**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS Assessment Tool, dated 8/7/23, listed diagnoses for Resident #21 which included non-Alzheimer's dementia, Huntington's (a disease which causes nerve cells in parts of the brain to gradually break down and die) disease, and [NAME]-[NAME] Syndrome(a disorder where two or more neck vertebrae [types of bones] were fused together from birth). The MDS documented the resident required limited assistance of 1 staff for bed mobility, transfers, walking, dressing, eating, and personal hygiene, and extensive assistance of 1 staff for toilet use and bathing. The MDS identified the resident had 1 fall with a non-major injury during the review period and listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A 2/16/23 Incident/Accident Report stated staff found the resident on the floor in front of her chair and she had her seat alarm pushed to the side of her chair. A 3/14/23 Incident/Accident Report stated the resident was found on her back on the floor. She sustained a 3 centimeter (cm) x 2 cm pink abrasion to the back of the neck to the right side. A 3/15/23 Care Plan entry stated the resident had a chair alarm on at all times when not in bed. A 4/19/23 Incident/Accident Report stated the resident leaned forward from her chair, went to her knees, and then bumped her head on the floor. An 8/9/23 Incident/Accident Note stated staff heard a thud from the Nursing Station and found the resident on the floor of the bathroom doorway with her pants down. The resident had a small bloody nose, a bump on her head, and small superficial (shallow) scrapes to her knuckles of the left hand. The resident stated she took herself to the bathroom prior to activities. Her call light was activated and her chair alarm was not on. A CNA took her back to her room at 9:30 a.m., after her bath and forgot to turn it back on. The resident reported nausea and lightheadedness 30 minutes after her fall and had an emesis (referring to vomit). The resident transferred to the Emergency Department (ED) at 12:10 p.m. An 8/9/23 Nurse's Notes stated the facility received a call from the ED nurse and the resident would transfer to a different hospital. An 8/9/23 Major Injury Determination Form stated the provider stated after reviewing the circumstances, injury, and prognosis of the patient, she believed the injury sustained was a major injury. An 8/10/23 ED report stated the resident had a closed non-displaced fracture (a fracture in which the bone cracked but retained proper alignment) of the first cervical vertebra (a bone of the neck). The report stated she would transfer to another hospital. An 8/10/23 Nurse's Note stated the resident returned from the hospital and was at baseline with ambulation(walking). A statement documented by Staff G, CNA, dated 8/10/23, stated she assisted the resident with a bath and walked her back to her room. The resident sat in her chair and Staff F handed her, her tablet, call light, and blanket and left the room at approximately 9:30 a.m. On 10/17/23 at 2:08 p.m., Staff G stated on the day of the resident's fracture, she assisted the resident with a bath and back to her recliner. Staff G stated she forgot to turn the resident's chair alarm back on after her bath. On 10/18/23 at 10:45 a.m., the DON stated she sat at the Nursing Station and she heard Resident #21's call light alert. She stated she heard another staff member say she would answer the call light. She stated it was not long after this that they found her in the doorway of the bathroom with her pants pulled down. She stated she thought this was less than 3 minutes after the call light alerted and stated the chair alarm was not on. The DON stated this was an oversight and the CNA forgot to turn it back on after assisting her. The DON stated alarms should function correctly. 3. The MDS Assessment Tool, dated 12/19/22, listed diagnoses for Resident #16 which included non-Alzheimer's dementia, anxiety disorder, and adjustment disorder. The MDS identified the resident was independent with transfers, and the resident's BIMS score as 11 out of 15, indicating moderately impaired cognition. A 1/2/23 Incident Accident Report stated the resident was found on the floor of the bathroom and sustained a small bump on the back of the head. On 1/3/23 at 7:17 a.m., Nurse's Notes stated staff heard the resident yelling and found her lying on the floor on the right side. The nurse noted 2 different bumps on the head after the fall. On 1/3/23 at 6:15 p.m., an Incident/Accident Report stated the resident sat in the wheelchair in the hallway and arched her back and slid off the wheelchair to her bottom. The resident had no injuries or complaints of pain. On 1/3/23 Care Plan entries stated the resident would have a Physical Therapy and Occupational Therapy Evaluation to treat following a recent fall and stated the facility would provide a smaller and shorter wheelchair to prevent her from sliding out. On 1/4/23 at 6:05 a.m., Nurse's Notes stated the resident was very confused and would bear no weight with transfers. The facility would transfer the resident to the hospital due to her change in mentation. An 1/4/23 ED Provider Note stated the resident presented to the ED following 3 falls in the last 24 hours. The note stated the resident had a femoral neck fracture (a type