**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, facility document review, staff interviews and facility policy review, the facility failed to use safe transfer techniques for 1 of 3 residents. Resident #37 had fell in the bathroom and sustained bruising and a skin tear after staff assisted him without the use of a gait belt or proper footwear. The facility also failed to implement new interventions with repeat falls to reduce the risk for Resident #37. The facility reported a census of 43 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment dated [DATE], Resident #37 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 (minimal cognitive deficit.) He required substantial/max assistance for toileting hygiene and transfers. Resident #37 had diagnosis including anxiety disorder, Post Traumatic Stress Disorder (PTSD) and Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation. The MDS documented the resident had fallen in the last month. According to a Nursing Advanced Skilled Evaluation note dated 9/18/24 at 10:02 AM, upon admission, Resident #37 was able to move all extremities and his gait was unsteady with poor balance. The Care Plan dated 9/24/24 for Resident #37 documented he was at high risk for falling due to falls at home preceding admission here. The care plan listed a goal the resident will not have a fall related injury. The care plan directed staff with the following interventions: -Fall risk evaluation. -Labs when ordered. -Monitor for side effects of medication: cardiac and psychotropic medications as ordered. -Toileting per urinary/bowel section of this care plan. The toileting plan created on 9/24/24 and revised on 11/5/24 documented intervention for staff to assist with transfer to the toilet. Offer and assist with toileting before and after meals, at bedtime and as needed. The Progress Notes for Resident #37 documented the following: On 10/29/24 at 10:39 PM one assist with transfer to wheelchair, toilet and bed. One assist for bedtime ADL's (activities of daily living). Education on call light location and use. Encouraged to voice needs. On 10/29/24 at 11:28 PM resident hit the back of his head on the glove holder in his bathroom removed the skin flap to a healed skin tear. Measures 1.3 cm x 0.5 cm. On 10/29/24 at 11:45 PM it is unknown how long the wound has been present. The resident reports when up to the bathroom he hit the back of his head on the glove holder box on the wall by the stool. On 11/1/24 at 6:09 PM moderate assistance of 1 with most ADL's. One assist with toileting. Some confusion noted at times. Pleasant and cooperative with staff. On 11/2/24 at 8:30 AM fall at 7:45 AM in resident's room. Nurse 2 rooms down from resident when aide asked to immediately come to the resident's room. Observed resident lying on his back with his head propped against the air/heat unit. Noted blood on the unit and on the residents head and arms. Pressure applied with towel and ice. Noted skin tear with heavy amounts of bleeding. When asked what happened the resident stated he was trying to go to the bathroom so he got up and fell. Resident sent to the local emergency room for evaluation. On 11/2/24 at 12:28 PM call to hospital for update and notified the resident has a C3 fracture and will need to be referred to neurologist. On 11/2/24 at 4:16 PM the hospital called and resident being admitted . To have an MRI tomorrow. Dressing being applied to scalp and C-collar on. On 11/3/24 at 9:41 PM resident returns from the hospital. able to pivot transfer and take several steps. 15 minute visual checks initiated. The Discharge MDS dated [DATE] for Resident #37 documented the resident had an unplanned discharge to the hospital. The MDS documented the resident had fallen since admission/entry or the prior assessment and had an injury. The Care Plan for Resident #37 directed staff with the following interventions updated on 11/4/24: -15 minute visual checks upon return from the hospital. -Replace old gripper socks with new gripper socks. The Progress Notes for Resident #37 documented the following: On 11/4/24 at 10:31 AM reviewed incident thoroughly with IDT team. New interventions: replace old gripper socks with new, 15 minute checks upon return from the hospital, Social Services to check with family for permission to place sign in room reminding resident to use his call light and wait for staff assistance prior to rising. On 11/6/24 at 11:16 AM IDT team met and reviewed incident on 11/4/24. Current interventions are 15 minute checks, replace old gripper socks with new socks and staff to prompt resident to and from meals and activities. On 11/6/24 at 11:41 AM late entry for November 4, 2024 at 3:40 PM interview with resident completed by Administrator and DON. The resident stated he got up out of bed, and sat himself in his wheelchair at bedside. He stated he stood upright and his feet went out from underneath him and he started to fall backwards so he leaned forward losing his balance and fell to