**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #25 required extensive assistance of two persons with bed mobility, dressing, and toilet use. In addition, she required total dependence on two persons for transfers, and extensive assistance of one person for personal hygiene. The assessment indicated that Resident #25 could not ambulate (walk) and needed one person to push her wheelchair. The MDS included diagnoses of cancer, heart failure, diabetes, depression, and a compression fracture of the spine (broken bone caused by weakness in the back). On 5/30/23 at 10:53 AM Resident #25 stated she fell out of a lift and fractured her back. She stated she went to the hospital and had a raging urinary tract infection (UTI), fluid on her heart, and a fracture in her back. In another interview the same day at 1:05 PM, the resident explained that she fell out of a standing lift, as Staff D, Certified Nursing Assistant (CNA), operated it. She reported that she did not have anyone else in the room when it happened. Resident #25 added that staff now use a full-body mechanical lift to transfer her. Resident #25 explained that oftentimes the staff transfer her alone when there is supposed to be two people. On her wall at the head of the bed, observed a sign that instructed to only use a nonmechanical stand-to-sit for Resident #25. The Health Status Note dated 4/16/23 at 9:00 PM indicated that Resident #25 reported that her pain management routine worked and she slept better. She added that she could get around better with her medication schedule with the Tylenol and tramadol (pain medication). The Health Status Note dated 4/18/23 at 12:54 PM written by Staff F, Registered Nurse (RN), indicated that a Certified Nurse Aide (CNA) reported that Resident #25 did not stand well in the mechanical standing lift with an assist of one. The CNA described that Resident #25 pulled her arms up and bent her knees. The Health Status Note dated 4/19/23 at 1:38 AM documented by Staff E, Licensed Practical Nurse (LPN), that Resident #25 continued to have difficulty standing with transfers. The Health Status Note dated 4/25/23 at 6:54 AM labeled Late Entry written by Staff F indicated Resident #25 complained of shortness of breath, shallow respirations, poor eye contact, flat voice, and diminished lung sounds. Resident #25 had stable vital signs, oxygen saturation of 98% on room air, denies pain while in bed, and when up has pain of 7 of out 10 (0 no pain, 10 the most pain). The nurse encouraged Resident #25 to increase their activity. The Communication - Other Note dated 4/25/23 at 2:50 PM listed that the nurse requested a muscle relaxer per therapy recommendation. The Communication/Visit with Physician Note dated 4/25/23 at 8:30 PM labeled Late Entry detailed new orders by the provider. Resident #25 will have X-rays on the next day of the T-Spine (upper middle back), and L-Spine (middle to lower back). In addition, the provider provided an order for baclofen (muscle relaxer) one tablet three times a day as needed for back spasms. The nurse notified the family and updated the clinical record. The Health Status Note dated 4/26/23 at 11:56 AM indicated that Resident #25 had an X-ray. She continued to complain of pain with activity. The Lab/Diagnostics Note dated 4/27/23 at 5:41 AM listed that the facility received the x-ray results and faxed them to the Primary Care Provider (PCP). The Health Status Note dated 4/27/23 at 9:30 AM written by Staff F indicated that Resident #25 continued to complain of sharp pain on her left of her back radiating to the flank area (lower left side of back) without radiation to her left arm. Vital signs remain stable with an oxygen saturation of 88% (normal is 90% and above), blood pressure of 126/58, temperature of 95 (average 98.6), pulse of 88 (typical range 60-100), and respirations (typical range 12-20). As the staff assisted Resident #25 to the bath chair in the standing mechanical lift, she complained of a sharp pain in her left side of her back. Resident #25 received her scheduled Tramadol (pain medication) and Tylenol earlier in the morning. The Communication/Visit with Physician Note on 4/27/23 at 10:12 AM identified the nurse called the PCP's office to provide an update on Resident #25's condition. The Communication/Visit with Physician Note on 4/27/23 at 1:41 PM indicated that the facility received a fax from the physician that dictated that Resident #25 had chronic (long-term) degenerative changes. The physician directed to schedule an appointment with her PCP in the office unless she would not wait. The nurse updated the resident and her niece then got a bed hold agreement. The nurse provided a report to the emergency room (ER). The Health Status Note dated 4/27/23 at 1:50 PM recorded that Resident #25 went to the ER with staff in the facility van. The ED Provider Notes dated 4/27/23 at 2:37 PM listed Resident #25's chief complaint as a report of slipping from the sit-stand machine and jarred her back making her pain worse in her back around to her abdomen. Resident #25 came to the ER for an evaluation of mid back pain. She reported when in a lift the machine came down somewhat quickly and stopped. As that happened she developed immediate onset of mid back pain. Resident #25 denied extension of the pain into her legs but did feel like it came across her upper abdomen to her chest. She reports a history of chronic low back pain but explained her current pain is different. Resident #25 denied any exacerbation of her regular back pain. She tried tramadol that day with little or no relief. Resident #25 did have an X-ray the day before that had negative results of any acute fracture. The assessment revealed that Resident #25 had some tenderness at approximately T-11 on palpation (a type of touch used to assess). The Discharge instructions directed to increase her tramadol to 50 milligrams (mg) three times a day for one week and continue Tylenol. Apply ice to the affected area for 20 minutes per hour while awake for that day and the next day. If worsening or changing symptoms contact the clinic and follow-up as needed. The Final Impression list thoracic back sprain, initial encounter. The Progress Notes dated 4/29/23 at 9:29 AM indicated that Resident #25 had back pain of the thoracolumbar region for greater than six weeks. She started on a muscle relaxant and received tramadol for her pain without improvement. The etiology of the pain could be from a kidney infection, however, due to the musculoskeletal nature, regarding the full-boy mechanical lift incident in the nursing home, proceed with CT scans to rule out a compression fracture or any other potential etiology of her back pain while hospitalized . The CT Thoracic Spine without contrast dated 4/29/23 impression listed the following a. Inferior endplate fracture at the T8 b. Degenerative change of the spine. There is central canal stenosis and neurol foraminal narrowing at T10-11. c. Small effusions with bibasilar atelectasis d. Findings suggesting pulmonary edema. The Progress Notes dated 4/30/23 at 8:23 AM indicated that Resident #25 told her PCP that she had an incident at the nursing home where she fell. She described the