**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status 5 out of 15 for Resident 12. A BIMS of 5 indicated a significant cognitive impairment. Diagnoses documented dementia, osteoporosis, tibia fracture and urge incontinence. Alarms documented a wander guard. Care plan dated 9/1/22 documented a risk for falls. Interventions included call light within in reach and right lower extremity brace must be on when up. Interventions included snacks between meals, activities, Record review revealed the following: Orders dated 9/6/22 directed the use of a hinge knee brace. Progress Notes revealed the following Resident 12's admission to the facility for a right tibia fracture on 8/2/22. Prior falls dated 8/6/22 (x2) 8/23/22, 10/4/22 and 10/10/22. 10/4/22 documented a urine test was performed to rule out a urinary tract infection after a fall. 10/7/22 started on Bactrim for a urinary tract infection pending culture and sensitivity. 10/9/22 Resident 12 was last visualized 2:20 AM and was found on the floor at 2:35 AM with right lower extremity shortened and rotated outward. 10/10/22 transferred to hospital after a fall and admitted for right hip fracture. Hospital documentation dated 10/24/22 documented comfort measures. Interviews revealed On 10/19/22 10:32 AM Staff G, CNA stated that Resident 12 had a broken right leg and wore a brace on that leg. On 10/19/22 at 11:51 AM Staff E, CNA stated she was headed to break and saw Resident 12 in the fish room, in a chair and her wheelchair was next to her. She was unable to report if Resident 12 was wearing her leg brace. She reported she knew Resident 12 was a fall risk. She was told that [NAME] was restless because she wanted to go outdoors. She was unable to confirm a time of the observation but stated she typically took breaks between 2:30 and 3:30 and when she came back from break she was told Resident 12 had been sent out after a fall. She confirmed there were no other staff or residents around and the resident wore a wander guard but did not have access to a call light in the fish room. On 10/19/22 at 11:24 AM Staff F PTA stated resident was ordered to wear hinge brace at the time of the fall. She stated a hinge brace would offer support to a weakened leg and may assist in preventing a fall. Based on documents review, interviews, and observation, the facility failed to ensure development and implementation of interventions based on corresponding assessment data in order to prevent fall incidents, and minimize complications resulting from falls for 3 of 5 (#3, #9, #12) residents reviewed for accidents. The facility reported a census of 47 residents at the time of the survey. Findings include: 1. Resident # 3's electronic medical records showed an admission date of 2/9/22 after hospitalization related to right femur fracture. The records also showed that Resident # 3 had 2 incidents of fall since admission, as follows: Fall on 4/15/22 at 1:15 PM. On 10/20/22 at 9:38 AM, when followed up regarding her wound treatments, Resident # 3 replied, They keep saying it's getting better, I don't know. I want to be able to walk again but I had a bad fall. Resident # 3 said she called for help to use the bathroom and a staff came in to help. Resident # 3 said not knowing what happened but that she was just on the floor with my foot behind the toilet. Resident # 3 said, They did nothing! Resident # 3 further said they did not send her to the hospital after the fall, that X-ray was called in here and found out I had broken bone in my leg. Resident # 4 also said after that she had more pain and then the wound to her right heel. The clinical/medical records show details of Resident # 3's fall on 4/15/22 as follows: A. The documents that indicated Resident # 3's status and need for physical assistance during transfers prior to the fall, include the following: i) Resident # 3's admission Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS showed Resident # 3's active diagnoses including diabetes mellitus, depression, and fractures. The MDS also indicated Resident # 3 required physical assistance of 2 persons for transfers, dressing, and toilet use. ii) Resident # 3's care plan, which was downloaded from facility's electronic medical records system on 10/19/22, showed the care plan initiation date as 2/17/22, indicating the required assistance for Resident # 3's Activities of Daily Living (ADL) as 2-person physical assistance for dressing, personal hygiene, transfers, and toilet use. iii) The PT [Physical Therapy] - Therapist Progress & Updated Plan of Care dated 3/29/22, showed assessments on 3/3/22 (prior level) and on 3/29/22 (current level) related to Toilet transfer showed, Not attempted due to medical condition or safety concerns. However, that on the same day (3/29/22) that the current level assessment for toilet transfer was not attempted, the corresponding STG (short term goal) for Toilet transfer was upgraded, as noted, The [Resident # 3] is able to safely complete STS [sit to stand] transfers requiring min [minimum] assist [25% assist] verbal, tactile and visual instructions/cues. The document further noted that Resident # 3 required continued training in transfers to improve safety in SPT [stand pivot transfer]and STS [sit to stand]. iv) The OT [Occupational Therapy] Daily Treatment Note showed Resident # 3's level of tolerance for standing, need for maximum assistance for transfer and the use of transfer devices, on the following dates: - On 3/28/22, Resident # 3 went for an ortho appt [orthopedic appointment] where physician discontinued immobilizer on RLE (right lower extremity) and weight bearing status to WBAT (weight bearing as tolerated). The notes indicated maximum assist for STS [sit to stand] and for static standing balance at FWW [four-wheel-walker] and tolerating stand for approx [approximately] 30 seconds x 3 trials with SPT [stand pivot transfer] with max [maximum] assist on third trial. The notes also indicated that Resident # 3 had well tolerated the use of standing frame when tried. The notes further indicated upgrade of transfer status in PCC (point click care) and communicated with Staff Q, Certified Nurse Assistant (CNA). - On 3/29/22, Resident # 3 participated in group therapy. The specific focus for Resident # 3's treatment noted, Deficits in standing tolerance, UE [upper body] strength, and functional endurance in order to improve independence with functional sit to stand, and ADL pivot transfers. v) The OT - Therapist Progress & Updated Plan of Care dated 3/29/22, showed updated short term goal related to toilet transfer for Resident # 3 to safely transfer to toilet/commode with minimal assistance (25%). The document noted upgraded challenges to STS performance, standing tolerance, SPT (stand pivot transfer) including toilet transfer with increase in WBAT (weight bearing as tolerated) status, and staff education to use standing frame for all functional transfers with Resident # 3. The document indicated staff education as written, Staff educated in increase in RLE WB [right lower extremity weight bearing] status and upgrade from Hoyer lift to use of standing frame for all functional transfers. The document also noted, Patient continues to have deficits in standing tolerance, transfer performance, UB [upper body] strength, and functional activity tolerance which limit to safely perform functional transfers . and the document further noted, Due to safety reasons, the patient requires continued use of standing lift with facility staff to minimize fall risk during transfers at this time. vi) Resident # 3's electronic medical records showed that on 3/29/22, Resident # 3's care plan was revised as noted, The resident requires sit/stand lift for all transfers. In addition, the care plan showed revisions related to Resident # 3's ADL that indicated 1-2 persons physical assistance for dressing and personal hygiene. The records further showed that the care plan initiated on 2/9/22 (prior to the fall) and through the next care plan 5/23/22 (after the fall), Resident # 3's required need for 2 staff/persons assistance for toileting remained in place. vii) Resident # 3's 5-day Medicare MDS assessment dated [DATE] and signed on 4/6/22 (the most recent MDS assessment immediately preceding the fall), indicated need for physical assistance of 2 persons for transfers, dressing, and toilet use. viii) The Skilled Notes from 3/30/22 through 4/14/22 at 9:15 PM (prior to fall), showed 16 inconsistent skilled nursing notes entered for Resident # 3 regarding assistance for toileting and transfers, where 10 of 16 indicated that Resident # 3 required 2-person assistance and use of mechanical device for transfers, 2 out 16 indicated 1 staff assistance for ADLs and transfers, and 4 of 16 did not indicate transfers and assistance needed for ADL, as follows: - On 3/30/22 at 3:30 PM - 2 person assist with sit to stand lift. - On 3/30/22 at 9:28 PM - 2 person assist with sit to stand lift - On 4/2/22 at 3:14 PM - transfers sit to stand and assist of 1 - On 4/3/22 at 3:44 PM - using sit to stand