**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 7 of 13 residents (#6, #13, #26, #35, #44, #48, and #51) whose records were reviewed for quality of care. Specifically: - Resident #35 suffered harm when she sustained a hip fracture with pain after a fall and the fracture was not diagnosed until 10 days after the fall. - Resident #48 and #51 were at risk for undetected injury and neurological changes when fall assessments and neurological assessments were not completed after falls. - Resident #44 was at risk for undetected injury when fall assessments were not completed after falls. - Resident #13 was at risk for increased psychiatric symptoms related to missed doses of her antipsychotic medication. - Resident #51 was at risk for abnormally high or low blood sugar when his insulin was administered per physician order. - Resident #26 was at risk for abnormally low blood pressure when his blood pressure medication was not administered per physician ordered parameters. - Resident #6 was at risk for constipation or fecal impaction when physician orders for bowel care were not followed. Findings include: The facility's policy for Assessing Falls and Their Causes, revised March 2018, stated the assessment procedure after a fall included identifying the cause of a fall and fall risk within twenty-four hours and performing a post-fall evaluation. The policy further stated a Fall Risk Assessment was required when a resident fell. The facility's policy for Neurological Assessment, revised October 2010, stated a neurological assessment was completed upon physician order, following an unwitnessed fall or a fall with a suspected head injury, or when indicated by the resident's condition. The policy included a required assessment schedule as follows: - Every 15 minutes x 1 hour. - Every 30 minutes x 2 hours. - Every hour x 5 hours. - Every 8 hours x 16 hours. The facility's Fall Clinical Protocol policy, revised 3/2018, stated nursing staff monitored the neurological status of the resident if the fall was unwitnessed or if a resident hit his or her head. Staff followed up until the resident was stable and delayed complications such as late fracture, was ruled out. The policy stated delayed complications could occur within hours, days or even weeks after a fall. These policies were not followed. 1. Resident #35 was admitted to the facility on [DATE], and readmitted [DATE], with multiple diagnoses including left hip fracture, dementia, and anxiety disorder. Resident #35's quarterly MDS assessment, dated 2/9/22, documented she was severely cognitively impaired. The facility did not ensure timely treatment for Resident #35's fractured hip as follows: A progress note, dated 3/8/22 at 4:55 PM, documented Resident #35 fell as a CNA was entering her room. A nurse then entered the room and saw Resident #35 lying on the floor, crying. Resident #35 was unable to state what happened or if she was in pain. Staff used a blanket to lift Resident #35 into her Comfort Chair. Neurological checks were initiated, and the PA was notified. A progress note, dated 3/8/22 at 5:56 PM, documented the PA ordered one dose of Morphine for pain from Resident #35's fall. A progress note, dated 3/10/22 at 6:48 PM, documented Resident #35 appeared to be in pain and she was yelling and screaming. A progress note, dated 3/11/22 at 6:47 AM, documented Resident #35 had signs and symptoms of increased pain to her left hip and right upper arm. The note documented Resident #35 refused cares and screamed louder with all cares. She received two doses of Morphine Sulfate during the previous night shift. A PA note, dated 3/11/22, documented Resident #35 needed a refill of her pain medication, and ordered Morphine every two hours for pain, as needed. A progress note, dated 3/11/22 at 3:32 PM, documented Resident #35 had no latent injuries noted from her recent fall. The note documented she received Tylenol for her pain. A progress note, dated 3/12/22 at 4:30 AM, documented Resident #35 had signs and symptoms of increased pain to her left hip and right upper arm. The note documented Resident #35 refused care, turning and repositioning, and screamed louder with all cares. The note documented Resident #35 was medicated with four doses of Morphine during the previous night. A progress note, dated 3/12/22 at 5:03 PM, documented Resident #35 had no latent injuries from her fall and she received Tylenol for her pain. The note documented Resident #35 was displaying increased anxiety and was agitated throughout the shift. A progress note, dated 3/13/22 at 4:09 AM, documented Resident #35 yelled and screamed in agony with cares. The note documented Morphine was not covering her extreme pain symptoms which were documented as 8 - 10 on a 1 - 10 pain scale (a measure of pain severity, with 0 meaning no pain and 10 being the most extreme pain). The note further documented Resident #35 was screaming for an hour or two, despite being medicated, and the physician was notified. A progress note, dated 3/13/22 at 4:37 PM, documented Resident #35 had extreme pain between 8 and 10. Staff turned Resident #35 every two hours, and determined it was painful for her. A progress note, dated 3/14/22 at 1:11 PM, documented Resident #35 had been medicated with Morphine at 6:00 AM and 9:00 AM for pain and was yelling out and crying. An NP note, dated 3/14/22, documented Resident #35 had increased pain and required multiple doses of Morphine for pain control. The note documented nurses were requesting increased pain medication for Resident #35. The note documented Resident #35's left leg was shortened and externally rotated, and Resident #35 was protecting her left leg. The note further documented Resident #35 was able to point to her left hip