**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 46 residents. The sample included 16 residents, which included four residents sampled for accidents. Based on observation, interview, and record review, the facility failed to thoroughly investigate to identify causal factors of falls and/or initiate/implement immediate, appropriate interventions to prevent further falls for three sampled dependent residents, including Resident (R)15, related to a lack of wheelchair pedals for support while staff propelled the resident; R27, who experienced a fall with an inappropriate intervention; and for the multiple falls experienced by cognitively impaired R2, with the most recent fall resulting in major injury with two fractured (broken bone) vertebrae (bones of the spine). Findings included: - Review of R2's Physician Orders, dated 12/13/23, included diagnoses of fractured thoracic (middle section of the spine) vertebra, repeated falls, dementia (progressive mental disorder characterized by failing memory, confusion), need for assistance with personal care, lack of coordination, cognitive communication deficit, unsteadiness of feet, urinary incontinence, peripheral neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), hypertension (high blood pressure), overactive bladder, and gait (manner or style of walking) and balance abnormalities. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severe cognitive impairment. The resident required substantial/maximal assistance of staff for bed mobility, transfers, and toileting. She had no functional limitations in range of motion of the upper or lower extremities. She was always incontinent of bowel, occasionally incontinent of urine, and did not have a toileting program. She experienced two or more non-injury falls and one fall with major injury. The resident received Occupational Therapy (OT) for four days and Physical Therapy (PT) for four days of the look back period. The Discharge Return Anticipated MDS dated [DATE], documented the resident transferred to an acute care hospital on [DATE]. The Entry MDS dated [DATE], documented the resident returned to the facility on [DATE]. The Cognitive Loss/ Dementia, Communication, and Falls Care Area Assessments (CAA), dated 09/15/23, documented the resident lacked orientation with memory and recall deficits related to dementia, change in mental status, and short term/long term memory loss. She had a history of falls prior to admission, weakness, and physical performance limitations that affected balance, gait, strength, and muscle endurance. The Care Plan dated 12/22/23, included the following interventions: On 05/21/19, staff were to remind the resident to lock the brakes on the wheelchair before transfers. On 08/13/19, R2 experienced episodes of incontinence due to an overactive bladder if not toileted timely . (The care plan lacked any instruction staff on when to toilet the resident.) On 11/07/22, therapy was to screen, and staff would initiate a bladder diary to determine a toileting schedule. On 01/26/23, staff were to know the resident had a diagnosis of dementia and exhibited some restlessness and anxiety prior to a fall. R2 wandered into the wrong room and attempted to transfer to a bed unassisted. Nursing staff were to monitor the resident for behaviors every shift. If R2 was restless or anxious, staff were to report to the nurse to assess and treat. Staff would repeat urinalysis (UA). In addition, staff were to adjust the resident's bed height to a lower position for improved transfers. On 01/28/23, therapy assessed the resident's wheelchair, R2's positioning in the wheelchair, and therapy adjusted the wheelchair. Staff were to remind her to call for assistance for bathroom use. On 08/16/23, the facility asked R2's family to take Crocs (rubberized slip-on shoes) home. Staff were to encourage the resident to wear her tennis shoes. Staff would know the resident liked to wear her Crocs and remind her that they were not the safest footwear. Staff should remind the resident she cannot get up on her own and would know she may forget and may need reminders. On 09/19/23, nursing staff were to encourage the resident to utilize the grab bar in the shower room and ensure the wheelchair brakes locked before transferring the resident to the shower chair. On 09/20/23, R2 moved around the facility by self-propelling her wheelchair and would take assistance from staff if offered. The resident used bed rails to reposition and to get in and out of bed. The resident no longer used her walker for locomotion, but occasionally used the walker for transfers. The resident required two staff for transfers using a transfer belt and/or a mechanical lift as needed. Staff were to know the resident was forgetful and did not remember she needed assistance transferring. Staff were to keep pathways