**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent falls for one (Resident #135) of seven residents reviewed for falls, from a total sample of 41 residents. The findings include: A review of Resident #135's medical record revealed that he was admitted to the facility on [DATE], with his most recent readmission occurring on 7/31/23. Resident #135's diagnoses included unspecified fall, unspecified motor vehicle accident with injury; other injury of unspecified body region; and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. A review of the resident's admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 6/14/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. No behaviors were documented. His functional status was documented as follows: Bed Mobility/Self Performance - Total dependence, full staff performance of one staff member Transfer Self-Performance: Activity occurred only once or twice during the look-back period. Assistance of two staff members required. The resident was documented as non-ambulatory. Locomotion on the unit did not occur during the look-back period. Locomotion off the unit only occurred once or twice during the look-back period and required one-person physical assistance. Range of Motion to both upper extremities was impaired. He was always incontinent of bladder and bowel. (Copy obtained) A review of the resident's active Care Plans revealed the following Focus Areas: Focus: Falls [Resident #135] has potential for fall/fall-related injury due to deconditioning with functional decline secondary to motor vehicle accident with fractured pelvis, spinal cord injury status-post C-spine surgery, PEG tube (feeding tube) placement for dysphagia. Start date: 7/31/23. Interventions included: Keep bed at the appropriate height. Keep personal items within reach. Patient educated to call for assistance if needing to be repositioned. Low bed with mats. Start date: 7/31/23. Focus: Pressure Ulcers/Skin Prevention [Resident #135] is at risk for pressure ulcers and other skin related injuries due to healed wounds to right upper coccyx, healed area to left hip, impaired mobility, and bowel and bladder incontinence. Start date: 11/1/23. Focus: Pain [Resident #135] has risk for pain related to spinal cord injury status post stabilization. Start date: 7/31/23. [Resident #135] states exertion makes it worse. Interventions include: Offer and encourage as indicated nonpharmacological pain management and repositioning. Focus: Neurological Conditions [Resident #135] will not develop complications of spinal cord injury requiring outside medical intervention. Start date: 7/31/23. Interventions included: Maintain spinal stability as ordered. Utilize log rolling for bed mobility and avoid twisting the spine. Start date: 7/31/23. Focus: ADL (Activities of Daily Living) Functional/Rehab Potential [Resident #135] needs assistance with daily ADL care. Start date: 7/31/23. Interventions included: Bed Mobility: I need total assistance with one-person staff support. I use slide sheet assistive devices. Transfers: I need total assistance with two person staff support. I use a total lift assistance device. Mobility: I need total assistance of one-person staff support. I use wheelchair assistive device(s). (Copies of all Care Plans obtained) On 11/14/23 at 12:28 p.m., Resident #135 was observed in his room. His sister, who was his Power of Attorney (POA), was also present. The resident's bed was in the lowest position. Blue fall mats were present on each side of the bed. The resident was asked if he had fallen. He confirmed that he had fallen on 7/30/23. He stated a Certified Nursing Assistant (CNA), later identified as CNA N, was on her cell phone as she was providing him incontinence care. He stated he gave her several warnings that he was going to fall, however, she denied it and walked away before she had finished providing care. When she did, he rolled off the bed onto his side. The bed was in high position, and the resident stated the fall resulted in a laceration to his forehead which required five sutures. The resident's sister stated the facility notified her of the fall after the resident was transferred to the hospital. She was advised that he was found on the floor and was being transferred to the hospital for an injury he sustained. She stated this was unusual, as the resident had fallen in the past, however, because his bed had always remained in the lowest position, he had never sustained any injuries. She stated when she arrived at the hospital she observed the resident with blood over his right eye. When she asked the resident how he had sustained the injury, he advised her that his bed was raised up high while CNA N was providing incontinence care. He told her that CNA N was talking on her cell phone while providing his care and walked away before she was finished. Resident #135 told her he made attempts to warn CNA N that he was falling before she walked away. Prior to this incident, the resident rolled out of bed on 7/23/23, however the bed was low to the floor, so he didn't get hurt. The sister stated the nurse on duty at the time of the incident confirmed that CNA N was in the room at the time of the incident. She further stated the nurse was no longer employed by the facility. She was advised that the incident was reported, but she was never told to whom it was reported. She was never provided with any detailed information. She stated prior to this interview (11/14/23 at 12:28 p.m.), the facility provided her with a printout of an Interdisciplinary Note entered into the resident's record on the date of the fall. Per the note, Around 1800 p.m. (6:00 p.m.) today, the CNA called for assistance of staff RN to room [ROOM NUMBER]. Found patient lying on his right side on the floor . The entry was electronically signed by the registered nurse (RN) on 7/30/23 at 20:48 (8:48 p.m.). (Photographic evidence obtained) On 11/15/23 at 11:08 a.m., a facility staff member advised the survey team that the resident's sister/POA asked to speak with the team. The resident's sister entered the conference room where an interview was conducted in the presence of the entire survey team. She confirmed the full name of the nurse she had spoken with regarding the details of the fall Resident #135 sustained on 7/30/23. She stated both she and the resident gave specific details regarding the fall, including the fact that CNA N was on her cell phone while providing care. They explained to the facility that the resident attempted to warn CNA N several times that he was falling prior to the actual fall. She was asked for the details of the investigation of the fall. She advised the survey team that she was not aware of any investigation. The sister stated she, Resident #135, and the previous nurse (who was no longer employed by the facility) had advised Risk Manager S that CNA N had been on her cell phone while providing care and after that, no one came to ask them anything else regarding the incident. She was asked about the nurse and CNA N. She stated the nurse was no longer employed at the facility, but CNA N was still employed and was working on another nursing unit. During an interview with Licensed Practical Nurse (LPN)/Risk Manager S on 11/15/23 at 3:19 p.m., she was asked to provide the details of Resident #135's fall. She stated it occurred on 7/30/2023. He had a laceration across his eyebrow. She stated she interviewed the resident, and he told her he was trying to sit on the side of the bed, which was too high, when he fell and hit the floor. She stated he told her he did not press his call light. He told her that it was within reach. The resident was given a low bed with mats and was educated to use his call bell for help. She confirmed that the incident was unwitnessed. She was asked why it was not reported. She replied: I don't know. She was asked whether the facility typically reported a fall if it was unwitnessed, and the resident sustained an injury requiring them to be transferred out of the facility for a higher level of care. She replied, It should've been reported. On 11/16/23 at 12:32 p.m., CNA N was contacted via telephone for an interview. She stated she was familiar with Resident #135. She was asked if she was aware of any accidents the resident had while in the facility. She stated she was in the resident's room when the resident fell on 7/30/23. She was asked to provide details of the incident. She stated it happened at the end of her shift. She was in the room changing the resident and his sheets. She stated the bed was raised and when she went to turn the resident over, he wasn't on his other side or on the edge of the bed. When she went to the other side of the bed, he was slightly in the middle. She stated she was not sure if the resident jerked or moved over, but he rolled and hit the floor. She grabbed at his leg to try to prevent him from falling. She stated she didn't touch the resident while he was on the floor, but she did ask him several times if he was okay. He responded each time that he was okay. She stated she noticed that He nicked his head, and he was bleeding. At that time, she went to tell the nurse. She could not remember the nurse's name. She stated the resident denied pain. He was sent out to the hospital overnight and came back the next day. She was asked about the resident's functional status and whether he could sit up on the side of the bed without assistance. She referred to the resident as a total assist x 1, indicating that he was totally dependent, requiring one-person assistance for all of his ADLs. She gave him bed baths, as the shower bed was too uncomfortable for him. She stated the resident was unable to sit up on his own and required assistance due to lack of trunk support. She was asked about any statements and/or investigations regarding the incident. She stated she was required to submit a written statement to LPN/Risk Manager S with the details of the fall. She confirmed she documented that she was in the room with Resident #135 at the time he fell. On 11/16/23 at 2:37 p.m., Resident #135 was observed lying in bed. The bed was in the lowest position with fall mats present on each side. When asked, the resident denied pain. The resident was asked again about the falls he sustained in the facility. He stated the first incident (7/23/23) occurred when he rolled out of bed. He did not sustain any injuries as the bed was in the lowest position. The second fall (7/30/23) occurred when CNA N was on the phone while changing him with the bed raised in the high position. He was asked if the CNA held the phone by hand, used earbuds, or used another hands-free device. He stated she had the phone in her hand, and he told her he was falling, but she turned her back. He stated as he began to fall she quickly turned around and tried to catch him, but she didn't have time to, and he fell to the floor hitting his head. During an interview with LPN F on 11/16/23 at 1:43 p.m., she stated she was familiar with Resident #135. She stated the resident was unable to sit up unassisted and that she felt keeping his bed low was the best thing for him. The resident was not able to apply pressure to his arms to move himself, nor did he have enough tone in his legs to bear weight. He was able to make his needs known and would let her know if he was experiencing pain when she administered his medications. He can make his needs known. He hasn't