**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 2 of 4 residents (Resident #181 and 4) reviewed for falls, the facility failed to ensure a pelvic positioning belt was applied according to the care plan, and failed to ensure 2 staff were present when the resident was positioned and fastened to the mechanical lift, which resulted in Resident #181 falling forward out of the wheelchair and onto the floor and sustaining a comminuted femoral fracture, and for Resident #4 who was at risk for falls, the facility failed to ensure a rehabilitation screen was completed upon admission. The findings include: 1. Resident #181 was admitted to the facility with diagnoses that included encephalopathy and dementia. The quarterly MDS dated [DATE] identified Resident #181 had severely impaired cognition and required extensive 2-person assistance for dressing and transfers. The care plan dated 6/5/20 identified Resident #181 required the assistance of 2 staff to get in and out of the tilt in space adaptive wheelchair via a [NAME] (mechanical lift). Further, to position Resident #181 in the adaptive wheelchair with a cushion, head rest, lateral trunk supports, calf pads, leg rests, and pelvic positioning belt. A reportable event form dated 8/18/20 at 7:15 PM identified Resident #181 fell because the seat belt was not completely latched, and residents weight shifted forward. A nurse's note dated 8/18/20 at 11:10 PM, by RN #1, identified that she was called by the charge nurse, LPN #2, and observed Resident #181 on floor in front of the wheelchair on his/her side with a raised reddened area 2.0cm by 2.0cm by 1.0 cm area to forehead. Subsequent to physician notification, Resident #181 was sent to the emergency room for evaluation. Hospital emergency department notes dated 8/18/20 at identified Resident #181 was crying with pain to the left knee, 10 out of 10 by facial scale. The resident was medicated with Toradol 15mg (nonsteroidal anti-inflammatory drug used to treat pain) and Morphine 2mg (narcotic pain medication) via IV and transported to radiology. The notes further identified that at 9:13 PM the resident was medicated with Zofran 4mg (medication for nausea and vomiting) and Morphine 4mg via IV and transferred to radiology and CT scan. The note identified on 8/18/20 at 9:26 PM the resident received Ofirmev (analgesic for pain) via IV. A diagnostic report dated 8/18/20 identified a CT-Scan of the left leg identified severe osteopenia, and a comminuted (a bone that is broken in 2 or more pieces caused by severe trauma) femoral fracture with angulation and mild impaction. A nurse's note identified the resident returned from the hospital on 8/19/20 at 2:45 AM with a left lower leg immobilizer in place and a new order for Morphine 10mg every 4 hours as needed for pain. A nurse's note dated 8/19/20 at 2:08 PM identified the resident had a follow up orthopedic appointment on Friday 8/25/20 and will go via ambulance. A nurse's note dated 8/19/20 at 11:27 AM identified the resident complained of increased pain to the knee. Tylenol and Motrin had no effect. The physician was made aware and ordered Dilaudid 2mg until Morphine received from pharmacy. Leg brace in place and the first dose of Morphine was administered at 11:00 PM. A nurse's note dated 8/20/20 at 4:24 AM identified the resident complained of pain to the left leg, 5 out of 10, and Tylenol was given with good effect. A nurse's note dated 8/21/20 at 4:50 AM identified the resident complained of pain in the left leg 6 out of 10. Morphine scheduled given this shift with good effect. Interview with NA #1 on 2/24/22 at 1:47 PM identified Resident #181 had a habit of unbuckling the seat belt while in the adaptive wheelchair prior to the 8/18/20 fall. NA #1 indicated Resident #181 was on her assignment that night and after supper she brought the resident into the room and started to give the resident a bed bath while the resident was in the adaptive wheelchair. NA #1 indicated she went and got the Sara lift and placed the lift directly in front of Resident #181. NA #1 leaned Resident #181 forward to place the padded strap around the back of the resident and under his/her arms, and the resident fell forward out of the adaptive wheelchair onto the floor. NA #1 indicated at that time she realized Resident #181 may have unbuckled the seat belt so when she leaned Resident #181 forward to apply the lift strap, the resident fell out of the chair. NA #1 noted she was alone while attempting to hook Resident #181 up to the Sara lift. NA #1 indicated she was going to hook Resident #181 up to the lift and then get a second person to assist with the transfer. NA #1 indicated there must be 2 people to use a mechanical lift. Interview with LPN #1 on 2/24/22 at 2:20 PM identified she was the staff development coordinator and did general orientation when NA #1 was hired in 2019. LPN #1 could not recall if she did competencies for mechanical lifts with NA #1 and was unable to find any documentation. Interview with NA #2 on 2/24/22 at 3:01 PM identified she was the regular aide on that unit and Resident #181 had a seat belt for at least a few months prior to the fall 8/18/20. NA #2 indicated there should always be 2 people to use the Sara lift and nurse aides should get the second aide at the same time as they get the lift and do not set the resident up with the lift without another aide present in the room. Interview with the DNS on 2/24/22 at 3:00 PM identified the nurse aides must always have 2 people in the room with the Sara lift, and that one staff member stands next to the resident to guide the resident while the other staff member uses and directs the lift. Interview with RN #1 on 2/24/22 at 4:00 PM indicated she recalls there was an issue with the seat belt not being latched correctly and the nurse aide went to get a mechanical lift and the Resident #181 fell out of the wheelchair forward without the seat belt on and was sent to the hospital. RN #1 indicated she did a corrective action form right away with NA #1 about the seat belt not being latched correctly. Although attempted multiple times, an interview with LPN #2 was not obtained. Review of the Sara lift policy directed to use at least 2 nurse aides when transferring a resident using a mechanical device / Sara lift. The procedure directs to bring Sara lift carefully up to the resident placing the resident's feet on the footrest and continuing forward if possible until the kneepad is just in contact with the resident's knee, and or upper shin. Apply brakes. Help the resident's arms through the sling if they cannot manage to do this independently. Tighten the cords so they are taut, and the sling is firmly across the residents back. If possible, the resident should now hold onto the padded frame with one, or both hands. 