the floor. The resident stated he hit his head on the armoire in his room during the fall to the floor. He could not remember if he put on his call light or not. On 11/6/24 at 11:51 AM reviewing incident with IDT team. Current interventions are every 15 minute checks, replace gripper socks, discarded gripper socks with little grippers left and ordered more. An Incident Report dated 11/6/24 at 10:25 PM, documented Resident #37 was up to the bathroom with assistance of one when he let go of his walker, reached out to grab the handle attached to the toilet, and lost his balance. A staff member was present and able to lower him to the floor. The nurse came in to assess the situation and noted that the resident was not wearing a gait belt. He had on one gripper sock with the grippers on the top of his foot, and a black sock on the other foot that did not have grippers. The resident sustained a skin tear to his elbow and his right foot was turned outward. He was sent to the emergency room for evaluation. The Care Plan for Resident #37 lacked updates/new interventions following the fall on 11/6/24. According to the Emergency Department Provider Notes dated 11/7/24 at 1:11 AM, Resident #37 had a large band-aid over the top of his head. No other areas of erythema, edema or ecchymosis. Range of motion without pain or discomfort. Minimal discomfort mid portion of the neck with no crepitus of step-off. The resident able to walk with his walker with no other injuries or trauma. A Post Fall Evaluation dated 11/7/24 at 8:43 AM, documented Resident #37 reason for fall was he lost his balance and fell in front of the stool while being assisted by staff with no gait belt or proper footwear. The resident had a trauma wound to the scalp related to a fall on 11/2/24, with partial flap loss and full thickness stripping of the skin. The skin tear measured; 10.5 centimeters (cm) x 5 cm x 0.1 cm. There was epidermis and dermis tissue loss with a yellow wound bed. The left posterior elbow skin tear measured 1 cm x 1.5 cm with edges non-attached and area bleeding was acquired on 11/6/24. In an observation on 11/12/24 at 10:54 AM, Resident #37 was laying in bed with supplemental oxygen per nasal cannula and had a bandage on the top of his head. The resident said that he lost his balance and fell. On 11/12/24 at 3:50 PM, Staff B, Registered Nurse (RN) stated that she remembered the fall in the bathroom. She had just started her shift when a Certified Nurse Aide (CNA) told her they needed her in the room of Resident #37. When she walked into the room, the resident was on the bathroom floor, his back was up against the wall, and the walker was next to the toilet. He was wearing one gripper sock that was upside down with the grips on the top, and a black sock that was not gripper. He did not have a gait belt on. The nurse noticed that his right foot was turned outward and he had a skin tear on his right elbow that was bleeding. They sent him to the emergency room and they found that he didn't have any broken bones. On 11/13/24 at 8:40 AM, Staff C, Certified Nurse Aide (CNA), stated that she worked at the facility just 2 times. She said she had limited orientation and was only given verbal report on the status of residents. She said that she wasn't able to get into the electronic chart to find resident information because she didn't have access. She said that on 11/6/24 she had gotten report from other CNAs that Resident #37 required 2 staff assistance. There had been another CNA in with her initially, but that aide left the room and went to help another resident. She walked Resident #37 to the bathroom with help of the walker, but when he got into the bathroom, he let go of the walker, reached out to grab the handle next to the toilet and he missed and started to go down. Staff C said that she had ahold of the resident with her arm under his armpit and lowered him to the floor. Staff C acknowledged that she had not used a gait belt because he had a walker, she didn't think he needed one. She added that there weren't any gait belts in the resident's room for her to use. On 11/13/24 at 12:25 PM, the Administrator, Director of Nursing (DON) and Nurse Consultant said that before a new staff (CNA) member was put on the floor, they were given verbal report from the previous shift. They were given access to the electronic chart so they could check on specifics needs of the residents. They said that they had an orientation checklist but they were unable to locate a list for Staff C. On 11/14/24 at 10:38 AM, the DON said that it was their policy to always use a gait belt and gait belts were kept in the resident's rooms. She said that agency staff were taught that they must use them as well as checking for the proper footwear before transferring a resident. According to a facility policy titled: Gait Belt Use updated on 3/22/07, gait belts would be used for residents needing limited, extensive or total assistance with manual transfers and/or ambulation.