**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Physician Order Sheet (POS), dated 04/06/21, documented Resident (R)2 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. He required extensive assistance of two staff for bed mobility, transfers and toilet use. His balance was not steady, and he was only able to stabilize with staff assistance. He used a walker and a wheelchair for mobility and had two non-injury falls since the prior assessment. The Falls Care Area Assessment (CAA), dated 03/11/21, documented the resident had decreased safety awareness related to impaired cognition and used a wheelchair for most mobility needs. The quarterly MDS, dated 12/17/20, documented the resident had a BIMS score of three, indicating severely impaired cognition. He required limited assistance of one staff for bed mobility, transfers, and toilet use. He had two non-injury falls since the prior assessment. The falls care plan, updated 04/16/21, instructed staff to keep the resident's pathways clear and to provide adequate lighting due to the resident's decreased safety awareness. Staff were to ensure the resident had on appropriate foot wear at all times, to put him on the couch or the recliner following meals, and to initiate a toileting diary to determine appropriate toileting times for the resident. Review of the resident's electronic medical record (EMR), revealed a fall assessment, dated 04/16/21, which placed the resident at a high risk for falls. Review of the facility's fall report, documented 04/16/21, included: Staff discovered the resident on the floor in the commons room lying on his right side, propped up on his right elbow. His range of motion (ROM) was intact and he had no injuries. Staff assisted him up to his wheelchair with extensive assistance of two and taken to the bathroom. The resident had been incontinent of bowel. The fall report lacked analysis for the fall. The staff did not initiate an immediate intervention following this non-injury fall. Review of the facility's fall report, documented 02/18/21, included: The staff discovered the resident lying on the floor of his room. Resident complained of right hip pain. The resident's ROM was intact and his neuro signs were within normal limits (WNL). The fall report lacked an analysis for the fall. The staff did not initiate an immediate intervention following this non-injury fall. On 05/11/21 at 12:20 PM, the resident sat in his wheelchair in the dining room eating lunch. The resident wore appropriate footwear and an anti-rollback break was in place to the back of his wheelchair. On 05/11/21 at 01:10 PM, the resident rested in bed. The fall floor mat was in place on the floor next to his bed. The bed was in the lowest position. On 05/12/21 at 01:33 PM, Licensed Nurse (LN) G stated, when a resident falls the nurse will complete an assessment. The nurse was to initiate a fall intervention immediately to prevent further falls. On 05/13/21 at 09:40 AM, Administrative Nurse D, stated it was his expectation that the nurse immediately initiate a fall intervention following each fall. The facility failed to initiate interventions following this dependent resident's two falls. The facility policy for Falls, last approved 12/2019, included: The documentation of the identified interventions should be maintained in the resident's clinical record. The facility failed to timely implement adequate interventions to prevent further falls for this dependent resident. - The Physician Order Sheet (POS), dated 04/07/21, documented Resident (R) 33 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. He required extensive assistance of two staff for bed mobility, transfers and toilet use. He had no falls since admission to the facility. The Falls Care Area Assessment (CAA), dated 03/22/21, documented the resident had not had any falls since admission to the facility and was at risk for falls due to an unsteady gait. Staff were to assist the resident with transfers and mobility. The Falls Care Plan, dated 03/15/21, instructed staff the resident was at risk for falls due to him being a recent admission to the facility. Staff were to keep his pathway clear, provide adequate lighting, and keep his bed at an appropriate height. Review of the resident's electronic medical record, revealed a fall assessment, dated 03/30/21, which placed the resident at a high risk for falls. Review of the facility's fall report, documented 03/23/21, included: The resident attempted to get up from his bed without assistance and was found on his back on the floor of his room. He had no injuries from the fall. The fall report lacked an analysis for the fall. The staff did not initiate an immediate intervention following this non-injury fall tp prevent further falls. Review of the facility's fall report, documented 03/30/21, included: Staff discovered the resident on the floor of the hallway. He had stood up from his wheelchair, lost his balance and fell to the floor. Staff were