of hip fracture). A Major Injury Determination Form, dated 1/4/23 form stated the provider believed the injury sustained was a major injury. The form stated the resident was independent in the facility with a walker prior to the fall. A 1/4/23 Nurse's Note stated the resident returned from the hospital and required the assistance of staff to transfer into the wheelchair. A 1/6/23 Care Plan entry stated a remote sounding floor alarm was placed in her room and directed staff to utilize it when left unattended. The MDS assessment tool, dated 1/11/23, stated the resident required extensive assistant of 2 staff for transfers. On 3/6/23 at 6:25 a.m., Nurse's Notes documented staff entered room and the resident was on the floor. The note stated the resident's left leg was shorter and rotated inward. The resident had a floor alarm in place but it was not sounding. The facility transferred the resident to the ED. On 3/6/23 at 9:13 a.m., Nurse's Note stated the hospital called and the resident did not have a fracture or break. On 10/16/23 at 1:56 p.m., the resident walked down the hall with 1 staff member and a gait belt. Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to prevent falls causing major injuries for 3 out of 5 residents reviewed with falls and a history of major injury (Residents #16, #21 and #36). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #36 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 7 out of 15 and had the following diagnoses: Chronic Systolic Congestive Heart Failure, Debility, Cardiorespiratory Conditions and Alzheimer's. The MDS documented Resident #36 required extensive staff assistance with bed mobility, transfers, locomotion on the unit, toileting and personal hygiene, and totally dependent on staff for bathing. Review of the Care Plan dated 3/8/22 identified the resident with the problem that she required assist with her cares due to arthritis and had falls when she was at home and directed staff to: a. Transfer the resident with a Hoyer with assist of two staff using the blue sling and place lambs wool between legs where sling wraps around. b. Transfer per stand lift. c. She prefers showers, enjoys baths, but transfers with the lift chair scare her. A review of the Nurse's Notes documented the following: On 9/28/23 7:10 AM, Staff walked by her door and saw Resident #36 sitting on the floor with her back against the mattress. Denied hitting head. Stated she slid off side of the bed. Assisted back to bed with assist of 3 staff members using the stand lift. Did not voice any discomfort. Able to bear weight per usual. Resident screened for signs/symptoms of COVID. Resident denies shortness of breath/dyspnea/cough/sore throat or other concerning symptoms. Respiratory rate regular and unlabored. A review of the Incident Report dated 9/30/23 at 8:20 AM, documented the following: a. Resident #36 had a witnessed fall in the hallway. Staff A, Certified Nursing Assistant (CNA) was pushing the resident in wheeled shower chair to Resident #36's room. Upon coming to the threshold in hallway, Staff A stood in front of the chair to pull over threshold. Staff A reported Resident #36 started to lean over which caused the chair to tip. Staff A attempted to keep the chair upright and had to lower Resident #36 to the floor between her legs. The resident sitting on her bottom when the nurse got to her. Resident #36 was not sent to hospital. b. Intervention: No transporting resident in wheeled shower chair. c. Addendum: Sent to emergency room (ER) at 6:15 PM and diagnosed with bilateral femur fractures and pneumonia. A review of a statement written by Staff A, CNA dated 10/1/23, revealed she gave Resident #36 her shower on Saturday, September 30, 2023, while washing her legs she told me they hurt and looked swollen. After she completed the shower, she notified the Director of Nursing (DON) to look at Resident #36's legs. The DON applied an ace wrap to Resident #36's legs after she assessed her and left with instructions to elevate her legs when in the recliner. Resident #36 was upset about her hair washed, so Staff A thought to move her with the shower chair to her room. She moved Resident #36 to the first doorway and got in front of her to move the chair over the bump. Then Resident #36 leaned forward and the chair moved out from under her. Staff A attempted to keep her from falling, however her foot (Staff A) slipped and Resident #36 landed on the floor. Three staff members assisted getting the resident up and transported her to her room to her recliner. A review of the Nurse's Progress Notes revealed at 9/30/23 at 8:30 AM, Resident #36 sat on the floor in doorway threshold with shower chair behind her and Staff A standing next to her. Staff A reported she transported Resident #36 back to the room in the shower chair when Resident #36 leaned forward which caused the shower chair to tip. Staff A attempted to stop the fall and lowered Resident #36 to the floor. Assessed for injuries, none noted. Resident #36 could not describe what happened. Assisted by staff and gait belt on to chair and taken to her room. No new injuries noted. Stand lift used to transfer her into the recliner and her feet were noted to be puffy. Feet elevated. Intervention for this incident is that resident is not to be transported per shower chair. On 9/30/23 AT 6:05 