Revised post IDR Based on interview and record review, it was determined that for two (R14 and R38) out of two residents reviewed for accidents, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents. R14, a cognitively impaired resident with dementia and identified as high risk for wandering, eloped from the building on 2/18/23 and was found outside on the community grounds by a bystander. R14 was at risk of a severe adverse outcome. An IJ (immediate jeopardy) was identified on 12/4/23 at 2:17 PM and abated on 12/4/23 at 11:59 PM. For R38, a cognitively impaired resident who was at high risk for falls upon admission, the facility failed to implement appropriate person-centered fall interventions taking into consideration her continued impulsivity, lack of safety awareness and her diagnosis of a urinary tract infection (UTI). R38 had four falls (9/18/22, 10/5/22, 10/6/22 and 10/8/22). After each fall, the facility failed to reassess the effectiveness of the fall interventions. R38's fourth fall on 10/8/22 resulted in her being emergently transferred to the hospital where she was diagnosed with a right-sided subdural hematoma. As a result of the facility's failure, R38 was harmed. Findings included: The facility's policy and procedure on Elopements and Wandering Residents, policy explanation and compliance guidelines dated 2023 stated, The facility is equipped with wander guard system to help avoid elopements; residents will be assessed for risk of elopement and unsafe monitoring upon admission and throughout their stay by the interdisciplinary care plan team; and adequate supervision will be provided to help prevent accidents or elopements. 1. Review of R14's clinical record revealed: 9/10/22 - R14 was admitted to the facility with dementia and history of stroke. 9/10/22 - The Wandering Risk Assessment score was 14 indicating high risk. The Wandering Risk Assessment also documented R14 was a known wanderer/history of wandering. 9/16/22 - The admission MDS for R14 documented a BIMS score of 8. A score of 8 to 12 suggests a moderate cognitive impairment. The was no evidence of a care plan to address the risk of wandering. 12/14/22 - The quarterly MDS documented a BIMS score of 8. 12/22/22 - R14 had a readmission to the facility from the hospital. 12/23/22 - A Wandering Risk Assessment incorrectly scored a 5 indicating moderate risk. The assessment did not include the diagnoses of dementia and history of wandering. 12/29/22 - R14's discharge MDS documented a memory problem and some diffculty in new situations only. 1/1/23 - R14 was readmitted to the facility from the hospital. 1/4/23 - A Wandering Risk Assessment was conducted that incorrectly scored a 8 indicating moderate risk. The assessment did not include the diagnoses of dementia and history of wandering. 2/18/23 - During an interview with E2 (DON) it was revealed that while self-propelling in a wheelchair, R14 eloped from the facility and staff did not appear to know that he was gone. 2/18/23 - A statement from E5 (RN, supervisor) documents that when F1 (family member of resident) was notified of the elopement, F1 stated (R14) had done it multiple times at the condominium and (F1) wasn't surprised. Per the Statement Form, E5 notes a Wander Guard was placed on (R14's) wheelchair. Per the facility's documentation of the incident report and staff statements, at 3:30 PM, R14 exited from the Health Center onto the driveway, passing through the employee parking lot. R14 was found by a bystander (I1) and brought to the main entrance of the community where Health Center staff were notified that R14 was at the receptionist's desk. 2/18/23 - The temperature was approximately 38 degrees at 2:51 PM and 39 degrees at 3:51 PM, according to www.timeanddate.com. 2/18/23 - An order obtained from E3 (Medical Director) to ensure the Wander Guard was in place on patient wheelchair every shift due to the outside wandering incident. 2/20/23 - A review by E25 (former NHA) dated 2/20/23 about R14's 2/18/23 incident identified the following results: supervisors should not leave desk uncovered unless responding to an emergency, meeting with family concerned about incident, to be included, and consider wander guard on all wheelchairs that resident can self-propel in an effort to avoid any resident attempting to navigate the hill in a chair. 2/20/23 - The facility's findings of R14's exit from the Health Center documented that the receptionist in the main lobby asked something about how did you get here, [R14] replied, I am bored, and my hands are cold. The facility's conclusion of findings revealed E1 (NHA) viewed the cameras on 2/20/23. The camera indicated that [R14] exited the Health Center by wheeling himself in his wheelchair through the main entrance of the Health Center at 3:30 PM. The camera then indicated [I1] (independent living resident) pushing [R14] up the ramp to the main entrance of Stonegates. They were coming from the employee parking location. [I1] (independent living resident) confirmed picking up [R14] at the garage. He was pushed past the employee entrance and towards the main entrance to Stonegates. The Health Center was notified that [R14] was in the lobby and the Health Center responded and assisted [R14] back to his room in the Health Center. A wander guard was placed on [R14's] wheelchair to prevent him from exiting the Health Center. 