Based on record review, interview, observation and review of other facility documentation, it was determined, for one (R19) out of four residents sampled for accidents, that the facility failed to ensure the resident received adequate supervision and fall prevention measures appropriate for a resident with severe cognitive impairment. R19's fall on 9/18/21 resulted in harm when R19 broke his neck, resulting in pain and limited use of his right arm affecting the ability to feed himself. Findings include: The facility policy entitled Falls Management (revised 8/10/21) identified that interventions are to be re-evaluated after each fall. When changes are added to the care plan involving new interventions these new interventions need to be dated. Any occurrence of falls along with interventions will be documented in the nursing notes. The assessment process will include an investigation using the Fall Investigation analysis sheet. This is to help identify the root cause and whether or not the fall was avoidable or unavoidable. Review of R19's clinical record revealed: 12/28/20 - R19 was admitted to the facility with diabetes and dementia (brain disorder with memory loss, poor judgement, personality changes, disorientation, loss of mental functions such as memory and reasoning that interferes with a person's daily functioning). 1/21/21 - A care plan for falls was initiated (last updated 8/5/21) and included fall prevention interventions: answer calls, anticipate needs, keep call bell within reach, provide [verbal] safety reminders, keep room well lit and clutter free, therapy to evaluate and treat, non-slip socks/shoes at all times, perimeter mattress (mattress with raised sides to help reduce rolling out of bed), soft touch call bell, visual sign to remind him to call for assistance before transfer, vital signs as needed for dizziness or lightheadedness due to medications. Encourage / remind [verbally] to use rolling walker (3/20/21 after fall). Therapy evaluate for balance, intermittent [verbal] reminders to use walker and call for assistance with transfers, medication review, restorative ambulation program (4/28/21 after fall). Offer toileting / bedpan around 11:30 PM, Physical Therapy to evaluate (5/17/21 after fall). Interventions of providing verbal reminders to call for help as well as physical therapy evaluations were repeated in response to falls in April and May 2021. 1/21/21 - A care plan for ADLs (Activities of Daily Living) included that R19 needed limited assist with one staff person for transfers, used a rolling wheeled walker with limited assistance from one staff member and was independent for eating. 6/24/21 - A fall risk assessment documented that R19 was a moderate risk for falls with a score of nine (ten or more indicated a high risk for falls). 6/27/21 - A Quarterly MDS assessment was completed and revealed R19 had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 4 (0-7 equals severe impairment). July - August 2021 - Review of facility fall investigations revealed that R19 experienced multiple falls: 7/12/21 (8:40 PM): R19 stated he fell, skin tear sustained. The care plan was updated on 7/13/21 to include recent room move, staff will continue to offer verbal reminders and cue resident to use call bell. R19 had dementia with severe cognitive impairment which affected his short term memory, reasoning and judgement. The facility added verbal reminders for R19 to call for help, which had already been included several times in the care plan. A person with severe cognitive impairment cannot remember verbal reminders. 7/17/21 (4:00 PM): Seated on the floor with his back against the bed, no injury, room door closed, not wearing non-slip footwear as in care plan. Care plan updated 7/18/21 to offer toileting around 3:30 PM. Interventions included signs to call for help before getting up which was previously in the care plan. The facility added written reminders (signs) to call for help. A person with dementia and severe cognitive impairment cannot understand the written reminders. There was no evidence that the facility verified that R19 could read the written reminders where they were posted or understand the meaning of the wording. 7/18/21 (6:45 PM): Seated on the floor with his back against the wall, skin tear. Interventions included to offer [verbal] reminders to call for help. The facility added verbal reminders to call for help, which had already been included several times in the care plan. It was clear that this severely cognitive impaired resident with dementia could not remember the verbal reminders as he had fallen three times within one week. 8/4/21 (12:15 PM): Laying on the floor on his back, re-opened previous skin injury. Care plan updated 8/5/21 with PT/OT evaluation for balance strengthening and gait training, orthostatic blood pressure checks (checking BP and heart rate when sitting and standing to see if the BP drops which can cause dizziness). Elastic compression stockings to legs to help keep the BP from dropping when standing) was added on 8/11/21. There was a lack of thorough fall investigation to determine the root cause of the falls as evidenced by incomplete and inaccurate information related to the medications R19 received that could have contributed to his falls: - 7/12/21: blood pressure medication, insulin and anticoagulant. - 7/18/21: antidepressant, insulin and anticoagulant medications. - 8/4/21: insulin. Review of fall risk assessments found that after the 7/12/21 fall, R19 was at high risk for falling. 8/10/21 - A Physician Progress Note documented falls with a reduction of BP (blood pressure) when standing leading to dizziness . recommended trial of elastic stockings to legs. August 2021 - The pharmacy consultant's medication regimen review recommended to check glucose (blood sugar) with falls. The physician response was to defer the recommendation until the following month. 