**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interviews the facility failed to provide the assistance required to prevent falls for 2 of 5 residents reviewed for falls (Resident #8, and Resident #223). The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 8/30/23 , listed diagnoses for Resident #8 that included: Type 2 diabetes, dysphagia (difficulty swallowing), severe intellectual disability, and fracture of lower right leg. The MDS assessed the resident required extensive assistance of one staff for: bed mobility, transfers, and walking in the room and the corridor; and supervision with set up help only for eating. The MDS did not list the resident's Brief Interview for Mental Status (BIMS) score. The Care Plan revealed a focus area of at risk for falls due to history of falls, impaired balance/poor coordination initiated on 5/27/21. A Progress Note dated 8/20/23 revealed the resident incurred a witnessed fall after using the bathroom. The fall did not result in an injury. A Fall Risk Assessment complemented on 8/20/23 lacked a completed conclusion/narrative summary. A Progress Note dated 8/23/23 revealed the resident had a witnessed fall in the bathroom. Due to not being able to tolerate standing, the resident transferred to the local hospital and an x-ray confirmed a right ankle fracture. A Fall Risk Assessment complemented on 8/23/23 lacked a completed conclusion/narrative summary. The resident remained hospitalized until 8/26/23, when she discharged back to the facility. The clinical record lacked a Fall Risk Assessment upon readmission. The Care Plan revealed a focus area of at risk for falls due to history of falls, impaired balance/poor coordination initiated on 5/27/21. Interventions listed in the Care Plan included providing assistance to transfer and ambulate as needed initiated on 5/27/21. During an interview on 11/1/23 at 3:36 PM, Staff P, Certified Nursing Assistant (CNA) stated she assisted the resident to the bathroom on 8/23/23. Staff P stated the resident got out of bed, and walked to the bathroom with her walker. Staff P stated she walked behind the resident to ensure safety. Staff P stated she was unsure if she used a gait belt to assist the resident. Staff P stated the resident's walker blocked her from being able to sit on the toilet. Staff P stated she reached over the resident to move the walker, while the resident reached for the grab bar. Staff P stated the resident then fell to her knees. During an interview on 11/1/23 at 3:57 PM, Staff Q, Registered Nurse (RN) stated she did not witness the residents fall, but assessed the resident after the fall. Staff Q stated when she entered the residents bathroom, she found the resident resting on her knees. Staff Q stated the resident could not tolerate standing so she transferred to the local hospital for evaluation. Staff Q stated Resident #8 did not have a gait belt on when she came to the bathroom to assess. Staff Q stated the CNA should have used a gait belt as the resident has a history of falls and can be unsteady. During an interview on 11/6/23 at 4:02 PM, the Director of Nursing (DON) stated she expects staff to use a gait belt when assisting any resident who has a fall history. The facility policy, with a revised date of 11/2023, titled Fall Occurrence Purpose indicated the purpose of the policy is for the facility to ensure that residents are evaluated for fall risks and interventions implemented to minimize risk for falls and/or risk for injury from falls. Procedure #1 of the policy directed staff to complete a Fall Risk Assessment upon admission, readmission, and as necessary. Procedure #2 of the policy directed staff to implement Care Plan interventions to be based on the assessment. 2. The Minimum Data Set (MDS) assessment tool, dated 9/11/23, listed diagnoses for Resident #223 that included Metabolic encephalopathy (chemical imbalance in the brain), cirrhosis, and adult failure to thrive. The MDS assessed the resident required extensive assistance of two staff for bed mobility, and toilet use. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The Care Plan, initiated on 9/13/23, included a focus area for risk of falling due to impaired mobility. A Physical Therapy Discharge summary, dated [DATE], Functional Assessment for bed mobility indicated the resident is dependent to roll left and to the right. A Progress Note, dated 10/9/23 at 7:55 PM, documented the resident rolled out of bed while a CNA (Certified Nursing Assistant) changed the resident. The initial assessment revealed a large skin tear to the left inside of the resident upper arm, and a large laceration on the outside of the upper arm. The resident transferred to the local hospital for evaluation and treatment. A Progress Note, dated 10/9/23 at 11:10 PM, documented