incident as the staff tried to transfer her and pivot her standing, her legs gave out and she went down rather hard on her buttocks into the chair. She reported that she felt the worsening back pain at that time but could not remember when the incident occurred. The Communication/Visit with Physician on 5/2/23 at 3:57 AM the facility received Resident #25's X-ray results the PCP wrote that the X-rays on 4/26/23 with negative results. The X-ray results on 4/29/23 revealed a compression fracture at her T-8. The PCP questioned if Resident #25 had a fall. The nurse responded that they did not know of any falls but she did use a sit to stand with a sling. Resident #25 chicken wings (bends her arms at an upward angle) and needs to sit quickly. The Communication/Visit with Physician dated 5/2/23 at 2:21 PM indicated the PCP reviewed the X-Ray and Resident #25 remained in the hospital. The PCP wrote that Resident #25 reported that she fell at the nursing home. The PCP explained that Resident #25 had a compression fracture of her T-8. The PCP indicated that her record did not have any documented falls. On 5/31/23 at 1:35 PM the Director of Nursing (DON) reported that they did not do an investigation or report regarding resident's compression fracture findings due to the hospital discovering it. She explained that they reviewed their records and found no staff reports or documentation of a fall. On 5/31/23 at 2:45 PM Staff F reported that she did not think that she documented on 4/18 that anyone told her that Resident #25 had problems with the mechanical standing lift, and if she did, she couldn't remember. She denied remembering any incidents or concerns with Resident #25 using the stand. On 5/31/23 at 3:06 PM Staff E, Licensed Practical Nurse (LPN), remarked that she could not remember documenting on 4/19 that Resident #25 had difficulty with the mechanical standing lift. She reported that she did not know about any incidents with Resident #25 using the stand and complaining of back pain. When asked what she would do if that someone reported that to her, she replied that she would let therapy know, but therapy said resident did fine with the mechanical standing lift so to keep using it. On 5/31/23 at 3:20 PM Staff H, Occupational Therapist (OT), explained that that all staff received training that they could always do more for the resident, but not less. She stated if the staff or the resident felt uncomfortable using the standing mechanical lift or standing lift, they could always use a full-body mechanical lift to transfer the resident without having to call them before using it, and have the nurse notify them of the concern to address it the following day. She stated that Resident #25 did do well with the lift in therapy and that in her opinion, Resident #25 tried harder for them (therapy). She also felt that Resident #25 felt more comfortable with some staff than others. She stated that staff use chicken winging, but it can present differently from one staff member to another, such as elbows pointed out away from the body or pointing upwards like a flapping motion. On 6/1/23 at 10:30 AM Resident #25's physician from the ER explained her compression fracture was consistent with a sudden stop coming down in the lift. 3. Resident #42's MDS assessment dated [DATE] listed a readmission date of 2/17/23 from an acute hospital. The MDS identified a BIMs score of 14, indicating intact cognition. The MDS indicated that Resident #42 required extensive assistance of two persons with bed mobility and toilet use. The MDS listed that Resident #42 required total dependence of two persons with transfers and could not ambulate. The MDS identified that Resident #42 had an indwelling catheter. The MDS identified Resident #42 is at risk for developing pressure ulcer and that he had an unhealed stage 2 pressure ulcer during the seven-day lookback period. The MDS included diagnoses of hypertension (high blood pressure), obstructive uropathy, end stage renal disease, and malnutrition. On 5/30/23 at 1:28 PM Resident #42 reported that he went to the hospital a couple of days ago. The Care Plan Focus revised on 7/21/22 indicated that Resident #42 had an indwelling catheter related to benign prostatic hyperplasia with obstructive uropathy (prostate gland enlargement with obstructed urinary flow). The Care Plan intervention dated 12/9/21 directed the staff to monitor for signs and symptoms of a urinary tract infection such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increase pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. The Transfer to Hospital V5 note dated 2/13/23 at 3:23 p.m. indicated that Resident #42 went to the hospital due to urosepsis (severe UTI). The eAdmin Record (Default Note) dated 2/16/23 at 1:26 p.m. indicated that Resident #42 remained in the hospital. The Last BM and Admit/Re-Admit note dated 2/17/23 at 7:13 p.m. indicated that Resident #42 had a septic UTI that required hospitalization. Resident #42 required physical therapy for strengthening. A Physician order dated 2/17/23 directed staff to administer Apixaban (anticoagulant/blood thinner) 2.5mg (milligrams) two times a day for atrial fibrillation (irregular heart rate). The Care Plan revised on 5/17/23 identified Resident #42 was on anticoagulant therapy and directed staff to monitor, document and report to the doctor as needed for signs and symptoms of anticoagulant complications such as bruising. The Health Status note dated 5/20/23 at 3:58 p.m. indicated that Resident #42 had strong smelling dark urine. The note directed to push fluids. The Communication/Visit with Physician dated 5/23/23 at 1:38 p.m. identified that Resident #42 saw the physician for nursing home rounds. The physician gave no new orders. The Health Status note dated 5/24/23 at 12:07 a.m. documented that Resident #42 experienced confusion. He attempted to change the channel on his tv with his recliner remote. The Care Plan Review note dated 5/26/23 at 7:46 a.m. indicated that Resident #42 used apixaban without adverse reactions. The Health Status dated on 5/27/23 at 2:09 p.m. listed that the nurse faxed the physician on 5/26/23 due to Resident #42's strong smelling urine that contained mucus and his confusion. At the time of the note, the physician had not responded to the fax. Resident #42 appeared slumped in the chair most of the time, with purple urine in his urinary catheter. He reported being fine just tired. The nurse noted his vital signs with in normal range for him. Resident #42 described his urine flowing across the floor that made a puddle in front of him that he could see. The nurse looked at the floor and noted it as dry. The nurse visited with the ER staff about Resident #42 and received an order to send him for an evaluation. At 2:40 PM Resident #42 left the facility in route to the hospital with his family following. Resident #42's After Visit Summary from the ER dated 5/27/23 listed a diagnosis of a urinary tract infection with hematuria (blood in urine). The form instructed the facility to administer Bactrim DS as ordered. The Health Status note on 5/28/23 at 2:26 a.m. indicated that Resident #42 returned to the facility at 7:35 p.m. with a diagnosis