clear and decrease clutter to minimize the risk of falls. Staff were to keep the resident's wheelchair beside the bed. Staff were to ensure the resident wore secure footwear when out of bed. She sometimes lost her gripper socks and/or placed unsafe slippers over the gripper socks. Staff were to assist the resident in putting gripper socks back on. On 10/09/23, staff were to obtain a UA for the resident. On 11/14/23, staff were to lay R2 down after meals to prevent confusion and ensure safety. Review of the Progress Notes and Fall Investigation Reports revealed the following concerns related to falls experienced by R2: On 07/03/23 at 06:45 AM, the resident adjusted herself in the wheelchair and started to fall forward. Staff were able to catch the resident and assist her to the floor on her buttocks. The fall investigation report failed to identify causal factors to determine an immediate and appropriate intervention to prevent further falls. On 08/13/23 at 07:33 AM, two unidentified residents reported R2 got up from her wheelchair and fell. The intervention was to have family take R2's Crocs home and utilize sneakers. On 08/15/23 at 01:30 PM, an unidentified CNA reported R2 had an unwitnessed fall from the toilet, resulting in a goose egg sized, raised area to the back of the resident's head. The documentation noted the casual factor of the fall as the resident was impulsive and sometimes confused and should not be left on the toilet by herself. She had uneven balance and did not have her walker at the time of the fall. The facility educated the unidentified CNA regarding the importance of staying with a dependent, cognitively impaired resident while the resident was on the toilet and to provide supervision, to prevent falls. On 09/16/23 at 08:10 PM, R2 reported she attempted to transfer from the sofa to the wheelchair and fell to the floor. The fall was not witnessed, and the resident was noted to have severe cognitive impairment. The investigation lacked a causal factor and immediate appropriate intervention to prevent further falls. The facility placed an intervention to provide the unidentified CNA education. On 09/19/23 at 09:05 PM, an unidentified CNA reported they found R2 on the floor wearing a gown and socks. The resident reported she started to sit down, missed the chair, and landed on the floor. On 10/08/23 at 11:15 PM, staff found the resident sitting on the floor in front of the bathroom. The investigation report failed to provide an immediate intervention to prevent further falls. On 11/16/23 at 03:00 PM, the resident attempted to toilet herself and fell to the floor landing on her backside. She hit her head, causing a goose egg, which measured approximately two centimeters around, to the back of her head. The facility placed an intervention to prevent further falls, which included instructions to staff to remind the resident to use her call light for assistance for transfers and to ensure the resident used non-slip footwear. Review of the resident's care plan revealed both interventions were already implemented following previous falls. The Investigation Report, lacked a new immediate intervention to prevent further falls. The Progress Note dated 11/27/23 at 01:30 PM, revealed R2 was in her wheelchair when an unidentified Certified Nursing Assistant (CNA) served the resident's meal at 01:00 PM and left the room. Approximately five minutes later, an unidentified CNA heard a crash and found the resident on the floor with the bedside table on top of her. The nurse assessed the resident and called 911 for transport to the emergency room (ER). The Progress notes dated 11/27/23 at 05:30 PM, documented the nurse received a call from the ER with a resident status update. She had fractures of thoracic spine. The Hospital Discharge Summary dated 11/30/23, documentation included the resident sustained a fracture of the 10th and 11th vertebra of the thoracic (bones of the spine (mid back) following a fall on 11/27/23 at the nursing facility. Review of the R2's Electronic Medical Record, (EMR) from 07/01/23 through 01/10/24, revealed the resident had a history of falls and experienced eight falls in the five months prior to the fall on 11/27/23 at 01:05 PM, which resulted in two fractured thoracic vertebrae. Observation on 01/10/24 at 11:03 AM, revealed the resident sat in the wheelchair in the commons area. She wore multicolored Crocs, with her feet on the pedals of the wheelchair. A brace was visible beneath her shirt, that covered her chest wall. On 01/11/24 at 09:30 AM, observed Certified Nurse Aides (CNA) P, CNA MM, and CNA NN transferred and provided toileting to R2. The staff transferred the resident to the toilet with a gait belt. R2 wore Crocs on her feet. The staff reported she wore her crocs all the time. On 01/11/24 at 09:30 AM, CNA P reported the