9/17/21 10:42 PM - A nursing progress note documented [R19] found lying near bathroom door as if he was trying to go there, lying on left side at approx (approximately) 2140 (9:40 PM), minimal injury noted with skin tear to right arm, resident able to move all extremities and had complaint of minimal pain, PRN (as needed) tylenol given with good effect. VS (vital signs) stable and neuro checks WNL (within normal limits). [R19] unable to specify what he was trying to do . stated he didn't (sic) hit his head . assessed by 2 nurses and supervisor, able to move all extremities . assisted back to bed with education to use call bell if needing assistance. MD made aware via teamhealth book (book where notes are written for the medical team), POA will need to be updated in the morning. 9/17/21 - Review of the facility fall investigation and written statements obtained during the investigation included: R19 was in the middle of treatment for low glucose when he fell at 9:40 PM. E13 (CNA) assisted [R19] back to bed at 9:15 PM after taking the resident to the toilet and that E13 helped R19 get into bed 3 times in around 30 minutes. After the fall R19 was verbally educated to use the call bell if needing assistance. R19 had severe cognitive impairment which affected his memory, reasoning and judgement. There was no evidence that the facility implemented additional interventions or increased supervision after the 9/17/21 fall. This severely cognitive impaired resident with dementia could not remember the verbal reminders to call for help before getting up. 9/18/21 - Review of a facility fall investigation revealed that around 4:45 AM during rounds, found [R19] on his left side on the floor. He was alert, verbally responsive and able to make needs known. Assisted up from floor, able to move all extremities and new neuro check initiated and brought to the dining room for close observation. Able to ambulate on his own with assist of his walker. Sustained skin tear on his left hand and dressing applied. No acute distress. [R19] was [verbally] encouraged to call for help at all times. 9/18/21 - Review of E16's (CNA) written statement about the fall included that the CNA last toileted R19 at 2:30 AM when he walked to bathroom using his walker with staff assistance. E16 last saw R19 at 4:10 AM. When I returned back from my lunch break nurse told me [R19] was on the floor. 9/18/21 7:36 AM - A nursing progress note documented POA was updated on falls and skin tears, no questions at this time, reassured POA that staff is monitoring resident and will keep POA updated on any changes. resident sitting comfortably in dining area at this time. 9/18/21 9:57 AM - A nursing progress note documented This nurse was called . resident had 2 fall (sic) one on 3-11 last evening on one on 11-7 last night. Resident now stating neck and back are hurting and . resident not able to ambulate as usual d/t (due to) pain. Team Health called and notified of the same that stated to give tylenol 325 mg (2 tabs) 3 times a day and if there is no improvement then call back. R19's eMAR revealed he received tylenol at 8:30 AM. 9/18/21 12:49 PM - A nursing progress note documented [R19] was medicated for pain but stated that he was still having pain, resident noted to not being able to stand freely, needed two staff members to assist with standing, after standing, resident could not self ambulate with his rolling walker as usual, resident cont (continued) to c/o(complaint of) neck and back pain, resident also noted with raspy voice and difficulty swallowing and difficulty in holding his head up, this nurse called his daughter and a message was left. On call MD was called and new order received to send resident to the ER for evaluation. 9/18/21 6:51 PM - A nursing progress note documented that R19 was being admitted due to a fracture to his C7 and pneumonia, residents daughter is aware, nursing supervisor and [physician] made aware. 12/8/21 9:03 AM - During a random breakfast observation, staff was feeding R19 his breakfast. 12/9/21 9:00 AM - During a random observation two signs were visible hanging in R19's room to remind him to use the call bell and wait for help to get up. One sign was on the wall across from the foot of the bed and the other to the right of the closet across from R19's lounge chair. 12/9/21 9:10 AM - During an observation staff was encouraging R19 to feed himself, but the resident just sat, stared and did not attempt to self feed. 12/17/21 at approximately 10:55 AM - During an interview E29 (OT) stated that she had been working with R19 to improve his right arm movement and strength since he had impairment after he broke his neck. 12/20/21 10:05 AM - During an interview, E15 (LPN) stated that before the fall R19 could take himself to the toilet using his walker and use the call bell. Now, he was more confused. 12/20/21 10:59 AM - During an interview with E1 (NHA in Training) and E2 (DON), the Surveyor to reviewed R19's falls and the incomplete fall investigations. The Surveyor pointed out that many interventions added in response to a fall, were previously in the care plan, including non-skid footwear and reminders to use the call bell E2 stated that she understood that interventions to be added should not already be included in the care plan. The Surveyor explained that when current interventions were not effective then additional measures would be warranted. E2 offered no further information. The facility continued to remind R19 verbally and with signs to call for assistance prior to getting up. R19 had severe cognitive impairment which affected his memory, reasoning and judgement. A person with dementia who was severely cognitive impaired cannot understand written reminders or remember the verbal reminders to call for help before getting up. There was no evidence that the facility identified the reasons for R19's falls or implemented additional interventions or increased supervision when the current fall prevention measures were ineffective. After the 9/18/21 fall, R19 was diagnosed with a broken neck, experienced pain and developed the limited ability to use his right arm. R19's residual right arm impairment affected his ability self feed and to ambulate due to not being able to use his wheeled walker. Findings were reviewed during the exit conference on 12/20/21 at 4:05 PM with E1 (NHA in Training), E2 (DON), E3 (Executive Director), E4 (Medical Director), and E5 (ADON), E9 (Regional Nurse), and E30 (Ombudsman) participated by telephone.