**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement interventions to prevent falls for 1 of 6 (R122) residents reviewed for falls in a sample of 55. This failure resulted in R122 falling and sustaining a left intertrochanteric fracture and subsequent hospitalization. The Findings Include: R122's admission Record documents an admission date of 1/8/25 with diagnoses including unspecified dementia, weakness, and atrial fibrillation. R122's admission Record documents a date of discharge og 1/14/25 to a local acute care hospital. R122's Order Summary Report with a print date of 1/31/25 documents an order for a bed alarm and chair alarm every shift with an order date of 1/8/25. R122's Care Plan has a focus area of being at risk for falls and injuries related to weakness, CVA (cerebral vascular accident), and Atrial Fibrillation. The goal for this focus area is to decrease risk of fall and/or minimize injuries form falls for 90 days. The interventions for the focus area include: assist to toilet prior to laying down with an initiation date of 1/13/25, bed and chair alarms in place with an initiation date of 1/8/25, and mat at bedside when in bed date with an initiation date of 1/13/25. R122's Minimum Data Set (MDS) 5 day assessment dated [DATE] Section J documents that R122 did not have a fall prior to admission. This same section documents R122 had one fall with a minor injury and one fall with a major injury after admission. The same MDS Section C documents a Brief Interview of Mental Status (BIMS) score of 11, indicating that he has moderately impaired cognition. R122's Progress Note dated 1/8/25 documents Resident is a high fall risk. New orders received for bed/chair alarm. Alarms in place at this time and functioning properly. R122's Progress Notes dated 1/11/25 document the following: 6:57 PM: notified POA (Power of Attorney), MD (Medical Doctor), and V2 (Director of Nursing/DON) of situation and R122 was being transferred to the local emergency room via EMS (Emergency Management Services) for evaluation. 7:04 PM: Resident had an unwitnessed fall while eating dinner in his room. Resident had small red mark on head back of head, roommate stated he witnessed him hit his head when he fell. Family called, DON notified, MD notified. Report called into (name of local hospital), and EMS notified. Report given to (name of nurse at local hospital), all information passed along and questions answered. EMS arrived as report to (name of local hospital) was finishing up. Resident was transferred via one assist on to gurney. Paperwork given to EMS, all information passed along and questions answered. Resident was secured and loaded into ambulance. R122's Unwitnessed Fall report dated 1/11/25 documents under the incident description: CNA's (Certified Nurse's Assistant) reported to nurse (self) that resident had fallen on the floor. Fall was not witnessed. Roommate stated resident hit head when he fell. Resident stated he was trying to get up but could not state why he was getting up. Resident was hoyered (used a mechanical lift) from floor 3x assist. Resident denied pain, but had a small red bump on head. Sent to hospital due to resident being on blood thinners for precautionary measures due to inability to judge confusion level due to resident's normal cognitive state. Resident stated he was trying to get up but could not remember why. Resident is unsure if he hit his head or not. This same document lists the root cause of the incident: R122 attempted to stand up out of bed unassisted and fell, hitting his head. Intervention is to assist R122 to toilet before assisting to bed. R122's Progress Note dated 1/13/25 at 5:34 PM it is documents: Resident slid out of his bed onto his bedroom floor at 0630 (6:30 AM) this morning. Resident received a head-to-toe assessment. VS (vital signs) and neuro (neurological checks) started per facility protocol. Resident was assisted back into his wheelchair with 2 staff. Resident denied any pain or discomfort at this time. Resident expressed pain and discomfort at approximately 1100 (11:00 AM) of L (left) hip. (MD) was notified and received orders for L hip and pelvic X-ray. Notified (name of mobile X-ray company) and waiting for call back. Resident c/o (complains of) pain to L should while doing PT (Physical Therapy). (MD) notified again, and