Based on observation, interview and record review, the facility failed to ensure a consent with the identified medical reason for the use of a restraint was completed at the initiation of the restraint, to establish a time frame for continuing the use of the restraint and to establish how the restraint would be decreased and discontinued for 1 of 1 resident reviewed for restraints. (Resident 70) This deficient practice resulted in Resident C having three (3) falls with major injuries while using the restraint, had 3 emergency room evaluations and was diagnosed with nasal fractures, lacerations to her face which required sutures, and a laceration to her upper lip which required sutures. Finding includes: During an observation, on 6/13/24 at 11:48 a.m., the resident was observed to be walking in a merry walker (a walker made of plastic PVC type tubing which enclosed the resident in the tubing frame and had a seat at the back of the frame). During an interview, on 6/17/24 at 11:09 a.m., the Director of Nursing (DON) indicated the resident was not able to get out of the Merry [NAME] on her own and it was considered a restraint. The clinical record for Resident 70 was reviewed on 6/14/24 at 9:59 a.m. The diagnoses included, but were not limited to, dementia with agitation, repeated falls, restlessness and agitation, anxiety, a psychotic disorder with delusions due to a known physiological condition, dementia with a behavioral disturbance, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 3/12/24, indicated the resident utilized a physical restraint daily and the resident was severely impaired cognitively. A care plan, which was initiated on 10/24/22, indicated the resident was at risk for falls related to confusion, decreased mobility, and decreased safety awareness secondary to dementia. The goal was for the resident to be free of falls through the next review date. The interventions included, but were not limited to, assessing for injury when the resident sits on the floor, engaging in activities which improve strength, balance and posture, and keep areas free of obstructions to reduce the risk of falls or injury. A care plan, initiated on 11/2/22 and last revised on 6/19/23, indicated the resident was an elopement risk and would wander throughout the facility. The resident had a history of attempts to leave the facility unattended and had impaired safety awareness. The resident wandered aimlessly and significantly intruded on the privacy of others. The interventions included, but were not limited to, assessing for fall risk and distracting from wandering. A physician's order, dated 7/10/23, indicated for the resident to use a merry walker every 2 hours for gait release and to release the resident from the merry walker every 2 hours for toileting, hygiene, rest, food, and fluids. The resident was to be out of the merry walker at mealtimes and to attempt for the resident to sit in the dining room chair. There were no diagnoses or clinical indication for use documented on the physician's order. A progress note, dated 7/10/23, indicated the resident's daughter was called to discuss the use of a merry walker for the resident's mobility. The daughter was instructed that the resident would be released every 2 hours from the walker for 10 minutes. The safety of the resident while in the merry walker was discussed and the daughter agreed to the use of the Merry Walker. The progress note did not indicate the clinical rational for the use of the device, a plan to ensure the device was the least restrictive alternative for the least amount of time, when the ongoing need for the device would be re-evaluated and did not include the risks of using the device. There was no written consent signed by the daughter when the device was initiated. A progress note, dated 7/13/23 at 8:15 p.m., indicated the resident had a witnessed fall while using the device. The CNA had observed the resident's merry walker tipping over a chair as the resident ran into it. The resident was lying face down in the merry walker. The resident had moderate bleeding from her nasal cavity. An Emergency Department discharge note, dated 7/13/23, indicated the resident had a fall and received a non-displaced fracture of the nasal bone, a facial hematoma, and a periorbital hematoma. A progress note, dated 7/13/23 at 10:30 p.m., indicated the resident returned to the facility from the Emergency Department and had bruising and swelling to her left eye lid, rug burns circling her left eye, and her nose was swollen. A facility fall note, dated 7/13/23, indicated the resident had a nasal bone fracture which occurred while in the merry walker. The walker tipped over a chair as the resident ran into the chair. The CNA was unable to reach the resident in time. The resident had a moderate sized hematoma above the left orbital cavity. The resident went to the Emergency Department and was diagnosed with a nasal bone fracture. A progress note, dated 7/14/23 at 10:06 a.m., indicated the fall was discussed with the resident's daughter. The anti-tippers for the merry walker were discussed. The progress note did not indicate the clinical rational for the use of the device, a plan to ensure the device was the least restrictive alternative for the least amount of time, when the ongoing need for the device would be re-evaluated and did not include the risks of using the device. There was no written consent signed by the daughter when the device was initiated. There was no documentation in the medical record to show the facility reassessed the resident for the appropriateness of the merry walker after her fall with injuries. A progress note, dated 7/26/23 at 9:00 a.m., indicated the staff talked