unable to reach him before he landed on the floor. He received no injuries from the fall. The fall report lacked an analysis for the fall. The staff did not initiate an immediate intervention following this non-injury fall to prevent further falls. On 05/11/21 at 11:49 AM, the resident sat in his wheelchair in the dining area. He wore appropriate shoes. On 05/12/21 at 09:39 AM, Certified Nurse Aide (CNA) PP, checked on the resident who was sleeping in his bed. The resident had a fall floor mat next to his bed and worse non-slip socks. On 05/12/21 at 01:33 PM, Licensed Nurse G stated, when a resident fell, the nurse will complete an assessment. The nurse was to initiate a fall intervention immediately to prevent further falls. On 05/13/21 at 09:40 AM, Administrative Nurse D, stated it was his expectation that the nurse immediately initiated a fall intervention following each fall. The facility failed to initiate interventions following this dependent resident's falls. The facility policy for Falls, last approved 12/2019, included: The documentation of the identified interventions should be maintained in the resident's clinical record. The facility failed to timely implement adequate interventions to prevent further falls for this dependent resident. The facility reported a census of 74 residents with 22 selected for review, which included eight residents reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure appropriate fall interventions were in place by determining the causal factors of the fall for four of the eight sampled residents. Of these Resident (R) 47 fell and sustained a nasal fracture and forehead laceration which required 11 sutures, with R2 and R33 experiencing repeated falls. The facility further failed to investigate and develop interventions for one of the eight residents, R51 who sustained repeated skin tears to the arms on three occasions. Findings included: - Review of R 47's Physician Order Sheet, dated 04/07/21, revealed diagnoses that included repeated falls, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with polyneuropathy (nerve damage in multiple nerves), hypertension (elevated blood pressure) and dementia (progressive mental disorder characterized by failing memory, and confusion). The Annual Minimum Data Set, dated 04/01/21, assessed the resident with a Brief Interview for Mental Status score (BIMS) of 14, which indicated normal cognitive status. The resident required extensive assistance of two staff for bed mobility, transfers, and locomotion on the unit. The resident required staff assistance to maintain balance and had no impairments in range of motion in her upper or lower extremities. The Falls Care Area Assessment (CAA), dated 04/01/21, assessed the resident as having a high risk for falls. The facility determined the falls were a result of the resident transferring herself without asking for assistance of staff or using her call light. The resident required frequent reminders to ask for assistance but continued to attempt self-transfers. The resident was able to propel herself when in a wheelchair. The resident received therapy services for training and safety training. The Care Plan, dated 02/15/21 and revised 05/05/21 instructed staff to know the resident had a memory problem with impaired decision-making skills and an impaired ability to comprehend due to dementia. The resident was blind in her right eye. The resident could propel herself when in the wheelchair for short distances. The resident was continent of bladder with occasional incontinent episodes. Staff were advised the resident chose to not request help with transfers at times, due to impulsiveness. The resident had a fall mat beside the low bed and a transfer bar. The resident should wear nonskid socks, had a soft touch call light, and nonskid strips on the fall mat. The care plan instructed staff to perform frequent visual checks of the resident. The resident required therapy for safety awareness and transfer techniques. Staff should encourage the resident to call for assistance as she had poor safety awareness. The Safety Event Entry-Working Copy dated 03/03/21 revealed dietary staff found the resident on the floor in her room on 03/01/21 at 02:15 PM. The resident stated she tried to find her remote. Measures in place included a low bed, assist rail, and nonskid socks. The facility failed to identify the casual factors of the resident's fall. The resident said she fell trying to reach for the remote. The new intervention for this fall indicated to obtain general lab per physician order. The facility obtained a urinalysis (UA) on 03/01/21 which was negative for urinary tract infection (UTI). The Safety Event Entry-Working Copy dated 03/16/21 at 09:15 AM, revealed the resident was found on the floor with her head near the dresser and her legs on the bedside table, with the wheelchair next to the foot of the bed. The resident reported she was reaching forward to secure her cell phone charger