3/13/23 - R14's quarterly Wandering Risk Assessment score was 12 indicating high risk for wandering. 11/30/23 10:45 AM - An interview with E2 (DON) revealed the elopement occurred on Saturday 2/18/23 on the evening shift. R14 was in a self-propelled wheelchair and went out the door. The nurse on duty saw [R14] coming down the hall. The nurse was stopped by someone or something, continued to pursue the resident but R14 had turned down the hall in a different direction. R14 had gone outside and another resident who was outside walking saw [R14] who was then wheeled to the front reception area and the receptionist called staff. When asked what interventions were in place prior to the elopement, E2 replied, No he wasn't known to be a wanderer. When asked what interventions were put in place after the elopement E2 stated, Wander Guard was placed on [R14's] wheelchair and it alarms at the door and at the nurse's station. 12/1/23 10:35 AM - During an interview with E5 regarding the elopement, on 2/18/23 revealed R14 was sitting in the wheelchair talking with staff. Staff then began attending to other residents then E5 (RN, supervisor) asked where was R14. We started looking for him. Then I got a call from the front office saying [R14] was here. I was out looking near where our cars are parked. Wander guard was placed as soon as we brought [R14] in. 12/1/23 12:51 PM - E7 (RN) was interviewed and stated that (R14) was out in the hall in his wheelchair. [E7] found [R14] in the hall and asked [R14] 'do you know what you're doing?'. [R14] didn't answer. E7 then answered a call light and other staff were talking to a family, then E7 answered another call bell. E7 had not seen R14 for a while then they received a call from the main entrance saying R14 was there and to come get him. 12/1/23 1:24 PM - An interview with E8 (RN) revealed the incident happened around 3:30 PM and .he was outside for about 15 minutes. 12/4/23 2:17 PM - During an interview with E1 (NHA) and E2 were advised that R14's admission Wandering Risk Assessment had identified him as being high risk and the lack of interventions to ensure the prevention of R14's elopement was an Immediate Jeopardy. 12/4/23 4:03 PM - The facility's abatement plan included: 1. All residents will be audited for wandering. This will be completed by 12/4/23 at 11:59 PM. 2. All residents identified during the audit with a score representing wandering potential will have interventions and care planning in place by 12/4/23 at 11:59 PM. 3. Education of all nurses on wandering assessment for accuracy and completion, to include care planning implementation of interventions and documentation of exit seeking behaviors will be completed by 12/4/23 at 11:59 PM. 12/5/23 - Reviewed list of audit findings. The facility census was 35 with 7 residents identified as risks for wandering. The interventions and care planning were documented. 12/5/23 - Reviewed list of RN and LPN staff who received education on Wandering/Elopement Assessment and Care Planning conducted with staff on 12/4/23 in-person, or via phone call or via text message. Training content included: Wandering assessments should be completed on admission, quarterly and with any significant change; the assessment must be accurate and complete; any resident with a score that represents wandering should have interventions and care plan in place; notify immediate supervisor of any resident whose score indicates at risk for wandering; assessments must be completed timely; and document any exit seeking behaviors. 12/5/23 10:56 AM - Interviewed E6 (ADON) regarding in-service 12/4/23 on the Wandering Risk Assessment, and care planning. Per E6 (DON), The training reviewed elopement, wandering and scoring, to make sure we're doing accurate and complete assessments. Making sure it's looked at. If a resident is at risk then making sure interventions are put into place. Would update the care plan if interventions are put into place. If there's any score at all you need to do a care plan. Would decide as a team what to do with interventions. For high risk, would do hourly checks. A care plan is in place if at risk at all. At least wander guard is needed if at moderate risk. 12/5/23 - The abatement plan was validated with staff interviews, and review of care plans and interventions for those residents identified as a risk for elopement/wandering during auditing. 12/5/23 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E6 (ADON). 