the resident returned to the facility. A Progress Note, dated 10/10/23 at 12:10 AM, documented the resident had the left forearm laceration sutured with 11 stitches, and a left humerus fracture. The Facility Investigation Witness statements revealed on 10/9/23 Resident #223 transferred to bed with the use of a Hoyer lift and assistance from two CNA's. One CNA left the room, the other resident assisted the resident with incontinence care. While rolling the resident towards the window, the aide was unable to stop the resident and the resident fell off the bed to the floor. An Employee Warning Notice, dated 10/11/23, issued to an agency CNA due to Violation of Policy and Procedure. The notice documented: On the evening of 10/9, a resident sustained a fall with injury due to staff not having proper staff assistance. During an interview on 11/6/23 at 3:19 PM, the Administrator stated the staff involved in Resident's #223 fall had been an agency staff and is no longer able to work at the facility. The Administrator stated two staff transferred the resident with a Hoyer, but only one staff assisted with incontinence care. The Administrator stated both staff should have stayed with the resident until after all care tasks had been completed. The Administrator stated since this fall, the facility has changed their policy now requiring two staff to assist with bed mobility if the resident required two staff for a transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, document review, resident and staff interviews, the facility failed to prevent an injury of unknown origin on 6/10/23 which resulted in a hematoma and facial bruising for 1 of 3 resident's sampled (Resident #6) and failed to utilize a gait belt per the therapy recommendations for safety for 1 of 3 residents reviewed (Resident #20). The facility completed an investigation for injury of unknown origin to assure resident safety from abuse from 6/10/23 - 6/15/23. The facility reported a census of 65 residents. Findings include: 1. Resident #6's MDS dated [DATE] showed Resident #6 with long/short term memory impairment and severely impaired decision making. The Resident exhibited fluctuating symptoms of inattention (easily distractible or having difficulty keeping track of what was said); disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject); and an altered level of consciousness (startles easily to any sound or touch; lethargic - repeatedly dozes off when being asked questions, responds to voice or touch; stuporous - very difficult to arouse and keep aroused for an interview; comatose - not being able to arouse). The Resident required extensive assistance for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), dressing, toileting, and personal hygiene. The MDS listed diagnoses of atrial fibrillation, hypertension, peripheral vascular disease, diabetes mellitus, depression, anxiety, cognitive communication deficit, and weakness. The MDS identified the Resident had not fallen since the last assessment. The Care Plan dated 10/04/21 documented Resident #6 at a risk for falls due to impaired mobility, weakness, and repeated falls. The Care Plan directed staff to use body pillows when in bed and encourage to transfer and change positions slowly. An Order Review Report signed by the Provider on 6/06/23 showed Resident #6 received Eliquis 2.5 milligrams (mg) 1 tablet orally twice a day for chronic atrial fibrillation. Eliquis is a prescription anticoagulant, or blood thinner, used to lower the risk of strokes and blood clots in people with an irregular heartbeat known as atrial fibrillation. The medication carries of risk of bleeding. A Progress Note dated 6/10/23 at 7:30 a.m. entered by Staff H, RN documented a CNA reported the Resident almost rolled out of bed at 4:00 a.m. on rounds during incontinence care. The first shift CNA reported the Resident had a bruise on her forehead measuring 4 centimeters (cm) x 7 cm. The facility notified hospice. Vital signs and neurological checks were done. All were within normal limits. As needed pain medication had been administered to the Resident. A Facility Investigation Brief Description of the Incident completed by the Director of Nursing (DON) with an incident date of 6/10/23 documented at approximately 6 a.m. Staff F, CNA and Staff G, CNA went into Resident #6's room to get her up for the day. Upon entering the room and turning on the lights, they noted the Resident had a big bump and bruise on the right side of her head. Staff F and Staff G reported this to Staff H Registered Nurse (RN). The Resident's room, upon entering, was set up with a bedside night stand on the Resident's left and an over-bed table on the Resident's right, perpendicular to the bed. Staff H administered the Resident as needed pain medication and