**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 5 residents (Resident #91, 22 and 124) reviewed for accidents, for Resident #91, the facility failed to provide the physician ordered 1:1 supervision which resulted in a fall with injury, for Resident #22, the facility failed to provide adequate supervision to prevent a fall, and for Resident #124, the facility failed to ensure the bed was locked to prevent a fall, and for 1 of 5 residents (Resident #93) reviewed for unnecessary medications, the facility failed to ensure that pharmacy recommendations were reviewed and implemented for a resident with a history of multiple falls. The findings include: 1. Resident #91 was admitted to the facility in August 2022 with diagnoses that included dementia, difficulty in walking and repeated falls. The care plan dated 12/1/22 identified Resident #91 required assistance related to confusion. Interventions included providing contact guard for transfers, toileting, and ambulating although the resident was noncompliant with asking for and waiting for assistance due to cognitive deficits. Further, Resident #91 was at risk for falls due to cognitive loss, lack of safety awareness, and dementia. Interventions included to encourage to accept cues for safety reminders, encourage to sit in common area after morning care for breakfast as he/she allows, encourage to accept cues for safety reminders and to offer toileting four times per shift as resident allows. A physician's order dated 12/15/22 directed the resident to receive 1:1 supervision at all times. The quarterly MDS dated [DATE] identified Resident #91 had severely impaired cognition, required extensive assistance with transfer, walking in room/corridor, locomotion on unit, and toilet use. Additionally, Resident #91 had unsteady balance when moving from a seated to a standing position, while walking, turning around, moving on and off toilet, and was only able to stabilize with staff assistance. The physical therapy Discharge summary dated [DATE] identified Resident #91 was using an assistive device up to 100 feet with contact guard. The physician's order dated 3/1/23 directed the resident to receive 1:1 supervision at all times. Although requested a fall risk assessment prior to the fall on 3/5/23 was not provided. The reportable event form dated 3/5/23 at 1:30 AM identified Resident #91 fell in the bathroom and sustained a laceration to the top of the head that measured 3.5 cm and was bleeding. Resident #91 was transferred to the hospital at 2:00 AM for treatment. Neurological and skin assessment performed. The reportable event form identified there was no witness to the fall. Review of the neurological assessment flow sheet dated 3/5/23 at 2:00 AM identified neurological checks was within normal range and Resident #91 had a fall with a head laceration and Resident #91 was transferred to the hospital. The nurse's note dated 3/5/23 at 2:11 AM identified RN #6 Resident #91 fell in the bathroom and sustained a laceration to the top of the head that measured 3.5 cm with bleeding noted. Resident #91 fell at 1:30 AM and left the facility at 2:00 AM. Resident was on 1:1 at all times. Review of the nurse aide flow record identified that NA #3 provided care to Resident #91 on 3/5/23 during the 11:00 PM - 7:00 AM shift (at the time the resident fell on 3/5/23 at 1:30 AM). Review of a statement written by NA #3 dated 3/5/23 identified NA #3 found Resident #91 on the floor by the bathroom after he had left the room and gone to get report from the nurse. NA #3 identified the last time he saw Resident #91 was at 1:00 AM and the resident was sleeping in bed. Review of a statement written by NA #5 dated 3/5/23 identified NA #5 went to assist with Resident #91. NA #5 indicated when she arrived in the room Resident #91 was up on his/her feet and walking. NA #5 indicated Resident #91 looked alright and his/her head was bleeding. NA #5 indicated they called for the nurse LPN #3 and the RN #6. The nurse's note dated 3/5/23 at 5:48 AM identified Resident #91 returned from the hospital with 4 staples to the top of the head and staff resumed 1:1 supervision. Review of the hospital W-10 form dated 3/5/23 identified Resident #91 was admitted on [DATE] at 2:25 AM. Resident #91 was discharged with a diagnosis of laceration of scalp and sutures to be removed within one week. Review of 1:1 supervision in-service sign in sheet dated 3/6/23 identified when a resident is placed on a 1:1 the staff are to complete the 1:1 form and staff need to be either inside or outside of the resident room as directed by the supervisor. Review of the 1:1 binder on 2 North (the dementia unit) on 5/9/23 at 11:00 AM failed to reflect documentation that Resident #91 had been monitored on 1:1 on 3/4/23 and 3/5/23. Interview with the DNS on 5/17/23 at 2:39 PM identified she was not employed by the facility at the time of the incident. The DNS indicated NA #3 should not have left Resident #91 alone because Resident #91 had an order for 1:1 monitoring. Although attempted, an interview with NA #3 was not obtained. Although attempted, an interview with LPN #3 was not obtained. Although attempted, an interview with NA #5 was not obtained. Although attempted, an interview with RN #6 (supervisor) was not obtained. Review of the facility enhanced patient supervision: continuous 1:1 policy directed to when using continuous 1:1 supervision, designated staff will be assigned to manage the 1:1 supervision of the patient. The