to the resident's daughter about the safety and potential risks of the merry walker. The daughter was concerned a wheel would get stuck and tip the merry walker over. The staff reinforced to the daughter the anti-tippers were on each side and not the front or back of the merry walker. The resident was still a fall risk and still had the potential to tip the walker over. The resident would have staff supervision while in the merry walker and would be out of the merry walker every 2 hours at a minimum. A facility fall note, dated 1/23/24 at 11:10 a.m., indicated the resident had a fall at 10:40 a.m. The resident was face down on the floor in the merry walker. The CNA reported the resident's merry walker got caught on the corner of the wall by the nurse's station. The merry walker was laying on its side and the resident was laying on her right side. The resident was sent to the Emergency Department and returned at 3:40 p.m. The resident had three sutures on the bridge of her nose and two sutures to the upper lip. The daughter indicated she understood the risks of the merry walker. A hospital Emergency Department note, dated 1/23/24, indicated the resident presented to the Emergency Department after a fall. The resident was in her merry walker, and it flipped over causing her to fall face forward on the ground. The resident's injuries included mildly displaced bilateral nasal bone fractures, a small left frontal scalp contusion, a 0.5-centimeter (cm) laceration to the superior lip closed with two sutures and a 1.5 cm laceration on the nose closed with 3 sutures. There was no documentation in the medical record to show the facility reassessed the resident for the appropriateness of the merry walker after her second fall with injuries. A restraint informed consent, dated 3/4/24, was signed by the physician and the daughter. There was no written informed consent for the use of the merry walker located in the resident's medical record prior to the one dated 3/4/24. A facility fall note, dated 4/10/24 at 5:05 p.m., indicated the CNA reported the resident yelled for help and when she went to the resident, the resident was face down on the carpet, pushing herself up and rolling to her right side. There was blood coming from the resident's nose and mouth. The resident's merry walker was laying on its side by the resident. The resident had a laceration on her upper lip, facial abrasions to her forehead, chin and nose. The resident was sent to the Emergency Department and returned at 7:40 p.m., with 12 dissolvable sutures to her upper lip laceration. She also had an abrasion above her eyebrow, an abrasion to the bridge of her nose, and swelling to her nose. This was the third documented fall with injury to the resident while the merry walker was in use. A progress note, dated 4/11/24 at 10:46 a.m., indicated the daughter agreed the resident was only to be in the merry walker if the staff were able to be with the resident 1:1 or if the family was present. A physician's order, dated 4/11/24, indicated to use the merry walker with 1:1 or when family was present. Must release every 2 hours and as needed if still using 1:1 or with family for toileting, food, fluids and rest. The intervention of staff to be with the resident 1:1 did not occur until the third fall with injuries. During an interview, on 6/13/24 at 11:49 a.m., RN 3 indicated the resident was placed in the merry walker twice a shift. The Certified Nursing Assistants (CNAs) or the activity staff could help with the walker. The resident used the merry walker until she was tired and then the staff would remove the resident from the merry walker. During an interview, on 6/14/24 at 3:06 p.m., the Director of Nursing (DON) indicated the original consent for the merry walker was the verbal discussion with the daughter. The DON had verbal conversations with the daughter about the risks of the merry walker use. During an interview, on 6/17/24 at 10:09 a.m., the Assistant Executive Director (AED) indicated the physical therapist was in the quality assurance meetings when the merry walker was discussed but there were no assessments from the physical therapist (PT) for the use of the merry walker. During an interview, on 6/17/24 at 11:09 a.m., the Director of Nursing (DON) indicated the resident was not able to get out of the Merry [NAME] on her own and it was considered a restraint. There was no plan to stop using the merry walker which was considered a restraint. The first time the resident fell on 7/13/24 while using the merry walker, the anti-tippers were added to the walker. The resident was not supervised 1:1 until after the fall, on 4/10/24, and the intervention was put in place. During an interview, on 6/18/24 at 9:06 a.m., the daughter indicated she was not aware of the product the merry walker until the staff told her about it. Her mom would walk a few steps and then decide to sit down. At first, she was glad for the independence the merry walker gave her mom. After the first fall, anti-tippers were put on the walker, but they didn't work to keep her from falling. After the fall in April when her mom's tooth went through her mouth and she needed sutures, the daughter decided this was not working and her mom could only use the walker if someone was right with her to keep her from falling. Her mom did not understand she could not get into tight spaces, and this caused the falls. During an interview, on 6/18/24 at 2:33 p.m., the AED indicated the merry walker was a restraint and the facility thought this was the least restrictive device to be used to enhance the resident's life. The resident had zero safety awareness and was able to stand up and ambulate and was able to sit down in the