notified hospice who came up to see the Resident and the family, who also joined hospice at the facility. An interview of the staff that worked that night was conducted. It had been noted that Staff N and Staff O, CNA's, entered the Resident's room about 5:30 a.m. to check and reposition the patient for the last time on their shift. They both reported the Resident did not have any bumps or bruising on her face upon entering the room. During this time the bed was raised to working level. Staff O was on the Resident's left side and Staff N was on the Resident's right side. Staff N placed an incontinence brief on the Resident. The Resident was on her left side facing Staff O and he assisted in supporting and rolling the Resident. The Resident unexpectedly rolled forward more causing her feet to slide off the bed. At that time, Staff N went to the left side of the bed to help Staff L get the Resident's legs back in bed. Staff O was supporting the Resident's upper body while Staff N placed the Resident's legs back in bed. They did this without further incident, finished up cares and made the Resident comfortable in bed. Both CNA's stated they did not see or hear the Resident hit their head. They both said they were focused on getting her legs back in bed so they were looking in that direction. Both CNA's agreed it was possible her head hit on the bedside table but neither saw this happen and the Resident did not call out in pain or call out at all. Both CNA's stated when they left the room about 10 minutes after entering, the patient had nothing visible on her face or head and did not say anything about her face or head. The Type of Injury documented a right frontal and periorbital (the area around the eyes)/premolar (the permanent teeth located between the molars in the back of your mouth and your canine teeth, or cuspids, located in the front) soft tissue contusions (bruising caused by a direct blow to the body that can cause damage to the surface of the skin and to the deeper tissues) without underlying fracture (broken bone) identified. The Facility Investigation detailed the following immediate actions taken on 6/10/23: a. 6:00 a.m. large bump noted upon entering the room on the Resident's head. b. 6:15 a.m. as needed morphine given for pain and the on-call hospice nurse notified. c. 7:40 a.m. as needed morphine given again for pain. d. 8:55 a.m. hospice called for an in-person visit. e. 9:25 a.m. hospice arrived. f. 11:00 a.m. family arrived. g. 12:30 p.m. a decision was made to send the Resident to the emergency room and the Resident was transferred out. h. 3:00 p.m. call from the hospice nurse stating everything is negative and the Resident would be returning. i. 4:00 p.m. call from the hospice nurse stating the Resident would not be returning and had been admitted to the hospital. The Facility Investigation Disposition documented the Resident had been sent to the emergency room following bruising and a hematoma to the right side of the face with unknown origin. The Resident admitted to the facility on [DATE]. She had a primary diagnosis of chronic atrial fibrillation. The Resident is dependent for all activities of daily living (ADL's) and transfers with assist of two staff with a hoyer lift. The Resident at times needs assistance with feeding, but is able to feed self at times. Upon admission her BIMS was a 7 (10/09/21); BIMS of a 4 (11/24/21) and by March of 2022 she was not able to participate successfully to complete a BIMS. The Resident had recently been placed back on hospice at the beginning of June 2023. She did not have a strong fall history. The facility was unable to interview her on the incident as she had no short-term memory recall. She could answer simple yes/no questions but not with 100 percent accuracy. The Resident called out when she wanted to lay down, get up, or have a drink. She spent most of her days in bed at her request, but did get up for meals. The family decided to send her to the emergency room (ER). The ER nurse called the hospice nurse, who called the facility around 3 p.m. that same day and stated there were no injuries found. The computer tomography (CT) scan (a CT scan is a diagnostic imaging exam that uses X-ray technology to produce images of the inside of the body) and x-rays were negative. The Resident would get a liter of fluid and return to the facility. About 1 hour after that the ER nurse called the hospice nurse who call the facility and said the Resident would not be returning and had been admitted with a diagnosis of a concussion. A head to toe assessment had been done and there were no further new injuries. The Resident's roommate had a BIMS of 9 and could not be interviewed. All residents with a BIMS of 13 or above were interviewed on 6/10/23 in regard to abuse. All residents