resident was at risk for falls and had several falls. The resident used to walk, and the staff could walk her back and forth to the bathroom but stated R2 had not walked in almost a year. CNA P said when a resident fell, the nurse should put an immediate intervention in place to prevent further falls. CNA P said the new interventions should be added to the care plan, and staff have access to the care plan for directions on caring for the resident. On 01/17/24 at 10:13 AM, Licensed Nurse (LN) I stated when a resident fell, the charge nurse should do an assessment, which included vital signs, range of motion, and a head-to-toe skin assessment. If the fall was not witnessed or the resident hit their head, staff should complete a neurological assessment. The nurse should notify the physician, the resident representative, and the Director of Nursing. The charge nurse should initiate an investigation at the time of the fall to determine the cause. An immediate new and appropriate intervention should be put in place and communicated to the staff. LN I stated a resident with dementia was not a reliable reporter for the cause of the fall and it would not be appropriate for a resident with dementia to use an intervention to remind the resident to use a call light. A resident that required assistance with transfers to the toilet and was cognitively impaired should not be left unattended in the bathroom. Staff should use the resident's care plan for guidance for fall interventions. New staff were not familiar with long term care and the system to put new appropriate interventions on the resident's care plan immediately to prevent further falls. On 01/17/24 at 01:15 PM, Administrative Nurse D stated on 11/27/23, R2 had an unwitnessed fall. The investigation revealed the probable cause was due to the resident reached for the wheeled end table and she fell. Administrative Nurse D stated the resident had a diagnosis of dementia and a history of multiple falls due to her poor impulse control where she would try to stand, transfer, and toilet herself without staff assistance. Staff had R2 transported to the hospital for an evaluation and R2 was admitted due to fractured vertebras. She was sent back to the facility with a brace to stabilize her fractured vertebrae. Staff removed the wheeled table from the resident's room and replaced it with a stationary table. The charge nurse should initiate a new immediate and appropriate fall intervention to prevent further falls. The resident's BIMS score should be 13 or higher for resident education to be an appropriate intervention. R2's interventions were not appropriate, and no new interventions were put in place to prevent further falls prior to the resident falling on 11/27/23, which resulted in fractures. The 02/2017 facility's policy for Clinical Care Systems Guidelines for Falls did not address initiating a new, immediate, and appropriate intervention based on causal factors of each fall experienced by a resident, in order to prevent further falls. The facility failed to thoroughly investigate to identify causal factors of the fall and/or initiate/implement, new immediate, appropriate interventions to prevent further falls for cognitively impaired R2, who had multiple falls, one of which resulted in two fractured vertebrae. - The Physician Order Sheet (POS), dated 01/02/24, for Resident (R)27, documented a diagnosis of weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. He required extensive assistance of two staff for transfers and extensive assistance of one staff for locomotion on the unit with the use of a wheelchair. He had no limitations in his range of motion (ROM) and no falls since the prior assessment. The Falls Care Area Assessment (CAA), dated 08/02/23, documented the resident had a history of falls due to weakness and had impaired gait and mobility which required him to have staff assistance with transfers. The Quarterly MDS, dated 11/01/23, documented the resident had a BIMS score of five, indicating severe cognitive impairment. He required extensive assistance of two staff for transfers and extensive assistance of one staff for locomotion on the unit with the use of a wheelchair and had no limitation in his ROM. He had one fall with injury (except major) since his prior assessment. The falls care plan, revised 01/08/24, instructed staff that the resident would forget he was unable to stand on his own, creating possible safety risks. Staff were to help remind him of safety issues. He had anti-tip brakes applied to his wheelchair to prevent the wheelchair from rolling backwards if he did attempt to stand up on his own. Staff were to keep the resident in the front commons area between meals. The resident received physical therapy (PT) following a prior fall. Review of the resident's EMR revealed Fall Assessments which