**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, document review, and facility policy review, it was determined the facility failed to provide adequate assistance during incontinence care to prevent a fall with injury for one (Resident #56) of three sampled residents whose clinical records were reviewed for accidents. This deficient practice resulted in Resident #56 sustaining lacerations to both lower extremities and being sent to a hospital for treatment. Findings included: A review of the facility policy titled, Positioning and Moving the Patient, last reviewed on 12/04/2021, revealed for log rolling a resident It is the intent of this center to provide patients with care that promotes good body alignment. According to the policy guidelines, staff should Slide both your arms under the patient's back to his/her far shoulder. Slide the patient's shoulder toward you on your arms. Slide both your arms (as far as you can) under the patient's buttocks. Slide the patient's buttocks toward you. Slide the patient's feet between the knees and ankles. Slide the patient's feet towards you. Place the pillow between the patient's legs. Cross the patient's legs in the direction that he/she should be rolled. Roll the patient onto his/her side like a log. A review of Resident #56's Face Sheet revealed the resident had diagnoses that included diabetes, hypertension, atrial fibrillation, anemia, anxiety, depression, arthritis, obesity, unsteadiness, and need for assistance with personal care. A review of Resident #56's significant change Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident needed extensive assistance of one staff member for bed mobility (turning side to side and positioning). The MDS also indicated the resident was always incontinent of bowel and bladder and was dependent on one staff member for toileting and personal hygiene. Further review revealed Resident #56 had no history of falls since the previous assessment/entry/reentry and weighed 206 pounds. According to Resident #56's MDS, activity of daily living (ADL) functional/rehabilitation potential and falls were triggered care areas and were addressed on the resident's care plan. A review of Resident #56's care plan, updated on 12/28/2022, revealed the resident was at risk for falls related to osteoarthritis, atrial fibrillation, diabetes, hypertension, a history of falls, obesity, anemia, neuropathy, anxiety, shortness of breath, and a fall sustained on 12/28/2022. Prior to the 12/28/2022 update, interventions to prevent falls included assisting the resident with ADLs and mobility as needed, keeping the bed in the low position, keeping personal items within reach, educating the resident and family on risks for falls with injury, and reminding the resident to call when assistance was needed. A review of Resident #56's care plan, updated on 11/02/2022, revealed the resident had a self-care deficit related to obesity, anemia, anxiety, shortness of [NAME], falls, and assistance needed with toileting and hygiene. The facility developed interventions that included providing assistance bars to the head of the bed, assisting with ADLs as needed, and offering to turn and reposition frequently as the resident allowed. During an interview conducted on 12/27/2022 at 11:42 AM, Resident #56 stated the resident had a concern about a certified nursing assistant (CNA) who worked nights at the facility. The resident stated on the day before Christmas Eve (12/23/2022), early in the morning, CNA #7 came in to change the resident and pushed the resident off the bed. Resident #56 stated CNA #7 was changing the resident's (incontinence) brief because the resident had a bowel movement, and the CNA pushed the resident on his/her side to clean the resident. The resident said the CNA grabbed the resident's right wrist area and was pulling on it and pushing the resident over to his/her left side. Resident #56 stated he/she was hanging onto the grab bar on the left side of the bed with his/her left hand, but the CNA kept pushing the resident. The resident said the CNA kept saying loudly, Roll, roll, roll over, while pushing on the resident's back side. The resident told the CNA that the resident could not roll any further because the resident was already on the edge of the bed. The resident stated the CNA pushed the resident one more time and the resident's legs fell off the bed. The resident stated he/she hung onto the grab bar and the left side of the bed with both hands; however, the resident's legs and feet were on the floor. Resident #56 yelled at the CNA and told her that she pushed the resident off the bed. CNA #7 ran out and yelled for help and a nurse came in and started taking care of the resident. The resident stated the nurse got the resident back in bed utilizing a mechanical lift. Resident #56 stated his/her legs hurt a lot and there was blood all over. The resident told the nurse that the CNA defiantly pushed the resident off the bed. According to Resident #56, the resident was transferred to the hospital for treatment of the legs. On 12/27/2022 at 11:50 AM, an observation of Resident #56 revealed multiple areas of discoloration to the resident's thumb on the left hand and the second toe on the left foot was discolored from top to bottom and was purple in color. Further observation revealed slight swelling was noted to both legs and there was a large 4 inch by (x) 4-inch adhesive bandage to each lower leg. Resident #56 stated he/she had skin tears where the adhesive bandages were located. A review of a facility Event report for Resident #56, dated 12/23/2022 at 4:15 AM, indicated the resident fell from bed while a staff member was changing the resident's incontinence brief. The report indicated staff rolled the resident too far and the resident fell out of bed. The report indicated the resident sustained a large skin tear to each leg and an abrasion to the left upper thigh. According to the report, the staff called 911. A review of a Nurse Note, dated 12/23/2022 at 4:15 AM, revealed Licensed Practical Nurse (LPN) #3 documented that a CNA called her to Resident #56's room. Per the note, the resident and the resident's roommate were also yelling out for help. When LPN #3 entered the room, Resident #56's lower body was on the floor, while the resident was holding onto the handrail to keep his/her upper body from hitting the floor. Resident #56 indicated the resident did not hit his/her head. The note revealed there was feces, urine, and blood on the floor. According to the note, the resident's bed was elevated. The nurse lowered Resident #56's bed and the resident was able to continue to hold onto the bed while the nurse lowered the resident's upper body to the floor. The nurse then positioned the resident on his/her side and conducted an assessment. Resident #56 sustained an abrasion to the left upper leg, a two-inch skin tear to the left lower leg, and a two-inch skin tear to the right lower leg with a tendon exposed. According to the note, the right leg skin tear approximated from top to bottom [and] the middle had tendon showing. The nurse's note indicated the nurse practitioner stated the resident would have to be sent to the hospital for staples. Further review of the nurse's note revealed the CNA stated she was providing care and the resident rolled out of bed. However, the resident and roommate disagreed with the CNA's account of the encounter. The nurse documented that Resident #56 stated the CNA kept pushing the resident. A review of Resident #56's hospital emergency room (ER) record, dated 12/23/2022, revealed the resident was treated for a fall and a laceration to the leg. A review of the resident's computerized tomography (CT; provided more details than an x-ray) scan report, dated 12/23/2022, revealed there was edema (swelling) in the soft tissue of the left upper leg. The CT scan report of the right leg, dated 12/23/2022, revealed there was an Apparent skin defect and bandaging overlying the anterior shin with Minimal associated subcutaneous induration [minimal involvement beneath or under all layers of the skin]. During an interview conducted on 12/28/2022 at 2:23 PM with CNA #7 via telephone, she stated that during the early morning on 12/23/2022 she had to change Resident #56's incontinence brief twice. She stated the first time the resident had loose stool and the CNA had to change the resident in the bed. She stated everything went well and there were no problems. The CNA stated the second time, approximately one hour later, the resident turned on the light and stated he/she had another bowel movement. Resident #56 had loose, diarrhea stool and the CNA asked the resident to turn toward the window. CNA #7 stated the resident grabbed the grab bar on the left side of the bed and started to turn. She stated she saw that the resident had feces on the back side of the right arm and elbow. She stated she hung onto the resident's arm at the wrist to hold the arm up while she cleaned the elbow and back of arm. She stated she asked the resident to roll over and picked up the resident's right leg and put it on top of the left leg so the resident could turn over. Resident #56 was then on his/her left side, and the CNA began cleaning feces from the resident's buttocks and back. The CNA stated she then rolled up all the dirty sheets and tucked them under the resident and started putting on the clean sheet. She stated she was not pushing the resident and did not have her hands on the resident. CNA #7 stated she was using both of her hands to put the sheet on the bed and tuck it under the resident. The CNA stated she was almost ready to tell the resident to roll back so the CNA could go to the other side of the bed when the resident rolled off the bed. According to CNA #7, the bottom half of the resident's body was on the floor and the resident continued to hold onto the grab bar on the left side of the bed. The CNA stated she was scared and ran from the room to the hallway to yell for help. She stated the nurse came and assisted the resident. CNA #7 stated the resident had skin tears to both lower legs and there was a lot of blood and urine on the floor. The CNA stated the resident was yelling for help. During a phone interview conducted on 12/28/2022 at 2:43 PM, LPN #3 stated that on the night of 12/23/2022 at approximately 4:30 AM, she heard CNA #7 calling down the hall for help. The nurse stated she went to Resident #56's room, and the resident was on the floor on the left side of the bed between the bed and the window. The resident was hanging onto the small grab bar on the left side of the bed with both hands and the resident's face was toward the floor. The rest of the resident's body was hanging off the bed and his/her legs and feet were on the floor. She stated she ran over to the resident and the resident was lying in