**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on observation, interview, and record review, the facility failed to ensure staff effectively implemented fall prevention interventions while using an assistive device in the shower to prevent accidents for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident 6 experiencing a fall that required hospitalization for the treatment of a subarachnoid hemorrhage. 2. The facility failed to ensure fall interventions were in place while utilizing an assistive device for 1 of 2 residents reviewed for positioning and mobility. (Resident 23) Findings include: 1. Resident 6's record was reviewed, on 7/11/24 at 10:38 a.m., and diagnoses included, but were not limited to, traumatic subarachnoid hemorrhage, chronic pain syndrome, polyosteoarthritis, morbid (severe) obesity, and muscle weakness. The record indicated Resident 6 was hospitalized , from 4/13/24-4/17/24, after falling off a shower bed. The record indicated Resident 6 sustained a subarachnoid hemorrhage as a result from the fall. A Quarterly Minimum Data Set (MDS) assessment, dated 2/6/24, indicated Resident 6 was dependent- helper does ALL of the effort with shower/bathing, personal hygiene, and bed mobility (rolling left to right). Resident 6 required two staff person assistance with transfers and had impairment on both sides to the upper and lower extremities. The MDS indicated that Resident 6 was cognitively intact for daily decision making and was consistent and reasonable for daily decision making. A written statement from the former maintenance staff, dated 4/13/24 and signed, indicated the following, .Called in Saturday morning around 10:40 a.m. to fix a shower bed that someone had fallen out of. Upon my inspection of the shower bed I found that the pins which hold the siderails up were missing. I went to the hardware store and bought enough bolts of the right size and length to keep the rails in upright position and secure for the shower bed in the 200 hallway. I then went to check the bed in the 100 hallway and secured it as well The hospital Discharge summary, dated [DATE], indicated the resident suffered a traumatic brain injury which commonly causes confusion, dizziness, memory loss, nausea, and a headache. A care plan for Potential for Fear and Anxiety was initiated, on 4/19/24, and indicated the following, .the resident has the potential for fear and anxiety due to recent fall out of a shower bed A care plan titled ADL [Activities of Daily Living] Assist Required, initiated on 5/13/22 and revised on 4/29/24, indicated the following, The resident [Resident 6] requires up to x2 [times two] staff. The x2 staff was handwritten on the paper care plan without a date to indicate when Resident 6 was to need staff assistance with two people and for what specific ADL task. An observation was conducted, on 7/11/24 at 11:46 a.m., with the Nurse Consultant. The shower bed was observed to have a pipe rail bed frame with two side rails, which required the insertion of two pins on each side to hold the rail. Each pin was observed to be attached to the side rails with a gray strap. The frame was observed to have four legs with attached, locking wheels. During an interview with Certified Nursing Assistant (CNA) 3, on 7/11/24 at 11:08 a.m., she indicated that she was getting Resident 6 onto the shower bed and had the bed rails in the up position. She indicated she rolled Resident 6 onto her left side to wash her backside and when Resident 6 reached for the siderail, the rail broke off the shower bed, and Resident 6 fell off the bed, and landed on the floor headfirst. CNA 3 indicated the pins were in place before the shower began but came out once Resident 6 put weight on the railing. An interview with CNA 3, on 7/11/24 at 11:48 a.m., indicated she had not locked the shower bed wheels before or after Resident 6 was placed onto the shower bed. CNA 3 indicated she normally did not lock the wheels and she was not familiar with the shower beds. CNA 3 indicated she had only given one shower during clinicals, and, during orientation, shower beds were not covered that much. An interview with Resident 6, on 7/11/24 at 1:55 p.m., indicated the shower bed was not pushed all the way up against the shower wall and there were no siderails up. She indicated she was always told to reach for the handicap rail attached to the wall when turning because the shower bed rails were broken. Resident 6 indicated when CNA 3 instructed her to roll onto her left side, she reached for the handicap rail as she was always instructed to do, but she could not reach it, and the bed rolled, and she fell off the bed onto her head hitting the floor. Resident 6 indicated she knew the wheels were not locked that day. Resident 6 indicated she had a lot of head pain due to the fall and continued to have tingling above her right eyebrow and it still hurt at times. During an observation and interview with Resident 6, on 7/12/24 at 10:58 a.m., she was observed sitting in a mobilized wheelchair and indicated she was dependent on all her daily activities, especially mobility and bathing. An interview with the Executive Director (ED), on 7/11/24 at 12:29 p.m., indicated she was notified of the fall on 4/13/24, and Resident 6 slid off the shower bed. The pins broke and was the root cause of the fall. The ED indicated that the former maintenance staff came into the facility Saturday, believed to be 4/13/24, and stated the pins were gone. So, he (former maintenance staff) got new pins to put onto the shower bed. The ED indicated she was not aware that the brakes were not locked on the shower bed. A policy for Showering a Resident was provided by the Executive Director, on 7/11/24 at 2:18 p.m., and indicated the following, .Assist resident into shower and lock wheels of shower chair . A document titled PVC Healthcare Equipment Owner's Manual was provided by the ED on 7/11/24 at 2:18 p.m. The document indicated the following, .never allow the user to lean outside of the frame of the equipment .always apply the brakes on casters when needed The document did not indicate any weight limit specifications but only referenced always abide by weight limit capacities for each product. 2. The clinical record for Resident 23 was reviewed on 7/12/2024 at 10:45 a.m. The medical diagnosis included Alzheimer's disease. A Quarterly Minimum Data Set Assessment, dated 6/21/2024, indicated Resident 23 was not cognitively intact and dependent on transportation with her manual wheelchair. A fall care plan, reviewed on 4/15/2024, indicated that Resident 23 was at risk for falls related to weakness and dementia. An intervention to ensure that Resident 23 was utilizing her assistive device as indicated, including her Broda chair (a type of manual wheelchair). An in-service for Resident 23, dated 4/7/2024, was provided by the Director of Nursing on 7/10/2024 at 2:30 p.m. The document indicated that Resident 23 is to have her wheelchair dipped when in transit to raise feet form ground. During an observation, on 7/10/2024 at 1:21 p.m., Resident 23 was sitting in her wheelchair in the common area by the nurses' station. CNA 2 pulled Resident 23 backwards in her wheelchair in the common area into the tiled hallway. Resident 23's feet were noted to be contacting the ground during the backwards motion. CNA 2 paused momentum, tilted the wheelchair back some, then began a forward momentum to take Resident 23 to her room. Resident 23's feet were noted to make contact intermittently during the forward momentum. During an interview with CNA 2, on 7/10/2024 at 1:23 p.m., CNA 2 indicated that staff did not use foot pedals with Resident 23. She indicated that Resident 23's feet touch the floor sometimes when she transports Resident 23 in the wheelchair, and that nursing staff are working with PT [Physical Therapy] about a new wheelchair. During an interview with Certified Occupational Therapy Assistant (COTA), on 7/10/2024 at 1:46 p.m., indicated that she was familiar with Resident 23 and her use of a pedal Broda chair. COTA indicated that this chair was selected as the most appropriate option because it would allow Resident 23 to have versatility in her movements and body mechanics. Resident 23 does not utilize foot pedals with it due to her non-functional purposeful movements. Staff are to dip the chair back so that Resident 23's feet have clearance from the floor when assisting her with transportation. A policy entitled, FALL PREVENTIONS PROGRAM, was provided by the Administrator on 7/11/2024 at 2:18 p.m. The policy indicated the purpose of the policy was to identify residents who are at risk for falls and subsequently implement appropriate individualized fall prevention interventions. 3.1-45(a)(1) 3.1-45(a)(2)