received orders to add L shoulder to x-ray. Resident had x-ray completed at 1651 (4:51 PM). Awaiting results. Resident is currently resting in his room. R122's Progress Note dated 1/14/25 at 1:01 AM documents that a call was received with x-ray results indicating a left intertrochanteric fracture. A facility Incident Report dated 1/13/25 at 6:30 AM documents that R122 was oriented x1 and had no injury to report. The investigative statement on this report documents that R122 stated he was ready to get in his wheelchair. R122 stated then that he thought he could do it himself, and before he knew it he had slid onto the floor, sitting on his bottom. This report documents under actions: a fall assessment, skin assessment, a pain assessment were completed and diagnostic services ordered. On 1/30/25 at 2:31 PM, V4 (Certified Nurse Assistant/CNA) stated that she was the staff member who found R122 on the fall that occurred on 1/11/25. V4 stated that she heard a loud noise and ran to his room and found him on the floor. V4 stated that there was no fall mat observed in the room and R122 did not have an alarm sounding. V4 went on to state that he would not ever stay still and did not listen to reminders of not getting up to walk alone. V4 stated that she found him close to the doorway, and thinks he was likely getting up to go to the bathroom. V4 stated that he was refusing to want to use a mechanical lift to get up from the floor and did not want to go to the hospital, but she got help from the staff to assess him properly and R11 did go to the emergency room since they were unsure of whether he hit his head. On 1/30/25 at 2:38PM, V7 (CNA) stated on a telephone interview that she was the staff that found R122 on his fall that occurred on 1/13/25. V7 stated that she has just clocked out for the shift but was waiting to let her car warm up when she came back in the facility and walked by R122's room and saw him on the floor. V7 stated that she got staff to assist her with getting him assessed by the nurse and back in his chair. On 1/30/25 at 2:45PM, R44 who is alert to person, place and time stated that he was R122's roommate and the alarm did not sound for either of the falls. R44 stated that he remembers R122 getting up and being all wobbly and that he couldn't do anything to help him because he is unable to walk. On 1/30/25 at 2:55PM, V2 (Director of Nursing) stated that the CNA's check placement and function at the start of each shift of resident's bed/chair alarms. V2 stated that she is unsure why the alarm did not sound after each of the falls. V2 stated that all the alarms at the current time are working. V2 went on to state that the alarm should have been placed both in the chair and in the bed. On 1/30/25 at 2:55 PM, V1 (Administrator) stated that R122 was here a very short time and had a couple of falls. R122 stated that after the second fall he never returned to the facility as planned due to going on hospice and expiring at the hospital. On 1/20/25 at 3:38 PM, V5 (CNA) and V6 (CNA) stated that they check placement and function every shift for alarms. On 01/31/2025 at 12:44 PM, V17 (Licensed Practical Nurse) stated she was the nurse the night of 01/11/2025. V17 stated that she had just started her shift at 6:00 P.M. V17 stated that it had been reported to her that R122 had been restless for day shift and had gotten up and down all day from his bed and chair. V17 stated it was her understanding that R122's baseline is that he is confused. V17 stated that she was alerted by the CNA that R122 had fallen. R122's emergency room provider notes, dated 1/14/24 at 3:37 AM from the local hospital, documents under chief complaint that R122 is from the nursing home and presents with complaint of left hip pain. Per nursing home report patient had a fall this morning x-ray report this evening showing left hip fracture. History is limited by patient's mental status. It is unclear if he had any associated head or neck injury. Differential diagnosis includes likely hip fracture, less likely head or cervical spine injury. The hospital records document CT (Computed Tomography) results for the head and cervical spine dated 1/14/25 are negative for fractures. An Orthopedic Consult dated 1/14/25 documents a recommendation of surgical repair. A Brief Op (Operative) Note dated 1/15/25 documents that