seat of the merry walker. Without the merry walker, the resident would decline in her ability. There was no documentation in the electronic health record (EHR) to show this was the least restrictive device and there was no plan in the EHR to show a decrease or discontinuation of the restraint. The verbal plan would be to stop the restraint when the resident could no longer walk or bear weight since there would be a time in her disease process when she could not walk. During an interview, on 6/18/24 at 3:57 p.m., the AED indicated there was no written consent for the merry walker prior to 3/4/24. She was not able to provide documentation to show how often the use of the merry walker as a restraint was reviewed. A current policy, titled Restraints Use, dated as last revised on 4/2/2009 and received from the AED on 6/17/24 at 11:00 a.m., indicated .To ensure residents are provided a safe environment and that the use of restraints is carefully monitored to protect resident rights, personal comfort, and safety, assuring the least restrictive means are used .To use protective devices only when all other means of keeping a resident safe have been exhausted. The use of protective devices must be monitored in such a way as to minimize the impact on resident quality of life and functional status .To use protective devices or confinements only to treat medical symptoms in accordance with a physician's order and informed consent from the resident or responsible party .Initial assessment for the use of protective devices shall be followed by a monthly assessment for the first three [3] months and then quarterly assessments thereafter .Definition .Physical protective devices or restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot easily remove and that restricts freedom of movement or normal access to one's body .least restrictive measures .together with appropriate exercises and restorative nursing programs, shall be considered prior to the use of restraints .Care plan team participation in evaluation of restraint use and progress related to interventions and goals will be documented in the individual disciplinary progress notes .The interdisciplinary team, including specialized therapy staff, is responsible to participate in care planning interventions which may reduce or eliminate restraint use .Each physician's order for restraint shall be complete and specifically define the type, reason, duration, circumstances of restraint .If after a trial of alternative measures has been attempted and a determination that a physical restraint would enable and promote greater functional independence, or is necessary to provide lifesaving treatments, then the use of the restraint must first be explained to the resident, family member, or legal representative and written consent for use obtained .The care plan will reflect specific circumstances and medical symptoms for restraint use, time frames, and identify activities to occur during release periods .a licensed nurse is responsible for documenting, at least quarterly, in the nursed notes or on a physical restraint assessment the resident's response to the use of the restraint and goals identified in the plan of care and well as any attempt to reduce the use of restraints 3.1-26(a) 3.1-26(n) 3.1-26(o)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect a resident from injury while walking with the resident from the bathroom to the resident's recliner without using a gait belt for 1 of 3 residents reviewed for accidents. (Resident B) Resident B fell and hit their head resulting in a laceration which was treated with staples and an interval development of a right frontoparietal convexity subdural hematoma (a blood vessel in the space between the skull and the brain was damaged). Finding includes: During an observation, on 9/28/23 at 9:41 a.m., Resident B was observed sitting in a recliner with her feet elevated. She appeared clean and dry and was wearing nonskid socks. There was a walker with a gait belt lying across the top and the room was free of obstacles. Resident B did not verbalize responses to questions, instead she nodded for yes and shook her head for no. She denied pain at the time. An Incident Report to the Indiana State Department of Health, dated 9/21/23, indicated the resident was being assisted by staff from the bathroom after bedtime care. The resident fell, hitting their head on the doorway. The type of injury sustained was a laceration to the head and an interval development of a right frontoparietal convexity subdural hematoma (a blood vessel in the space between the skull and the brain, the subdural space, was damaged). The record for Resident B was reviewed on 9/28/23 at 2:30 p.m. Diagnoses included, but were not limited to, traumatic subdural hemorrhage without loss of consciousness, metabolic encephalopathy, and Parkinson's disease. A care plan, initiated on 9/17/23 and in effect on the day of the resident's fall, indicated .Transfer: extensive assistance with 1-2 staff, GB [gait belt], and walker to w/c [wheelchair] A nursing note, dated 9/22/23 at 8:05 a.m., indicated RN 4 was called to the resident's room to find, upon entering, the resident lying on her back in front of the entry door. She had hit her head on the door during the fall and sustained a laceration to the back of her head. At 7:40 p.m., the family and management staff were notified. A nursing note, dated 9/22/23 at 5:16 a.m., indicated the resident was admitted to the hospital with a diagnosis of a traumatic subdural hematoma. Resident B also had a laceration on her scalp and four (4) staples were placed. A Computed Tomography report (CT report), dated 9/21/23, indicated the resident had an internal