2. Resident #4 was admitted to the facility on [DATE] with diagnosis that included dementia, hypertension, blindness right eye and low vision left eye. A fall risk assessment tool dated 8/12/21 identified Resident #4 was at moderate risk to fall. The history and physical (H&P) dated 8/12/21 identified Resident #4 was in generally good health for his/her age, had been ambulating independently at home, but becoming more easily fatigued and napping more frequently. Resident #4 was being admitted as a long-term resident of the facility secondary to increased level of frailty. H&P identified Resident #4 had decreased vision, evidence of kyphosis and would be seen and evaluated by physical therapy. Review of the clinical record 8/12/21 through 10/18/21, over 2 months, failed to reflect physical therapy screening or evaluation had been done. Physician's orders dated 8/12/21 through 10/18/21 (date of fall) failed to reflect Resident #4's activity/mobility or ADL status. A nurse's note dated 8/12/21 identified Resident #4 was blind in the right eye and sees only shadows with the left eye due to glaucoma. Additionally, Resident #4 had a 4 wheeled walker with seat that was rarely used. The resident representative indicated they would bring in a cane from home and otherwise the resident usually held someone's hand when walking longer distances. The admission MDS dated [DATE] identified Resident #4 had moderately impaired cognition, required supervision of 1 staff with transfers, ambulation in room and locomotion on and off unit. Balance during transitions and walking indicated resident was not steady, but able to stabilize without human assistance. Resident #4's vision was highly impaired, indicating object identification in question, but eyes appear to follow objects. The care plan dated 8/26/21 identified Resident #4 was at risk for falls due to osteoporosis and right eye blindness. Interventions included to increased staff supervision with intensity based on resident need, provide individualized toileting interventions based on needs/patterns and bed alarm while in bed. Review of the nurse aide [NAME] prior to the fall, identified Resident #4 had a 4 wheeled walker and a cane and required continual supervision, cues (no hands-on assist) when walking. Physician's order dated 10/3/21 directed PT/OT/ST as needed due to change in condition. A reportable event form dated 10/18/21 identified at approximately 10:15 AM the housekeeping staff heard Resident #4 calling out for help and the resident was found by the housekeeper lying on the floor in a supine position. The Unit Manager was summoned, and the resident identified his/her legs just gave out. The resident denied feeling dizzy prior to falling and indicated he/she fell onto the right elbow. Resident #4 was able to actively move the right hand, however, could barely move the right arm without wincing in tremendous pain. Subsequent to physician notification, x-rays of right elbow and shoulder were obtained, and bloodwork was scheduled for the following day. X-ray report dated 10/18/21 identified an acute fracture involving right humeral neck with mild displacement. Subsequent to physician notification the following was ordered; PT evaluation and treatment, a sling to right upper extremity, schedule appointment with bone & joint for further evaluation and administer Tramadol 50mg every 4 hours as needed for severe pain. Corrective action plan to prevent reoccurrence identified ADL status changed to assist of one including transfers and bed mobility, use of wheelchair for mobility, adaptive equipment was added to continue independence with meals, resident was encouraged to call for help when needed and resident was currently receiving skilled OT and PT. Resident Activity Order form dated 10/20/21 identified Resident #4 now required assist of 1 with transfers out of bed to standard wheelchair using no assistive device. Interview with PT #3 and PT #2 (Directory of Rehabilitation) on 2/28/22 at 1:40 PM identified they could not find any documentation that a screen had been completed on Resident #4 when he/she was admitted to the facility on [DATE]. PT #2 indicated it was their policy to at least do a screen for all new long-term care residents and an evaluation for any short-term rehab residents. PT #3 identified she did not recall seeing the resident prior to the fall on 10/18/21 but was informed by nursing staff that resident had been using a 4 wheeled walker independently before the fall. Interview with the DNS on 2/28/22 at 2:30 PM identified that all new admissions should be screened on admission and should have an activity order. The DNS identified she did not know why there was no screen found and identified that although their facility policy did not indicate new admissions required a therapy screen, it was best practice to ensure screens were completed when new to the facility. Interview with PT #1 (Area Manager) on 3/1/22 at 10:00 AM identified that she was the Acting Director of Rehabilitation at the time of Resident #4's admission in August 2021. PT #1 identified not knowing why the resident was not screened upon admission but should have been especially because of his/her advanced age, being admitted for long term care, impaired vision and use of a 4 wheeled walker. PT #1 identified that someone could have screened the resident, took a quick look and felt resident was okay to ambulate with walker independently, however there was no documentation to support this. PT #1 identified that she might have been on vacation during that time but there was always someone else in charge who would have been responsible for screening the resident on admission. Review of Preferred Therapy Solutions Clinical Services Policies and Procedures identified the screening process is used to identify the need for rehabilitation evaluation and to determine the patient's ability to participate in either skilled rehabilitation or restorative nursing. It is also utilized to aid in the care plan process. The procedure directs to screen all newly admitted and re-admitted patients within 48 hours of admission to the facility. Document the results of the screen using Preferred Therapy Solutions approved screen forms. The screen will be logged on the Screen Log which documents the date and type of the screen and whether an evaluation was recommended.