placed the resident at a high risk for falls, dated: 06/11/23, 09/11/23 and 10/30/23. Review of a Fall Report, dated 12/23/23 and provided by the facility, revealed the resident had a witnessed fall on 12/23/23 in the front commons room when he attempted to stand up from his wheelchair, took a couple of steps and fell to the floor, landing on his right side. The resident had a decrease in his ROM on his right upper extremity and was transported to the ER for evaluation, where it was found he had a re-fracture of his right clavicle (collar bone). Staff were following all fall interventions at the time of the fall. The new intervention for the fall was to obtain a urine sample for a urinalysis (UA-lab analysis of urine) to check for a urinary tract infection (UTI-an infection in any part of the urinary system). Review of the resident's EMR lacked a lab result for the UA which had been ordered on 12/23/23. On 01/17/24 at 01:15 PM, Administrative Nurse E stated the facility had failed to obtain a UA to send to the lab for analysis at the time of the fall. Administrative Nurse E stated that had been an inappropriate fall intervention. The facility policy for Falls, dated February 2017, included: The interdisciplinary team (IDT) will review the post fall investigation and summarizes the team recommendations for interventions. The facility failed to initiate an appropriate fall intervention following an injury fall for this dependent resident to prevent further falls. - Review of Resident (R)15's Physician Order Sheet dated 12/13/23, revealed diagnoses included Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). . The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired decision making. The resident was rarely/never understood. The resident the resident was able to wheel herself in her wheelchair and was dependent on staff for transfers. The resident had no impairment in the upper or lower extremities. The Cognitive Loss Care Area Assessment (CAA), dated 10/27/23, assessed the resident was unable to always make her needs known. Staff assist the resident with all cares and the resident self-propelled herself to/from the dining room. The Falls CAA, dated 10/27/23, triggered secondary to impaired gait and mobility and level of assistance required with transfers. Contributing factors includes history of falls prior to admission, weakness and physical performance limitations affecting balance, gait, strength, and muscle endurance. The Care Plan reviewed 11/02/23, instructed staff the resident propelled herself in her wheelchair but did need assistance with direction. The resident was at high risk for falls, had weakness and poor understanding of safety issues. Observation, on 01/10/24 at 12:25 PM, revealed Certified Nurse Aide (CNA)Z propelled the resident in her wheelchair which lacked foot pedals, to the dining room. The resident thighs were slouched forward from the seat bottom. her knees were bent under the wheelchair, and her feet skimmed along directly touching on the floor. Observation, on 01/17/24 at 11:25 AM, revealed the resident seated in her wheelchair with her thighs slouched forward from the seat bottom of the wheelchair and she attempted to propel herself about in the common living area. Administrator A at that time, propelled the resident to the dining room without foot pedals on the chair and her feet skimmed along directly touching on the floor. Administrative Staff A obtained foot pedals for the resident's wheelchair, but the resident was unable to keep her feet on the pedals due to posture. Interview with Administrative Staff A revealed the resident needed a wheelchair seating evaluation as the resident usually propelled herself and took the pedals off the chair stating staff should guide the resident to the dining room while she propelled herself. Administrative Staff A stated when staff propel her, her feet should be on wheelchair pedals. Interview, on 01/17/24 at 11:28 AM, with Consulting Staff GG, confirmed the need for a wheelchair evaluation. Observation, on 01/17/24 at 11:32 AM, revealed CNA Q propelled the resident to the dining room in her wheelchair without foot pedals. The resident could not hold her feet up off the floor consistently and her feet skimmed the floor. Interview at that time with CNA Q revealed the resident slouched in her wheelchair, and thought the resident needed a different wheelchair. CNA Q stated the resident could propel herself, but often became confused and could not follow directions. The facility did not provide a policy for use of wheelchair pedals. The facility failed to ensure proper wheelchair seating seating/positioning/foot pedals to prevent accidents for this resident when staff aided with propelling to avoid injury as the resident's feet skimmed along directly touching on the floor under the wheelchair.