PM the Nurse Practitioner (NP) called in orders to send to the ER of choice for evaluation and treatment post fall. A review of the Nurse's Progress Notes revealed the following: a. On 9/30/23 at 6:15 PM, Resident #36's daughter wanted her sent to the hospital. Ambulance called and report called to the ER. b. On 9/30/23 10:03 PM, Received telephone call from the hospital who reported Resident #36 was admitted to acute care with diagnoses of pneumonia and bilateral femur fractures. Treating with antibiotics and no surgical intervention at this time. A review of the History and Physical by the Emergency Department (ED) physician dated 9/30/23 at 8:06 PM, documented the following: A review of the x-rays of both knees performed at the hospital revealed a fractures of the distal femoral shaft (thighbone) to the left and right femurs. On 9/30/23, the Care Plan updated to include the new intervention that Resident #36 will not be transported out of shower or bathroom in shower chair or bath chair. A review of the Nurse's Notes at the facility had documented on 10/2/23 at 5:10 PM, call received from the hospital. Resident #36 passed away today at 4:40 PM. In an interview on 10/17/23 at 9:25 AM, Staff A, CNA reported Resident #36 did not have a history of falls until 9/28/23 and 9/30/23 and to be transferred with assist of 2 using the stand lift. On 9/30/23, after she showered Resident #36 and tried to transport her in the hall in the shower chair, Resident #36 leaned forward and the shower chair went out from underneath her. She did not transfer her to a wheelchair as Resident #36 was already upset about having her hair washed and thought one less transfer would not be as upsetting. Resident #36 was sent to the hospital later that night. In an interview on 10/17/23 at 10:00 AM, Staff B, Licensed Practical Nurse (LPN) reported Resident #36 did have a history of behaviors and was to be transferred with a stand lift with 2 people. Staff B also reported staff occasionally have used the shower chairs to transport residents, however, she felt it was not a safe practice. Staff B also reported the threshold between the fire doors is made out of wide metal and staff have caught different things on that threshold, such as the med cart. If Staff A had used a wheelchair, the fall could have been prevented. In an interview on 10/17/23 at 2:39 PM, Staff C, Registered Nurse (RN) reported she could not recall if Resident #36 had a history of falls, however, she did recall that Resident #36 would try to get up on her own. Fall interventions implemented included: keeping her room close to the Nurse's Station, transfer with stand lift and if they had problems, could use the Hoyer lift. Staff C also reported the fall could have been prevented if a wheelchair was used to transport the resident rather than using the shower chair. In an interview on 10/17/23 at 12:29 PM, the DON reported Resident #36 was already upset about having her hair washed and Staff A thought that one less transfer from shower chair to the wheelchair would be less upsetting to her. The fall could have been avoided if she had transported Resident #36 in a wheelchair rather than the shower chair. After that incident, she told all staff they would no longer use shower chairs to transport residents out of the shower room. She eliminated the use of that particular shower chair and purchased a larger shower chair. In an interview on 10/18/23 at 8:39 AM, Staff D, CNA reported the aides used the shower chair to transport only one or two residents from the shower room to their rooms. She did not work the day Resident #36 fell, however, reported the fall could have been avoided if Resident #36 was transported in a wheelchair instead of the shower chair. In an interview on 10/18/23 at 8:49 AM, Staff E, CNA reported the bump in between the fire doors could be hard to push shower chairs and the fall with Resident #36 could have been avoided if she was transported in a wheelchair rather than a shower chair. In an interview on 10/18/23 at 9:10 AM, Staff F, CNA/Certified Medication Aide (CMA) reported Resident #36 did not have a history of falls before her first fall on 9/28/23 and she was not here when Resident #36 fell on 9/30/23. Fall precautions in place were use of a low bed and transfer with a stand lift with assist of 2. The fall on 9/30/23 could have been avoided if the resident had been transported in a wheelchair instead of a shower chair. A review of the facility policy titled: Falls and Fall Risk, Managing dated as last reviewed 6/10/22 documented the following under Resident-Centered Approaching to Managing Falls and Fall Risk: a. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. b. If a systemic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). c. Examples of initial approaches might include exercise and balance training a rearrangement of room furniture, improving footwear, changing the lighting, etc. d. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated within increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. e. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. f. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. g. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g.,hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. h. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.