with a BIMS below 13 had skin checks conducted. There were no verbal reports or concerns identified and no physical new areas of concern identified. Staff N's Witness Statement dated 6/10/23 documented last night on rounds about 5:30 a.m. she had been helping Staff O with Resident #6's. She was on the right side of the bed. She cleaned the Resident up and the Resident faced the wall where Staff O stood. Staff N tucked the pad under the Resident who was resisting some and pushing back on her. She tried to calm her down by talking to her and telling her what she was doing and that it would be okay. Suddenly the Resident stopped resisting and when she did her whole body moved forward and the lower part of her legs fell off the side of the bed. Staff O was on that side of the bed holding her upper body from falling. She went to the other side of the bed to help him put her legs back in the bed. Staff P CNA was coming into the room at this time to see if we needed help and Staff N shut the door, Staff P went down and told Staff H the nurse that they may need help. Staff H came into the room and asked if everything was okay. By that time, they had her legs back in bed and she was okay. They finished her cares by fastening her brief, getting her centered in the bed, comfortable, put her bed down to the ground, gave her the call light, covered her and left. The Resident did not have any injury when she left the room. She did not see her hit her head but assumed that it might have happened as her head was toward the edge of the bed and the table was right next to the bed. She had been focused on her legs and getting her them back in bed. The Resident did not say anything that would have indicated she hit her head. She did not call out in pain. Staff O's Witness Statement dated 6/10/23 at 8:55 a.m. given by a company representative documented he and another aide were in the process of changing the Resident. They had her rolled toward him and her feet slipped off the bed. He stated she was close to the edge. He held her up while the other aide went to get her legs back on the bed and stabilize her. He stated he didn't notice any injuries or bumps anywhere. He stated his main concern was for her to not fall on the floor as she was high up due to being changed. He said that when she slipped she may have hit her head on the table by her bed as that was the side he was trying to hold her up on. He had let the supervisor know and if there were more questions, someone would reach out to him. Staff P's Witness Statement dated 6/10/23 documented he did not provide cares to the Resident that night. After his last rounds he could hear the Resident yelling, which was not abnormal because she yelled a lot with cares but he went to her room anyway to check if she was yelling for help or if someone was in the room and needed help. He got to the door of the Resident's room and started to open the door and Staff N pushed the door back in his face. He stood outside the door for about 1-2 minutes then Staff H came down and went into the room so he figured they were okay and walked away. Later Staff N and Staff O informed him that the Resident's legs had fallen out of bed and Staff N had pushed the door back on him because she was running over to help put the Resident's legs back in bed and the door was in the path of that. He didn't actually go into the resident's room at any point that night. Staff F's Witness Statement dated 6/10/23 documented when she came in and got report nothing was mentioned about the Resident. At 6:00 a.m. she went into the Resident's room with Staff G, they immediately noticed a big bump on her head. They proceeded to get her dressed and ready for the day. As they were rolling her the Resident shouted, don't drop me again! She was shouting for a doctor as well. They finished getting her up and reported what had happened to the nurses. Staff G's Witness Statement dated 6/10/23 documented when she and Staff F entered the Resident's room, they noticed a red swollen bump on her head. They continued to dress her and get her up for the day. She brought her out to the nurse's station and asked Staff H and Staff Q, RN if anything had been reported. Neither knew about any injury. Nothing had been reported. While getting her dressed she kept yelling, don't drop me again. Staff H Witness Statement, undated, documented during the early morning medication pass on 6/10/23, Staff O and Staff N were doing final round check and changes. They changed Resident #6 at approximately 5:20 p.m. Afterwards Staff O stated to him that the Resident had almost fallen out of bed during incontinence cares, but he was able to keep her from falling. He described she was close to rolling off the edge of the bed, but a fall was narrowly missed. The day shift