2. Review of facility's Fall policies and procedures revealed: The facility's policy entitled Fall Prevention Program, (undated) stated, . 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions . 6. High Risk Protocols: a. Implement interventions from Low/Moderate Risk Protocols. b. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. c. Provide additional interventions as directed by the resident's assessment, including but not limited to: . Assistive devices . Increased frequency of rounds . Fall alarms (chair, bed, or clip alarm) . Fall mat . Sitter, if indicated . Medication regimen review . Low bed . Alternate call system access . Scheduled ambulation or toileting assistance . Family/caregiver or resident education . Therapy services referral . 8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statement in the case of injury. The facility's Fall Risk Assessment policy, dated 2023, stated, . 2. The risk assessment will contain the following components: a. Identify environmental hazards and individual risk, including the need for supervision. b. Evaluate and analyze hazards and risks. 3. An 'At Risk for Falls' care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. 4. The 'At Risk for Falls' care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. 5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice. R38's clinical record revealed: 9/10/22 - R38 was admitted to the facility from the hospital after a fall where she sustained a cervical (neck) fracture requiring a neck brace, right-sided subarachnoid hemorrhage (bleeding in the space that surrounds the brain) and a fracture of the left hand fifth finger. 9/10/22 - The baseline care plan documented, . History of falls: fall . (neck) fx (fracture) . Alarm: bed alarm once available . mild confusion/early dementia. admitted for a fall resulting in (neck) fx and subarachnoid hemorrhage (stable) . Res (resident) able to transfer in bed independently & (and) an assist of walker to walk, transfer to BR (bathroom). Res is a fall risk and proper bed alarms/fall mats to be placed when available . 9/10/22 at 4:10 PM - The Morse Fall Scale assessment score was 85, which identified R38 as a high risk for falling upon admission to the facility. Nurse's notes documented the following: - 9/11/22 at 1:03 AM - R38 was a fall risk and will have a fall alarm mat and bed alarm placed. - 9/11/22 at 9:01 PM - R38 was . confused . She continues to get out of bed without using the call bell which in reach . has been redirected to use call bell when she has to get up to use the restroom or if she needs help with anything . states that she understands but, she is very forgetful. Clip alarm in place and fall mat with alarm next to bed . was seen by CNA taking her clip alarm off. Supervisor continue to educate her on the importance of using the call bell system due to her having her C-collar (neck brace) in place and how she needs to be very careful not to fall again. Supervisor will alert oncoming shift about her behavior at this time. - 9/12/22 at 2:19 AM - R38 was . confused, continues to get oob (out of bed) unassisted without ringing. staff alerted by fall mat alarm . - 9/13/22 at 1:32 AM - R38 was . confused, continues to get frequently oob (out of bed) unassisted and not ringing prior to getting up . 9/13/22 - An occupational therapy daily note documented . Pt (Patient) displayed (decreased) safety awareness while with COTA (Certified Occupational Therapy Assistant). Pt attempted to walk to bathroom c (with) pants down. COTA explained fall risk to Pt. Pt reluctantly pulled pants up to walk to bathroom. Poor rollator safety c mod (moderate) v/c (verbal cues) for placement and locking of brakes. 9/14/22 at 3:33 AM - A nurse's note documented that R38 continues to get oob unassisted without ringing. also removing her clip alarm. reminded to ring prior to getting up. resident expressed understanding. 9/14/22 - A physical therapy note documented that R38 . Advised Pt that she should always ask for assistance as she is high risk for falls. Pt will need continued reminders, also spoke to nsg (nursing) re (regarding) Pt is getting up by herself in room . Pt requires almost constant cues to decrease shuffling and increase foot floor clearance. 9/15/22 at 11:05 PM - A nurse's note documented that R38 and R14 (husband) have very short memories are very forgetful. 