**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and evaluate an individualize plan to include supervision and monitoring to reduce the risk for falls for a resident with a dementia and poor safety awareness. This affected one of three (R1) residents reviewed for safety and fall prevention. This failure resulted in R1 having an unwitnessed fall being sent to the local hospital and treated for left femur fracture. Findings include: R1 face sheet shows diagnosis of vascular dementia, fracture of femur neck, muscle weakness, difficulty walking, abnormalities of gait and mobility, Parkinson disease, and history of falling. R1 fall risk evaluation assessment, dated 2/17/24, denotes a score of 8, risk factors are decreased mobility, confused, one to two falls in past three months, R1 takes medication that have a diuretics effect or increase GI (gastrointestinal) mobility, drugs that affects the thought process, drugs that create a hypotensive effect, R1 is regularly incontinent, needs assist to get to the toilet. R1's Minimum Data Set/MDS, dated [DATE] section C, shows BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact), when asked the day of week, R1 coded for 0 (incorrect answer). Section GG for functional abilities and goals denotes on admission R1 walked 10 feet with supervision or touching assistance, toilet transfer denotes 04 (supervision or touching assistance), Section J denotes yes for falls within the last month prior to admission and yes for fractures related to fall in the 6 months prior to admission, yes for falls since admission, 1 is coded for major injury. Facility final incident report to the department denotes R1's name, R1's date of birth , date of admission, R1's diagnoses- included but limited to chronic obstructive pulmonary disease, hemiplegia and hemiparesis and affecting right dominant side, vascular dementia, parkinson disease. R1 is a [AGE] year-old male, alert and orient x2, forgetful, able to make needs known to staff. R1 is in the facility for short term rehab status post fall at home. Description of occurrence on February 22nd, 2024 staff noted (R1) lying on the floor on his right-side. (R1) was transferred to hospital for evaluation and admitted for a diagnosis of overriding fracture of the femoral shaft. MD (medical doctor) and family made aware investigation initiated. Investigation completed interviews and record reviews were conducted (R1) is [AGE] year-old male admitted to the facility on [DATE] for physical therapy and occupational therapy for diagnosis noted above. (R1) is ambulatory using a walker with a slow steady gait. On February 22, 2024, around breakfast time (R1) was eating breakfast in his bed as his usual routine with call light within reach. (R1) voice nothing else was needed before staff left the room and was reminded to use the call light for staff assistance. The housekeeper went into the residence room to complete daily cleaning and observed resident lying on the floor. Nurse on duty was immediately notified. Per resident he needed to go to the bathroom but did not call for staff assistance. When asked why he didn't call for assistance resident didn't answer and just shrugged his shoulders. Per staff interviews resident routinely called for staff assistance when needed by activation of call light. Residents score 14 on the BIMS (Brief Interview Mental Status) and had no prior incidents or accidents in the facility. On 2/17/2024, 2/18/2024 and 2/21/2024, resident was educated on safety precautions and to not get up without staff assistance and to use call light. Upon resident return care plan will be reviewed and updated accordingly. R1 emergency room records, dated 2/22/2,4 shows diagnosis of fracture of left femur. Chief complaint, paperwork lists vascular dementia as a diagnosis, but he is able to give history appropriately. States he was walking with his walker, and the wheels of the walker locked up, and he fell forward/ tripped. Has pain and deformity of the L (left) hip, cannot stand or move the leg too well. No head or neck injury. Tore the skin of the L (left) arm, but has normal function, normal ROM (range of motion). No weakness. No new numbness. No neck pains. Physical exam left leg shortened and internally rotated at the hip. New left femur shaft fracture, discussed with hospitalist, will need further surgery. R1 root cause analysis for fall on 2/22/2024 denotes, on February 22, 2024, (R1) was going to the bathroom without calling for assistance. Based on the investigation the factor that contributed to his fall was right sided weakness. He stated he fell on his left side but was observed by staff on the floor on his right side. R1 progress notes, dated 2/22/24 at 8:20am, denotes, A staff member called for author's attention this morning because the staff member was passing patient's room when they saw that the patient was on the floor. Author immediately went to patient's room; patient's call light was not on. Author assessed the patient, and he is noted to be on his right side in front of the doorway. Author asked patient to describe what happen, but patient unable to give a clear story as the patient is forgetful at baseline. Patient is alert and responsive. Patient states he was walking on his own with the walker to use the bathroom when he lost his balance, patient states he did not call for any help or use his call light. Patient is currently on his right side, but patient able to recall that he fell onto his left side. Noted 2 skin tears with bleeding to the left