of a UTI and a new order to start Bactrim DS (antibiotic) by mouth twice a day for five days. The Order Details dated 5/29/23 identified an order for Bactrim DS Oral Tablet 800-160 milligrams (MG) one tablet two times a day for a UTI for 5 days. Resident #42's clinical record lacked documentation, assessment, treatment, and follow up on Resident #42's urinary symptoms after 5/20/23 until 5/27/23. On 6/1/23 at 7:25 a.m. observed Resident #42 lying in bed with his catheter drainage bag hanging from the bed and touching the floor. The urinary catheter contained pink tinged urine in the tubing and the bag. Resident #42's arms appeared to have extensive bruising (dark in color), the left arm looked to have an old scabbed skin tear. Staff C, LPN, reported that Resident #42 commonly had bruises to his arms. On 6/1/23 at 1:07 p.m. Staff S, License Practice Nurse (LPN), acknowledged that he made an entry in the progress notes on 5/20/23 regarding Resident #42's dark and strong-smelling urine. Staff S reported having concern because he knew Resident #42 had a history of UTIs and sepsis. Staff S stated he thought he faxed the physician but could not state for sure. Staff S explained that he only worked weekends and did not know what happened on Monday through Thursday. Staff S verified that he sent Resident #42 to the ER the following Saturday (5/27) due to Resident #42 appearing dopey, slouchy, and had purple colored urine. On 6/1/23 at 1:38 p.m. the Director of Nursing (DON) reported that she could not locate a physician notification on or after 5/20/23 until Resident #42 went to the ER. On 6/1/23 at 4:51 p.m. the DON reported the facility did not have a policy for UTIs. The Change in Condition Policy revised 3/29/23 instructed the purpose of the policy related to the following: 1.To improve communication between nurses and a provider with nursing is monitoring a change in condition. 2. To enhance the nursing evaluation of and documentation of a resident who has a condition change. 3. To provide a standard format to collect pertinent clinical data prior to contacting the provider when there is a condition change. 4. To standardize shift to shift communication about a resident change in condition On 6/5/23 at 10:52 a.m. the DON stated she expected the nurse to notify the Physician with a condition change and to complete a follow-up urinary assessment. On 6/5/23 at 4:25 p.m. observed Resident #42's bilateral arms and hands with extensive dark colored bruising. Observed two black colored scabbed areas to the left wrist area and one black colored scab to the left elbow area. Observed Resident #42's bilateral arms were very dry. Resident #42 reported the bruising occurred from bumping his arms. On 6/5/23 at 4:30 p.m. Staff T, Certified Nursing Assistant (CNA) reported Resident #42's arms usually appear like that. Staff T, CNA stated Resident #42 picks at his arms at times and usually wears short sleeve shirts. Review of Resident #42's clinical record lacked documentation, assessment, and treatment on the bruises and scabbed areas to the bilateral arms and hands. In addition, the record lacked a skin assessment, an incident report, notification to the physician or his family. The clinical record lacked an intervention or treatment to reduce the risk of further bruising. The clinical record contained no request for labs related to his use anticoagulant therapy and bruising. The facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised 4/26/23 documented if staff observed a bruise, contusion, abrasion, or skin tear on a resident, staff should report it to the nurse immediately. The policy further directed to monitor the bruise/contusion/skin tear/abrasion every week, document any changes and/or progress towards healing, and update the resident's Care Plan. On 6/5/23 at 5:10 p.m. the DON explained that she expected an assessment of bruises and scabbed areas with documentation according to the facility policy. Based on facility record review, hospital record review, resident, and staff interviews, the facility failed to investigate a change in condition for three of three residents reviewed (Residents #22, #25, and #42). Two of the residents had a sudden increase of pain (Residents #22 and #25). Resident #22 walked independently in the facility and experienced a bout of dizziness causing her to fall on 5/13/23. At the time of the fall, Resident #22 denied pain but started to report pain later that evening and requested pain medication. Resident #22 did not use any as needed medication until after her fall on 5/13/23. Resident #22 received no evaluation by a provider until 5/17/23. During the hospital stay, the staff determined Resident #22 had multiple compression fractures in her back. Resident #22 received treatment to one of the compression fractures involving an invasive procedure. Resident #25 received a scheduled pain medication for chronic pain and used a standing lift for transfers. Resident #25 reported that she had an increase in pain after a staff member transferred her with the standing mechanical lift. The facility failed to determine when the injury occurred and failed to have Resident #22 evaluated following her increased pain until Resident #22 requested to go to the emergency room. After a change in condition, the facility sent Resident #25 to the hospital who discovered a compression fracture. In addition, the facility failed to assess Resident #42 who had a history of urinary tract infections (UTI) and sepsis (an infection that is so severe it spreads to the blood) when he experienced signs and symptoms of a UTI. The facility did not provide interventions to Resident #42 until he transferred to the emergency room (ER) seven days after the first documented symptom. Findings include: 1. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated the Resident #22 required limited assistance of one person with dressing. She could independently move in bed, walk in her room, walk in the corridor, use the toilet, and complete her personal hygiene. Resident #22 used a walker and a wheelchair. She could stabilize herself without staff assistance but was not steady with moving from a seated to a standing position, turning around, moving on and off the toilet, and surface-to-surface transfer. Resident #22 received a scheduled pain medication in the previous five days of the lookback period. She had one fall without injury since the previous assessment. The Care Plan Focus revised 6/9/22 indicated that Resident #22 had a risk for falls related to her history of falls. The interventions directed the staff to monitor her for significant change in gait, mobility, positioning device, standing balance, sitting balance, and lower extremity joint function. On 6/1/23 at 2:10 PM observed Resident #22 in her recliner in her room. Resident #22 said that she did not have pain but she did have a lot of pain before and after her back surgery. She said that she got getting dizzy and that's what caused her falls. The Incident Report dated 5/13/23 at 10:30 AM indicated that Staff K, Licensed Practical Nurse (LPN), witnessed Resident #22 fall backwards to the floor landing on her buttocks, then she laid herself down. The