9/16/22 - The admission MDS assessment documented R38 as having a BIMS (Brief Interview for Mental Status) score of 4, which identified R38 as cognitively impaired. In addition, the assessment documented that R38 required supervision with one staff person assist for transfers, walking in the room/corridor and toileting; and limited assistance with one staff person assist for dressing. R38's first fall on 9/18/22 at 8:01 PM: - The incident report documented: CNA called nurse reporting resident (R38) was on the floor sitting cross-legged. A chair alarm was implemented as an immediate intervention. - 9/18/22 at 8:49 PM - A nursing note documented that R38 was found to be seated on the ground outside of her bathroom by CNA . Spoke with pt (patient) and husband they both stated that she did not hit her head, neck or back. After the pt was toileted Nurse completed a skin check and neuro check found pt to be WNL (within normal limits). Spoke with (family) and (physician). He (physician) had no new orders and just asked us to keep him posted if (sic) any changes. Will continue to monitor pt closely. While a chair alarm was implemented after the 9/18/22 fall, this intervention was never added to R38's care plan nor was it captured in R38's clinical record where nursing staff were required to sign off that it was consistently in place and check the alarm functioning every shift during her time in the facility. In addition, the facility failed to complete a Post-Fall assessment as per their policy and procedure. 9/19/22 - R38's comprehensive care plan for at risk for falls related to dementia, deconditioning, gait/balance problems listed the following interventions: - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. - Ensure bed exit alarm is in place. - Ensure fall mat is at bedside at bedtime. - Ensure that the resident is wearing appropriate footwear shoes/non-skid socks when ambulating or transferring. -PT (physical therapy) evaluate and treat as ordered or PRN (as needed). Nursing notes documented the following: - 9/19/22 at 11:09 AM - . Alert and oriented to name and place only. Resident did not remember falling yesterday. Ambulates to the BR (bathroom) with stand-by assist . Keep reminding resident to use call bell for staff assists when getting up. Resident has a chair alarm on now and call bell in reach . - 9/19/22 at 10:15 PM - R38 was reminded to use call bell when ambulating. 9/20/22 - An Occupational Therapy Screen documented that R38 was currently receiving OT/PT at this time with encouragement to use rollator in room. In addition, resident has bed & (and) chair alarms placed on furniture in room to (increase) safety alert when resident getting up to move. Nursing notes documented the following: - 9/20/22 at 1:44 PM - . Resident still gets up without calling for help, however chair and bed alarms in use and call bell within reach . - 9/21/22 at 3:06 PM - . Ambulating around the room and to the bathroom without ringing. Chair and bed alarm in place with call light in reach. - 9/22/22 at 10:45 PM - Resident non-compliant with call bell use. Continuously ambulating to BR (bathroom) unassisted, forgets to use call bell, alarms in place . - 9/24/22 at 3:13 AM - Resident up most of the night, transferring from bed to recliner x (times) 4. Forgetful of call bell use when needing any assistance . R38's eMAR revealed the following documented notes by nursing under the fall intervention to Ensure fall mat in place every evening and night shift for safety. Make sure fall mat is in place at bedtime. - 9/24/22 at 11:15 PM - Unable to locate mat at this time. - 9/25/22 at 9:56 PM - No fall mat in patient room. - 9/26/22 at 2:35 AM - not in use. 9/26/22 at 3:40 AM - The physician order for Ensure fall mat in place every evening and night shift for safety . was discontinued with the reason being not in use. Review of R38's clinical record lacked evidence of a progress note as to why the fall mat was not being used and discontinued. 10/1/22 - A physician order was obtained to perform a urine analysis to determine if R38 had a urinary tract infection (UTI). 10/2/22 - R38's at risk for falls care plan was revised to remove the intervention: Ensure fall mat is at bedside at bedtime. The facility never implemented placement of a fall mat as an intervention after discontinuing it on 9/26/22. 10/5/22 - R38's urine analysis was positive for a UTI and she was ordered an antibiotic. 10/5/22 - An occupational therapy note documented, . Pt required v/c (verbal cues) to pull her pants down closer to toilet as pt started to pull pants down in doorway to bathroom. Pt was able to toilet self . again required v/c to pull pants all the way up. Pt walked away from toilet c (with) pants 1/2 down. Pt did not notice pants were not up all the way . R38's second fall on 10/5/22 at 10:30 PM: - The incident report documented: Nurse supervisor was at the desk watching the monitor in the (resident's) room . I was at the desk and saw (R38) was lying on her right side and went to reach for something on the floor with her left hand and then she slid out of the bed head and torso first. Then her legs and feet followed. I immediately made the nurses around me aware she fell and we ran into the room. We saw her laying on her left side on the floor next to her bed. Her head never made contact with the floor. Myself, and 3 other staff members were in the room and got her back onto a seated position on the bed. Pts (Patient's) speech was garbled and she was very confused. She had a small skin tear to