when asked where she was hurting. The NP ordered an x-ray of Resident #35's left hip related to her fall on 3/8/22. A progress note, dated 3/15/22 at 3:44 AM, documented Resident #35 was in pain during the night shift and required several doses of morphine. The note documented the NP examined Resident #35 and determined Resident #35 needed to have an x-ray of her left hip. A progress note, dated 3/15/22 at 10:29 AM, documented Resident #35 would have an x-ray of her hip the following day. A progress note, dated 3/16/22 at 1:46 AM, documented Resident #35 tolerated an increase of Morphine, which controlled her pain for longer periods of time. A progress note, dated 3/16/22 at 3:27 PM, documented Resident #35 had her pain controlled with Tylenol and nursing staff did not need to use Morphine for her pain. The note documented an x-ray was to be taken the following day. A progress note, dated 3/18/22 at 1:52 AM, documented Resident #35 was medicated with some relief of pain in her left hip. The note documented Resident #35 screamed in agony with cares provided by staff. The note stated the x-ray report documented Resident #35 had a left hip fracture which caused her leg to turn inward. Messages were left for the facility Administrator, ADON, Resident #35's PA, and Resident #35's representative, notifying them of the fracture. A progress note, dated 3/18/22 at 2:20 AM, documented Resident #35's representative returned the facility's phone call and was informed of Resident #35's hip fracture related to the fall on 3/8/22, 10 days after the fall. A progress note, dated 3/18/22, documented the NP examined Resident #35 and her x-ray report and ordered transport for Resident #35 to the emergency room for further treatment. On 5/25/22 at 10:00 AM, the DON stated on initial examination it did not appear Resident #35 sustained injuries from her fall on 3/8/22. The DON stated Resident #35 was non-verbal and often cried out when cares were performed, making it difficult to assess the true nature of her pain. The DON stated Resident #35 was assessed every morning and it was not apparent she had a fracture. The DON stated staff were to notify her if Resident #35 had a change in condition or continued to be in severe pain. Resident #35 was harmed when she fell and sustained a hip fracture with increasing pain and did not receive treatment for the fracture until 10 days after the fall. 2. Resident #51 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Type 2 Diabetes Mellitus with diabetic chronic kidney disease, low back pain, and hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a stroke. Resident #51's Quarterly MDS assessment, dated 5/2/22, documented he was mildly cognitively impaired. The facility did not ensure Fall Risk Assessments or Neurological Assessment were completed for Resident #51 as follows: - An I&A report, dated 10/2/21, documented Resident #51 had an unwitnessed fall at 2:00 AM. There was no Fall Risk Assessment documented in Resident #51's record after the fall. - An I&A report, dated 11/22/21, documented Resident #51 had an unwitnessed fall at 10:10 PM. There was no Fall Risk Assessment or Neurological Assessment documented in Resident #51's record after the fall. - An I&A report, dated 1/7/22, documented Resident #51 had an unwitnessed fall at 12:15 PM. There were no Neurological Assessment documented in Resident #51's record after the fall. - An I&A report, dated 1/16/22, documented Resident #51 had an unwitnessed fall at 9:54 AM. There was no Fall Risk Assessment or Neurological Assessment documented in Resident #51's record after the fall. - An I&A report, dated 1/17/22, documented Resident #51 had at 2:00 AM. There was no Neurological Assessment documented in Resident #51's record after the fall. - An I&A report, dated 5/11/22, documented Resident #51 had an unwitnessed fall at 11:50 PM. There was no Neurological Assessment documented in Resident #51's record after the fall. On 5/27/22 at 10:45 AM, the DON stated Resident #51 did not have Fall Risk Assessments or Neurological checks completed for his falls as required by their policies. 3. Resident #44 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including right thigh muscle atrophy (a condition in which muscles shrink and cause weakness) and dementia. The facility did not ensure a Fall Risk Assessments was completed for Resident #44 as follows: - An I&A report, dated 7/11/21 at 6:05 AM, documented staff heard a loud thump and found Resident #44 sitting on the floor between the wheelchair and his bedside. Resident #44 said he slipped when coming back from the bathroom and fell. A nurse's note, dated 7/11/21 at 6:05 AM, documented that Resident #44 was observed in pain, and his left knee was swelling. Resident #44 was sent to the hospital for evaluation at 7:15 AM. A hospital Discharge summary, dated [DATE], documented Resident #44 was admitted to the hospital on [DATE] with a left femur lateral condyle (on the end of the thigh bone near the knee) fracture. He had an open reduction and internal fixation surgery for the fracture on 7/13/21 and discharged from the hospital on 7/14/21. A progress note, dated 7/15/21 at 3:53 PM, documented that Resident #44 returned from the hospital on 7/14/21. Resident #44's record did not include a Fall Risk Assessment after his fall on 7/11/21 after returning to the facility. - An I&A report, dated 9/19/21 at 7:33 AM, documented staff was alerted by Resident #44's roommate that he needed assistance. The staff found Resident #44 sitting on the floor in his room on his buttocks with his legs extended. Resident #44 said he was trying to get into his wheelchair and did not make it. There was no Fall Risk Assessment documented in Resident #44's record after his fall. On 5/26/22 at 1:05 PM, the clinical resources nurse said the Fall Risk Assessment was not completed for Resident #44's fall incidents on 7/11/21 and 9/19/21, and it should be completed within 24 hours after the fall or upon readmission. 4. Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including diabetes, dyskinesia (involuntary muscle movements), schizophrenia (a mental disorder characterized by continuous or relapsing episodes in which people have a disconnection from reality), and moderate intellectual disabilities. Resident #48's I&A reports, from 2/2021 to 4/2022, documented he had nine falls in approximately 14 months. There were no Fall Risk Assessments documented in Resident #48's record after the nine falls on 7/7/21, 2/18/21, 7/29/21, 10/5/21, 12/10/21, 3/20/22, and 4/15/22. Resident #48's I&A report documented he had two unwitnessed falls on 7/29/21 and 3/20/22. There was no Neurological Assessment documented in Resident #48's record after the two unwitnessed falls. On 5/25/22 at 3:15 PM, the DON said Resident #48's Fall Risk Assessments were not being completed after each of the nine falls, and they should be completed within 24 hours after the fall. On 5/25/22 at 3:15 PM, The DON said per policy, a neurological assessment should be performed after each unwitnessed fall. She said Neurological Assessments were not completed after Resident #48's unwitnessed falls on 7/29/22 and 3/20/22. 5. Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including hemiplegia and hemiparesis (paralysis on one side of the body), schizoaffective disorder (a condition where symptoms of both psychotic and mood disorders are present together during one episode, or within a two-week period of each other), and anxiety disorder. The facility's policy for Administering Medications, revised 4/2019, stated medications were administered in accordance with prescribed orders, including any required time frame. Medication administration times were determined by resident need and benefit, not staff convenience, including enhancing optimal therapeutic effort of the medication, preventing potential medication or food preferences, or honoring resident choices and preferences. Medications were administered within one hour of their prescribed time. This policy was not followed. Resident #13's quarterly MDS assessment, dated 3/8/22, documented she was mildly cognitively impaired. A physician's order, dated 3/18/22, documented to administer Risperdal Consta suspension (medication to treat a mental disorder) intramuscularly to Resident #13 one time a day every 14 days related to schizoaffective disorder. Resident #13's MAR did not document Risperdal Consta was administered on 5/6/22 or 5/20/22. On 5/26/22 at 4:45 PM, the DON stated there was no documentation in Resident #13's MAR or in the nursing notes to determine whether or not Resident #13 received her Risperdal Consta as ordered. The facility did not administer Resident #13's Risperdal Consta as ordered by the physician. 6. Resident #51 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Type 2 Diabetes Mellitus with diabetic chronic kidney disease, low back pain, and hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a stroke. The Mayo clinic website, accessed on 6/3/22, stated, Blood sugar that's either too high or too low for too long may cause various serious conditions, all of which can lead to a diabetic coma. The facility's policy for Administering Medications, revised 4/2019, stated medications were administered in accordance with prescribed orders, including any required time frame. Medication administration times were determined by resident need and benefit, not staff convenience, including enhancing optimal therapeutic effort of the medication, preventing potential medication or food preferences, or honoring resident choices and preferences. Medications were administered within one hour of their prescribed time. This policy was not followed. A physician's order, dated 1/18/22, documented Resident #51 was to receive Insulin Glargine (long acting insulin), 10 units subcutaneously (injection under the skin) one time a day for diabetes mellitus. The medication was ordered to be given at 7:00 AM. Resident #51's insulin glargine was not documented as given as ordered or within 1 hour per the facility policy, as follows: - Resident #51's insulin glargine was administered on 3/1/22 at 3:33 PM, greater than 8 hours from the time it was scheduled. - Resident #51's insulin glargine was administered on 3/10/22 at 3:28 PM, greater than 8 hours from the time it was scheduled. - Resident #51's insulin glargine was administered on 3/25/22 at 1:15 PM, greater than 6 hours from the time it was scheduled. - Resident #51's insulin glargine was administered on 5/15/22 at 12:11 PM, greater than 5 hours from the time it was scheduled. On 5/26/22 at 4:45 PM, the DON stated Resident #51's insulin glargine was administered late on 3/1/22, 3/10/22, 3/25/22 and 5/15/22. The facility did not administer Resident #51's insulin glargine as ordered by the physician or facility policy. 7. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including hypertension (high blood pressure). A physician's order, dated 1/19/22, documented Resident #26 was to receive metoprolol succinate (medication to lower blood pressure) ER (extended release) 25 mg, one time a day for hypertension and staff were directed to hold the medication if his pulse rate was less than 60 or if his systolic blood pressure (top number of blood pressure reading) was less than 110 mmHg (millimeters of mercury). Resident #26's May 2022 MAR, documented his systolic blood pressure was less than 110 mmHg on the following dates: -5/6/22: blood pressure was 102/60 -5/10/22: blood pressure was 101/63 -5/13/22: blood pressure was 101/59 Resident #26's May 2022 MAR, documented he received 25 mg of metoprolol, on 5/6/22, 5/10/22, and 5/13/22. On 5/25/22 at 10:32 AM, the DON stated Resident #26's metoprolol should have been withheld on the days when his systolic blood pressure was less than 110 mmHg. The facility did not follow Resident #26's physician ordered parameters when administering his blood pressure medication. 