Incident Note dated 5/13/23 at 10:30 AM labeled as a Late Entry listed that Staff K witnessed Resident #22 fall. She walked form her bathroom to her chair and fell backward landing on her buttock, then she laid herself down. Resident #22's had range of motion (ROM) within her normal limits. She denied pain and did not hit her head. The staff assisted her with two and a mechanical lift to bed. The nurse notified the Director of Nursing (DON), the physician, and the daughter. The eAdmin Record (Default Note) on 5/13/2023 at 7:07 PM indicated that Resident #22 received a tramadol HCl Oral Tablet 50 milligrams (MG) for back and shoulder pain. Resident #22's family remained at her bedside and requested as needed (PRN) administration as soon as possible (ASPA) as she rarely had such a high pain level. The eAdmin Record (Default Note) on 5/14/23 at 7:45 AM listed that Resident #22 complained of pain from her fall the day before. The eAdmin Record (Default Note) on 5/15/23 at 12:13 AM recorded that Resident #22 could not sleep and requested a PRN pain medication due to pain all over. The Care Plan Review note dated 5/15/23 listed that Resident #22 had one fall during the lookback without injury. She met her pain goal with routine Tylenol. The eAdmin Record (Default Note) on 5/16/23 at 7:30 AM documented that Resident #22 reported back pain. The Communication/Visit with Physician on 5/16/23 at 7:33 PM indicated that Resident #22 had a lot of pain at the start of the shift. She reported the pain came from a fall over the weekend. The physician gave an order for an X-ray of her spine. At 5:45 PM she received the X-ray. In addition, the physician gave an order for a urinalysis (UA). The physician reported that too much tramadol could cause hallucinations. The Health Status Note dated 5/17/23 at 4:15 AM Resident #22 experienced hallucinations and complained of pain but did not know why. Resident #22's May 2023 Medication Administration Record (MAR) listed the following orders and usage: a. 3/24/23 - Tramadol 50 milligrams (mg) one tab three times as day as needed (PRN) for pain. i. Resident #22 did not use the medication until the 13th. ii. Resident #22 received on 5/13 for pain of 6/10, 5/14/23 for pain 8/10, and 5/15/23 for pain of 5/15. b. 3/24/23 - Tramadol 50 MG a half tablet three times a day PRN pain. i. Resident #22 did not use the medication until the 13th. ii. Resident #22 received a half tablet of Tramadol on 5/15 for pain of 8/10. 5/16 for pain of 4/10. The Transfer to Hospital V5 on 5/17/23 at 3:34 PM revealed the nurse sent Resident #22 to the hospital due to complaints of pain rated 8 out of the 10-pain scale (0 no pain, 10 worst pain ever) in her left and right scapula. The Provider Progress Notes dated 5/20/23 at 6:47 PM lists Resident #22's assessment finding as a closed fracture of multiple thoracic vertebrae and an acute cystitis without hematuria (bladder infection without blood in the urine). The Plan directed that the MRI showed a burst fracture (A type of traumatic spinal injury in which a vertebra breaks from a high-energy axial load such as traffic collisions or falls from a great height or high speed, and some kinds of seizures), with shards of vertebra penetrating surrounding tissues and sometimes the spinal canal) at C7 and an endplate compression fracture of L1. The MRI Thoracic Spine without Contrast Results dated 5/20/23 indicated that the evaluation of Resident #22's thoracic spine demonstrates mild exaggeration of the normal thoracic kyphosis. Resident #22 had vertebral body hemangiomas (common vascular lesion found within the vertebral body of the thoracic and lumbar spine) on the T12, T11, and T4. Resident #22 had a T6 burst fracture with fracture line extending to involve the back and front cortex (an outer or surrounding layer of an organ or body part) of the vertebrae. The Provider Progress Notes dated 5/26/23 at 9:54 AM indicated that Resident #22 had a fall two weeks before. She had increased pain since that time. The pain increases with movement and appears constant within the mid back. The pain severity ranges from 6-9 out of 10 on the pain scale. The MRI (specialized assessment images of the body) demonstrated an acute (short-term) supra endplate compression (a type of vertebral fracture that occurs when the vertebrae compress and collapse) of the T6 vertebral body with approximately 50% loss of height. The note indicated to proceed with vertebroplasty (a procedure involving special cement injected into a fractured vertebra - with the goal of relieving spinal pain and restoring mobility). The Discharge summary dated [DATE] included four diagnoses Resident #22 received treatment for in the hospital. a. Osteoporosis b. Closed fracture of multiple thoracic vertebrae c. Closed stable burst fracture of the sixth thoracic vertebra with delayed healing. d. Closed fracture of lumbar vertebra, unspecified fracture morphology, unspecified lumbar vertebral level. The Discharge Summary directed the nursing facility to schedule the Prolia injection (injection used to treat bone loss). On 6/1/23 at 3:40 PM Resident #22's Representative (RR #22) said that they got a call from the facility after her fall on 5/13 that Resident #22 had a great deal of pain. She thought they facility called her over a weekend, and they brought in a portable X-ray machine on a Monday or Tuesday. Resident #22 had surgery and then she fell again the day she went back to the facility. On 6/5/23 at 1:37 PM a Clinic Nurse verified that the clinic received a call from the facility on 5/13/23 regarding Resident #22's fall. She did not see in the notes that the doctor responded with any specific questions or new orders. On 6/5/23 at 9:35 AM Staff K said that as she walked down the hallway, she saw Resident #22 fall back as she transferred to her chair. She said that Resident #22 denied pain at the time, she called an on-call nurse, and left a message. She denied knowing if the doctor called back for a follow up or if anyone followed up later with the doctor. On 6/6/23 at 8:11 AM the DON said that she expected the nurse to call the on-call doctor who worked as the emergency room (ER) doctor over a weekend, if an incident occurred at the facility. The DON agreed that someone followed-up with the doctor when Resident #22 continued to have pain after her fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, emergency room, hospital and facility record review, the facility failed to provide adequate nursing supervision to prevent injuries for 3 of 4 residents reviewed (Residents #22, #25, and #33) for falls. In addition, the facility failed to complete neurological assessments for 1 of 4 residents (Resident #22) reviewed for falls. Despite the facility documenting that Resident #25 had difficulties with standing with her transfers using the mechanical standing lift, no one adjusted the transfer technique to ensure her safety with transfers. Due to the staff continuing to transfer Resident #25 with an unsafe technique, she fell out of the standing lift resulting in a compression fracture in her back. Resident #33 had a history of falls and the facility added interventions to the Incident Report or the