**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was at high risk for falls had a timely treatment after a fall which resulted in actual harm when staff continued to transfer him in and out of bed, he was taken to participate in therapy, and his mobile x-ray was canceled after no physician's order could be provided to the x-ray technician for 1 of 3 residents reviewed for falls (Resident D). Findings include: During a phone interview on 1/27/23 at 11:05 a.m., Resident D's family member indicated an e-mail grievance had been sent to the facility Administrator on 1/10/23 regarding a delay in treatment for Resident D after a fall. According to the family member, they called to check in on Resident D on 12/31/22 and he complained of pain at that time. It wasn't until 1/3/23 when x-ray results were received and revealed a broken hip that the family member was notified of the fall and a new order had been given to send him to the hospital. The family member indicated Resident D had complained of pain for several days and wondered why he had not been sent out earlier. The staff just said, Resident D had refused to go to the hospital, which was odd, because when the family member spoke to him, Resident D indicated he was in pain and waiting for treatment. If the facility had called sooner, the family member indicated they would have been able to convince him to go to the hospital. When the family member was notified of the fall, they were told he fell from his bed after reaching for his urinal which he was accustomed to using, so the family member wondered why it was out of reach. Further, the family member complained that the bed controls had not worked, so there was no way to know if his bed was lowered. Often when the family member visited, his bed was at regular height. The family member indicated one of Resident D's friends came to visit him and noted he was in pain and complained that it was taking too long to get help. The family member also wondered if his several room moves contributed to his confusion and fall. He was originally put in a room upstairs, then he was told he needed to move rooms for new residents, but he would be put in a bigger room. He was moved a third time to a room at the end of the hall, where the service lights weren't working so he had to call out for help a lot. During a phone interview on 1/31/23 at 2:00 p.m., a former co-worker and close friend indicated she visited Resident D on afternoon of New Year's Eve, 12/32/23. When she arrived, he was sitting up in a chair and complained of pain, so she did not visit for long. She asked what happened, and he indicated he fell. She asked if he was still getting physical therapy and he said, yes- they took him down earlier. A nurse came in the room, and she told her that Resident D was complaining of pain because he fell he and wanted to get back in bed. When asked about Resident D's bed position, the friend indicated it was a regular bed, not too high and not too low. Resident D's friend indicated the resident was not one to complain much, but he was uncomfortable enough that he asked for pain medicine. On 1/31/23 at 2:32 p.m., a phone interview was conducted with Resident D, who no longer resided in the facility. Resident D indicated he did remember being at Evergreen and that he fell out of bed. He indicated, I fell out of bed, I just rolled over and fell out, it didn't feel good at all, and it hurt for days. I think I was sleeping and just rolled over. He did not remember how he got off the floor or back in bed. He indicated he was at another facility still rehabilitating from the fall. On 1/27/23 at 8:30 a.m., Resident D's medical record was reviewed. Resident D had been admitted to the facility on [DATE] after an acute hospital stay. A hospital discharge report, dated 10/28/22, indicated Resident D had been treated for breakthrough seizures which resulted in a fall with a hematoma (A pool of mostly clotted blood that forms in an organ, tissue, or body space) to his forehead. A physical therapy note on the discharge report indicated, some confusion, but pleasant .Sat [on the] edge of bed with assist of 1 today but [unable] to tolerate transfer to stand, stating his right leg felt too weak and 'I will fall.' He is considered a high fall risk currently due to his dependent mobility level and poor safety awareness Upon admission to Evergreen, Resident D had diagnoses which included, but were not limited to hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) which affected his right/dominant side, epilepsy, unsteadiness on his feet and anxiety. An admission nursing evaluation, which also included the 48-hour baseline care plan, was dated 10/28/23. The baseline care plan indicated Resident D had experienced a fall within the previous 30 days but did not make a note of his head injury. Interventions from the baseline care plan were as follows; Ensure resident was wearing appropriate non-skid footwear, refer to therapy, place call bell within reach, room to be well let and free of clutter, assist with ADLs (activities of daily living), bed in lowest position, remind resident to call for assistance. Further, the baseline care plan indicated bed assist bars were in place. An admission fall risk assessment, dated 10/28/22, indicated Resident D was at risk for falls and gave instructions to proceed to the care plan. Resident D's care plans lacked documentation that he had a vagal nerve stimulator placed as preventative equipment to treat his epilepsy and seizure disorder, which also placed him at a greater risk for falls. Resident