nurse at 6:00 a.m. was a no show. At 6:15 p.m. Staff H notified management of the no show. Shortly thereafter, the day shift CNA's brought Resident #6 out to the hallway by the nurse's desk. The Resident was agitated and had an obvious bruise above her right eye extending into her hairline. The short hall day shift nurse, Staff Q, administered as needed morphine and called the hospice after hours answering service. He was aware that the Unit Manager was on his way to relieve him. The hospice on call nurse returned a call and stated to continue to treat for pain, do vital signs and neuro checks, and apply ice if needed. The hospice staff would be in to assess. He administered her scheduled medications, because they included Tylenol and lorazepam. Her vital signs and neurological checks were within normal limits. Her pupils were equal and reactive. Her right eye was not swollen shut. No changes in mentation were noted. When the Unit Manager arrived, he instructed me to enter it under risk management and skin issues since a fall was not reported but still under risk management. Hospice would be in to assess and issue orders from there. At that time the bruise measured 4 centimeters (cm) by 7 cm long. When he left, the Resident had been sitting in the wheelchair in the hallway. The Unit Manager was the nurse on the hallway and hospice was coming in to assess. The DON's Written Statement dated 6/10/23 documented she had been notified by the Unit Manager who was working as a floor nurse that day. The Resident had a rather large bump on her head and hospice had been called and was coming in. Staff were unclear about what had happened. She was scheduled to work on the floor following the Unit Manager midday. She arrived to work and went to the Resident's room first. The Resident's son, daughter, daughter's husband and the hospice nurse were in the room. The hospice nurse told her she was discussing options with the family as far as sending her to the ER. She had explained what would happened with her hospice care both ways. She also explained the risks and benefits of being seen. All other options were explained to the family. She joined in the conversation supporting the hospice nurse. At that time, she only knew the Resident was bruised with a bump. She had not talked with all staff. She assured the family they would conduct an investigation and the incident would be turned into the State of Iowa (Iowa Department of Inspection and Appeals, DIA) for further review. Around 12:30 p.m. the hospice nurse approached her and said the family was going to send the Resident to the ER and she had called for transport. She gathered the paperwork needed and called report to the ER nurse. She informed the ER Nurse of the situation and that her next steps were to do a formal report to DIA. A Second Witness Statement with Staff O dated 6/10/23 completed by the DON documented she wanted to clarify the incident with Staff O. Staff O repeated he did not see the Resident bump her head. The Resident did not call out in pain and he did not hear anything. When he left the room, the Resident was resting in bed and nothing was on her face. He stated he was a bit shook up because he was worried she was going to fall and was very glad that a fall from bed had been prevented. He stated he had told the nurse about the near fall incident after leaving the room. The Unit Manager's Witness Statement dated 6/12/23 documented on Saturday 6/10/23 when he arrived to work to relieve the 3rd shift nurse (Staff H), the Resident was sitting in the hallway against the wall in her wheelchair. During report Staff H informed him that the Resident had a large goose egg to her forehead above her right eye. Staff H stated that nothing had been reported to him until the day shift CNA's got her up for the day. He proceeded to do his skin protocol and stated the hospice nurse was aware of the situation. The Resident talked at the time and was taken down to the dining room for breakfast. Around 8:30 a.m. the Resident came back to her room and was placed in bed. At 8:50 a.m. the Resident was lying in bed. Her goose egg had swollen and her right eye was starting to swell shut. Per nursing judgment ice was placed and hospice was notified to come see the Resident at 8:55 a.m. Hospice arrive to see the Resident at 9:25 a.m. Hospice started to make their calls and notifications. He continued with his medication pass and treatments as scheduled. Hospice informed him the family was going to be coming to see the Resident and would decide what they would like done. The Family arrived around 11:00 a.m. and met with hospice. The hospice nurse asked for Tylenol and Lasix to see if she would take her medication which she did. The DON relieved him at 12:00 p.m. The DON took over the situation