**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate assistance was provided during a mechanical lift transfer and ensure staff used the equipment in accordance with facility policy for a resident who required extensive assistance of two staff and mechanical lift for transfers (Resident 137). The facility failed to ensure adequate supervision was provided in the bathroom for a cognitively impaired resident at risk of experiencing falls and failed to ensure a toilet seat was properly attached to the toilet for a resident (Resident 2). The facility failed to ensure new interventions were immediately implemented after a fall for Resident 137 and Resident 2 to prevent further falls for 2 of 3 residents reviewed for falls. This deficient practice resulted in Resident 137 sustaining a right femur fracture and Resident 2 sustaining a right hip fracture that required surgical repair. (Resident 137, Resident 2) Findings include: 1. An Indiana Department of Health (IDOH) incident report, dated 8/29/24, indicated Certified Nurse Aide (CNA) 20 was involved when a resident had fallen during a transfer, was transferred to the hospital, and the hospital nurse reported to the facility Resident 137 had a right femur fracture. On 12/4/24 at 1:28 P.M., Resident 137's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease and history of a stroke. The most recent Quarterly Fall Risk Assessment, dated 3/7/24, indicated Resident 137 was a high risk to fall. The clinical record lacked documentation of a Fall Risk Assessment being done between 3/8/24 and 8/29/24. The most recent Significant Change MDS (Minimum Data Set) assessment prior to the fall, dated 8/1/24, indicated Resident 137's cognition was unable to be assessed, had impairment of both lower extremities, used a mechanical lift, and required an extensive assist of two staff for bed mobility and transfers, and was totally dependent on two staff for toileting. A Physician's Order Summary, dated August 2024, did not include information to indicate staff should use a mechanical lift for transfers. A plan of care for falls, revised 8/5/24, included, but was not limited to, interventions to use a mechanical lift for transfers and to perform fall risk assessments quarterly and as needed. The plan did not include documentation to determine the number of staff required for the mechanical lift transfer. A Health Status Note, dated 8/29/24, indicated the resident fell during a transfer, signs of pain were present, and the resident was transferred to the hospital. The note did not include documentation to determine the specific details of the fall, the number of staff present at the time of the fall, and any new interventions to prevent further falls were immediately implemented. The progress notes, fall assessments, and care plans dated 8/29/24 through 9/3/24, did not include documentation of the specific details about the fall or to show immediate interventions were implemented to prevent further falls. On 12/4/24 at 2:08 P.M., the Administrator provided an incident report for the fall on 8/29/24 but indicated it was a facility document only and not part of the clinical record. At that time, she indicated the details about the fall would be documented in progress notes, assessments, and care plans. An internal fall investigation summary tool, dated 8/29/24, provided by the DON indicated the mechanical lift transfer of Resident 137, on 8/29/24, was performed without the extensive assistance of two staff, the mechanical lift was used improperly, and no new interventions were immediately implemented to prevent further falls for Resident 137. During an interview on 12/5/24 at 9:46 A.M., the Director of Nursing (DON) indicated no additional documentation could be provided regarding the resident's fall on 8/29/24. On 12/4/24 at 3:30 P.M., the hospital discharge record, dated 9/3/24, indicated Resident 137 fell from a mechanical lift at the long-term care facility, sustained an acute fracture of mid-femoral diaphysis (a break in the middle of the femur bone) that required surgical repair, and was admitted to the hospital on [DATE]. The record indicated that the resident was discharged back to the facility on 9/3/24. On 12/5/24 at 11:59 A.M., the employee file of CNA 20 indicated mechanical lift skills competency was not completed. The CNA was suspended from duty for performing a mechanical lift transfer without a second staff person present. Education was provided and the CNA was terminated for continued noncompliance of facility policy. During an interview, on 12/5/24 at 11:05 A.M., Licensed Practical Nurse (LPN) 25 indicated she was Resident 137's nurse, on 8/29/24, when the fall occurred. LPN 