D's care plan lacked documentation of his bowel/bladder status, level or frequency of incontinence, and/or his use of and preference for a urinal at his bedside. A Nurse Practitioner (NP) progress note, dated 11/8/22 at 9:59 a.m., indicated, Resident D was being seen for an initial psychiatric consult. Resident D had increased anxiety and yelled out frequently, often for something he could reach, other times for assistance that he was unable to do alone. Resident D indicated he did not remember yelling out loudly. His medications were reviewed, and a new order was given to start Buspar (an anti-anxiety medication that can cause some people to become dizzy, lightheaded, drowsy, or less alert than they are normally). A nursing progress note, dated 12/23/22 at 3:37 p.m., indicated, Resident D was noted to have loud outbursts every 15-30 minutes and put his call light on. Staff would enter the room, and he would not remember putting the light on. He was checked for incontinence as he wore briefs. Resident D's therapy progress notes were reviewed and indicated the following: A Speech Therapy (ST) noted, dated 12/31/22 at 11:28 a.m., indicated, Patient stated he had a fall reaching for his urinal earlier this morning and was requesting something for pain. Nursing was immediately notified and stated not being aware of his fall. A Physical Therapy (PT) note, dated 12/31/22 at 2:26 p.m., indicated, transferred with maximum assistance from bed to wheelchair (wc) and wc to bed. Patient needed moderate assistance for supine to sit and moderate assistance for sit to supine getting lower extremities into bed as well. Patient needing visual cues for sequencing/safety and patient yelling out wincing due to pain throughout each transfer. Patient completed 15' (feet) on sci-fit (a specialized piece of therapy equipment similar to a seated bike and row machine) on level 2, with his left lower extremity and both upper extremities to improve strength, range of motion and endurance. Patient reported severe pain in right hip/thigh area due to fall. Per nursing nothing was reported. Patient was unable to extend right knee past 40 degrees today without pain increasing and patient resisting. Patient completed bilateral lower extremity exercises in sitting to improve strength and range of motion. Patient did what he could tolerate. Patient nurse notified of change in transfers and range of motion. A ST progress note, dated 1/2/23 at 1:54 p.m., indicated Resident D had increased confusion. A ST progress note, dated 1/3/23 at 4:03 p.m., indicated Resident D was seen in bed that day due to increased pain in his leg. During an interview on 1/27/23 at 12:21 p.m., PT 50 indicated she had worked with Resident D on 12/31/22 and put the above progress note in. She indicated, she saw him earlier in the day, before lunch time. She went down to get him that day and remembered his bed was at a normal height, not lowered, and not left very high. Ne needed maximum assistance to transfer into his wheelchair. He went to therapy and participated but with decreased ability, they only worked his left side since his right leg hurt. She took him back to the nurses' station and reported his pain, and the nurse was unaware of any new pain. A late entry nursing progress note was dated effective as of 12/31/22 at 2:50 p.m. but had been created 1/6/2023 at 3:03 p.m. The note indicated Resident D had no pain, even though ST and PT both reported pain in his right hip on 12/31/22 before lunch. A late entry nursing progress note was dated effective as of 12/31/22 at 3:03 p.m. but had been created 1/2/2023 at 10:46 a.m. The note indicated Resident D had no pain, even though ST and PT both reported pain in his right hip on 12/31/22 before lunch. A late entry nursing progress note was dated effective as of 12/31/22 at 4:35 p.m. but had been created 1/1/2023 at 4:55 p.m. The note was a post fall evaluation which indicated the physician had been notified of the fall on 12/31/22 at 1:30 a.m., and Resident D complained of pain in his right hip. A late entry nursing progress note was dated effective as of 12/31/22 at 8:32 p.m. but had been created 1/2/2023 at 9:00 a.m. The note indicated, update to note: resident did fall. Upon further investigation, resident did admit to falling. Resident states he was in bed, reaching for his urinal and slid out of bed. When sliding out of bed resident states he hit his hip on the bed. Mild pain of 2, [as needed] given and effective. In house NP notified and ordered x-ray due to pain A late entry nursing progress note was dated effective as of 12/31/22 at 8:35 p.m. but had been created 1/4/2023 at 3:11 p.m., family aware. A late entry nursing progress note was dated effective as of 12/31/22 at 8:40 p.m. but had been created 1/3/2023 at 3:30 p.m the note indicated .spoke with NP and advised [a contracted mobile x-ray company] could not come out prior to 1/1/244 resident denies going to ER to be evaluated NP resident and family aware Resident D's completed and discontinued physician orders were reviewed. An order for Resident D's right hip/pelvis was not placed until 1/3/23 at 10:45 a.m. The x-ray was ordered due to fall, pain and decreased mobility. He had an order for Acetaminophen (Tylenol) 325 mg (milligrams) with instructions to give 2 tablets every 6 hours as needed for pain, which was only administered once in the month of December on the 31st at 7:34 p.m. On 11/28/22, Resident D had a procedure to pace Vagal Nerve Stimulator, (VNS- an implanted medical device placed by a surgeon near the collarbone to help control