development of a right frontoparietal convexity subdural hematoma, a mild increase in the size of the left subdural hematoma, and a scalp laceration with staples. A facility document, titled INVESTIGATION, dated 9/22/23, indicated .CNA was assisting resident from BR [bathroom] to recliner after hs [hour of sleep/bedtime] care. Per CNA resident got feet tripped up and fell backwards while ambulating hitting her head on door frame. Resident wearing non-skid footwear, using walker, staff s [without] gait belt During an interview, on 9/28/23 at 9:44 a.m., CNA 1 indicated the information related to how a resident transferred could be found in the computer system. She went into the computer system every morning for resident information. During an interview, on 9/28/23 at 9:45 a.m., CNA 2 indicated the information for transfers was in the [NAME] found in the computer system. She checked it every morning. During an interview, on 9/28/23 at 9:57 a.m., the Director of Nursing indicted staff were educated on gait belt use in July. They were not re-educated after Resident B's fall in September. During an interview, on 9/28/23 at 10:18 a.m., the Assistant Executive Director indicated audits for gait belt use were being completed. The staff member who did the audits was off on Friday, 9/22/23, and this was why the audit was not completed after the incident on 9/21/23. When the employee returned on Monday, 9/25/23, she was busy auditing other things. During an interview, on 9/28/23 at 11:30 a.m., the Assistant Executive Director indicated the policy, of the facility, was to use a gait belt. During a telephone interview, on 9/28/23 at 1:48 p.m., CNA 3 indicated on the day of the fall, she and RN 4 transferred the resident to the bathroom and then the nurse left the room. After assisting Resident B with toileting, they (CNA 3 and Resident B) were walking from the bathroom and Resident B's feet slipped out from under her. CNA 3 was not using a gait belt. She indicated my hand was on her back. She did not think about using a gait belt; she had been educated on the facility policy to use a gait belt. She indicated when the nurse came in to initially assist her with getting the resident up, they did not use a gait belt. She did have access to the [NAME] and information on how the resident was to transfer, and checked the information when she charted at about 7-8 p.m. She did not look at the [NAME] for transfer information. During an interview, on 9/28/23 at 2:10 p.m., RN 4 indicated she was called to Resident B's room around 7:30 p.m. The resident was observed lying on the floor with her legs extended. Resident B had hit her head. RN 4 did an assessment to include neurochecks and vital signs. The resident did sustain a laceration to the back of her head measuring 1.2 centimeters (cm). She had the CNA get an ice pack. She assessed the resident to make sure Resident B had no hip, neck, or back pain, and then they transferred her to her recliner. RN 4 indicated she did assist the CNA to get the resident up before and they did use a gait belt as well as when they got her off the floor and to her recliner. She did a teachable moment with the CNA after the incident and indicated the Director of Nursing educated/reminded the staff on the Ground Floor Unit, the next day, to use gaits belts. Information related to how to transfer the resident was in the care profile and the physician's orders. During an interview, on 9/28/23 at 2:22 p.m., the Director of Nursing indicated care plan and mobility/transfer information was in the [NAME] in the computer system. The CNAs had access to the information. All CNAs had access to the system, and they should always get their orders from that area. When the orders were updated by the nurse, they populate to the [NAME] when the care plan was updated. They should not be using a paper sheet. They could use the paper sheet throughout their shift, but if someone was new to the unit or if questioning mobility orders, they should check the [NAME]. CNAs did give report and information was passed on from shift to shift. A facility document, titled 7/24/2023, was received from the Assistant Executive Director on 9/28/23 at 9:00 a.m., indicated Please review the information in your mailboxes regarding the gait belt policy and mechanical lift use. It is imperative not only for your own safety, but also for the safety of the residents we care for that we follow the appropriate transfer orders .Please sign and return the sheet in your mailbox acknowledging that you received the information The document was dated 7/24/23 and signed by CNA 3. At the bottom, it indicated .9-22-23 Re-educated on gait belt policy . and was signed by the Director of Nursing and CNA 3. A facility document, titled Wesley Manor Weekly Audit 2020, was received from the Assistant Executive Director on 9/28/23 at 10:22 a.m. The gait belt audits were dated 9/2/23, 9/9/23 and 9/15/23. There were no further audits completed at the time the documents were provided. A current policy, titled Nursing Services Policy, dated as last reviewed on 12/2/19 and received from the Assistant Executive Director on 9/28/23 at 9:00 a.m., indicated .Nursing care is provided to meet resident needs by .Receiving appropriate nursing interventions .Residents will be protected from accidental injury using the proper equipment in a safe manner. Assistance is provided for transfers, including mobility devices as needed A current policy, titled Gait Belts, dated as last revised on 12/14/14 and received from the Assistant Executive Director on 9/28/23 at 2:59 p.m., indicated .Gait belt availability and use is required at all times This Federal Tag relates to Complaint IN00418063. 3.1-45(a)(2)