from there. During an interview on 6/26/23 at 2:09 p.m. Staff Q reported he had picked up a four-hour shift on 6/10/23. When the aides on first shift brought Resident #6 out to breakfast, she had a red lump on her head. Bruising had started on her right forehead but wasn't very pronounced at that point. He stated by 10:15 am judging from time how fast it started to swell and bruise, he thought something had probably happened on the last rounds between 4-5 a.m. The night shift had one agency aide, Staff O and two other aides, Staff N and Staff P. He gave the Resident morphine around 6:15 am. On 6/27/23 10:57 a.m. The Hospice Patient Care Director reviewed the Resident's medical record and reported a call first came through their triage around 6:43 a.m. The nurse returned a call to the facility within 2 minutes. Staff H reported the Resident had a goose egg on the right side of the forehead measuring 4 cm x 7 cm. A CNA reported she had almost rolled out of bed, but didn't. At 8:46 p.m. the Unit Manager called triage to notify the area was getting larger and requested a hospice visit. The Unit Manager reported the Resident did not receive her morning insulin as she didn't eat breakfast. When the hospice nurse arrived, the Resident lay in bed with her eyes closed. She opened her left eye and said her name, but wouldn't answer any other questions. The facility should have notified the family as it took them a long time to get to the facility. The hospice nurse called the son within about 10 minutes of getting to the facility. The family was very distressed at what had happened at the facility. The POA questioned if they dropped her on her head or hit her in the head with something. The hospice nurse went through options with the family. They decided to have to go to the ED due to using Eliquis and potential for a brain bleed. Two aides reported the Resident had been unable to eat that morning. She acted like she didn't know how to chew. They took food out of her mouth and took her back to room and laid her down. The facility staff denied a fall or injury. The hospice nurse followed up with the hospital staff in the afternoon. She had a soft tissue contusion. The x-rays showed no fractures. She stayed at the hospital per family request until they could find another facility. On 6/10/23 at 4:17 p.m. the hospice nurse called to report the Resident had been admitted to the hospital unable to eat or drink and with concussion. On 6/27/23 at 3:34 p.m. The Hospice RN Case Manager reported she got to the facility and the Resident lay in bed with a hematoma and bruising to her right forehead and along the top of her hairline. The bruising had started to move downward on her forehead. The right eye was swollen and looked like it had water injected into it. It was starting to turn black. She was on Eliquis (blood thinning medication) 2.5 mg. As she had walked to the Resident's room, the Unit Manager stood there and said they found her with a bump on her head and they were not sure what had happened. The resident did not say anything to her while she was at the facility. She asked her questions but she did not get answers the questions. By what the family said, she could answer yes or no questions, but couldn't carry on a conversation. When she examined her head it seemed like the injury impact happened on the top of her head and the swelling was settling more on the forehead. She could not speculate about the injury. She said the facility thought she had rolled and hit her on the nightstand. She didn't see that as a viable option, she feels there would have been a laceration or an abrasion to the side of the head and the hematoma probably would be smaller. It seemed like there was a direct impact with the top of her head. It would make sense if someone rolled her she could have rolled out of bed onto her head but that is speculation only. She contacted the daughter who was in shock. She wanted to know what happened to her mom. She told her the facility didn't know at that point what had happened. She asked her to come to the facility so they could make decisions on if the Resident needed to stay in the facility or transfer out. At first the family thought she was on hospice and it seemed like they were not going to send her out. The son got agitated since there were no answers on what happened, so he wanted her sent to the hospital so he knew what the extent of the injuries were. She reported she followed up with the hospital on 6/10/23 at 15:15 p.m. there were no brain bleeds and no fractures to the face and the hospital was sending her back to the facility. Then 16:20 p.m. hospital called and said she had a bad concussion and couldn't eat or drink so they were going to keep her. During an interview on 6/27/23 at 5:27 p.m. Staff O reported