seizure activity via electrical stimulation) and had been given a 6 tablet prescription for Oxycodone (a narcotic pain medication) 5 mg every 6 hours as needed for pain. Although a pharmacy prescription summary was provided, no physician's ordered was placed in his record for the Oxycodone, therefore, no corresponding Medication Administration Record, (MAR) was available to verify the administration. The 6th and final tablet was signed out on 1/2/23 at 1:00 p.m., even though no pain was indicated on his MAR. On 2/1/23 at 2:50 p.m., the [NAME] President of Compliance and Internal Operations for mobile x-ray company provided recorded phone messages and internal notes related to Resident D's x-ray orders. A phone recording, timestamped 12/31/22 at 8:46 p.m., (approximately 9 hours after ST initially reported acute pain to nursing), Registered Nurse (RN) 50 called and ordered a regularly scheduled x-ray. At 8:52 p.m., six minutes later, she called back to verify the right hip had been requested. A phone recording, timestamped 1/1/23 at 3:24 p.m., Licensed Practical Nurse (LPN) 52 called to inquire when they would be coming to complete Resident D's x-ray. His appointment was located in the system as a routine x-ray scheduled for Tuesday 1/3/23, to which LPN 52 indicated, oh no, no. He's complaining of pain, his family is here. We need that called in STAT, they are going to take him to the hospital, but he has dementia .so he needs to be going to the hospital right now Representative 53 checked to see if there was an x-ray technician in the area and re-ordered the x-ray from routine to STAT (immediately). LPN 52 asked for an estimated time of arrival and Representative 53 indicated, the technologist is going to reach out to your facility to give you guys an ETA on when they are on the way to the facility, I can't guarantee a time frame they are going to be the ones to give the ETA, I do need to let you guys know there is only one tech and its extremely busy in the area so it could be a later than usual ETA. LPN 52 entered a late corresponding nursing progress note, dated effective 1/1/23 at 7:21 p.m., but created 1/3/23 at 4:08 p.m., which indicated, several attempts to call the mobile x-ray company were made and there were two patients before Resident D. A phone recording on 1/1/23 at 5:11 p.m., was the assigned x-ray technician, Tech 54 who called internally to see if Resident D's x-ray could be rescheduled due to care trouble. Representative 55 indicated she would tell the facility it would be tomorrow. Representative 55 called Evergreen on 1/1/23 at 5:16 p.m. but the call went unanswered. A mobile x-ray company GPS transmitter indicated X-Ray Tech 56 arrived to Evergreen on 1/2/23 at 5:47 p.m., and left at 6:17 p.m. The X-ray order was cancelled at that time due to no physician order for the exam was on the resident's file. A phone recording on 1/3/23 at 9:32 a.m., was Nurse Practitioner 56 who called to inquire about Resident D's x-ray. Representative 58 explained a technician had been out the day before but was unable to complete the x-ray because there was not a doctor's order so the exam was cancelled. NP 56 re-ordered the exam STAT and indicated, can we please order that STAT because we are going to end up taking our patient to the ER. On 1/3/23 at 10:28 a.m., the x-ray was performed and the results were received at 10:41 a.m., which revealed, an acute subcapital fracture proximal right femur with angulation and superior displacement of distal fragment. A nursing progress note, dated 1/2/23 at 8:49 a.m., indicated Resident D complained of mild pain, and his PRN medication was administered. However, there was no documentation on his Medication Administration Record (MAR) that the medication was administered. On 1/3/23 at 11:44 a.m., .patient alert and oriented has pain but continues to refuse any pain medication . New orders were given to send Resident D to the ER where he was admitted to the hospital for evaluation and treatment, approximately 72 hours after Resident D initially complained of pain. During an interview on 2/1/23 at 2:22 p.m., NP 57 indicated she had been notified of Resident D's complaints on pain on the evening of 12/31/22. By that time, he had self-reported a fall, so NP 57 ordered an x-ray. Initially he did not want to go to the hospital, and when she came in to see him on 1/3/23 a STAT x-ray was reordered because there was some mix up with the x-ray company, but throughout those day he never complained of pain. During an interview on 2/2/23 at 10:15 a.m., Certified Nursing Assistant (CNA) 14 indicated she worked with Resident D on New Year's Eve and her ADL charting activity was reviewed with her. She indicated Resident D called out for help a lot and often forgot that he had. He was used to using the urinal by himself. CNA 14 indicated she had finished working with another resident and was taking some trash out when she heard Resident D call out, Help! Nurse nurse! She indicated when she entered his room, she found him on the floor and asked, oh my god, what happened? and he only said, I fell. She went to get help and it took three staff member to get him off the floor. During an interview on 2/2/23 at 10:39 a.m., Qualified Medication Aid, (QMA) 26 indicated she did not know Resident D had a fall until therapy reported it to her and she went to tell her nurse. QMA 26 indicated PT came down to get him and took him to therapy like usual, but when they returned the therapist indicated Resident D had complained of pain and could not continue. During a follow up interview