R122 had an Open Reduction Internal Fixation of the left hip/ trochanteric (fixation nail) performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to utilize a gait belt to safely transfer a resident for 1 of 3 residents (R1) reviewed for transfers in the sample of 3. This failure resulted in R1 experiencing a large hematoma causing acute anemia that resulted in a blood transfusion and a six-night hospital stay. This past non-compliance occurred between 10/27/23 and 10/31/23. Findings include: R1's Face Sheet documents Diagnosis to include: Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Aphasia following Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Polyneuropathy, Anxiety Disorder, Contracture Right hand, Acute Pulmonary Edema and Contusion of Right Shoulder. R1's MDS (Minimum data set) dated 08/23/23 section C documents a BIMS (Brief Interview of Mental Status) as 6 indicating cognition level is severely impaired, section GG documents R1's chair/bed to chair transfer as 2 (substantial/maximal assistance) - helper does more than half the effort. Helper lifts, holds trunk or limbs and provides more than half the effort, toilet transfer is documented as 3 (Partial/moderate assistance) - helper does less than half the effort, helper lifts, holds or supports trunk or limbs, but provides less than half the effort. R1's care plan dated 03/11/23 documents: R1 has a self-care deficit as evidenced by: needs (extensive) assistance with ADL's (activities of daily living) related to impaired mobility and cognition, weakness, hemiplegia and CVA (cerebral vascular accident) with an initiated date of 03/01/23 and documents R1 is a 1 assist transfer. R1's PT (Physical Therapy) discharge summary documents: Transfers chair/bed to chair transfer = partial/moderate assistance, dated 10/11/23 by V4 (PT). On 11/06/23 at 10:00 AM, R1 stated, she has a large bruise and it hurts bad. She stated she did not have a fall. R1 indicated it happened during a transfer. R1 started breathing very quickly with short shallow breaths when asked about her bruise. R1 moved the neck of her blouse to show the bruise and then started rubbing it. R1's bruise was dark purple under her right armpit area. The bruise was approximately 10 inches long by approximately 5 inches wide. On 11/08/23 at 2:30 PM, R1 was lying in bed whining while rubbing the bruised area under her arm. When asked if it hurts, she shook her head yes. On 11/08/23 at 9:55 AM, V9 (Family) stated, she saw V3 (Assistant Director of Nursing/ADON) and V7 (Certified Nurse Aide/CNA) transfer R1 inappropriately, the evening of 10/27/23. V9 stated she saw them transfer R1 under her arm. She stated, she heard R1 yell out when they transferred her to her bed. V3 and V7 put her into bed and put her feet up, due to her blood pressure was low. V9 stated, they did not use a gait belt to transfer R1 at that time and she has seen them (staff in general) transfer R1 several times without a gait belt. V9 stated she has had to remind them several times to use a gait belt. V9 stated R1 has a large bruise under her arm along her side to under her breast on her paralyzed side. She also stated R1 also has a knot under her bruise that was a blood clot and they had to give her more blood than usual at the hospital. V9 stated R1 was in the hospital six nights. V9 stated she thought her shoulder looked dislocated but she believes it turned out to be a knot after the X-rays. V9 stated, R1 still has a lot of pain with the injury and rubs it all the time. On 11/08/23 at 3:46 PM, V7 (Certified Nurse Aide/CNA) stated, she and V6 (CNA) took R1 to the bathroom and put her on the toilet on 10/27/23 just after 3:00 PM. Then V6 got busy doing something different so she and V3 (ADON) transferred R1 from the toilet back to her chair, then to her bed. V7 stated they did not use a gait belt. V7 stated V3 was on R1's paralyzed side and held her under her arm and the back of her pants. V7 stated when V3 grabbed her under her arm and transferred her, R1 yelled out in pain. V3 stated she didn't grab her under her armpit but she did. V7 stated, she feels V3 grabbed her harder than she thinks she did. V7 stated, she knows she was on the left side because she was not comfortable with being on her paralyzed side, no one at the facility had given her specific instructions on how to transfer R1 but she knows you are not supposed to mess with the weak side unless you have a gait belt. V7 stated she has never seen anyone use a gait belt with R1 except PT (Physical Therapy). On 11/06/23 at 1:15 PM, V6 (Certified Nurse Aide/CNA) stated on 10/27/23 she did put R1 on the toilet and told V7 (CNA) that she had to go do something else and that R1 was on the toilet. V6 stated, R1 is an easy transfer, she can assist you with the transfer most of the time, she just is paralyzed on her right side due to her stroke. V6 stated she got R1 up for supper but when she was putting R1 to bed after supper she saw the bruise and told V2 (DON). V6 stated a standard transfer would be with a gait belt. On 11/08/23 at 12:15 PM, V3 (Assistant Director of Nursing/ADON) stated, she was working on the floor that day and V7 (CNA) told her that R1 was on the toilet. V7 told her R1 was not acting right and she was clammy. V3 stated she went down to assist V7 with getting R1 off the toilet. They got her off the toilet and she called V10 (Medical Doctor). V3 stated, R1 was not completely unresponsive. R1 had a large BM (bowel movement) on the toilet and thought that could be why she was somewhat unresponsive. They got R1 into bed and raised her feet. R1's blood pressure came up. V3 stated she wanted a pain pill prior to the toilet but they did not give her a pain pill due to her blood pressure being low, around 3:45 PM R1's blood pressure came back up. When they got R1 off the toilet they transferred her with a two-person transfer. V7 was on the right side, R1's weak side. During the transfer from her wheelchair to her bed she was on her weak side and they did not have a gait belt. V3 stated, she used her pants but did not pull on her arm. V3 stated she did not yell out or anything because her blood pressure was low. She doesn't remember how V7 transferred her. On 11/08/23 at 11:30 AM, V5 (Physical Therapy Manager) stated, the standard transfer with residents is with a gait belt. In her opinion R1 should be transferred with a gait belt due to her right-side paralysis, it would just be safer that way. On 11/06/23 at 10:45 AM, V4 (Physical Therapy) stated, a standard transfer is with a gait belt. V4 stated, R1 is an easy transfer if you tell her what you are going to do, you just put the gait belt around her waist area because you don't want it to get too high with her paralysis, and lift, she will assist, she has strength, her balance is just not great and she leans due to the right-side paralysis. On 11/08/23 at 1:45 PM, V2 (Director of Nursing/DON) stated on the evening of 10/27/23 R1 told her her arm was broke and was flopping it up and down. V2 stated, she told her, your arm hasn't worked for years. R1 then started pointing to her shoulder area. V2 asked R1 if her shoulder injury happened today and R1 shook her head yes, when she asked if it was around the time they took her to the bathroom and she shook her head yes. V2 then stated R1 was utilizing hand motions to describe V3 (ADON) and pointed to the area with the bruise. V2 stated V7 (CNA) stated R1 had an episode on the toilet, and that she (V7) and V3 transferred R1. V3 stated, R1 was kind of limp and was not as responsive as usual. V2 stated, V9 (family) was at the facility. V2 stated V9 (family) told her V3 (ADON) transferred R1 and R1 yelled out in pain. V2 stated, if it was her with R1 she would have tried to get a hold of her pants to assist her. V2 stated typically R1 can pretty much stand on her own, but she does have problems with her balance and leaning to the right. V2 stated, the safest way to transfer R1 would be with a gait belt but it was a more urgent situation. V10's MD (Medical Doctor) note dated 11/02/23 at 13:39 (1:39 PM) documents: R1 was recently hospitalized for the following diagnoses: UTI (Urinary tract infection) chest wall hematoma. R1 was recently hospitalized for weakness and diagnosed with UTI along with acute shoulder pain with workup showing no fractures of shoulder or ribs. CT showed a large hematoma of the axilla and anterior chest most likely due to pectoralis muscle tear. Injury uncertain. R1 is still having pain in the area of swelling and nurses note it is hard to gauge her pain because she always has pain. She (R1) points to the right chest as area of pain and withdrawals prior to me touching