he had been coming to the facility for approximately 1 month. He didn't recall a crashing sound, or the Resident calling out for help. He didn't notice any injuries while they were in the room. He was on his way home from work when Staff H called and asked him what had happened as the Resident had a knot on the side of her head. He had assisted Staff N with incontinence cares on the Resident. The Resident lay in the first bed as you entered the room. The room layout was her bedside stand, the bed, the space between the two roommates, her roommate's recliner, then her roommates' bed. He had been on the left side of the bed. She had been hollering out earlier in the night and they had said she does that when she is wet. They went in the room and by then she had calmed down and had her eyes closed. She was pretty out of it at that time, sleeping. They did a check and change and her legs rolled off the bed and she came toward him so fast. He supported her body weight. Her feet never hit the floor but her left arm was the only thing on the bed. The rest of her body was laying on him. He was trying to keep her from hitting the floor. They had put the bed height up so that they could do the check and change. She just rolled off the bed with her legs going to the left. She was laying on her arm with her belly and body across him. Her left arm was still on the bed. Her legs were hanging off the bed and her head was hanging off the bed. The rest of her body was laying on him. He didn't want her to hit the floor. Staff N grabbed her legs and rolled her back over onto the bed. He never heard a bang or heard the resident yell out to indicate that she had hit anything with her head. Once they got the check and change completed he went out in the hallway to get some linens and told Staff H she almost rolled off the bed. The nurse stated as long as she didn't hit the floor, it was okay. The nurse didn't even go in to see her at that time. The resident never said anything. He was holding almost all of her body except the arm that was touching the bed. Her legs were off the side of the bed and her head was hanging off the bed. He did not hear a bang or anything or hear her say ouch. The bedside stand was up next to the bed. She could have hit that with her head but he didn't see it. It had happened so fast. He doesn't recall if the bed was higher than the bedside stand. He didn't remember where her head was but it was hanging off the bed. She did not have any side rails up on her regular size bed. He guessed she had been a little too close to the edge of the bed. They should have moved her over in the bed before rolling her to her side so that it would not have happened. He was not meaning for her to get hurt. He was trying to keep her off the floor, but she got hurt anyway. He thought the way her legs went over so fast and she came out of the bed so fast, they should have moved her over in the bed before rolling her. On 6/28/23 at 10:22 a.m. Staff F reported she had asked if anyone had fallen during the night as part of report that morning. There had been no falls. They always get the Resident up right after report in the morning around 6:06 a.m. Staff G had walked in the Resident's room right after her and the Resident lay in bed with a large bump on the right side of her head that looked like a cone head. Staff G went to talk to the nurse and she stayed with the Resident. The Resident stated her head hurt and to please don't drop me again. They got her up via hoyer lift. She was in her normal disposition when they hoyered her into her chair. She yelled out her head hurt and to take her to the doctor, she kept repeating that over and over until they took her out for breakfast for about an hour. She kept checking in with the Unit Manager to see where they were with things. The Unit Manager said they were waiting on hospice. She took her out to breakfast and tried to feed her. The Resident just let food sit in her mouth. She wouldn't chew or swallow. It was frustrating to her as the resident clearly was not okay. Around 9:00 - 9:30 a.m. she and Staff G took the Resident back to her room and laid her down. They put the head of the bed up. At that point she was developing more swelling on the right side of her face and trailing down from the bump on her forehead. Her bruising was more pronounced. It looked like she was bleeding out of her pores. Hospice came shortly after and put ice on her head. They were trying to make her comfortable. A review on 6/28/23 of the Emergency Department to Hospital admission records from 6/10/23 for Resident #6 documented Resident #6 as a [AGE] year old female with a history of dementia, insulin dependent diabetes, congestive heart failure, atrial fibrillation and presented to the emergency department via