had any falls recently. They do all of his ADLs, and his sister tells them to brush his teeth. She stated the resident was totally dependent for all his ADLs. During an interview with CNA G on 11/16/23 at 3:19 p.m., she stated she was familiar with Resident #135. The resident didn't like to sit up, and when he was placed in a sitting position, he would holler and scream out in pain. She stated the resident told her it hurt him to sit up, and that he would not stay in his wheelchair. The resident was unable to sit up unassisted. He required total assistance from staff. He could feed himself and move his arms but was unable to sit up or get out of bed unassisted. She stated the resident preferred to remain in a fetal position, and when attempts were made to move him out of that position, he would ask to be returned to that position. A review of a facility report, dated 7/30/23 at 6:00 p.m., revealed that following the fall, Resident #135 stated he was okay. He was asked what he was trying to do, and he stated he was trying to sit on the side of the bed, but the bed was a little too high. The fall was documented as unwitnessed. The resident was documented as not incontinent at the time of the incident, and range of motion was documented as within normal limits. Interventions included a low bed with mats. The nurse's signature was illegible. (Copy obtained) A review of a facility Huddle Report dated 7/30/23 at 6:00 p.m., revealed the following: What human factors impacted the outcome? Answer: No assist at time of fall. The report indicated that staff were competent and no changes to in-servicing or orientation were necessary. Safety measures documented were non-skid socks. Two team members were documented as having attended the Huddle meeting. Their signatures were illegible. (Copy obtained) A review of a facility report dated 7/31/23 at 11:00 a.m., revealed that Resident #135 was interviewed by the QD (Quality Director). The resident stated he was trying to sit on the side of the bed, and it was too high. He stated he lost his balance and fell hitting his head. It was documented that the QD asked the resident whether he had used his call light for assistance and he responded that he did not. According to the report, the QD explained to the resident that he had been educated before to call for assistance. Interventions: low bed and mats. (Copy obtained) A review of an undated, unsigned, typed statement from the assigned nurse on duty at the time of the resident's fall, revealed that the name typed on the statement was the same name that was given to the survey team by the resident's sister, who stated this was the nurse who assessed the resident after he fell on 7/30/23. This name was also listed on the Interdisciplinary Note. The statement indicated that at 6:00 p.m. on 7/30/23, the nurse was summoned to Resident #135's room to find him lying on the floor on his right side. The resident said he was trying to sit on the edge of the bed and fell to the floor, sustaining a laceration to his right eyebrow. The laceration was draining a moderate amount of sanquinous fluid. A pressure dressing was applied. The resident was alert and oriented x4 (person, place, time, and event). The nurse assisted support staff in getting the resident back in bed while awaiting emergency transport to the emergency room for further evaluation due to the laceration to his eyebrow. The bed was noted in high position. His call bell was clipped to the sheet and had not been activated. The nurse educated the resident by reminding him to use the call light for assistance with sitting up. (Copy obtained) An interview was conducted on 11/16/23 at 4:40 p.m. with the survey team, the current Administrator, the new Administrator, the Director of Nursing (DON), and LPN/Risk Manager S. The DON was asked about the nurse's unsigned and undated statement. She was specifically asked when the statement was written and why the nurse was not required to sign it. She stated, I don't know when she wrote it. She didn't sign it. We have it in our records. The LPN/Risk Manager S stated the resident gave her his statement the day he returned from the hospital (7/31/23). He was alert and oriented. She was asked about the resident's functional status. She replied, I have never transferred him, so I can't say what his functional status is. I just met with him in his room. That was the only time that I saw him. There were no follow-up interviews with him. She was asked about the assigned nurse's unsigned statement. She replied, We attempted to have her come back in many times to have her sign it. On 11/16/23 at 4:59 p.m., the DON was accompanied to Resident #135's room. The resident was greeted and stated he did not know the DON. The DON greeted the resident. The resident was asked about the falls he sustained while in the facility. He explained during his first fall (7/23/23), he rolled out of bed on his own but wasn't hurt because the bed was in the low position. He then stated he fell when CNA N was changing him. She had the bed raised too high and she was on the phone. He stated she tried to catch him, but she couldn't because her back was turned. He stated he was sent out to the hospital because he had a cut over his right eye that required five sutures. The DON asked Resident #135 if anyone had come in to talk to him about the fall the day it occurred. He replied no. She asked if anyone came to speak with him the next day when he returned from the hospital and again he said no. She asked him if he was able to sit up on the side of the bed and he replied that he could not. He stated the aides had to help him get up. He stated he could not sit up on the side of the bed independently. .