for transfers - On 4/4/22 at 3:44 PM - assist of 2, and use of sit to stand mechanical lift for transfers - On 4/6/22 at 11:44 AM - no notes about transfers; - On 4/7/22 at 11:44 AM - no notes about transfers; - On 4/8/22 at 11:44 AM - no notes about transfers; - On 4/9/22 at 11:44 AM - no notes about transfers; - On 4/10/22 at 3:15 PM - Resident [#3] requires assist of one [1] with ADLs. Requires sit-to-stand mechanical lift with all transfers. The document further noted, Education with resident on using mechanical lift with nursing staff, and standing with FWW and gaitbelt with therapy only at this time, until determined safe. Understanding demonstrated by reiteration. - On 4/11/22 at 2:15 PM - Requires sit-to-stand mechanical lift with all transfers. - On 4/12/22 at 9:15 AM - Requires sit-to-stand mechanical lift with all transfers. - On 4/13/22 at 9:15 AM - 1 assist with adls and transfers. - On 4/13/22 at 9:15 PM - Transfers with hoyer lift. requires assist with ADLs. - On 4/14/22 at 9:15 AM - Transfers with hoyer lift, requires assist with ADLs. - On 4/14/22 at 9:15 PM - Transfers with hoyer lift, requires assist with ADLs. ix) The PT - Therapist Progress & Discharge Summary dated 4/14/22, showed an assessment of current level that indicated when therapy ended on 4/14/22, toilet transfer was not attempted due to Resident # 3's medical condition or safety concerns. The document noted Resident # 3's current level for transfers from sit to stand as Substantial/maximal assistance where helper does more than half the effort. The document also noted that physical therapy goals including standing balance, strength, and transfers were not met on 4/14/22 because of unexpected therapy discharge. The document further showed discharge plans and instructions indicating Resident # 3's need for ongoing therapy as noted, Remain in LTC [Long Term Care] and continue therapy services under Medicare part B[.] x) The OT - Therapist Progress & Discharge Summary dated 4/14/22, showed that STGs (short term goals) related to activity tolerance for standing and toilet transfers were not met (STGs noted in v above). The document also noted, [Resident # 3] was progressing with OT POC [plan of care] steadily but slowly progressing towards all goals. However, [Resident # 3 was discharged ] from skills OT services prior to all goals met due to Insurance cut and lost appeal this date. The discharge plans and instructions noted, Recommend continued OT services as able to continue functional progression for maximal safe level of independence in ADLs. B. The documents revealed Resident # 3's call for assistance, and fall during toilet transfer by 1 person that resulted to increased discomfort/pain, include the following: i) The call light log indicated that on 4/15/22, Resident # 3's call light was on from 1:05 PM and off at 1:32 PM for a total response time of 27 minutes. ii) The progress notes on 4/15/22 showed Staff P's entry that read, Approximately 1315 [1:15 PM] this nurse was asked by resident to get help to go to the bathroom. This nurse used gaitbelt and had resident stand. Wheelchair was locked. Resident's legs became week and started lowering. This nurse lowered resident to the floor. iii) The progress notes showed Resident # 3's complaints of right leg pain and received as needed (PRN) pain medication or Tramadol Hydrochloride (HCl) tablet 50 milligram (MG) 0.5-1 tablet on 4/15/22 at 10:22 PM, 4/17/22 at 1:05 AM and Resident # 3 was quoted as saying, My right leg is really hurting. and on 4/17/22 at 11:03 PM. iv) The Medication Administration Record (MAR) for the month of 4/22, indicated Resident # 3 had increased discomfort after the fall starting on 4/15/22, where her PRN pain medication (Tramadol) and PRN medication for muscle spasms (Tizanidine) were administered at a more frequent interval than the preceding days, as follows: - On 4/13/22 - no PRN pain medications - On 4/14/22 - no PRN pain medications - On 4/15/22 at 10:22 PM, Tramadol 50 milligrams (mg) on - On 4/17/22 at 01:05 AM and at 11:03 PM - Tramadol 50 mg; - On 4/18/22 at 11:32 PM - Tramadol 50 mg and Tizanidine 2 mg; - On 4/19/22 at 07:48 PM - Tramadol 50 mg; - On 4/20/22 at 05:16 AM - Tramadol 50 mg; at 09:53 PM - Tramadol 50 mg and Tizanidine 2 mg; - On 4/21/22 at 3:03 PM - Tramadol 25 mg; at 10:25 PM - Tramadol 50 mg and Tizanidine 2 mg; - On 4/22/22 at 05:36 AM - Tramadol 50 mg; at 01:13 PM - Tramadol 25 mg; at 6:24 PM - Tizanidine 2 mg; - On 4/22/22 starting at 10:00 PM - Tramadol 50 mg and was then scheduled