8. Resident #6 was admitted to the facility on [DATE], discharged to the hospital on 5/11/22, and readmitted on [DATE], with multiple diagnoses including schizophrenia (a mental disorder characterized by continuous or relapsing episodes in which people have a disconnection from reality), and retention of urine (difficulty urinating and completely emptying the bladder.) Resident #6's physician order included as needed bowel management orders as follows: - Day 2 no BM (bowel movement): Encourage fluids; licensed nurse to offer prunes, prune juice, or 2 tablespoons of BAP (a constipation recipe with a mix of bran, applesauce, and prune juice) by mouth from dietary. Administer Senokot (laxative and stool softener) 8.6 mg, one tablet by mouth BID (twice a day). Report any liquid stools with no formed BM to the physician as needed. Document the results of Senokot (color, odor, blood, soft, hard, large or small amounts, if gas was expelled,) as applicable, how the resident tolerates the procedure, if the Resident refuses the procedure, and why. Order start date 6/11/18. - Day 3 no BM: Encourage fluids, offer prune juice or 2 tablespoons of BAP by mouth, BID from dietary. Administer Senokot 8.6 mg one tablet by mouth BID and Glycolax (laxative) 17 gm (gram) in 8 oz (ounce) fluid by mouth BID. Report any liquid stools with no formed BM to the physician as needed for constipation. Document the results of Senokot & Glycolax (color, odor, blood, soft, hard, large, or small amounts, if gas was expelled,) as applicable, how the resident tolerates the procedure, if the resident refuses the procedure, and why. Order start date 6/11/18. - Day 4 no BM: Encourage fluids; licensed nurse to offer prunes, prune juice, or 2 tablespoons BAP by mouth BID from dietary. Administer Senokot 8.6 mg one tablet by mouth BID, Glycolax 17 gm by mouth BID, Lactulose (synthetic sugar used to treat constipation) 30 cc (cubic centimeter) by mouth BID, and Dulcolax suppository 10 mg per rectal early in the morning. If there is no BM by noon of day 4, notify the physician for further instructions. Report any liquid stools with no formed BM to the physician as needed for constipation. Document the results of Senokot, Glycolax, Lactulose & Dulcolax (stimulates bowel movement) suppository (color, odor, blood, soft, hard, large, or small amounts, if gas was expelled,) as applicable, how the resident tolerates the procedure, if the resident refuses, and why. Order start date 6/11/18. - Day 5 no BM: Continue to offer prunes, prune juice, or BAP 2 tablespoons by mouth BID, Senokot 8.6 mg by mouth BID, Glycolax 17 gm in 8 oz fluid BID, Lactulose 30 cc by mouth BID. If there is no BM, the licensed nurse will complete the assessment, listen to bowel tones and check abdominal distention, and check the rectal vault per nursing standards. If there is no BM by 2 PM on Day 5, notify the physician or further orders as needed for constipation. Document the results of Senokot, Glycolax, Lactulose, and Dulcolax suppository (color, odor, blood, soft, hard, large, or small amounts, if gas was expelled,) as applicable. How the resident tolerates the procedure, if the resident refuses, and why. Order start date 6/11/18. An ADL report for May 2022, documented Resident #6's BM as follows: - One normal medium BM on 5/3/22 and no BM for 7 days from 5/4/22 to 5/10/22. - One normal large BM on 5/17/22 and no BM for 8 days from 5/18/22 to 5/26/22. Resident #6's MAR for May 2022 did not include documentation bowel care was administered as ordered. On 5/26/22 at 5:00 PM, the DON reviewed Resident #6's MAR and record and said Resident #6's bowel management orders were not being administered and documented for May 2022. The DON said Resident #6's last BM was on 5/17/22, and she had no BM until today, 5/26/22. The DON said if Resident #6 did not have BM later today, it would be the 9th day. The DON said the nurse was to follow the bowel management order and notify the physician if the resident had no BM on the fourth day and to receive new orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure a resident received appropriate care to prevent and treat a pressure ulcer. This was true for 1 of 2 residents (Resident #22) reviewed for wound care. This failure resulted in harm when Resident #22 developed an abrasion on his right trochanter (upper end of the thigh bone that is connected to the hip bone) which became an unstageable pressure ulcer. Findings include: The National Pressure Injury Advisory Panel website, accessed on 6/2/22, defined pressure injury as a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (friction to the skin causing it to separate from the bottom layer of skin). Stages of pressure injury are as follows: Stage 1- Intact skin with localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration these may indicate deep tissue pressure injury. Stage 2- Partial thickness skin loss with exposed dermis. The wound bed is viable, pick or red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (non-viable yellow, tan, gray, green, or brown tissue) and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3- Full thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4- Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this in an Unstageable Pressure Injury. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, high blood pressure, muscle weakness, and abnormalities of gait and mobility. An annual MDS assessment, dated 3/15/22, documented Resident #22 was severely cognitively impaired, at risk of developing pressure ulcers, and no pressure ulcers were present. Resident #22's care plan, initiated on 3/24/22, documented he was at risk for skin impairment related to his history of incontinence of bowel and bladder and due to diagnosis of Alzheimer's disease. The care plan directed staff to provide treatments as ordered, perform weekly skin assessments, check his nails to ensure they were trimmed and filed with no jagged edges, notify the provider if new areas were noted/seen, apply protective cream after each incontinent episode, and assist him with clothing changes. Weekly Skin Assessments, dated 3/7/22, 3/10/22, 3/15/22, and 3/21/22, documented Resident #22 had no alteration to skin integrity and no new skin issues were noted during a 24-hour period. A nurse practitioner's note, dated 3/21/22, documented Resident #22 had a wound to his right trochanter (bony top of the thigh bone in the hip area). The nurse practitioner directed staff to cleanse Resident #22's wound to his right hip every three days and PRN with a wound cleanser, pat dry, cover with Tegaderm (a transparent film dressing), and monitor him for signs and symptoms of infection and wound healing. A Nurse's Note, dated 3/23/22 at 1:13 PM, documented Resident #22 had a lesion (wound or injury) present to his right hip that was blanchable (the reddened area turns white when pressed on) throughout the reddened area and the top layer of the skin was missing. The note documented the reddened area matched the size and shape of the incontinence brief adhesive tab. The Nurse's Note documented when the adhesive tab was removed it took off the top layer of Resident #22's skin. The note also documented it was on the side Resident #22 preferred to lay on. The note further documented orders to clean the wound every three days with wound cleanser, pat dry with gauze, and cover the wound with Allevyn (foam dressing). Resident #22's care plan was not updated to include the lesion/wound to his right hip. A Weekly Skin Assessment, dated 3/31/22, documented Resident #22 had no alteration to skin integrity and no new skin issues were noted during a 24-hour period. A nurse practitioner's progress note, dated 4/11/22, documented Resident #22 had a 4x4 [sic] wound to his right trochanter with necrotic eschar [dead tissue] covering and surrounding erythema [redness]. The nurse practitioner documented Resident #22 would benefit from a wound specialist. The nurse practitioner directed staff to refer Resident #22 to a wound care specialist, cleanse his wound every 72 hours and PRN with wound cleanser, pat dry, apply Medi-Honey (helps create a moist wound healing environment which aids in debridement and removal of necrotic tissue), cover with Allevyn dressing, off-load Resident #22's right hip, and turn him every two hours. A physician note, dated 4/13/22 at 8:10 AM, documented an order to administer Bactrim DS (antibiotic), one tablet two times a day for 14 days to treat the wound on Resident #22's right hip. A physician assistant's note, dated 4/15/22, documented Resident #22 had severe anxiety and significant behaviors. The note stated Resident #22 would be difficult to transfer out of facility for cares, and will try to treat in house first. The physician assistant discussed Resident #22's right hip wound with the staff and documented will try to tx [treat] here first with Santyl [medicine that removes dead tissue from wounds so they can start to heal] if it does not improve will have to send out to wound care. A Nurse's Note, dated 4/22/22 at 10:32 AM, documented Resident #22's wound had changed to eschar and it was breaking-up and pink tissue was remaining, and there was no drainage. The April 2022 MAR documented Resident #22 completed his Bactrim on 4/27/22. A Nurse's Note, dated 4/30/22 at 2:23 PM, documented Resident #22's wound to his right hip was cleansed with normal saline, patted dry, Santyl was applied with a sterile cotton tipped swab, and the wound was covered with an adhesive border gauze. The note documented the wound continued to have a moderate amount of yellow/green drainage and the bandage was completely saturated. The Nurse's Note further documented Resident #22's wound had some redness to the peri-wound (tissue surrounding a wound) and he might require more frequent dressing changes due to increased drainage. A Nurse's Note, dated 5/3/22 at 4:49 PM, documented Resident #22's wound dressing was changed, and the top of the wound was black. The note documented there was redness to the outer border and no drainage was noted. Resident #22 stated the wound was tender and he appeared to feel discomfort during wound cleansing. A care plan, initiated on 5/3/22, documented Resident #22 had an unstageable area to his right hip and staff were to assess him for signs and symptoms of pain with wound care, schedule/administer analgesic (pain reliever) prior to treatment, communicate with the physician if area was not healing or worsened, perform wound care as ordered, encourage Resident #22 not to sleep on his right hip, and perform skin checks weekly. The care plan was updated five weeks after it was noted in Resident #22's record. A Weekly Wound Observation Tool, dated 5/6/22 at 12:11 PM, documented Resident #22 had an unstageable open area to his right hip that measured 5.25 cm x 1.6 cm, with black eschar that was sluffing off (shedding) and there was more pink tissue present. The wound had no drainage or odor, infection was not suspected, and it was being treated with Santyl and a hydrocolloid dressing (waterproof). A Nurse's Note, dated 5/11/22 at 4:21 PM, documented Resident #22's wound was very odorous with signs and symptoms of infection present. The note documented sluff was present to the outer bed of the wound with redness on the peri-wound. The note also documented the wound was very painful for Resident #22 and Resident #22's provider would be notified. A Weekly Wound Observation Tool, dated 5/13/22 at 10:36 AM, documented Resident #22 had an acquired unstageable open area to his right hip that measured 6.5 cm x 4.25 cm, with 70% eschar that was pulling away from the wound edges, the peri-wound was pink. Resident #22's wound had no odor or drainage, and was treated with Medi-Honey and covered with a hydrocolloid dressing. A physician assistant's note, dated 5/13/22, documented Resident #22 was seen due to staff concerns the wound looked worse, with increased drainage and smell. The note documented Resident #22 was on Bactrim prior and it seemed to help. The physician assistant assessed the wound as cellulitis and ordered Bactrim DS for 10 days and try Medi-Honey, if does not improve consider wound care next. Resident #22's wound had increased in size by 1.25 cm x 2.65 cm in 7 days. There was no documentation he was referred to a wound clinic. A nurse practitioner's note, dated 5/16/22, documented Resident #22 had increased pain to his right hip wound and was on a low dose Duragesic (skin patch containing fentanyl, an opioid/narcotic pain medication) pain patch. The note documented Resident #22 would benefit from additional pain control. Resident #22 was prescribed Tramadol (an opioid/narcotic pain medication) 50 mg, one tablet two times a day. A Weekly Wound Observation Tool, dated 5/20/22 at 10:39 AM, documented Resident #22 had an unstageable open area to his right hip that measured 6.5. cm x 4.25 cm and was treated with Santyl and a hydrocolloid dressing. The note documented the wound had no drainage or odor, and infection was not suspected. A physician's assistant order, dated 5/23/22 at 10:09 AM, documented to refer Resident #22 to the wound clinic for his right hip wound. This was ordered 22 days after it was first ordered by the nurse practitioner on 4/11/22 and nine weeks after the wound was first identified. A Nurse's Note, dated 5/23/22 at 12:01 PM, documented Resident #22 had complaints about his wound and the wound was slightly odorous, with blackened content. The note documented they would continue to monitor the wound. The May 2022 MAR, documented Resident #22 completed his second round of Bactrim on 5/26/22. On 5/26/22 at 3:25 PM, the DON stated Resident #22 went to a Wound Clinic that morning. The DON stated Resident #22's unstageable pressure ulcer to his right trochanter started as a small abrasion from the sticky part of his undergarment and he always laid on his right side. The DON stated staff encouraged Resident #22 to lay on his left side, but he always refused. When asked why Resident #22 was not referred to a wound care specialist as ordered by the nurse practitioner on 4/11/22, the DON stated Resident #22 was seeing a podiatrist for a lesion on his left big toe and also saw an eye specialist. The DON stated they wanted to avoid causing Resident #22 anxiety by leaving the facility so often. The DON stated she talked to the nurse practitioner who then ordered to clean and treat Resident #22's right hip wound with Santyl first. The DON stated Resident #22's wound started to peel from the side, then became unstable in the center. When asked about the Weekly Skin Assessment, dated 3/31/22, which documented Resident #22 had no alteration to skin integrity, and the Nurse's Note, dated 3/23/22, documented he had a lesion to his right trochanter, the DON stated she performed weekly wound assessments and documented them on paper. The DON provided Resident #22's paper wound assessment and the assessment did not include the date the abrasion was first identified. Resident #22 was harmed when the abrasion on his right hip deteriorated and became an unstageable pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of I&A reports, and staff interview, it was determined the facility failed to ensure adequate supervision was provided to residents to prevent falls. This was true for 1 of 5 residents (Resident #47) reviewed for falls. This resulted in harm to Resident #47 when he sustained bruises and a fracture to his finger. Findings include: The facility's policy Fall and Fall Risk Managing, revised 3/2018, documented staff completed a fall risk assessment and enter it into the resident's medical record. Staff would identify the cause of the resident's fall and document interventions related to a resident's specific risks and causes, try to prevent the resident from falling, and try to minimize complications from falling. Staff were to implement a resident-centered fall prevention plan to reduce specific factors of falls for each resident at risk and would monitor and document each resident's response to interventions. If a resident continued to fall, staff would re-evaluate the situation and determine if interventions were appropriate or needed to be changed. This policy was not followed. Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including dementia with behavioral disturbance, altered mental status, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors and sometimes loss of awareness). A quarterly MDS assessment, dated 5/5/22, documented Resident #47 had severe cognitive impairment, required extensive assistance of one to two person with ADLs and set-up for eating. The MDS also documented: - He was not steady with moving from a seated to standing position but able to stabilize with human assistance. - He was not steady with walking, turning around and facing the opposite direction while walking and moving on and off the toilet but able to stabilize with human assistance. - He had two or more falls since admission. Resident #47's care plan documented he was at risk for falls related to his diagnosis of unsteady gait and epilepsy. Interventions included the following: - Encourage him to sit-up and stand slowly, initiated on 12/20/16 and revised on 7/20/18. - Fall risk assessment after any fall, quarterly and PRN, initiated on 3/9/18. - Encourage adequate hours of sleep at night and rest periods during the day, initiated on 6/5/19. - Encourage appropriate nonskid footwear when ambulating, initiated on 6/14/19. - Support bars were installed around his toilet related to his report of attempting to sit and missing the seat, initiated on 3/28/18 and revised on 12/6/19. - Continue to encourage to ask for assistance with cares to address fall risk/actual fall, initiated on 12/23/19. - Provide him a safe place to sit in his room. Physical Therapy(PT) to evaluate and treat him as needed. Remind and encourage him frequently to call for staff assistance, initiated on 5/10/19 and revised on 12/26/19. - Move nightlight from bedside to area by the sink due to bed being moved per his preference and nightlight would be near his head when he is trying to sleep, initiated on 5/20/19 and revised on 1/29/20. - Encourage him to sit all the way back on the chairs and not on the edge of the chair, initiated on 2/25/19 and revised on 4/6/20. - Assure his room is lit at night. He uses a night light in his room, initiated on 6/14/19 and revised on 4/6/20. - Remind him to slow down when changing positions, transferring and ambulating, initiated on 5/17/20. - Ensure he has a cold soda in the refrigerator at all times, initiated on 12/16/19 and revised 5/25/20. - Move him closer to the nursing station for higher observation, initiated on 8/18/21. - When he is in common area there is a Visual Aide to keep him in line of sight at all times, initiated on 11/12/21. - Bed should be in lowest position and locked when in bed, initiated on 11/12/21 - Be sure the call light is within reach and encourage him to use it for assistance as needed was initiated on 2/16/22. - Redirect/Assist him to the nearest bathroom if he is having sudden toileting needs, initiated on 2/16/22. Resident #47's record, documented he experienced a total of 7 falls in five months, as follows: A Fall Scene Investigation Report, dated 1/20/22 at 2:11 PM, documented Resident #47 had an unwitnessed fall. He was found on the floor in his room. Resident #47 stated he wanted to lay down after using the toilet. No injuries were noted. An Interdisciplinary Team (IDT) Review for the fall on 1/20/22, dated 1/27/22, documented the root cause of the fall was that Resident #47 had no safety awareness and he did not recognize his limitations. Resident #47 believed he was more independent that he really was. The IDT review documented Resident #47 was on 15 minute checks, and had a pressure sensitive alarm in his wheelchair. The IDT documented his interventions were appropriate. A Fall Scene Investigation Report, dated 4/29/22 at 1:00 AM, documented Resident #47 had a witnessed fall. Staff heard Resident #47 getting out of his bed unassisted and went to his room. Staff observed Resident #47 fall forward and hit his head on the nightstand which was next to his bed. He was assisted to a sitting position on his bed. An IDT review of the fall on 4/29/22, dated 5/6/22, documented the root cause of Resident #47's fall was he attempted to self-rise and ambulate. The IDT documented Resident #47 had 1:1 staff which would often cause him to have increased agitation at times. Resident #47 had been on 15 minutes checks in the past and no changes to him falling. Interventions were initiated to have Physical Therapy screen Resident #47. Resident #47 was evaluated on 5/2/22, 4 days prior to the IDT review. A Fall Scene Investigation Report, dated 4/29/22 at 10:03 PM, documented Resident #47 had an unwitnessed fall. Resident #47 was found on the floor next to his bathroom door. Loose watery stool was observed on the floor, on the back of his clothing, and in his wheelchair. Resident #47 stated he could no longer hold it and lost his balance. An IDT review of the fall on 4/29/22, dated 5/2/22, documented the root cause of Resident #47's fall was he had loose/watery stool and slipped in the bowel and fell. The IDT review stated it was an isolated incident. A Physical Therapy Evaluation and Plan of Treatment, dated 5/2/22, documented Resident #47 was willing to participate. However, his cognitive deficits negatively affected his overall progress. A Speech Therapy, progress note, dated 5/3/22, documented Resident #47 had severe dementia and required 24-hour care for ADLs and safety. The note stated Resident #47 and caregivers would benefit from identification of additional supports or aides to use as dementia progressed. A Fall Scene Investigation Report, dated 5/9/22 at 11:03 PM, documented Resident #47 had an unwitnessed fall. He was observed sitting on his buttocks on the floor in his room and leaning backwards in front of his endtable with socks in his hand. All three drawers of the endtable were open. Resident #47 appeared to be agitated and he was noted to have bleeding above his right eye with his right eye turning red and bruising and an abrasion was also noted above his left eye. Resident #47's right hand was noted to have some redness to his ring finger as well as to his chin, and right cheek. An IDT review for the 5/9/22 fall, dated 5/11/22, determined the root cause of Resident #47's fall was he was self-rising and attempted to ambulate and stand when he needed assistance