arm. Redness is noted on patient's head, but patient states he did not hit his head. Patient neuro is intact, able to answer questions, upper extremities are strong. Patient has pain to his left leg and is unable to straighten his leg on his own at this time. Nursing staff is present with the patient and did not move patient, placed pillow behind patient's head to make him comfortable. Called 911 due to patient being on blood thinners and pain to left surgical leg for evaluation. Doctor made aware with orders to send out to (city) ER (Emergency Room) for evaluation. Left arm skin tears cleansed with NSS( normal saline) and covered with dressing. Patient was transferred to (city) ER with 911. Patient's wife (name) made aware and is amenable. Doctor (orthopedic surgeon) office called, and PA (physician assistant) made aware and will alert Doctor that patient is at the hospital. Facility employee interviews denotes V6 (Unit Manger) coming from front walking to a nursing station nurse on duty asked me to help ( room number) when I walked in patient was noted laying on the floor on his right side with his left arm bleeding his walker was next to him call light was not on. (V4) and (V7) asked him what happened patient stated he was trying to go to bathroom by himself. Paramedics arrived and assisted him on the stretcher two of the paramedics lifted him by his arms and did not support his legs as they were transferring him patient was then taken to hospital. On 5/4/24 at 9:11am, V1 (R1's family) said R1 was admitted to the facility after a fall at home where he sustained a left hip fracture requiring surgery. V1 said R1 fell at home while going to the bathroom. V1 said she received a call for the facility on 2/22/24, and she was informed R1 was observed on the floor, and that he will be sent to the hospital for evaluation. V1 said R1 was diagnosed with a left femur fracture and required surgery. V1 said R1 told her he fell while going to the bathroom. V1 said she doesn't remember if R1 said he put his call light on prior to taking himself to the bathroom. V1 said R1 does need help going to the bathroom. V1 said she informed the facility R1 fell at home, and the facility was aware that R1 was a fall risk. On 5/4/24 at 11:06am, V2 (Nurse) said he was notified R1 was on the floor, he went to assess R1, R1 observed on his right side but R1 was able to communicate that he fell on his left side. V1 said R1 was not moved, and 911 was summoned to escort R1 to the hospital for evaluation. V1 said the physician and surgeon were made aware and the physician gave orders for R1. V1 said he doesn't recall where R1's walker was at that time. On 5/4/24 at 2:31pm, V3 (Director of Nursing) said R1 had an unwitnessed fall sustaining a fracture. V3 said her investigation concluded R1 got up to go to the bathroom without assistance from staff. V3 said R1 has right side weakness and he fell. V3 said she doesn't know if R1 had on shoes, she doesn't know if R1 had on skid free socks, she doesn't know if R1 tripped over something, she doesn't know if R1's urinal was available to him, she doesn't know if it was full and not able to be used. V3 said R1 was usually complaint with using the call light for assistance to the bathroom. V3 said she doesn't know what was different on that day. V3 said the facility keeps all the residents roller walkers at the bedside. V3 said it is better the resident be able to reach the walker than fall trying to reach the walker. V3 said R1 call light was within reach, attached to the side half rail. V3 said she is aware R1 had a fall at home, but she doesn't know the situation surrounding the fall. V3 said R1 has dementia. V3 said she would have to find out if R1 has poor safety awareness. V3 said she conducted the fall investigation for R1. V3 was asked, How is the facility reducing the risk for falls when the roller walker is left at the bedside for the resident to reach and use at liberty? V3 did not respond. On 5/4/24 at 2:40pm, V4 (Rehab Director) said he did not complete R1's physical therapy evaluation, but was agreeable to review the evaluation. V4 said, (R1) was referred to therapy, (R1) was evaluated, and (R1) ambulates with minimal assist meaning support of 25% is needed. Support can be provided with use of gait belt, and someone is physically there. (R1) needed support because (R1) was a fall risk, he had forward lean, he wobbled and had a weak pelvis. V3 said R1 should not be ambulating by himself. V3 said R1 had poor safety awareness, needed verbal cueing during walking. with ambulation. V4 said, The walker should not be left at the bed side because you don't want to promote the resident to use the walker. It can stay in the room but away from the resident. Facility policy titled care plans, dated 8/2020, denotes management of falls the facility will assess hazards and risk develop a plan of care to address hazards and risk, implement appropriate resident interventions, and revise the resident plan of care in order to minimize the risk for fall incidents and or injuries to the resident. Develop a plan of care to include goals and interventions which addresses residence risk factors. Risk factors may include but are not limited to the following contributing diagnosis disorders disease processes active infections other comorbidities history of fall incidents incontinence medications assistance required with ADL's gate transfer balance issue behaviors and or cognitive status. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards.