and rolled herself onto the back (supine) position. +1 pupil dilation to the left eye with no reaction to the right. Resident was left in supine position until EMS arrived at 1:05 p.m. Resident did not lose consciousness. Resident alert and oriented x4 per usual. MDS notified the specialty clinic that the resident was being sent to ER instead of her appointment. MDS notified the power of attorney (POA) with transfer to ER. While EMS transferred the resident from asphalt to stretcher resident further complained of right knee pain above boot, back pain, and hip pain. 2. Facility investigation Review of the facility transportation accident investigation, dated 12/1/21, provided by the NHA 12/13/21 at 2:04 p.m., revealed: On 12/1/21, Resident #28 fell out of the facility ' s transport van when the transportation driver left the resident unattended to open the driver's side passenger door to allow for more room to get the resident fully into the van in order to secure the resident's manual wheelchair into place for safe transport to a medical appointment. Resident #28 fell approximately three feet out of the van onto the parking lot asphalt and sustained pain and bruising all over body and face, and multiple skin tears on face and arms. The transportation driver (TD) was interviewed on 12/1/21 at 12:45 p.m., by the NHA. The TD said the resident was in the middle of the van prior to the WC rolling out of the van. The TD told the resident that she was going to open the door on the other side of the van so she would not hit her foot. The TD went around the vehicle to the driver ' s side and opened the door, then the TD turned to go back to the passenger side and heard a squeal from the resident. When the TD turned around, the resident was still in the vehicle and was in the process of falling out of the vehicle. The TD saw the resident ' s body folding forward and ducking her head (like a somersault); she then fell out of the vehicle. An email witness statement from licensed practical nurse (LPN#2) addressed to the NHA, minimum data set coordinator (MDSC), and DON, obtained on 12/1/21 at 1:43 p.m.; revealed: LPN #2 was notified that during transport the resident fell out of the WC and was on the floor. LPN #2 observed resident lying supine in parking lot with right foot externally rotated more than normal while in boot. The resident complained of hip, back, and leg pain. Emergency medical services (EMS) were called for transport to the emergency room (ER). Contusion and bruise to left eye and cheek bone observed. Skin tears to the left arm with bleeding. Transport reported to the nurse that the resident was lying face down after falling and rolled herself onto the back (supine) position. While EMS transferred the resident from asphalt to stretcher, the resident further complained of right knee pain above boot, back and hip pain. The witness observed the resident's WC with the front wheels hanging from the vehicle on the driver's side passenger door. Brakes were not fully engaged on either side. Witness statement from minimum data set coordinator (MDSC) dated 12/1/21 at 12:50 p.m., revealed: the MDSC was asked to assist in the parking lot due to a resident fall. Upon arrival, the MDSC said she observed the transportation van had both the passenger ramp door and the driver's side passenger doors opened on either side of the van. The resident's WC with front wheels touching the asphalt. Observed resident lying on her back with her right lateral foot in boot and touching the asphalt parking lot. The resident was alert and talking and stated her head hurts, there was observed bruising to the left forehead and temporal region down to the cheek. The resident's glasses and face mask were on the ground near the resident's head. The nurse observed that the right wheelchair brake was not engaged, and that the left was not fully engaged. Resident #28 ' s interview statement dated 12/1/21 revealed the wheelchair was rolling in the van before she fell out of the van onto the parking lot below. 3. Facility investigative summary findings Skin assessment 12/6/21 at 10:44 p.m., documented post injury findings: Skin is pale in color. Mucous membranes are moist. Skin warm/dry to touch. Skin is dry/cracked. Skin is fragile. Decreased skin turgor. Resident has current skin issues. Skin issue:-Bruising left side of forehead Length: 2.0 width centimeters (cm), width 2.1 cm. -Bruising outside left eye socket Length: 4.0 Width:1.5. -Bruising below left eye.-Bruising left upper arm down left elbow irregular shape Length: 20.0 Width: 19.0. Skin Issue: -Skin Tear scab left upper arm near elbow Length: 1.5 Width: 2.0 Wound Exudate: None. Peri Wound Condition: Fragile.-Skin Tear below left elbow s shape with steri strips Length: approx 14.0 Wound Exudate: None. Peri Wound Condition: Fragile. Skin Issue: Discoloration left shin. -Bruising left top foot/ankle Length: 10.0 Width: 8.0. -Bruising top left foot Length: 5.5 Width: 4.5. -Abrasion top left 5th toe Length: 0.4 Width: 0.5 Wound Exudate: None. Peri Wound Condition: within normal limits (WNL). No wound odor. No tunneling. No undermining. -Abrasion left 2nd toe Length: 0.3 Width: 0.2 Wound Exudate: None. Peri Wound Condition: WNL. No wound odor. No tunneling. No undermining. -Bruising right thigh Length: approx 14.0 Width: 2.0. -Bruising upper right arm Length: various Width: various. -Bruising. Length: back left knee Length: 15.0 Width: 11.0. -Discoloration right shin callous to L plantar. scattered smaller bruises to bilateral upper extremities and bilateral lower extremities. The right inner ankle area has no further draining and appears healed. Had a fall on 12/1/21. -There were conflicting statements regarding brakes among all statements. Based on review of the facility ' s investigative report and the resident interview (see above), the resident did not remember brakes of her wheelchair being engaged, but remembers rolling out of the van and falling onto the asphalt, and being injured. The charge nurse (LPN#2) stated neither brake was on, and the DON and MDSC stated the left brake was not on and the right brake was halfway on. -Root cause analysis: 1.Resident boot and extended pedal bumping into vehicle prompting driver to open secondary sliding door (on the drivers side). The vehicle was not big enough to accommodate the length of the resident ' s WC with the leg rest pedal extended versus making pedal adjustments. 