for safety. Resident #47's physician was made aware and reviewed his medications and laboratory results. The physician gave an order for Resident #47 to see his neurologist. A Fall Scene Investigation Report, dated 5/10/22 at 6:10 PM, documented Resident #47 had a witnessed fall. He was seen leaning over to pick-up his cup off the floor and his wheelchair went out from under him and he fell on his coccyx. An IDT review of the fall on 5/10/22 at 6:10 PM, dated 5/11/22, determined the root cause of Resident #47's fall was his wheelchair rolled out from under him when he stood. A Fall Scene Investigation Report, dated 5/10/22 at 9:05 PM, documented Resident #47 had an unwitnessed fall. Resident #47 had been going to the double doors between the North and South areas of the building to wait for morning and meet with Social Services when staff heard a loud sound, went to the area and observed him on the floor. Resident #47 was mumbling and was noted to have difficulty formulating his words. An IDT review of the fall on 5/10/22 at 9:05 PM, dated 5/11/22, documented Resident #47 had been experiencing changes in his mental and physical functioning and they would continue to reach out to his neurologist for an appointment. A Fall Scene Investigation Report, dated 5/10/22 at 11:32 PM, documented Resident #47 had an unwitnessed fall. He was observed on the floor in his room between his bed and his door. Resident #47 was yelling help me over and over and it was difficult to understand what he was saying. An IDT review of the fall on 5/10/22 at 11:32 PM, dated 5/11/22, documented Resident #47 experienced an acute change of condition. Resident #47's medications were reviewed, and staff were trying to get him into his neurologist. Resident #47 experienced 3 falls on 5/10/22 between 9:05 PM and 11:32 PM. Resident #47's care plan was updated on 5/12/22, and directed staff to change his dresser to a plastic dresser to help prevent injuries. A Nurse's Note, dated 5/13/22 at 1:50 AM, stated Resident #47's physician gave an order for Resident #47 to start on Keppra (ant-epileptic) 500 mg twice a day, decrease his Dilantin (anti-convulsant) to 150 mg twice a day in two days and then check his Phenobarbital (anti-seizure) and Phenytoin (dilantin) levels in three weeks. Resident #47's care plan was updated on 5/13/22 and staff were directed to place an anti-roll back bars on his wheelchair. A physician's progress note, dated 5/13/22, documented Resident #47 injured his ring finger on his right hand during one of his falls. The physician documented Resident #47 had some swelling and bruising to the area and gave an order to x-ray Resident #47's right hand. A Physical Therapy discharge summary note, dated 5/18/22, documented Pt [patient] demonstrated progress initially with therapy with having decline and platue of progress d/t [due to] change in medical condition that nursing is currently treating. An X-ray report, dated 5/19/22, documented Resident #47 had an acute fracture right ring finger. A physician's order, dated 5/20/22, directed staff to buddy tape (act of bandaging a damaged or particularly fractured finger or toe together with a healthy one) Resident #47's fourth finger. On 5/23/22 at 12:22 PM, Resident #47 was observed in his room standing by the foot of his bed. Resident #47's bed was placed against the wall and in low position. There were two fall mats and a mattress next to his bed. On 5/26/22 at 2:57 PM, the DON stated she was informed every time Resident #47 had a fall. The DON stated Resident #47 used to have a 1:1 staff but he did not like to have a staff next to him he became more agitated, angry and combative. The DON stated a Visual Aide was provided to Resident #47 whenever he was in the common area. When asked the meaning of a Visual Aide, the DON stated it meant within the line of sight of the staff.The DON stated Resident #47 was moved to another room closer to the nurse's station, so he could be within the line of sight of the staff when they were in the nurse's station charting. When asked if there was a Visual Aide during the night, the DON stated the Visual Aide only worked until 8:00 PM. On 5/27/22 at 10:29 AM, the Administrator stated the 1:1 staff for Resident #47 was discontinued due to his behavior with the staff. The Administrator stated Resident #47 did not like to have 1:1 staff next to him, he became more agitated and angry when he had them, and he would yell and hit his 1:1 staff. The Administrator stated when they discontinued the 1:1 staff, Resident #47 started to talk and smiled at the other residents, and his wanting to leave the facility and hitting of the staff decreased. When asked the meaning of 1:1 staff supervision, the Administrator stated the staff should be within an arm's length of the resident. When asked about the Visual Aide, the Administrator stated the resident should be in the line of sight of the staff. When asked why Resident #47 was not provided with a Visual Aide while he was in his room since he had several falls in his room, the Administrator stated one of their interventions was moving Resident #47 to a room across the nurse's station, so the staff could easily see him when they were in the nurse's station. On 5/27/22 at 2:15 PM, the surveyor observed Resident #47 while he was in his room lying on his bed. Resident #47's bed was placed against the wall to the right side of his room as you enter, and he was not in direct view of the staff in the nurse's station. When the staff were in the nurse's station it was not possible for them to see Resident #47 directly, facing the nurse's station was the wall of Resident #47's room. Resident #47 experienced multiple falls which resulted in injury including a fractured finger.