on the bedside table and she slid off the edge of her wheelchair. The resident finished eating breakfast 15 minutes prior to the fall and propelled herself back to the room. The resident fell asleep during breakfast. The facility failed to identify the casual factors of the resident's fall. The resident said she was reaching for her cell phone charger on the table. The intervention for this fall was to complete a medication review and lab work. The facility obtained a UA on 03/19/21 (3 days after the fall), which revealed a UTI, then on 03/22/21, (3 days later and 6 days after the fall), the physician started the resident on antibiotics for the UTI. The Safety Event Entry-Working Copy dated 03/17/21 reported the resident was found on 03/17/21 at 01:00 PM, sitting in her room on the fall mat, the resident attempted to transfer herself from her wheelchair to bed. No immediate intervention was put in place. An intervention, dated 03/19/21 (2 days later), instructed staff to encourage the resident to wait for staff and use a mechanical lift if needed. The Safety Event Entry-Working Copy dated 04/24/21, documented on 04/24/21 at 09:20 AM, staff found the resident in her room on the floor. The resident reported she attempted to transfer herself from her wheelchair to her bed and fell, striking her head on the floor. The intervention for this fall was to encourage the resident to propel her wheelchair close enough to the bed for safe transfers. The Safety Event Entry-Working Copy dated 05/04/21, revealed staff found the resident in her room, on the floor on 05/04/21 at 12:40 PM. The resident sustained a puncture wound to her middle forehead, had blood coming from both nostrils, and had a large skin tear with fat exposure to her right forearm. The facility failed to identify the casual factor of the resident's fall in her room. Review of the Emergency Department Provider Report, dated 05/04/21, revealed the resident required 11 sutures to the laceration on her forehead, sustained a laceration to her right forearms, and had a closed nasal bone fracture. Observation, on 05/10/21 at 08:45 AM, revealed the resident propelled herself in her wheelchair towards her room. The resident had sutures in a cross formation on her forehead, and the top of her right hand had extensive bruising, with the right forearm wrapped with a dressing. The resident used the ball of her foot to propel herself, leaning forward in the chair. The resident's bed was in a low position and a fall mat was beside the bed. The resident's wheelchair had a self-locking device in place. The resident attempted to move in her wheelchair onto the fall mat beside her bed and reached forward with her outstretched arm towards her bed. Interview, at the same time with Certified Medication Aide (CMA) S, revealed staff needed to transfer the resident either to the toilet or bed after meals, but often the resident finished her breakfast and attempted to transfer herself to her bed before staff were done assisting other residents with eating their breakfast. CMA S stated they were in a dilemma when they left the residents still eating breakfast to transfer the resident, because she took a lot of time. Observation, on 05/12/21 at 09:45 AM, revealed Licensed Nurse I and Administrative Nurse E, removed the resident's dressing from her right forearm. The resident had an extensive skin tear with an area not approximated deep layered skin, exposing subcutaneous fat, measuring two by four centimeters. Administrative Nurse E cleansed the area and redressed it with Vaseline gauze, and wrapped it with elastic gauze wrap. Interview, with LN I at that time, revealed the resident was alert at times and cooperated with staff, but staff needed to keep her within their line of sight as she would try to transfer herself and did not use her call light. Interview on 05/11/21 at 09:26 AM with CNA Q revealed the resident required two staff for transfers. Staff transferred the resident to bed or toilet as she preferred, after meals. CNA Q stated the resident tried to transfer herself from her wheelchair to her bed, but had an anti-slide device in the chair, anti-tip bars on the wheelchair, and a low bed. Interview on 05/11/21 at 02:01 PM with Therapy Consultant Staff (TCS) II revealed the resident was not safe to transfer herself from the wheelchair to the bed and required much cueing. The resident attempted to follow TCS II with the process of transferring but could not remember the steps. The resident was somewhat drowsy during the exchange. TCS II stated the resident had poor safety awareness. Interview on 05/11/21 at 03:15 PM with CNA MM revealed the resident required two staff to transfer, staff kept the resident's bed in a low position, and kept her door open to keep an eye on her. Interview on 05/12/21 at 02:44 PM, with CNA P revealed the resident had variable levels of alertness. CNA P stated the resident did not like to wait for staff assistance, did not use her call