Progress notes but never updated the Care Plan to reflect the interventions. In addition, the facility knew that some of the interventions did not work but did not modify the intervention. The facility could not provide documentation to verify the implementation or modification of the interventions. On the fourth fall, Resident #33 fell fracturing her hip and required surgery to repair it. Resident #22 experience an unwitnessed fall that resulted in an emergency room visit following her discharge earlier in the day from the hospital. See F684 regarding additional information related to Resident #22. Findings include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #25 required extensive assistance of two persons with bed mobility, dressing, and toilet use. In addition, she required total dependence on two persons for transfers, and extensive assistance of one person for personal hygiene. The assessment indicated that Resident #25 could not ambulate (walk) and needed one person to push her wheelchair. The MDS included diagnoses of cancer, heart failure, diabetes, depression, and a compression fracture of the spine (broken bone caused by weakness in the back). On 5/30/23 at 10:53 AM Resident #25 stated she fell out of a lift and fractured her back. She stated she went to the hospital and had a raging urinary tract infection (UTI), fluid on her heart, and a fracture in her back. In another interview the same day at 1:05 PM, the resident explained that she fell out of a standing lift, as Staff D, Certified Nursing Assistant (CNA), operated it. She reported that she did not have anyone else in the room when it happened. Resident #25 added that staff now use a full-body mechanical lift to transfer her. Resident #25 explained that oftentimes the staff transfer her alone when there is supposed to be two people. On her wall at the head of the bed, observed a sign that instructed to only use a nonmechanical stand-to-sit for Resident #25. The Health Status Note dated 4/16/23 at 9:00 PM indicated that Resident #25 reported that her pain management routine worked and she slept better. She added that she could get around better with her medication schedule with the Tylenol and tramadol (pain medication). The Health Status Note dated 4/18/23 at 12:54 PM written by Staff F, Registered Nurse (RN), indicated that a Certified Nurse Aide (CNA) reported that Resident #25 did not stand well in the mechanical standing lift with an assist of one. The CNA described that Resident #25 pulled her arms up and bent her knees. The Health Status Note dated 4/19/23 at 1:38 AM documented by Staff E, Licensed Practical Nurse (LPN), that Resident #25 continued to have difficulty standing with transfers. The Health Status Note dated 4/25/23 at 6:54 AM labeled Late Entry written by Staff F indicated Resident #25 complained of shortness of breath, shallow respirations, poor eye contact, flat voice, and diminished lung sounds. Resident #25 had stable vital signs, oxygen saturation of 98% on room air, denies pain while in bed, and when up has pain of 7 of out 10 (0 no pain, 10 the most pain). The nurse encouraged Resident #25 to increase their activity. The Communication - Other Note dated 4/25/23 at 2:50 PM listed that the nurse requested a muscle relaxer per therapy recommendation. The Communication/Visit with Physician Note dated 4/25/23 at 8:30 PM labeled Late Entry detailed new orders by the provider. Resident #25 will have X-rays on the next day of the T-Spine (upper middle back), and L-Spine (middle to lower back). In addition, the provider provided an order for baclofen (muscle relaxer) one tablet three times a day as needed for back spasms. The nurse notified the family and updated the clinical record. The Health Status Note dated 4/26/23 at 11:56 AM indicated that Resident #25 had an X-ray. She continued to complain of pain with activity. The Lab/Diagnostics Note dated 4/27/23 at 5:41 AM listed that the facility received the x-ray results and faxed them to the Primary Care Provider (PCP). The Health Status Note dated 4/27/23 at 9:30 AM written by Staff F indicated that Resident #25 continued to complain of sharp pain on her left of her back radiating to the flank area (lower left side of back) without radiation to her left arm. Vital signs remain stable with an oxygen saturation of 88% (normal is 90% and above), blood pressure of 126/58, temperature of 95 (average 98.6), pulse of 88 (typical range 60-100), and respirations (typical range 12-20). As the staff assisted Resident #25 to the bath chair in the standing mechanical lift, she complained of a sharp pain in her left side of her back. Resident #25 received her scheduled Tramadol (pain medication) and Tylenol earlier in the morning. The Communication/Visit with Physician Note on 4/27/23 at 10:12 AM identified the nurse called the PCP's office to provide an update on Resident #25's condition. The Communication/Visit with Physician Note on 4/27/23 at 1:41 PM indicated that the facility received a fax from the physician that dictated that Resident #25 had chronic (long-term) degenerative changes. The physician directed to schedule an appointment with her PCP in the office unless she would not wait. The nurse updated the resident and her niece then got a bed hold agreement. The nurse provided a report to the emergency room (ER). The Health Status Note dated 4/27/23 at 1:50 PM recorded that Resident #25 went to the ER with staff in the facility van. The ED Provider Notes dated 4/27/23 at 2:37 PM listed Resident #25's chief complaint as a report of slipping from the sit-stand machine and jarred her back making her pain worse in her back around to her abdomen. Resident #25 came to the ER for an evaluation of mid back pain. She reported when in a lift the machine came down somewhat quickly and stopped. As that happened she developed immediate onset of mid back pain. Resident #25 denied extension of the pain into her legs but did feel like it came across her upper abdomen to her chest. She reports a history of chronic low back pain but explained her current pain is different. Resident #25 denied any exacerbation of her regular back pain. She tried tramadol that day with little or no relief. Resident #25 did have an X-ray the day before that had negative results of any acute fracture. The assessment revealed that Resident #25 had some tenderness at approximately T-11 on palpation (a type of touch used to assess). The Discharge instructions directed to increase her tramadol to 50 milligrams (mg) three times a day for one week and continue Tylenol. Apply ice to the affected area for 20 minutes per hour while awake for that day and the next day. If worsening or changing symptoms contact the clinic and follow-up as needed. The Final Impression list thoracic back sprain, initial encounter. The Health Status Note dated 4/27/23 at 6:15 PM written by Staff F indicated that Resident #25 returned to facility, refused supper, and requested to go to her room. She appeared alert and oriented. When the nurse went to give Resident #25 her evening medications, she noted involuntary jerking of resident's head and arms. She further documented that Resident #25 appeared pale and had a clear but