left elbow and left 5th finger was swollen . Pt went to bathroom . Assisted back to bed but preferred to be in chair. Safety measures in place, clip alarm on. Speech improved. Will continue to monitor. Handwritten at the bottom of the report was . Just Dx (diagnosed) c (with) UTI on 10/5/22 and started antibiotics. Fall was witnessed & (and) safety measures in place. Would not have prevented fall. There was no evidence in the clinical record that R38's family and the physician were notified of this fall and informed of R38's change of condition, including the garbled speech and injuries that may have needed further evaluation. In addition, there was no evidence in R38's clinical record and care plan that a monitor was being used in the resident's room to observe her. - 10/5/22 - While R38's at risk for falls care plan was revised with interventions for request for concave mattress bed with 1/4 side rails for mobility and transfers were added, these interventions were never implemented on R38's bed. - 10/6/22 at 12:05 AM - A Post Fall Analysis form for R38's second fall documented, . 3. Ask the resident OR DETERMINE what was different this time? n/a (not applicable) . Was the resident incontinent, was the visibility poor? yes and yes . What was the floor like? (checked) shiny . Was a safety alarm in place? if so, which alarm and was it sounding at the time of the fall? (checked) bed (alarm) . Additional information: pt has no side rails on bed. Despite R38's fall out of bed on to the laminate floor which was witnessed by a staff member watching the monitor from the nurse's station at a distance and an clip alarm on, the facility failed to reassess the effectiveness of the current interventions and implement person-centered interventions taking into consideration R38's impaired cognitive status, her impulsivity and the current diagnosis of a UTI requiring her to use the bathroom frequently and urgently. Nurse's notes documented the following: - 10/6/22 at 1:50 PM - . Resident continues to up and down oob (out of bed) every 5 minutes ambulating in room. Going in and out of the bathroom into hallway. Resident redirectable with short lasting effects. Remains on (antibiotic) for UTI . - 10/6/22 at 4:38 PM - R38's family expressed concern regarding (R38's) right knee, resident expressed discomfort with ambulation . pain resolved at rest. The facility lacked evidence of a follow-up assessment of R38's right knee pain. R38's third fall on 10/6/22 at 7:30 PM: - 10/6/22 at 8:40 PM - A Post Fall Analysis for R38's third fall documented, . 2. Ask the resident, what were trying to do? go to the bathroom . 3. Ask the resident OR DETERMINE what was different this time? n/a (not applicable) . 11. Was a safety alarm in place? . (checked) chair . 12. Additional information: resident will not use call bell or walker. - 10/6/22 at 8:49 PM - An incident note documented that Pt was found by staff member sitting on the floor in front of her recliner her feet out in front of her and one hand by side the other was holding her husbands hand. Husband was seated in the recliner right next to the pts (patients) . Pt stated she was trying to go to the bathroom and she slipped. Fall was unwitnessed. Pt offered no complaints of pain and no injuries noted. Family called and . is looking into a sitter for the pt due to the fact she will not use walker or call bell for assistance and continues to fall . Chair and bed alarms in place. Clip alarms in room but pt (R38) removes them herself. Will continue to monitor and coach pt to use walker and call bell. R38's at risk for falls care plan was revised and an intervention for Orthostatic BP (blood pressure) x3 days was added. Despite implementing orthostatic BP monitoring, the facility failed failed to reassess the effectiveness of the current fall interventions and implement person-centered interventions taking into consideration R38's continued impaired cognitive status, her impulsivity and the current diagnosis of a UTI requiring her to use the bathroom frequently and urgently. 10/7/22 at 1:51 AM - A nurse's note documented that R38 continues on (antibiotic) for UTI . Continues with frequency and urgency. Up and down oob every 10 minute (sic) to go into the bathroom. 10/7/22 at 1:45 PM - A nurse's note documented that R38 . at baseline with using the walker and walking to the bathroom frequently. Continue to be supervision (sic). This was the only nurse's note that mentioned supervision, but lacked details regarding what supervision was being performed. 