her. R1's hospital notes document an admission date of 10/27/23 and a discharge date of 11/02/23 with an admitting diagnosis of Anemia. R1's hospital History and Physical dated 10/28/23 documents: Chief Complaint: Right arm injury after lift assistant nursing home. Bruising in the right armpit and discomfort. R1's weight was documented as 135 pounds on 10/28/23. R1's Hospital preliminary report dated 10/27/23 documents: Clinical indication: Per EMS (Emergency Medical Service) pt (patient) (R1) had an episode in which the nursing home is unsure of how but right arm became bruised. Pt (R1) has bruise under right arm. HX (history) of stroke and is normally contracted on this side. V9 (family) at bedside and stated the nursing home pulls on this arm and doesn't use a gait belt and she thinks it is an injury from being pulled on. Limited movement with contracted right arm. R1's Hospital's Preliminary Report section - X-ray shoulder 3 views right shoulder 10/27/23 at 8:10 PM documents: there is a slight superior displacement of the distal right clavicle with respect to the adjacent acromion. The findings are consistent with mild AC joint separation, age indeterminate. R1's hospital notes dated 10/30/23 at 7:29 PM document: Imaging - Results - Other CT (computed tomography) chest wo (without) contrast dated 10/29/23. Indication: Hemorrhage, Unspecified injury of right shoulder and upper arm, sequela, chest pain, and localized swelling, mass and lump, trunk. CT examination of the chest: Indication: [AGE] year-old female nursing home resident, post cerebrovascular accident and right - sided weakness, a fascia, with bruising over the right upper extremity, anemia. Findings: There is a large right subpectoral hematoma, measuring at least 11.9 x 6.1 x 11.8 cm extending caudally from the right anterior shoulder along the right lateral chest wall and axilla. There are edematous changes in adjacent extrathoracic fat, extending into the right upper extremity , not included on these images. Impression: large right subpectoral hematoma with edematous changes extending into the adjacent extrathoracic fat. R1's hospital notes dated 10/29/23 at 4:30 AM document: progress notes lab called with Hgb (hemoglobin) drop 10/27 - 8.3 and now 10/28 - 5.7. Upon looking at admission photo the area around R1's pectoral on the right side is very swollen and firm. R1's hospital Discharge summary dated [DATE] at 1:40 PM documents: Discharge Diagnoses: 1) Acute anemia 2/2 (secondary to) large subpectoral hematoma d/t (due to) shoulder injury prior to admission, 2) Acute Cystitis, 3) HTN (Hypertension), 4) Troponin elevation 2/2 demand ischemia. Hospital Course: Patient (R1) presented with acute blood loss anemia, d/t (due to) subpectoral hematoma. The patient's Eliquis was held and she was given blood transfusion as needed to keep Hgb (hemoglobin) >8, d/t (due to) demand ischemia 2/2 anemia. The patient's hgb (hemoglobin) stabilized after 2 days of holding Eliquis. She was discharged once hgb (hemoglobin) stable. She will hold Eliquis on discharge for 1 week. The facility document titled, Witness Statement dated 10/27/23 documents a witness statement by R1. Statement documents: My arm is broke. Hurts. They, R1 demonstrated placing left hand underneath right axillae while stating hurt, signed per V2 (DON). The facility document titled, Witness Statement dated 10/27/23 documents a witness statement by V7 (Certified Nurse Aide/CNA). It documents: 10/30/23 at 1:56 PM, I V7 took R1 to the bathroom. R1 couldn't stand so I asked V6 (CNA) to help. V6 ended up transferring R1 by herself. I stood in the bathroom until she was done. When she finished I got V3 (ADON) to help me. After getting R1 in her chair she went unresponsive. V3 and I laid her down and put her feet up. R1 started to get better. R1 did scream out during the transfer but I didn't see a bruise until V6 showed me. Signed by V1 (Administrator) with the witness line signed with Via Phone signed and dated 10/30/23. The facility document titled, Witness Statement dated 10/27/23 documents a witness statement by V6 (Certified Nurse Aide/CNA). It documents: 10/30/23 I was asked by V7 (CNA) to transfer R1 to the toilet. R1 helped with the transfer using the left arm and I held on to her pants to secure her and transferred her to the toilet. Signed by V6 dated 