vague speech. Resident #25 could not hold her medication cup but could to take her medications without difficulty. The Health Status Note dated 4/27/23 at 8:15 PM written by Staff F described Resident #25 as continuing to act different from usual, she could not feed herself, she did not speak, and had weak extremities. The Communication - Other Note dated 4/27/23 at 8:20 PM identified that the nurse called the ER and notified them of Resident #25's condition. The ER recommended sending her to the ER for an evaluation. The nurse contacted 911. The ED Provider Notes dated 4/27/23 at 9:47 PM listed a chief complaint of an altered mental status. The nursing home staff reported that she could not speak, feed herself, or stand. The nursing home staff indicated this started after returning from the ER that afternoon. The note listed that Resident #25 came to the ER earlier in the day and had a negative work-up at that time. After returning to the nursing home, she became more lethargic, could not speak, or feed herself. Resident #25 returned to the hospital in an ambulance and could not give any history but could follow commands. Her physical exam revealed that she opened her eyes to a sternal rub (type of touch used when unable to arouse) and could make eye contact. She had generalized weakness but not focal deficits noted. The Plan/Medical Decision-Making section listed the hospital would admit her for neurological (neuro) checks and telemetry (heart monitoring). The provider indicated that they did not know the cause of her delirium but would check a urinalysis (UA) to rule out a cystitis (bladder infection). The Communication - Other Note dated 4/27/23 at 10:56 PM listed that the facility received a call from the ER nurse. The ER nurse reported they planned to keep Resident #25 for observation that night. The ER completed a CT Scan (special imaging) the revealed no changes. The ER planned to check neurological (neuro) checks (assessment to determine changes in the brain). They reported that she continued to be twitchy at times. Resident #35 had on and off issues with being able to talk, knowing her name, and knowing what was happening. The History and Physical dated 4/28/23 at 9:14 AM repeated the information from the ED Provider note from 4/27/23. The note added that the hospital found her to have nasty looking urine. They admitted her and started her on ceftriaxone (an antibiotic) with a diagnosis of acute delirium. The morning of 4/28/23 Resident #25 observed awake and responding appropriately. She appeared very somnolent, very cool, and clammy. The Assessment section listed delirium, permanent atrial fibrillation (irregular heart rate), type 2 diabetes mellitus with other specified complication. The Plan listed to admit her to acute care, already started on ceftriaxone for pretty nasty looking urine. Her last culture did grow Proteus (bacteria), which should be susceptible to ceftriaxone. The Communication - Other Note dated 4/29/23 at 1:06 AM identified that the nurse called the hospital for an update on Resident #25. The hospital reported that Resident #25 had congestive heart failure, elevated renal function, a urinary tract infection (UTI), an okay chest X-ray, and a negative CT of her head. Resident #25 received oxygen and albuterol treatments (inhaled steroids to open the lungs). She continued to have confusion and inability to track. The Progress Notes dated 4/29/23 at 9:29 AM indicated that Resident #25 had back pain of the thoracolumbar region for greater than six weeks. She started on a muscle relaxant and received tramadol for her pain without improvement. The etiology of the pain could be from a kidney infection, however, due to the musculoskeletal nature, regarding the full-boy mechanical lift incident in the nursing home, proceed with CT scans to rule out a compression fracture or any other potential etiology of her back pain while hospitalized . The CT Thoracic Spine without contrast dated 4/29/23 impression listed the following a. Inferior endplate fracture at the T8 b. Degenerative change of the spine. There is central canal stenosis and neurol foraminal narrowing at T10-11. c. Small effusions with bibasilar atelectasis d. Findings suggesting pulmonary edema. The Progress Notes dated 4/30/23 at 8:23 AM indicated that Resident #25 told her PCP that she had an incident at the nursing home where she fell. She described the incident as the staff tried to transfer her and pivot her standing, her legs gave out and she went down rather hard on her buttocks into the chair. She reported that she felt the worsening back pain at that time but could not remember when the incident occurred. The Communication/Visit with Physician on 5/2/23 at 3:57 AM the facility received Resident #25's X-ray results the PCP wrote that the X-rays on 4/26/23 with negative results. The X-ray results on 4/29/23 revealed a compression fracture at her T-8. The PCP questioned if Resident #25 had a fall. The nurse responded that they did not know of any falls but she did use a sit to stand with a sling. Resident #25 chicken wings (bends her arms at an upward angle) and needs to sit quickly. The Communication/Visit with Physician dated 5/2/23 at 2:21 PM indicated the PCP reviewed the X-Ray and Resident #25 remained in the hospital. The PCP wrote that Resident #25 reported that she fell at the nursing home. The PCP explained that Resident #25 had a compression fracture of her T-8. The PCP indicated that her record did not have any documented falls. On 5/31/23 at 1:35 PM the Director of Nursing (DON) reported that they did not do an investigation or report regarding resident's compression fracture findings due to the hospital discovering it. She explained that they reviewed their records and found no staff reports or documentation of a fall. On 5/31/23 at 2:45 PM Staff F reported that she did not think that she documented on 4/18 that anyone told her that Resident #25 had problems with the mechanical standing lift, and if she did, she couldn't remember. She denied remembering any incidents or concerns with Resident #25 using the stand. On 5/31/23 at 3:06 PM Staff E, Licensed Practical Nurse (LPN), remarked that she could not remember documenting on 4/19 that Resident #25 had difficulty with the mechanical standing lift. She reported that she did not know about any incidents with Resident #25 using the stand and complaining of back pain. When asked what she would do if that someone reported that to her, she replied that she would let therapy know, but therapy said resident did fine with the mechanical standing lift so to keep using it. On 5/31/23 at 3:20 PM Staff H, Occupational Therapist (OT), explained that that all staff received training that they could always do more for the resident, but not less. She stated if the staff or the resident felt uncomfortable using the standing mechanical lift or standing lift, they could always use a full-body mechanical lift to transfer the resident without having to call them before using it, and have the nurse notify them of the concern to address it the following day. She stated that Resident #25 did do well with the lift in therapy and that in her opinion, Resident #25 tried