every 8 hours thereafter. C. The documents revealed facility's actions following Resident # 3's fall (4/15/22), including: i) The MAR dated 4/22 and medication administration notes in the progress notes, showed staff members have been giving Resident # 3's PRN medications in attempt to relieve Resident # 3's right leg pain; ii) The progress notes entered on 4/20/22 at 10:06 AM, showed that on 4/18/22 (3 days post fall), the Nurse Practitioner (NP) visited and Resident # 3 reported no complaints of pain to NP related to fall, and no edema on bilateral legs. The NP noted, Fall without injury and the plan was to continue with medications and treatments. iii) The Order Summary Report showed orders for Physical Therapy and Occupational Therapy to evaluate and treat starting on 4/21/22. iv) Therapy documents showed Resident # 3 started assessment for therapy services on 4/21/22, still with complaints of right leg pain, as noted: - The Occupational Therapy Plan of Care dated 4/21/22, showed Resident # 3 reported pain of 8/10 in right anterior knee. - The Physical Therapy Plan of Care dated 4/21/22, noted, [Resident # 3] reports right [NAME] [lower extremity] pain, nursing aware and [Resident # 3] received Tylenol. v) The progress notes indicated Resident # 3's complaints of pain, and then discovery of fractured tibia and fibula on right leg, as noted: - On 4/21/22 at 5:48 PM, showed that Resident # 3 complained of right front lower leg pain, where pain medications had been given throughout the day with some relief. The notes indicated that Resident # 3's complaints had been reported to the NP, and that the NP to see tomorrow on rounds and to continue pain medications as needed. - On 4/21/22 at 11:22 PM, Resident # 3 complained of right lower leg pain and leg is swollen and bruised. Pain medication was given and an x-ray ordered due to increased pain and swelling. - On 4/22/22 at 5:49 AM, showed, Resident [#3] continues to complain regarding her right leg. Pain pill given at this time. Ordered x-ray last night stat [as soon as possible] and at this time they still haven't shown up to perform the xray. - On 4/22/22 at 8:45 AM, the x-ray results on Resident # 3's right lower extremity showed tibula/fibula fracture. Resident # 3 was sent to the emergency room (ER) for evaluation and treatment. - On 4/22/22 at 6:35 PM, Resident # 3 returned from the hospital with orders for non-weight bearing and to follow up with physician for orders. D. The documents confirmed Resident # 3's statement regarding more pain and pressure ulcer development on right heel following the fall, as follows: i) The progress notes on 5/6/2022, indicated Resident # 3's continued pain on right leg with increased anxiety, and new orders for Xanax 0.5 milligrams (mg) 2X a day for anti-anxiety and Norco 5/325 mg every 8 hours as needed for breakthrough pain. ii) The progress notes indicated the presence of pressure ulcer on right heel on 6/13/22, with treatment order noted, xeroform gauze to open area R heel, cover with optifoam, change [every] 3 days or PRN Betadine to intact skin on r heel and cover with optifoam every 72 hours for pressure area [right] heel iii) The care plan identified a pressure wound on Resident # 3's right heel was identified on 6/27/22. Staff interviews related to the fall on 4/15/22, are as follows: On 10/26/22 at 10:59 AM, the Nurse Practitioner (NP) said that on 4/14/22, staff reported to her about Resident # 3's fall when staff lowered her to the floor, and that assessments did not show injury nor pain, and no concerns reported. The NP said she does not know or review residents' transfer status and how many staff needed to assist, and that she will go by what staff members report. The NP further said that Resident # 3 was so inconsistent with what she was saying regarding her pain because when she (NP) personally went to ask, Resident # 3 reported no pain but then I get a call that she is in pain. The NP said she would go by her own assessment because it was difficult to know with Resident # 3's inconsistencies and the NP added, Of course there is pain after a fall, it could be anything, could be a residual discomfort, musculoskeletal twisting. The NP verified ordering x-ray on 4/22/22, the 7th day after the fall when Resident # 3's pain was not being relieved and there was swelling. On 10/26/22 at 12:40 PM,the Director of Nursing (DON) and Administrator verbalized their understanding that on 3/29/22, Resident # 3's requirement for transfer of sit to stand lift meant assist of 