designated staff will only be involved with the delivery of care to this patient and no other patient. The designated staff must be with the patient at all times; must obtain coverage for breaks; and will provide positive interaction in conjunction with therapeutic interventions. Continuous 1:1 supervision will be provided per nursing judgement or when recommended by a physician/advanced practice nurse. Designated staff will document patient activities every 30 minutes on the continuous 1:1 supervision flowsheet. Review of the falls management policy directed to patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented. In the event a fall occurs, an assessment will be completed to determine injury. Any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neurological check, per policy. The physician/APRN will be notified of any abnormal findings. 2. Resident #22 was admitted to the facility in February 2022 with diagnoses that included Alzheimer's disease, dementia, absence of left toes and non-pressure chronic ulcer of left/right foot. The care plan dated 2/5/23 identified Resident #22 was at risk for falls due to Alzheimer's disease, osteoarthritis of knee, and partial amputation of left foot. Interventions included that when the resident is tired, to encourage him/her to remain in view of staff until ready to go to sleep in bed. The nurse aide care card dated 2/5/23 identified for safety, when the resident is tired, to encourage him/her to remain in view of staff until ready to go to sleep in bed. Resident #22 is independent with ambulation using rolling walker. The physical therapy discharge evaluation dated 3/2/23 identified Resident #22 was to ambulate 200 - 300 feet with rolling walker with supervision and stand by assist (SBA) (cueing, coaxing, and stand by for safety), with supervision/touching assist. The annual MDS dated [DATE] identified Resident #22 had severely impaired cognition and required limited assistance with transfers, walking in room, walking in corridor, and required supervision with locomotion on unit. Additionally, Resident #22 was not steady, only able to stabilize with staff assistance with moving from seated to standing position, walking, and turning around. Further, Resident #22 had an impairment of range of motion on one side of lower extremity and used a walker with ambulation. A reportable event form dated 4/24/23 at 9:00 PM identified Resident #22 resides on the memory care unit and had a witnessed fall. NA #6 indicated she observed Resident #22 walking with the rolling walker in the hallway. NA #6 indicated Resident #22 then lifted the walker up, loss his/her balance and fell to the floor on his/her right side. Resident #22 complained of bilateral hip pain which was more prominent to the right hip. The physician was notified, and Resident #22 was transferred to the hospital for further evaluation. Review of the fall form dated 4/24/23 identified Resident #22 was observed in a right lateral position on the floor. A physician telehealth consult was done, and bilateral hip x-rays were ordered, however, Resident #22 was transferred to the hospital due to the length of wait time for x-rays and symptoms of fracture. The APRN progress note dated 4/27/23 identified Resident #22 returned from the hospital with a diagnosis of inferior pubis ramus fracture after a fall while ambulating with walker at facility. Resident #22 takes Dilaudid routinely for chronic pain due to severe peripheral vascular disease with history of toe amputation of left foot. Chronic osteomyelitis managed with Bactrim. Dementia due to Alzheimer's is managed with memory care and safety precautions. Diagnosis of pelvic fracture. Plan: acute pelvic fracture pain change Dilaudid to every 4 hours routinely with Robaxin and Tylenol. Follow up with physical therapy. The revised care plan dated 4/28/23 identified Resident #22 was at risk for falls: Alzheimer's disease, osteoarthritis of knee, and partial amputation of left foot. Interventions include to offer bed when observed walking around the hallway in the late evening as resident allows. Review of the summary report dated 4/29/23 at 5:31 PM identified Resident #22 was independent with transfer and ambulation with use of rolling walker. On 4/25/23 Resident #22 was re-admitted to the facility with no surgical interventions for the fracture. Resident #22 remains comfortable with pain management use of as needed Dilaudid and scheduled Methocarbamol every 8 hours for 14 days. Resident #22 was in no distress. The care plan was reviewed and revised to have rehab evaluate activity level. Administered pain medication as ordered. Update APRN/MD as needed. Interview and review of the clinical record with the Physical Therapy Director on 5/16/23 at 8:30 AM identified Resident #22 was discharged from physical therapy on 3/2/23 with the following: Resident #22 was to ambulate 200 - 300 feet with rolling walker with supervision to stand by assist (SBA) (cueing, coaxing, and stand by for safety), with supervision/touching assist. The Physical Therapy Director indicated Resident #22 was not independent with ambulation. The Physical Therapy Director indicated nursing staff were made aware of the recommendations on 3/2/23. Interview and review of the clinical record with the DNS on 5/17/23 at 2:40 PM indicated she was not aware of the physical therapy discharge notes dated 3/2/23 indicating Resident #22 needed supervision to stand by assist (SBA) with ambulation with rolling walker with supervision/touching assist. The DNS indicated she was not employed with the facility at that time. The DNS indicated she thought Resident #22 was independent with ambulation with rolling walker. The DNS indicated NA #6 witness Resident #22's fall. Although attempted, an interview with RN #8 was not obtained. Although attempted, an interview with NA #6 was not obtained. Review of the facility falls management policy identified patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented. In the event a fall occurs, an assessment will be completed to determine possible injury. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. 3. Resident # 93 was admitted to the facility on [DATE] with diagnoses that included dementia, psychosis, and anxiety disorder. The physician's orders dated 2/1/23 directed to administer Seroquel (an antipsychotic medication used for psychosis) Clonazepam (a benzodiazepine used for anxiety), Lorazepam (a benzodiazepine used for anxiety), and Morphine oral solution (an opioid used for pain relief). The quarterly MDS dated [DATE] identified Resident #93 had severely impaired cognition, was always incontinent of bowel and bladder, and required the assistance of 2 or more staff members with transfers, dressing, and toileting. The MDS also identified Resident #93 was receiving hospice care and had a history of falls. The care plan dated 2/2/23 identified Resident #93 was at risk for falls. Interventions included completing medication evaluations as needed. The monthly pharmacist medication reviews completed on 2/20/23 and 4/21/23 identified that the use of 2 concurrent benzodiazepines (Lorazepam and Clonazepam) increased the risk for falls, especially in combination with Seroquel and Morphine. Recommendations included considering reducing or eliminating Lorazepam and Clonazepam. The recommendation further identified that if the medications were continued, the facility should ensure that ongoing monitoring is in place for efficacy and potential side effects including new onset falls. The clinical record failed to identify that the pharmacy recommendations of 2/20/23 and 4/21/23 were reviewed or implemented by clinical staff at the facility. Review of the clinical record identified that Resident #93 had multiple falls without major injury on the following dates: 2/23/23, 2/28/23, 3/6/23, 3/23/23, 4/19/23, and 4/28/23. Interview with the Medical Director, (MD #1) on 5/17/23 at 12:05 PM identified that he or the facility APRN would usually review and sign the monthly pharmacy recommendations. MD #1 further identified that he and the APRN signed off all the reviews that were provided each month to them by the DNS, and the signed report is placed in the resident's paper chart. MD #1 identified that if a change was made based on the recommendation, the resident's orders would be updated. Interview with the DNS on 5/17/23 at 12:18 PM identified she was unsure why the pharmacy recommendations had not been reviewed by the facility staff or given to the physician or APRN for review. The DNS identified that she provided the provider (MD/APRN) with the pharmacy recommendations for review and signature, and the signed paperwork was placed in the resident's medical record. The DNS further identified that because Resident #93 was on hospice, she was unsure that the recommendations would have prevented the multiple falls Resident #93 had but was unable to provide any documentation to identify the recommendations had ever been provided to the MD or APRN for review. The facility policy on falls management directed that the purpose was to identify risks for falls and minimize the risk for recurrence of falls. The policy further directed that interventions would be implemented and documented according to the resident's risk factors. 4. Resident #124 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, dementia, and epilepsy. The care plan dated 3/13/23 identified Resident #124 was at risk for falls due to tardive dyskinesia. Interventions included assisting the resident to organize belongings for a clutter-free environment in resident's room and consistent furniture arrangement. The quarterly MDS dated [DATE] identified Resident #124 had severely impaired cognition, required supervision for walking in the room and hall without the use of an assistive device, was occasionally incontinent of bowel and bladder and had 2 or more falls since admission or prior assessment. A reportable event form dated 3/26/23 identified that at 5:00 AM Resident #124 was found in the prone (face down) position on the floor by RN #5, the bed was unlocked, and the resident was barefoot. A neurological evaluation flow sheet dated 3/26/23 identified neurological assessments began as per protocol at 5:00 AM and continued at 15-minute intervals and were normal. A statement by RN #5, dated 3/29/23 identified the bed was in the lowest position when the resident was found on the floor and that is what caused the bed to move. Interview with Administrator on 5/16/23 at approximately 10:40 AM identified although staff locks the beds, if lowered too low, the beds become unlocked, and although Resident #124 was cognitively impaired, he/she was known to raise and lower the bed independently. Review of the policy for accidents/incidents identified the interventions to eliminate (accidents) if possible, and if not possible, reducing the risk of the accident/incident after having been identified and implemented.