harder for them (therapy). She also felt that Resident #25 felt more comfortable with some staff than others. She stated that staff use chicken winging, but it can present differently from one staff member to another, such as elbows pointed out away from the body or pointing upwards like a flapping motion. On 6/1/23 at 10:30 AM Resident #25's physician from the ER explained her compression fracture was consistent with a sudden stop coming down in the lift. 2. Resident #33's MDS dated [DATE] assessment identified a BIMs score of score of 99, which indicating that Resident #33 could not complete the interview. The MDS identified a completed staff assessment for mental status that indicated Resident #33 had moderately impaired decision making. The MDS identified Resident #33 required supervision and assistance of one person with bed mobility. The MDS described Resident #33 as independent with transfers and ambulation. The MDS indicated that Resident #33 required limited assistance of one person for toilet use. The MDS documented Resident #33 had occasional incontinence of bladder. The MDS included diagnoses of diabetes mellitus, Alzheimer's disease, malnutrition, anxiety, and depression. The Incident Report (IR) labeled Found on Floor dated 1/4/23 at 9:30 a.m. indicated that the staff found Resident #33 on the floor with her pants and briefs around her knees. Resident #33 could not describe what happened. The Immediate Action Taken identified the nurse requested a urinalysis (UA) and wound culture from the Primary Care Provider (PCP) due to her high blood sugars. Resident #33's Falls Tool assessment dated [DATE] listed a score of 20, indicating a high risk for falls. The Incident note dated 1/5/23 at 5:22 a.m. identified that a Certified Nurse Aide (CNA) found Resident #33 lying on the floor with her supper tray. Resident #33's clinical record lacked an IR or a Fall Tools Assessment related to the fall on 1/5/23. The Health Status note dated 1/5/23 at 5:41 p.m. indicated the staff attempted the whole shift to obtain a urine specimen. Resident #33 did not understand the need and moved the collection hat from the toilet several times. The staff did get the wound culture. The clinical record lacked documentation that of completion of the 30 minutes checks for the 1/12/23 fall intervention. The IR labeled Slipped or Fell dated 1/12/23 at 7:25 p.m. identified that the nurse heard a loud thud and found Resident #33 lying on her right side next to the toilet with her head under the sink holding on to a dry brief and a dry pair of pants. Resident #33 reported she slipped while going to the bathroom. The IR documented an immediate intervention of 30-minute checks. Resident #33's Falls Tool assessment dated [DATE] listed a score of 19, indicating a high risk for falls. The IR labeled Found on Floor dated 1/21/23 at 7:00 p.m. indicated that a Certified Nurse Aide (CNA) found Resident #33 on the floor by her bathroom with her head facing towards the bathroom lying on her right side. The IR listed an immediate intervention of a motion alarm in her room to alert staff when she went to the bathroom. Resident #33's Care Plan lacked documentation of the intervention of a motion alarm following the fall on 1/21/23. Resident #33's Falls Tool assessment dated [DATE] listed a score of 19, indicating a high risk for falls. The IR labeled Found on Floor dated 2/21/23 at 7:45 p.m. indicated that the staff found Resident #33 on the floor in her room. The staff assisted Resident #33 to bed with a mechanical lift. After getting off the floor, Resident #33 started complaining of pain. The nurse sent her to the emergency room for possible fracture to her left hip. The IR lacked documentation if the motion sensor was in place and functioning at the time of the fall. The Immediate Action's description indicated the nurse put a pressure mat alarm to her recliner. The Transfer to the Hospital V5 note dated 2/21/23 at 8:15 p.m. indicated that Resident #33 went to the hospital due to a fall with a pain level of 10 on the pain scale of 0 meaning no pain and 10 meaning excruciating pain. The Health Status note dated 2/21/23 at 11:51 p.m. documented that the staff heard a loud noise in Resident #33's room at 7:45 p.m. Upon entering the room, they found Resident #33 on the floor rolling around calling for her mother. The nurse called for assistance of another nurse then assessed Resident #33. The assessment revealed that Resident #33 complained of significant pain in her left thigh/hip area. When the nurse palpated (assessment touch) the area during her assessment, Resident #33 did not respond with pain and the nurse did not notice shortness of her left leg at that time. After the staff assisted her with two people off the floor with a full-body mechanical lift and put her in her chair, she continued to complain of pain to her left thigh/hip. At 8:05 p.m. the nurse contacted the emergency room (ER) and received an order to transfer Resident #33 to the ER. The nurse contacted emergency medical services (EMS) who arrived and transported Resident #33 to the ER. The ER called the facility to notify them that Resident #33 fractured her left hip and they transferred her to another hospital. Resident #33's Falls Tool assessment dated [DATE] listed a score of 19, indicating a high risk for falls. The hospital's Discharge Documents dated 2/28/23 listed Resident #33's principal discharge diagnosis as a left intertrochanteric fracture (hip fracture) following an intramedullary nail (a type of repair in hip surgery) with a left hip hematoma (large bruise), anemia (low blood volume), and hypotension (low blood pressure). The Reason for admission indicated that Resident #33 fell at the nursing home and fractured her hip. Resident #33 did not appear lucid at the time of admission but her daughter consented to her having hip surgery. The documents included an order to for treatment of an incisional wound. The Last BM and Admit/Readmit note dated 2/28/23 at 3:10 p.m. recorded that Resident #33 went to the hospital for a left hip fracture. Resident #33 required the skilled services of a daily assessment, blood transfusion two times, and diabetes management. On 6/1/23 at 10:00 a.m. Staff M, Restorative Aide, described herself as the person responsible for checking the resident alarms in the facility. Staff M stated she put the alarms in place and check them on the 5th of each month. Staff M reported Resident #33 had an assigned motion sensor prior to her fall when she fractured her hip. Staff M reported that Resident #33 would turn around the motion sensor or put it in a drawer to prevent it from alerting the staff. Staff M stated after her fall with fracture, they decided to switch to a pressure alarm. Staff M reported that she tracked and documented the alarms on a flow sheet. On 6/1/23 at 10:17 a.m. Staff N, Certified Medication Aide (CMA), reported that Resident #33 used to have a motion sensor in her room. Staff N stated the motion sensor chimed at the nurses' desk. Staff explained that the alarm stop chiming after Resident #33 moved out of the way of the alarm. Staff N added that if staff are not at the nurses' station or in the hallway, they