on 2/2/23 at 2:23 p.m., CNA 14 indicated she may have remembered wrong and wanted to clarify that she did not find Resident D on the floor, but instead it appeared that he was slipping out of his chair and was almost on the ground, when she went in and was able to assist him back into his chair. On 2/2/23 at 2:33 p.m., the RN Divisional Risk Strategist provided a copy of the post fall investigation which included the following phone statements: a. RN 50 who indicated, [Resident D] did not fall on my shift, he said he was in pain after therapy, I went to assess him, I called [NP 57] she ordered an x-ray, I asked him did he want to go to the hospital and he said no. [Refer above: ST progress note reported pain to nursing on 12/32/22 at 11:28 a.m., and RN 50 did not call mobile x-ray to place the x-ray request until 12/31/22 at 8:46 p.m.] b. QMA 26 who indicated, He did not fall on my shift, I helped him in his chair, and he did complain of pain and we told the nurse. c. NP 57 who indicated, A nurse called me and stated he was in pain, I don't remember what nurse, but I gave an order for an x-ray, I did not order STAT because his pain was mild, at that time they did not know he had called. They also called to tell me that the x-ray had not been done and I told them to send him to the ER they called and told me he refused. I came in and saw him and encouraged him to go to ER and he refused, I put in an order for a STAT x-ray. d. Electronic Health Record Coordinator, (EHR) 7 who indicated, I came in Saturday 12/31/22 afternoon/evening. When I first came in, I did my rounds on the unit, I was not working the cart- I was helping on call person [nurse]. RN 50 stated patient was getting x-ray on patient due to pain states had fall. I asked her to come with me to patient's room, patient self-reported fall and instructed RN 50 to complete charting for fall- resident state he did not have pain at that time and refused to go to hospital. On 2/2/23 at 2:45 p.m., The RN Divisional Risk Strategist provided copies of an in-service sign in sheet, dated 11/28/22, and in-service material. At this time, she indicated, nursing staff had been in-serviced on the provided material upon Resident D's return from a procedure where he had a vagal nerve stimulator (VNS) placed for his epilepsy and seizure activity. She highlighted a portion of the training which stated, .all nursing staff must be aware that his seizures and VNS cause him to be at a higher risk for falls. Ensure that side effect monitor is in place, call light remains in reach, frequently used items (magnet, remote, cell phone, water, urinal wheelchair) are within reach, nonskid footwear as tolerated, environment clutter free, bed is locked, reminders to call for assistance as needed On 1/31/23 at 2:00 p.m., the Administrator, (ADM) provided a copy of current facility policy titled, Fall Prevention and Management, revised 6/1/22. The policy indicated, Is it the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage a resident's care if a call occurs . If the resident is identified to be at risk for fall, a care plan should be initiated that includes a plan to potentially diminish the risk of falls. The care plan can include interventions that address environmental factors, ADL factors, risk factors that result from dementia and other mental diagnosis, medical diagnosis that put the resident at higher risk. Issues such as toileting, eating, transferring, and impulsiveness should be considered. The care plan can address furniture arrangements, footwear, medications that can cause dizziness, drowsiness and instability. The care plan should also address how the resident can be transferred in and out of bed as well as how the resident can ambulate and move around the facility. The care plan should be reviewed and updated as needed with each change of condition On 1/31/23 at 2:00 p.m., the Administrator, (ADM) provided a copy of current, but undated facility policy titled, Urinal: Placement of. The policy indicated, If is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors . Self-Care: resident may be able to remove urinal himself and/or advise when he is finished, provide standby assist as needed, remain with resident if unable to advise when he is finished and provide privacy if you stay with resident, remove urinal On 2/1/23 at 3:50 p.m., the RN Divisional Risk Strategist provided a copy of current facility policy titled, Laboratory and Radiological Services and Results Reporting, revised 6/13/22. The policy indicated, .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents . the facility will have an on-going written agreement with a qualified laboratory(ies) and radiology units to provide services to meet the needs of the resident population . the facility will collaborate with the lab and/or radiology unit to provide reports to the facility in a timely manner On 2/1/23 at 3:50 p.m., the RN Divisional Risk Strategist provided a copy of the current Radiology Service Agreement, dated 2/25/21. The Agreement indicated, . all orders must include the exams to be performed, the number of views to be taken, the medical necessity of the exam, and if x-ray, why is was ordered to be done portably. As the legal custodian of the patient's medical records Facility will obtain and store within each patient's chart the signature of the practitioner who ordered that exam. Facility agrees to provide all required information and documentation for proper billing and/or related audits in a timely manner This Federal tag related to Complaint IN00399180. 3.1-37(a) 3.1-37(b)