10/30/23. The facility document titled, Witness Statement dated 10/27/23 documents a witness statement by V3 (Associate Director of Nursing). Documents: Alerted by CNA (V7) that R1 was clammy and didn't seem right. This nurse investigated to find R1 to be clammy and B/P (blood pressure) low. This nurse (V3) assisted CNA (V7) with transfer of R1 to chair. Alerted the MD. Then assisted the CNA (V7) with changing the resident out of the damp shirt. CNA (V7) then buttoned up shirt and we transferred R1 into bed. Blood pressure being so low had caused this nurse (V3) to hold pain pill R1 had requested and MD notified of this as well. R1 BP came up after this nurse (V3) reassessed R1. This nurse (V3) did not notice a bruise when changing or transferring R1, signed by V3 and dated 10/30/23. The facility document dated 10/27/23 titled, Bruise/Skin Resident: R1: Incident Description: V6 CNA summoned this nurse (V2 DON) to room. Upon entering R1 behind the privacy curtain sitting in wheelchair with blouse off and gown draped across the breast area to cover for privacy. Bruise noted to Right upper anterior arm and right chest to upper rib cage that is in the axilla area. R1 c/o (complaints of) pain to area. Area to chest in this area was also swollen and hard to touch. R1 is contracted to right arm and unable to use. R1 reports bruising is from staff who place their arm underneath her right axillae when transferring. R1 is not a lift assist and able to bear weight. R1 leans to one side so assist is needed by guiding R1 or assisting R1 with balance. The section titled, Resident Description documents: my arm broke. Hurts. R1 demonstrated by placing her good hand Left hand under the right armpit stating like this. R1's Order Summary Report (Physician Order Sheet) documents: Monitor hematoma to R (right) shoulder until resolved every shift for monitoring report any worsening sx (symptoms) to MD V10 (Medical Doctor) dated 11/06/23. The facility document with the subject documented as Transfer Policy dated 05/19/22 documents: Policy: To promote safe transfer for the residents, as well as the staff. Gait belts, Hoyer lifts and/or sit to stand lifts will be used, unless otherwise specified. Responsibility: It is the responsibility of all nursing staff to ensure the use of safe transfer techniques when transferring a resident. Prior to the survey date, the facility took the following actions to correct the deficient practice: A. An Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting was held with nursing and CNA staff which included the following: Identified Opportunity for Improvement/Deficient Practice: Proper transfer and reporting bruises. 1) Immediate Corrective Action for those affected by the deficient practice: Transfer assessments completed on all residents. Staff education on proper transfer of residents. Care plans reviewed for all residents on transfer status. Staff education on abuse policy with focus on reporting bruising of unknown origin. Skin assessment completed on all residents. 2) Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents could be affected by the deficient practice. 3) Measures put in to place/systematic changes to ensure the deficient practice does not recur: All licensed nursing staff were educated on transfers. All staff educated on the abuse policy. 4) Plan to monitor performance to ensure solutions are sustained: DON/designee will review twice weekly that skin assessments are completed and then randomly thereafter. All results will be reviewed at the monthly QA meeting and will make revisions as needed to ensure compliance. DON and/or designee will observe 3 residents 3 times weekly and then twice weekly times 2 weeks and then randomly thereafter to audit transfers. All audits will be reviewed in the monthly QA meeting and will make revisions as needed to ensure continued compliance. B. In-service sign in sheets were provided documenting Nursing and CNA staff were trained on the gait belt policy by V1 and V2 on 10/30/23 and 10/31/23. In-service sign in sheets were provided documenting Nursing staff were trained on abuse reporting and abuse of bruises by V1 and V2 on 10/30/23 and 10/31/23. In-service sign in sheets were provided documenting Nursing and CNA staff were trained on the proper transfer of residents with gait belts by V1 and V5 on 10/30/23.