25 was called to Resident 137's room and upon entering the room, the resident was observed on the floor, a handful of staff were standing in the room, and the mechanical lift was in the room, but she was unsure what position it was in at that time. LPN 25 indicated CNA 20 used the mechanical lift incorrectly and by herself instead of having two staff to do the transfer. LPN 25 indicated she did an assessment of Resident 137, and other than the resident appearing to have pain, there were no outward signs of injury. LPN 25 was not sure if the fall information should have been documented anywhere other than in the progress notes of the clinical record or how often fall risk assessments were completed on residents. LPN 25 indicated her head-to-toe assessment findings should have been documented in an assessment at the time of the fall but was unable to obtain these findings from the clinical record. During an interview, on 12/5/24 at 11:45 A.M., the Administrator indicated CNA 20 transferred Resident 137 alone and did not have the base of the lift all the way out which caused it to tip over and the resident to fall landing on the floor. The Administrator was here at the time of the fall and followed the nurse into Resident 137's room. Upon entry, the Administrator observed the resident laying on the floor in the lift pad and the lift was tipped over. The Administrator indicated CNA 20 was trained in another state where two staff were not required to perform a mechanical lift transfer. At that time, the Administrator indicated CNA 20 should have been trained on the mechanical lift policy and procedures during initial facility orientation but supporting documentation could not be provided to show the training occurred. The Administrator indicated CNA didn't use the lift correctly or ask for help with using the lift for the transfer of Resident 137 when the 8/29/24 fall occurred. 2. On 12/4/24 at 11:32 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease and anxiety. The most recent Annual MDS (Minimum Data Set) assessment, dated 9/13/24, indicated severe cognitive impairment, substantial to maximum assistance required with toileting hygiene and independent with toilet transfers. Resident 2 was at risk for falls, and falls risk assessments were completed on 3/10/23, 3/13/24, and 3/16/24. Current physician orders as of 12/4/24 included, but were not limited to: bed alarm while in bed, dated 5/27/24. No physician orders related to falls interventions were in place prior to 5/27/24. A risk for falls care plan, dated 5/31/23, included the following interventions: if fall occurs, initiate frequent neuro and bleeding evaluations per facility protocol and alert provider, initiate fall risk precautions, properly identify resident to indicate a fall risk to caregivers, review medications for drugs that increase the risk of falls, and utilize devices as appropriate to ensure safety, all dated 5/31/23. A current high risk for falls care plan, dated 4/16/24, indicated, but was not limited to, the following interventions: Anticipate needs, call light within reach and encouragement to use it, appropriate footwear while ambulating or using wheelchair, follow facility fall protocol, and participation in activities that minimize potential for falls, all dated 4/16/24. A current actual fall with the injury care plan, dated 4/16/24, indicated, but was not limited to, the following interventions: check range of motion and increased pain, swelling and bruising every shift until resolved, continue interventions for the at-risk plan, monitor, document and report pain, bruising, change in mental status, confusion, sleepiness, inability to maintain posture, or agitation, all dated 4/16/24. From March 2024 through May 2024, Resident 2 experienced the following falls: Fall 1 An incident note, dated 3/8/24 at 12:40 P.M., indicated Resident 2 had slid off the commode in her room due to a high-rise toilet seat that had been placed on the toilet and was not secured. The resident slid off the toilet with the riser and was found sitting on her bottom on the floor by a Certified Nurse Aide (CNA) who was passing trays. The resident hit the right side of her buttock/hip. The note indicated a full assessment had been completed, although the clinical record lacked the assessment A Health Status Note, dated 3/8/24 at 6:25 P.M., indicated Resident 2 was taken to the emergency room via ambulance. A Health Status Note, dated 3/8/24 at 8:18 P.M., indicated Resident 2 was admitted for a fracture of the right hip. A Health Status Note, dated 3/13/24 at 1:53 P.M., indicated Resident 2 returned to the facility from the hospital, and was transferred to bed with assistance