**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and procedure, record review and staff interviews, the facility failed to thoroughly investigate falls and implement adequate interventions to prevent falls and fall related injury for 1 (Resident #24) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility. The findings included: The facility policy Incident Report and Investigation Guidelines documented, All falls, altercations, elopements/unplanned exits, alleged neglect, alleged misappropriation or exploitation of resident property or other events leading to harm or injury to a visitor or resident (incidents) occurring in the facility or on facility property will be documented and investigated and recorded on an Incident Report and Investigation form. A thorough investigation of each incident shall be completed by the Director of Nursing (DON), Charge Nurse or Supervisor, and the facility Risk Manager. An adverse incident is an event over which the facility personnel could exercise control and which is associated in whole or in part with the facility's interventions, rather than the condition for which such interventions occurred, and which results in death, brain or spinal damage, permanent disfigurement, fracture or dislocation of bones or joints, a limitation of neurological, physical or sensory function, any condition that required the transfer of the resident within or outside of the facility to a unit providing a more acute level of care due to the adverse incident. The facility shall initiate an investigation and notify state and local authorities as required. Review of the clinical record revealed Resident #24 was a vulnerable [AGE] year old female with an admission date of 2/27/23. Diagnoses included syncope and collapse, dementia, muscle weakness, history of falling and fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing, The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 8/8/24 documented Resident #24 required partial to moderate assistance with toilet transfers. The MDS noted Resident #24's cognitive skills for daily decision making were severely impaired. The care plan initiated 2/27/23 identified the resident was at risk for falls related to weakness and history of falls. The interventions included, maintain bed in low position when in use. Cue for safety awareness, place call bell in reach. Review of the record showed a fall report dated 8/3/24 at 4:36 am., indicating Resident #24 had an unwitnessed fall and was found sitting on the floor next to her bed. The resident complained of pain to right arm and leg. The physician was notified and ordered x-rays of the right arm and leg. There was no documentation of the position of the resident's bed or the call light. On 8/3/24 the care plan was updated with the intervention of one floor mat on the door side of the bed when in bed. The follow up nursing documentation from 8/3/24 thorough 8/8/24 documented no reports of pain. On 8/23/24, an incident report documented, Resident was being transferred to commode by certified nursing assistant (CNA), resident's right leg gave out and staff lowered her to the floor. The form documented the resident had right upper leg pain. The physician was notified and ordered an X-ray of the hip with or without pelvis. The X-ray results documented no evidence of acute fracture or dislocation. Review of Resident #24's fall care plan revealed no evidence the care plan was updated with new interventions based on the root cause of the incident to prevent further incidents of falls. Review of the nursing progress notes documented the following: On 8/24/24 at 2:38 p.m., no complaints of pain or discomfort. On 8/24/24 at 6:32 p.m., denies any pain or discomfort. On 8/25/24 at 10:08 p.m., no pain or discomfort referred. On 8/26/24 at 6:17 a.m., no pain or discomfort referred. On 8/27/24 at 7:50 a.m., the DON documented Resident grabbing right mid-thigh stated it hurts. Pain noted called ARNP (Advanced Registered Nurse Practitioner) ordered stat femur right x-ray. On 8/28/24 the ARNP documented, Patient seen and examined today for follow up visit. Patient seen in her room, sitting in wheelchair. Nursing notes patient had a fall on 8/23/24 , she was being assisted by nursing staff when her right leg gave way and she was lowered to the ground. X-ray of hip was ordered and negative for any acute findings. Patient was complaining of right thigh pain yesterday and x-ray of femur was ordered and negative for any acute findings. Patient reports she is having pain to her right thigh area. Have ordered Voltaren gel (Medication applied to the skin to treat pain.) as well as a muscle relaxer. No swelling or bruising noted on examination. Will continue to monitor closely for any changes. On 8/28/24 at 8:56 p.m., the nursing progress note documented the resident was transferred to the dining room for dinner. Observed resident grimacing and rubbing her right thigh at 4:40 p.m. On 9/9/24 at 8:10 a.m., the DON documented Resident holding right leg up states it hurts. ARNP notified to order possible CT (computerized tomography) scan since both x-rays were negative. Resident #24 was sent to a diagnostic testing facility on 9/10/24 for a CT (computerized tomography) scan of the upper right leg. The findings available on 9/11/24 documented acute mildly displaced fracture of the right superior pubic ramus extending to the anterosuperior acetabular column and the posterior aspect of the inferior pubic ramus adjacent to the ischial tuberosity. On 9/11/124 at 5:00 p.m., the progress note documented: Resident CT scan revealed a pelvic fracture. DON arranged for Orthopedic consult for the end of the month. Notified resident's emergency contact of CT scan result and resident to follow up with orthopedic at end of this month. On 11/21/24 at 11:16 a.m., in an interview the DON said Resident #24 did not have pain from her fall on 8/3/24. She had a second fall on 8/27/24, she was lowered to the floor by a CNA. The aid had her in the bathroom with a transfer of 1 assist and her leg gave out. The CNA lowered the resident to the floor. On the fall on 8/3/24, a hip x-ray was negative and the nurses' notes all documented no pain. On 8/28/24 she was complaining of pain in the right mid-thigh so they ordered a stat right femur x ray. The ARNP documented on the fall and stated she had pain and the x-ray was negative. The resident reported pain in the right hip area and the ARNP ordered Voltaren gel and a muscle relaxer, Tylenol as needed and she stated there was no swelling or bring noted on her examination. On 9/9/24 the resident started to complain of her right leg hurting and the ARNP was notified and ordered a CT scan. She went for the CT scan on 9/10/24 and on 9/11/24 we got the results. The fracture was caused by her being lowered to the floor. The DON confirmed she did not have documentation of a complete and thorough investigation after the fracture was identified and said it was related to the fall on 8/23/24, not a fall but lowered to the ground. The DON confirmed Resident #24's fracture was an injury of an unknown cause then clarified it was from the lowering to the floor on 8/23/24. She confirmed she did not do an investigation of the fracture and said the Risk Manager would have done that. On 11/21/24 at 11:50 a.m., in an interview the Risk Manager said after the first fall on 8/3/24 Resident #24 did not complain of pain and during the three days post fall monitoring she had no additional pain. The Risk Manager said it wasn't until the resident was lowered to the floor on 8/23/24 that she had reported pain. The Risk Manager said You know how it can be they have an x- ray and it's negative and later an injury shows up on further testing. I read the nurse's notes, and she had no pain. I based the fracture on the nurse's documentation of no pain. She was lowered to the floor on 8/23/24 and that is how she sustained the fractured identified on 9/10/23. The Risk Manager confirmed she did not have documentation of a complete and thorough investigation of the fall on 8/23/24 and did not report the event to the appropriate State Agency once the fracture was identified. The Risk Manager said, I don't have an investigation; I told you already. I'm not answering that. I know what you want me to say but I'm not going to say that. She said, the resident had no pain after the fall on 8/3/24. I did not need to investigate the fracture because she did not complain of pain until after she was lowered to the floor on 8/23/24.