could not hear the chimes from the motion sensor. Staff N reported that sometimes she found the motion alarm turned towards the wall and she would correct it. Staff N explained that Resident #33 knew the purpose of the alarm. Staff N reported that Resident #33 received the pressure alarm after her fall with fracture. On 6/1/23 at 11:00 a.m. Staff I, Registered Nurse (RN)/MDS Coordinator, acknowledged and verified that Resident #33's Care Plan did not have the motion sensor added it. Staff I reported they placed the motion sensor in Resident #33's room and put the base for the motion sensor at the nurses' station. Staff I stated the motion sensor chimed at the desk while the resident is near the sensor and then it stopped chiming when she moved out of range. Staff I verified that staff could not hear the chimes if they are not close to the nurses' desk if it chimed. Staff I expressed that she hated alarms. The Weekly Monitoring of Alarms form indicated the staff checked Resident #33 pull tab alarm on 2/31/23 (2/28/23 last day in February 2023). The form lacked any documentation regarding a motion sensor for Resident #33. The Weekly Monitoring of Alarms form included a scribbled section that Resident #33 had a pull tab alarm. Above the scribble listed a chair pressure alarm. The form indicated that someone checked the alarm on 3/26/23 and changed the sensor mat on 4/5/23. The form included scratched out documentation for the battery change due date and the 5 for 4/5/23 with an 8 written above. The Fall Prevention and Management policy revised 3/29/23 listed the purpose of the policy as the following: a. To promote resident well-being by developing and implementing a fall prevention and management program b. To identify risk factors and implement interventions before a fall occurs c. To give prompt treatment after a fall occurs d. To prevent further injury e. To provide guidance for documentation. The policy directed staff after a fall to complete an Incident Report in risk management, complete a Fall Tool assessment, and update the Care Plan with any changes or new interventions. The Procedure directed the staff to not move the resident. In addition, the policy instructs to not move the resident has a suspected hip fracture. The Alarms - Bed, Chair, and Door policy revised 8/24/22 listed the Purpose of the policy as to ensure dignified and appropriate use of alarms based on the resident's condition and identify a process used to check the facility alarms. The policy further directed the Rehab or Nursing staff to check the motion sensor daily to check the alarms functionality. Staff should check the resident's condition to determine if the resident benefited from the use of an alarm. On 6/5/23 at 10:52 a.m. the DON reported that she expected the staff to assess the effectiveness of a fall intervention. If the intervention did not work, she expected them to change the intervention. On 6/5/23 at 5:15 p.m. the DON verified that she could not locate the 30-minute checks for 1/12/23. On 6/6/23 at 3:02 p.m. the DON reported that she expected the nurse to complete a Fall Risk evaluation quarterly and after a fall. 3. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated the Resident #22 required limited assistance of one person with dressing. She could independently move in bed, walk in her room, walk in the corridor, use the toilet, and complete her personal hygiene. Resident #22 used a walker and a wheelchair. She could stabilize herself without staff assistance but was not steady with moving from a seated to a standing position, turning around, moving on and off the toilet, and surface-to-surface transfer. Resident #22 received a scheduled pain medication in the previous five days of the lookback period. She had one fall without injury since the previous assessment. The Care Plan Focus revised 6/9/22 indicated that Resident #22 had a risk for falls related to her history of falls. The interventions directed the staff to monitor her for significant change in gait, mobility, positioning device, standing balance, sitting balance, and lower extremity joint function. On 6/1/23 at 2:10 PM observed Resident #22 in her recliner in her room. Resident #22 said that she did not have pain but she did have a lot of pain before and after her back surgery. She said that she kept getting dizzy and that's what caused her falls. The Discharge summary dated [DATE] included four diagnoses Resident #22 received treatment for in the hospital. a. Osteoporosis b. Closed fracture of multiple thoracic vertebrae c. Closed stable burst fracture of the sixth thoracic vertebra with delayed healing. d. Closed fracture of lumbar vertebra, unspecified fracture morphology, unspecified lumbar vertebral level. The Discharge Summary directed the nursing facility to schedule the Prolia injection (injection used to treat bone loss). On 6/1/23 at 3:40 PM Resident #22's Representative (RR #22) said that they got a call from the facility after her fall on 5/13 that Resident #22 had a great deal of pain. She thought the facility called her over a weekend, and they brought in a portable X-ray machine on a Monday or Tuesday. Resident #22 had surgery and then she fell again the day she went back to the facility. The Incident Note dated 5/26/23 at 11:58 PM indicated that the nurse went to Resident #22's room at 8:00 PM and found her lying on the floor by her bed on her left side. She appeared wrapped up in her bed pad and complained of pain when moved. Resident #22 had increased confusion talking about nonexistent children that she needed to find and that she had mouse traps around her bed. Resident #22 could not say what happened due to her confusion and hallucinations. Resident #22's Representative (RR #22) arrived while Resident #22 remained on the floor. She requested to have her evaluated at the hospital due to her having vertebroplasty (a procedure involving special cement injected into a fractured vertebra - with the goal of relieving spinal pain and restoring mobility) that morning. At 10:20 PM the hospital called to notify that Resident #22 would return to the facility by ambulance. They reported that she appeared alert, oriented, doing well, and walking ok. RR #22 questioned if she could have a motion alarm that night. The Neuro Check - V 4 dated 5/26/23 at 8:15 PM indicated that Resident #22 had weakness to all her extremities, confusion, and hallucination. The Neuro Check - V 4 dated 5/26/23 at 8:45 PM lacked an assessment of her eyes, hand strength, or orientation with the vital signs from the 8:15 PM assessment. The Comments section described Resident #22 as stable and the facility waited for the ambulance. On 6/5/23 at 8:06 AM the Director of Nursing (DON) said that when a fall occurred the team met to discuss the incident, but, they did not necessarily do a root cause analysis or document the meetings. On 6/6/23 at 8:11 AM the DON provided a hard copy the neurological assessments and referred to the electronic assessments that included eye assessment, hand strength and orientation. She said that she expected the staff to take a set of vitals and complete all the areas of the assessment when a resident had an unwitnessed fall.