blood, urine, and feces that was all over the floor. The nurse stated the resident kept repeating, She pushed me off the bed. She pushed me off the bed. LPN #3 stated she sent CNA #7 out of the room to get a mechanical lift because they had to get the resident off the floor. Resident #56 and the roommate were upset and yelling at the CNA. LPN #3 further stated that Resident #56's bed was in the high position because the CNA was changing the resident and the LPN lowered the bed. According to LPN #3, the resident's bed was unusually high, and believed it was about the height of the CNA's chest. After the LPN lowered the bed, she helped the resident let go of the grab bar, lowered the resident to the floor, and turned the resident over to fully assess the resident. She stated the CNA then came into the room and they lifted the resident back into bed with the mechanical lift. LPN #3 then did a head-to-toe assessment. LPN #3 indicated Resident #56 had large skin tears on both lower legs. The LPN stated the left skin tear was a couple of inches long and could be put together (approximated), but the skin tear on the right lower leg looked like the tendon was showing. Both skin tears were bleeding heavily. The resident also had a left knee abrasion and was complaining of pain. The nurse stated the resident told her, The CNA pushed me out of the bed. The resident said the CNA kept saying loudly, Roll, roll, roll! The resident told the CNA the resident was as far over as they could be and was already on the edge of the bed. The resident told the LPN that the CNA gave one more push and the resident rolled off the bed. The nurse stated she reported the incident to the Director of Nursing (DON) and the DON came into the facility that morning. During an interview conducted on 12/27/2022 at 1:14 PM with LPN #8, she stated she was aware of the fall Resident #56 experienced on the morning of 12/23/2022. She came on duty the morning of 12/24/2022 and the resident came back from the hospital. She stated when caring for Resident #56, the resident told her that CNA #7 pushed the resident off the bed when she was changing the resident's incontinence brief. The resident told her that the CNA was pushing the resident over onto his/her side but kept pushing even though the resident was already on the edge of the bed on his/her left side. The resident told her the CNA was yelling loudly, Roll, roll, roll as she was pushing the resident over on the left side of the bed, and then with one last push, the resident rolled off the bed. The resident told the CNA that the resident could not roll over anymore because he/she was on the side of the bed. The nurse stated the resident sustained skin tears to both lower legs, a bruised second toe of the left foot, an abrasion on the left knee, and bruising to the left thumb. During an interview conducted on 12/28/2022 at 5:12 PM, the DON stated staff notified him when he came in early on the morning of 12/23/2022 of Resident #56's fall with a report of what happened and the injuries the resident sustained. He stated the resident was transferred to the hospital just minutes before he came in. The DON stated the nurses described the incident to him and he talked to CNA #7 before she went home. The DON stated after he heard what happened from the nurse and talked with the CNA he went back to his office and wrote up an associate corrective action form. He stated he gave the form to the CNA's supervisor, LPN #4, to give to the CNA later. The DON stated the CNA needed to take more care with moving a resident and to pay attention to positioning and patient movement. A review of an Associate Corrective Action Form, dated 12/23/2022, indicated CNA #7 was assisting a resident in bed and moved the resident away from her, causing her to lose control of movement. The resident fell to the floor from the bed and sustained injury to the lower extremities (skin tears which required a hospital transfer for evaluation). The corrective action plan for CNA #7 was to take more care when moving residents, pay attention to positioning and patient movement, and ask for assistance from other CNAs when moving a resident who was bedbound or who had mobility defects. The form indicated with larger residents it was necessary to have a second person stand on the opposite side of the bed to assist with movement. Per the form, the resident should be moved close to the CNA and only moved when communication was completed, and the resident verbalized understanding. The form indicated the CNA should also remember to lower the bed to the lowest position when finished moving a resident. During an interview conducted on 12/30/2022 at 8:35 AM, LPN #9, the Resident Assessment Instrument (RAI) Coordinator, revealed he believed the root cause of Resident #56's fall was due to the CNA failing to position the resident away from the side of the bed before rolling the resident over and the CNA failing to ask for assistance with the resident's care. During an interview conducted on 12/28/2022 at 5:47 PM, the Administrator (ADM) stated she was not notified of the resident's fall/incident until Tuesday 12/27/2022 when she came into the facility. She stated she thought the incident was closed. A follow up interview with the Administrator on 12/30/2022 at 9:54 AM revealed CNA #7 had not worked in the facility since the night of the fall/incident and was suspended on 12/28/2022 pending investigation.