emergency medical services for evaluation of facial swelling. The nursing home reported the patient had been found to have swelling and pain over her right forehead and around her right eye. She was sent to the ED for further evaluation. The nursing home was unable to determine what had happened during the night to cause this injury. The Resident presented in the emergency room with a blood pressure of 168/92, heart rate of 72 beats per minute, respirations of 22 breaths per minute, temperature of 97.3 degrees, and an oxygen saturation rate of 92%. On Physical Exam she did not exhibit any acute distress and had tenderness and swelling to the superior aspect of the right orbit and lateral orbital region of the right eye. Swelling noted to the right upper eyelid. The Comprehensive Metabolic Panel showed an abnormally high sodium level of 151 (normal range 136-145). Further lab results showed a Protime (A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample) of 15.8 high (normal range 9.4 - 12.5) and an elevated INR (An INR (international normalized ratio) is a type of calculation based on PT test results. Prothrombin is a protein made by the liver. It is one of several substances known as clotting (coagulation) factors) of 1.3 (normal range 0.8 - 1.2). The Resident admitted to the hospital with a diagnosis of injury to head, dehydration, hypernatremia, and type 2 diabetes mellitus with other specified complication, with long-term current use of insulin. During an interview on 6/28/23 11:19 a.m. The Discharging Hospital Doctor of Osteopathic Medicine reviewed the Resident's sodium level from the emergency room records and reported Resident #6 was severely dehydrated and her electrolytes were off. He stated the family had stated she had been eating a banana and candy bars two days prior to the incident. He couldn't state that the dehydration was caused by the facility versus a result of a very recent head injury that caused her to quit eating and drinking. She had been hospice prior to the hospitalization and they were talking to the family about hospice again. They were going to send her back to the facility but then she was admitted for dehydration. He remembered the family did not want her to go back to the nursing home. She responded very well to the IV fluids treatment, woke up, was eating, talking, and discharged to a nursing home on hospice care. On 6/28/23 at 11:56 a.m. Staff G reported they went into the Resident's room around 6:00 a.m. She saw the lump and asked Staff F if she had seen it. She had a goose egg on her right side of her head by the hairline. They got her ready and took her out to the nurse's station. She asked Staff Q and Staff H if there were any falls or incidents and they both said no. They turned on the hallway lights and took a look at her. They took vital signs on her and started calling the CNA's to see what had gone on. They put her back in bed after breakfast. When they were rolling her in bed she screamed please don't drop me again. She repeated it again and again. She thought she probably went head down onto the floor and they picked her back up and didn't realize how bad it was. The Resident didn't say anything at the breakfast table she was very disoriented at the breakfast table. When at the nurse's station she had been asking to see a doctor. The nurses were really not paying attention to her. There were no actual cuts that she could see, but it looked like she was bleeding out of her pores by 9:30 a.m. The Unit Manager requested they start putting ice packs on her head when they laid her back down. She always used two aides to reposition her in bed. She was really stiff and if she went over too far, you would not be able to keep her from going down on the floor from the bed. To her knowledge night shift did not get her up with the hoyer that night. On 6/28/23 at 12:34 p.m. Staff N reported Staff O needed help just finishing rounds on his side. Resident #6 was worked up. She was on the Resident's right side of the bed and Staff O was on the left side of the bed. They rolled the Resident toward the wall and she was providing cares to her. She had one hand holding her by her hip a little bit, Staff O was holding her on her side as well. She cleansed her bottom and the Resident pushed back and was resisting care. The Resident didn't say anything, she was just really worked up. All of a sudden, the Resident stopped resisting and the counter pressure of her hand on her hip the resident went forward out the edge of the bed and her feet went off the bed. She kind of rolled over and Staff O was holding her up. She thought her bottom was still on the bed. She ran over to that side of the bed to get her feet back in the bed. Staff O supported all of the Resident's weight. At that time there was som