of one staff. A Health Status Note, dated 3/14/24 at 12:32 P.M., indicated Resident 2 had returned to the facility the previous day after an acute hospitalization related to a right hip fracture being surgically repaired. The falls care plan, dated 3/8/24, did not include documentation to indicate interventions were immediately implemented to prevent further falls. During an interview, on 12/6/24 at 11:44 A.M., the Director of Nursing (DON) indicated no documentation could be provided to show interventions to prevent further falls were immediately implemented after Fall 1 and should have been added to the plan of care. The progress notes, assessments, and plans of care, dated from 3/13/24 through 3/16/24 at 9:45 a.m., did not include documentation to indicate new interventions to prevent falls were implemented. Fall 2 A Health Status note, dated 3/16/24, indicated Resident 2 was found in her room on the floor on her back at approximately 10:00 A.M. The note indicated two nurses assessed the resident, although the assessment could not be located in the clinical record. The note indicated the bed would be placed in the lowest position and mats placed on the floor, and resident was to be placed by the nurse's station while awake Fall 3 A Health Status note, dated 5/26/24 at 12:05 A.M., indicated Resident 2 was found sitting on the mat in front of her bed. Neuro checks initiated and vital signs checked. The resident's son requested a bed alarm and was initiated as a new intervention. The progress note indicated that an assessment was completed but was not found in the progress notes or assessments portion of the clinical record. On 12/5/24 at 9:45 A.M., the Director of Nursing indicated all falls information was either in progress notes or assessments. Review of the progress notes and assessments from 5/26/24 through 12/4/24 lacked a falls assessment following the fall on 5/26/24 On 12/4/24 at 2:00 P.M., Licensed Practical Nurse (LPN) 5 indicated she was here at the time of Resident 2's fall on 3/8/24 (Fall 1). She indicated Resident 2 fell off of the toilet due to the seat riser coming loose and sliding off when the resident tried to sit on it. She indicated Resident 2 had a new roommate at that time (no longer in the facility) that was a larger person and possibly shifted the seat riser loose prior to Resident 2 using it. She indicated it was the kind of riser that clicked into place and that the risers were no longer used in the facility for any resident. On 12/5/24 at 1:26 P.M., the Maintenance Supervisor indicated there were two types of toilet seat risers at the facility while in use. They were either screwed on or bolted to the actual toilet bowl. He indicated they were checked periodically, but there were no scheduled checks for them that he was aware of. He indicated all risers had been removed from the residents' bathrooms and were no longer physically in the building. On 12/6/24 at 10:22 A.M., Resident 2 was observed lying in a low bed on a bed alarm. A fall mat was observed on the floor by the bed. On 12/6/24 at 10:31 A.M., LPN 5 indicated she was unaware of any checks that were done for the toilet seat risers when the facility used them. She indicated if the nurses or housekeeping were to notice anything wrong with them, they were supposed to fill out a work order for maintenance. On 12/6/24 at 10:34 A.M., the Director of Nursing (DON) indicated the system that was in place at the time of Resident 2's falls was not conducive to nurse input or documentation. She indicated care plans should have been updated following each fall with a new intervention, but the process to do so had not been in place at the time of the falls. On 12/5/24 at 11:40 A.M., a Mechanical Lift Policy, revised July 2017, was provided by the Administrator and identified as the most current policy. The policy indicated, .At least two [2] nursing assistants are needed to safely move a resident with a mechanical lift . On 12/6/24 at 1:16 P.M., a Falls Policy, dated 9/2012, was provided by the DON and identified as the most current policy. The policy indicated If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling . and will re-evaluate the continued relevance of current interventions . When a resident falls, the following information should be recorded in the resident's medical record . the condition in which the resident was found . assessment data, including vital signs and any obvious injuries . interventions, first aid, or treatment administered . Completion of a falls risk assessment . Appropriate interventions taken to prevent future falls . The staff will seek to identify environmental factors that may contribute to falling . 3.1-45(a)