light, and tried to transfer herself. CNA P stated he was working when the resident last fell. CNA P stated the resident finished meals sooner that other residents and staff were often assisting residents that needed staff assistance with eating. CNA P stated staff tried to get her up last for meals, but the resident still finished her meals sooner than others and took herself to her room, did not use a call light, and attempted to transfer herself Interview on 05/13/21 at 10:45 AM with Administrative Nurse F, revealed staff provided multiple interventions for fall prevention. Interview on 05/13/21 at 11:00 AM with Administrative Nurse D, revealed the resident had a normal BIMS score, but did require staff assistance for transfers. Administrative Nurse D stated multiple interventions were developed for the resident and the resident had multiple falls. Administrative Nurse D explained she thought staff had interventions in place for the resident's falls and that the Quality Assurance (QA) nurse reviewed the falls. On 05/13/21 at 11:20 AM, Administrative Nurse F reported being responsible for QA and that she reviewed the interventions put in place and then determined if they were appropriate. Nurse F explained she did the cause analysis on the falls but those were in the facility QA program so were unavailable for review. The facility policy Accidents and Incidents-Investigating and Reporting revised 01/2020, instructed staff accidents shall be investigated and reported and interventions initiated. The facility failed to determine the root cause for the resident's multiple falls and failed to develop appropriate interventions for these repeated falls, with the most recent fall resulting in nasal fracture, a laceration to her forehead which required 11 sutures and a laceration (skin tear) to her right arm exposing subcutaneous tissue - Review of resident (R)51's Physician Order Sheet, dated 05/04/21, revealed diagnoses included Parkinson's (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) with visual hallucinations, dementia (progressive mental disorder characterized by failing memory, confusion) and diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Annual Minimum Data Set, dated 07/23/20, assessed the resident with severe cognitive deficits, required extensive assistance of two staff for bed mobility, transfers and locomotion on the unit. The resident had no functional impairment of her upper or lower extremities. The Falls Care Area Assessment (CAA), dated 07/23/21, assessed the resident required staff assistance with ambulation and could propel herself in her wheelchair. The resident had decreased safety awareness and was at increased risk for falls/injury. A Nurses' Note, dated 05/01/21, documented the resident sustained two skin tears on her left elbow when Certified Nurse Aide staff assisted the resident to the bathroom and the resident stuck her arm out, which caused two skin tears on her upper left forearm, one measured 6 by 0.1 centimeters (cm) and another 3.5 by 0.1 cm. The Skin Evaluation Record, dated 05/10/21, documented a four cm C shaped left elbow skin tear. The resident had fragile aging skin and bumped the elbow. Staff to try Geri sleeves again. The Skin Evaluation Record, dated 05/13/21, documented a right calf skin tear which measured 4 by 1.5 cm. Observation, on 05/10/21 at 04:10 PM, revealed the resident seated in her wheelchair. Her left elbow contained a crescent shaped skin tear approximately 3.5 cm and within this another skin tear approximately 2 cm. The resident did not have protective sleeves on. Interview, on 05/11/21 at 03:15 PM, with Certified Nurse Aide (CNA) MM, revealed the resident propels herself backwards and backs into things and may have gotten the skin tears from running into things. Observation, on 05/13/21 at 08:00 AM, revealed the resident seated in her wheelchair with CNA Q propelling her. The resident had a skin tear on her left elbow area in a crescent shape, approximately 2 cm. The resident positioned her unprotected left arm above the wheel on the wheelchair (no positioned on her lab) nearly touching the wheel as CNA Q propelled the resident. Interview, on 05/23/21 at 10:30AM with Administrative Nurse E, confirmed the lack of interventions and investigations for the skin tears. Administrative Nurse E stated she thought at one point in time the resident wore protective sleeves but could not find that intervention on the resident's care plan to instruct the staff. The facility policy Skin Tears - Abrasions and Minor Breaks, dated 12/2016, instructed staff the to complete the investigation of causation and implement interventions to prevent additional abrasions. The facility policy Accidents and Incidents-Investigating and Reporting, dated 01/2020, instructed staff to investigate and initiate interventions. The facility failed to investigate and initiate interventions to prevent skin tears in this dependent resident with repeated multiple skin tears.