10/7/22 at 3:34 PM - A physical therapy (PT) note documented that R38 ambulated to and from bathroom with rollator x (times) 5 SBA (stand by assist), shuffling type gait with BLE (bilateral lower extremities) externally rotated worsening . falls in the last two days-fall screens completed. PT discussed these issues with family. Nurse's notes documented the following: - 10/7/22 at 10:53 PM - . incessantly gets up to use restroom . - 10/8/22 at 1:00 AM - . continues to ambulate self to the toilet intermittently this shift . One of (sic) one activity was provided by nurse and nurse educated on the importance of more fluid intake to help with UTI and to practice safe perineal hygiene when toileting by wiping front to back to prevent further UTI infections from occurring . - 10/8/22 at 6:10 AM - . Resident is constantly ambulating from bed to the bathroom this shift. Resident . is incontinent with multiple brief changes this shift . Safety checks in place bed at the lowest position with call bell and belongings within reach. Assistive device walker is close to bed. Nurse observed resident using assistive device walker incorrectly and educated resident on how to properly use the walker when walking . R38's fourth fall on 10/8/22 at 8:00 AM: - A nurse's note (10:39 AM) documented, Residents (sic) call bell activated and husband was coming toward the doorway to hall to alert staff that his wife was on the floor. Staff responded, including this nurse who found resident to be laying in supine position next to her bed. She was alert and responsive. Denied any pain or discomfort. She had on gripper socks and she was wearing her (neck brace). She was able to move all extremities without any pain or discomfort. Resident stated that she was unsure how she fell. She stated 'I don't know what happened, i just ended up on the floor.' States that she was trying to go sit on her husband's bed (she was laying next to her bed, not her husbands). Asked if she hit her head and she stated 'Im (sic) not sure' and then when asked again she stated 'I think so.' No obvious visible injuries to her head noted. Sat resident up for a few minutes and tolerated well, then assisted to her feet with x 2 assist. Resident able to stand and bear weight without difficulties. Resident did note with unsteady gait, more than her baseline. Upon further assessment, resident noted with right sided weakness, including decreased strength to right arm and leg, smile asymmetrical and tongue not midline. Speech was clear and appropriate, no drooling noted. Residents (family) . made aware. Placed call to (physician) . 911 called and resident transported to . ER (emergency room). - 10/8/22 at 10:58 AM - A Post Fall Analysis for R38's fourth fall documented: . What was the floor like? (unanswered) . Was the resident using an assistive device? (checked) N/A . Additional information: call bell activated from chair alarm . 10/8/22 - An occupational therapy discharge note documented . Resident has not met goals (secondary) to reluctance to participate in therapy. Status unchanged from original eval as of last being seen on 10/5/22. Resident having difficulty carrying out any safety measures ( . use of RW [rolling walker]) due to impulsivity. 10/8/22 at 7:09 PM - The hospital record documented that R38 was diagnosed with a acute on chronic left-sided subdural hematoma measuring 1.1 cm with 0.6 cm midline shift and admitted to surgical ICU (Intensive Care Unit) for close monitoring and evaluation pending family discussion with neurosurgery and determination of next steps. 10/13/22 at 11:58 AM - The hospital discharge summary documented that neurosurgery was consulted and recommended nonoperative/conservative management. Palliative care was consulted and family decided to pursue hospice services. 12/1/23 - In response to the Surveyor's request about grievances involving R38, E1 (NHA) provided a typed note from E25 (former NHA) regarding communications with R38's family, which stated: Date 10/7/22 at 11:00 a.m. 1) Discussed private duty suggestions. Concern regarding falls . (R38) non-compliant with using call bell . 12/1/23 at 1:36 PM - During an interview, E24 (CNA) stated that the facility had three CNAs during the day shift on 10/8/22 as one CNA called out. E24 stated that she remembered it was breakfast time when R38 fell. E24 also stated that she responded to the room and the nurses were already in the room. 12/1/23 at 3:40 PM - During an interview, E22 (PT) stated that R38 was not participating in therapy. When asked about supervision, E22 stated that supervision of residents occurred at the nurses station or in the living room with activities and this could be done even at night. The facility failed: - to implement appropriate person-centered fall interventions and reassess the effectiveness of the current interventions for a cognitively impaired resident who was at high risk for falls upon admission and had four falls in the facility within six weeks; and - to take into consideration R38's continued impaired cognitive status, her impulsivity and the current diagnosis of a UTI requiring her to use the bathroom frequently and urgently. 12/5/23 at 8:10 AM - Finding was reviewed and discussed with E1 (NHA) and E2 (DON) that this would be brought forth as a harm. 12/5/23 at 3:00 PM - Finding was reviewed during