1-2 staff members and can be with the use of a gait belt. The Administrator said that based on therapy recommendations, Resident # 3 can be assisted for transfers by 1 staff person using a gait belt and that was what happened when a nurse (that DON identified Staff P, a nurse manager) lowered Resident # 3 to the floor during transfer. The Administrator said that Staff P correctly followed the care plan. The DON said that Resident # 3 was discharged from therapy on 4/14/22 and the fall happened on 4/15/22, and so there was no time to revise the care plan but also reiterated that Staff P followed the care plan of sit/stand lift by using a gait belt by herself to assist Resident # 3. On 10/28/22 at 5:23 PM, Staff L, Physical Therapist (PT) verified having previously worked with residents at the facility. Staff L explained that if functional deficits that have not been attempted during the assessment period, such as toilet transfer, it was because of safety concerns for the patient. Staff L also clarified that a standing lift and a standing frame are machines (devices) used for patient transfers. Staff L said that a stand lift or EZ stand is used by nursing to transfer patients from one seated surface to another and a standing frame is used by therapy. Staff L said that for these to be used, it would not be safe even for one therapist to use because there needs another person to put a sling safely under the patient's armpits. Staff L further clarified that a stand lift or EZ stand is not the same as assist of one person using a gait belt to help a patient stand. Staff L said that recommendations of upgrading assistance when therapy goals were not met at discharge is case by case basis, that is why there is need for re-evaluation at discharge for whatever is safer for the patient. Staff L also stated assumption that if she noted a recommendation for a patient to remain in LTC (long term care) and continue services, it is because the patient needs more therapy. Staff P, the former nurse manager who lowered Resident # 3 to the floor did not return 3 attempted calls for interview on different days and time, despite voice messages left on phone. 2. Resident # 9's Quarterly MDS assessment dated [DATE], listed Resident # 3's active diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety disorder. The MDS indicated that Resident # 9 is on hospice level of care. Resident # 9's care plan directed staff to provide the extensive assistance of 2 staff members for transfers. The care plan indicated moderate risk for falls related to impaired mobility, and the care plan also showed multiple revisions indicating frequent falls. On 10/20/22 at 8:59 AM, Staff T, CNA while facing Resident # 9 in her wheelchair said, Give me a hug so I put you to bed. Staff T then hugged Resident # 9 and pivot-transferred her from wheelchair to bed. At 9:20 AM, the DON entered Resident # 9's room and surveyor asked Staff T to review the transfer process she just completed for Resident 9, Staff T then verbalized that she hugged Resident # 9 and transferred her to bed. Staff T acknowledged that she did not use a gait belt during the transfer. The DON said that Resident # 9 is a 2-person assist with the use of gait belt. The DON acknowledged that all care givers follow residents' care plans. The facility's policy titled, Fall Prevention, dated 10/18/2013, provides that it is the policy of Christian Horizons to provide each resident with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The policy provides, Residents are identified as at risk for falls, clinically appropriate interventions will be put into place to reduce the risk for falls and/or to prevent recurrence of falls. The facility's Resident Assessment (RAI) of MDS policy, dated 10/1/19, provides that the facility will use the most current version of RAI to conduct assessment of each resident's needs. The policy indicated use of the results of the assessment to develop, review, and revise the resident's comprehensive care plans. The facility's policy titled, Comprehensive Care Plans, dated 5/18/17, provides, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy also indicated that a person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. The policy provides that the care planning process will include a review of the resident ' s strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. The policy further provides that the comprehensive care plan will be developed within 7 days after the completion date of the comprehensive MDS assessment.