**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility policy review the facility failed to ensure one (1) of four (4) residents received adequate supervision to protect against hazards in the environment (Resident #3). The facility's staff failed to implement safety measures to prevent a fall by not locking the resident's wheelchair brakes and not using a gait belt when transferring a resident. The record review and staff interviews revealed that Resident #3 required assistance with the use of a gait belt for transfers and ambulation. On 1/30/23, one staff member (Staff A, Certified Nurse Aide CNA) assisted Resident #3 to transfer without a gait belt. As Resident #3 went to sit in the wheelchair, it had one unlocked brake causing the wheelchair to move. As the wheelchair moved and Staff A did not have a gait belt on Resident #3, he fell to the floor. Resident #3 required a transfer to the local emergency room (ER). While at the ER, they determined Resident #3 sustained a right intertrochanteric femoral neck fracture (broken hip). Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 14 of 15 on Brief Interview for Mental Status (BIMS) test, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), cerebrovascular accident (stroke), and respiratory failure. The MDS indicated that Resident #3 required extensive assistance of two persons for dressing, bed mobility, and transfers. Resident #3 did not have a fall since his admission. The Fall Management Promise signed on 9/14/22 by Staff A listed that she promised to do her part to reduce the number of falls the residents experience. She understood that it is up to her to observe the residents and offer interventions that might help keep the resident safe. Staff A realized that resident safety started with her. The Skills Review and Competency Checklists signed by Staff A on 9/14/22 indicated that she completed the transfers/gait belt use. The note listed that she successfullly completed the neighborhood tour and checklist. She felt confident that she could find her way around the building and locate the items listed. Staff A would be responsible and account for the information listed. The [NAME] Belt Policy signed by Staff A on 9/14/22 instructed to use gait belts for the transfer and ambulation procedures implemented for the residents in the facility. When worn around the waist of a resident, the gait belt assists team members by allowing a secure hold on the resident. It minimizes the risk of resident injury from falls. It minimizes the risk of injury for the team members assisting. The Care Plan Category started 11/20/22 related to activities of daily living (ADL's) indicated that Resident #3 needed help to complete his ADLs related to his recent Cerebrovascular Accident (CVA) and weakness. The Care Plan instructed that Resident #3 needed assistance with transfers, ambulation, and dressing. The Interventions directed the following dated 11/30/22: *Walk to/from the bathroom with front wheeled walker and one assist *Staff to hold onto gait belt for increased safety. The Interdisciplinary Notes dated 1/30/23 at 10:19 P.M., at 6:30 p.m. indicated that after arriving to Resident #3's room, they observed him lying on floor in supine position with his head pointed towards entry door and his feet towards the window. The staff witnessed Resident #3's fall. Resident #3 appeared alert and oriented to person, place, and time. The staff reported that as Resident #3 walked from the bathroom to his bed, midway through Resident #3 wanted to remove his jeans to put on his pajama bottoms. When Resident #3 attempted to sit on his wheelchair, it had only one brake locked and resident fell landing on right hip. The staff reported Resident #3 did not hit his head. The assessment revealed that Resident #3 wore shoes for foot wear, his floor did not have clutter, but the staff did not use a gait belt. Range of motion (ROM) to Resident #3's right lower extremity revealed that not with in normal limits. Resident stated I think I broke my hip. Right hip noted to have some swelling/bulging to anterior aspect. Resident was not able to move right leg without pain. A Fall Risk assessment dated [DATE] documented a score of 7, indicating a low risk for falls. The FSI - Falls Scene Investigation report listed that Resident #3 had a witnessed fall on 1/30/23 at 6:30 p.m. The report identified that Staff A assisted Resident #3 to stand up so he could put his pajamas on. When Resident #3 went to sit down, he only had one side of his wheelchair locked. The wheelchair slid out from underneath him, causing him to land on his right hip. Resident #3 complained of severe pain to right lower extremity and he could not bear weight. Resident #3 had a gait belt but it was not in use at the time of his fall. An X-Ray report dated 1/30/23 at 7:25 p.m. documented an acute comminuted right intertrochanteric femoral neck fracture related to a fall with pain and deformity. The Physician Transfer Order Report Instructions dated 2/7/23 at 1:07 p.m. indicated that Resident #3 had a diagnosis of closed fracture of right hip. The instructions directed that he keeps the operative extremity elevated as much as possible and weight bearing as tolerated. On 5/15/23 at 4:30 p.m., Staff A stated that on 1/30/23 Resident #3 wanted to stand and change from jeans into his pajama bottoms. Staff A confirmed that she did not use a gait belt. She added that when Resident #3 went to sit down in the wheelchair, he did not have one of his wheelchair brakes locked and the wheelchair rolled away causing Resident #3 to fall to the floor. Staff A recalled that Resident #3 complained of pain right away. Staff A explained that she had not checked his Care Plan and was new to the floor at the facility. Staff A reported that she received counseling to always follow the Care Plan. On 5/15/23 at 1:30 p.m., Staff B, Licensed Practical Nurse (LPN), reported that the staff called him to Resident #3's room after he fell. Staff B recalled being surprised right away when he entered the room and he did not have on a gait belt. Staff B replied that he expected all staff when providing transfers use a gait belt. On 5/15/23 at 5:30 p.m. the facility Administrator confirmed they expected for the staff to follow the Care Plan for resident transfers. In addition, the Administrator expected the staff to use a gait belt for all staff assisted transfers and ambulation. Staff A's Employee Counseling Report, listed a written warning dated 2/20/23. The report indicated that Staff A assisted Resident #3 with his hour of sleep cares. Staff A did not apply a gait belt when resident stood up from wheelchair to pull pants up. Then as Resident #3 attempted to sit down, the wheelchair did not have one brake locked, resulting in him falling and getting hip fracture. To the form instructed to correct the violation as using a gait belt when assisting a resident from sitting to standing, with transfers, ambulation, and lock wheelchair brakes when resident standing from wheelchair.