2.It was unclear if the WC brakes were fully engaged or even engaged at all due to conflicting reports among the resident, driver, and other responding witnesses. There was no system in place to do a safety check before staff left the resident unattended and moved to another task. 3. There were inconsistent procedures in place to ensure safe practices to establish standard protocol for communication of needed resources prior to a resident being taken to an appointment. No designated person/backup responsible for ensuring this task was completed. Processes were not in place to ask residents if they would like assistance, regardless of cognition. Transportation policies were not in place to establish a requirement for safety or to ask residents their preference for appointments. A request was made for documentation of competency check-off for all staff providing transportation assistance to ensure adequate skill for safe transportation was requested from the NHA on 12/14/21 at 11:00 a.m.; however, it was not provided during or after the survey. A request was made for documentation to show that the transportation driver involved in the resident falling out of the van was retraining on safe transportation practices was requested from NHA on 12/16/21 at 12:20 p.m.; however, it was not provided during or after the survey. 4. Hospital report Hospital notes 12/1/21 at 3:07 p.m. revealed: -CT scan of head due to fall from three feet, hit head, on blood thinners. Results read, no hemorrhage or other acute intracranial (skull) abnormality. -Right ankle x-ray due to fall and current right ankle fracture (from a prior fall at home). Results read, x-ray of the ankle show the prior fracture was stable, without any new fractures, compared to the prior exam. -Left ankle x-ray taken due to fall from the van and ankle pain. Results read, the resident had degenerative changes and slight irregularity of the medial malleolus (bump on the inner side of ankle), were inconclusive for a new fracture (not exactly known). The resident was found to have profound osteopenia (reduced bone mass). D. Staff interview The facility transportation driver (TD) was interviewed on 12/14/21 at 3:25 p.m. The TD said she had worked at the facility for 2.5 years. The TD said she had received on the job training for driving the facility bus and van. The TD said she had also received a certificate for defensive driving. -The TD said she went to get Resident #28 from her room on 12/1/21, and the resident stated that she wanted a certified nursing aide (CNA) to come to her appointment. The TD said this had not been pre planned although the NHA had said they should have a CNA go along with residents to all appointments. The TD said we usually had a CNA scheduled to go for safety and an extra set of hands, but no one was assigned that day. The social services director (SSD) decided to go. The TD said while she waited for the SSD to get ready for trip she loaded Resident #28 into the van alone. She pushed Resident #28 in her wheelchair up the ramp, into the middle of the van but positioned the wheelchair at a slant due to right foot being elevated and not being able to position the resident in the correct position for transport. The TD said she locked the wheelchair brakes. The TD said she went around to the driver's side of the van to open the opposite door of the van and returned to the passenger side ramp door, when she heard the resident squeal. The TD saw the resident leaning forward in her wheelchair and the chair was rolling out of the van door on the driver's side. The TD was not sure how the wheelchair rolled out of the van because she was convinced she had locked both of the wheelchair brakes on either side of the chair. The TD said the wheelchair somehow moved out of the center of the van and rolled out of the driver ' s side door. The wheelchair got stuck on the side of the van causing Resident #28 to fall out of the van onto the asphalt below, landing on her left side. The TD said Resident #28 did not have a seatbelt on and the wheelchair tie down straps had not yet been applied because she was unable to get the resident fully into the van in the correct position for transport. The TD acknowledged the failure and most likely cause of the resident's fall was that the right brake did not hook or tighten all the way. The TD said her process was to lock the brakes, hook/strap the WC, then put on the seatbelt. -The TD said the prior transportation driver (DA#3) completed retraining with her last week. The TD said the training consisted of demonstrating safe WC loading and DA#3 was seated in the WC as she practiced the correct and safest methods. The TD said DA#3 said to make sure to secure brakes and WC tie downs (hook/strap) first, and to not open the other door. The TD said having two staff members to load was safer. The TD said she now goes through a double check system to make sure the wheelchair was locked. The TD said she was also trained by licensed practical nurse (LPN#1) how to adjust and move the wheelchair foot/leg pedals on the WC. The TD said she was not proficient with moving the leg pedals prior because usually a CNA would adjust that. The TD said the new corrective action was to have two staff members for all medical appointments. She said the van now had a blanket and a safety sign that says, brakes on, seat belt on, resident secured. The TD said that safety checks for wheelchairs was the maintenance department's responsibility and they recently ordered some new parts. The TD said the WC brakes were important so that you would not move around. The TD said the SSD will now be responsible for securing staff to go with on appointments. The TD said they did not have a transportation policy prior but now have one. The TD she had glanced at the new policy. The NHA was interviewed on 12/16/21 at 12:20 p.m. She said if a resident requires a CNA assistance during transportation they will go with them, but said that was not based on transportation safety. The NHA said new safety procedures were put in place following the fall of Resident #28 during transportation on 12/1/21. The NHA said they would ask the resident if they would like someone to go with them 24 hours prior; SSD would be responsible for that. The NHA said once the resident was in the vehicle they would put the WC brakes on, and place hook/straps on the WC. The NHA said the facility updated it ' s transportation policy to double check WC brakes and added signage in the van. The NHA said the right WC brake was tough but others did not think so. The NHA said policies and procedures were not followed. III. Follow-up No further documentation was provided after the survey that was requested during the survey or that the facility wanted to provide for review.