**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 26 residents. The sample included 12 residents, with seven reviewed for falls. Based on observation, record review, and interview, the facility failed to follow two residents' care plans: Resident (R) 128, who sustained a tibia (bone of the lower leg) fracture (break) during ambulation, and R4, who slid off the bed while on a bed pan. This placed the residents at risk for further falls and avoidable injury. Findings included: - The Electronic Medical Record (EMR) for R128 documented diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), and pain. The Annual Minimum Data Set (MDS), dated [DATE], documented R128 had severely impaired cognition. R128 was dependent upon staff for toileting and lower body dressing. R128 received partial staff assistance for personal hygiene, mobility, transfers, and upper body dressing. R128 refused to ambulate. The MDS documented R128 had upper functional impairment on one side and had no falls. The Fall Care Area Assessment (CAA) dated 05/06/24, documented that R128 was on Hospice (specialized care that mainly aims to provide comfort and dignity to the patients by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life), had functional limitations in her upper extremities and no functional limitations in her lower extremities, and used a walker and wheelchair. The Quarterly MDS, dated 07/29/24, documented R128 had long and short-term memory loss with moderately impaired decision-making skills and was dependent upon staff for toileting, and lower body dressing. R128 required substantial staff assistance for transfers and partial assistance for upper body dressing, personal hygiene, and mobility. R128 did not ambulate. The MDS further documented R128 had upper functional impairment on one side and had two or more falls with injury. The Fall Assessments dated 07/23/24 and 09/29/24 documented R128 was at risk for falls. The Care Plan, dated 08/15/24, initiated on 01/04/24, directed staff to encourage R128 to use her call light and wait for staff assistance, place her motion sensor pointed towards the bed, and make sure to change batteries. The update, dated 02/05/24, documented a scooped mattress was placed on R128's bed. The update, dated, 02/09/26, directed staff to ambulate R128 short distance with one to two staff and a walker and please use a gait belt. The update, dated 05/21/24, directed staff to take R128 out to the west dining room when she had increased confusion and hallucinations so staff could keep an eye on her. The update, dated 08/12/24, documented R128 no longer ambulated as she consistently lifted her feet into the air. The Fall Investigation, dated 09/28/24 at 10:35 AM, documented Certified Nurse Aide (CNA) N assisted R128 to the bathroom and R128 went down to her knees. CNA N assisted R128 back to a standing position and assisted her to the toilet. R128 was weak and complained of right knee pain. The investigation documented the root cause of the fall was CNA N did not follow R128's care plan to not ambulate the resident and the gait belt was used incorrectly. The Witness Statement, dated 10/02/24, documented CNA N reported she had gone to get R128 up and out of bed so she could eat breakfast. CNA N removed the covers then sat R128 up onto the side of the bed, grabbed her walker, counted to three, and stood R128 up. CNA N stated she stood behind her as R128 ambulated to the bathroom. CNA N stated she hovered her hands around R128's waist as she walked with her. R128's right knee gave out and CNA N quickly put her arms under the resident's armpits, and R128's right knee touched the ground. CNA N further stated she held her body off of the ground except for her right knee. The toilet was close to them, so she rotated her to the toilet, sat her down, and went to get assistance. The Nurse's Note, dated 09/28/24 at 07:02 PM, documented Hospice was notified and stated they would come to the facility to evaluate R128 and would send an email to the family to ask if they wanted an X-ray (a type of electromagnetic radiation that can pass through objects and create images of their internal structures). The note documented R128's family declined an X-ray unless things seemed to get worse. The note documented R128's right knee had swelling, and she complained of right knee pain. The Nurse's Note, dated 09/29/24 at 04:09 PM, documented R128's right knee was swollen, bruised, and tender to the touch. The Nurse's Note, dated 09/29/24 at 06:00 PM, documented R128's grandson was in the facility and felt R128's right knee should be X-rayed. The staff documented the physician would be notified to see if the portable X-ray Service could come to the facility to X-ray her right knee. The X-Ray Report, dated 10/02/24, documented R128 had an acute fracture of the right tibia. The Physician's Order, dated 07/31/24, directed staff to administer Acetaminophen (pain medication), 650 milligrams (mg), by mouth, as needed, every 24 hours for pain. The Physician's Order, directed staff to not allow R128 to bear any weight due to the fracture in the right leg below the knee. The EMR documented R128 passed away on 10/10/24. On 01/23/25 at 10:30 AM, Certified Medication Aide (CMA) T stated R128 was on hospice, cognitively impaired, and non-ambulatory before the fall. CMA T further stated R128 was bedbound after the fall. On 01/22/25 at 04:25 PM, Administrative Nurse D stated she interviewed the CNA and discovered the CNA was not holding on to the gait belt when she ambulated the resident. Administrative Nurse D stated as they were walking, R128's right knee buckled and the CNA tried to keep her from falling by grabbing under her armpits, but her right knee hit the ground. Administrative Nurse D stated the CNA had not followed R128's care plan. The facility's Falls and Fall Risk, Managing policy, dated 2001. documented based on previous evaluations and current data, and staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from failing and to try to minimize complications from falling. If interventions have been successful in preventing falling. Staff would continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has been resolved. If the resident continued to fall, staff would reevaluate the situation and whether it was appropriate to continue or charge current interventions. As needed, the attending physician would help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician would document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. The facility failed to follow R128's care plan which resulted in a tibia fracture This deficient practice placed the resident at risk for further falls and avoidable injury. - The Electronic Medical Record (EMR) for R4 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), pain, congestive heart failure (CHF - a condition with low heart output and the boy becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), trochanteric fracture of the right femur (a break in the thigh bone), and atrial fibrillation (rapid, irregular heart rate). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition. R4 was dependent upon staff for toileting, supervision with mobility, transfers, and ambulation. R4 had upper functional impairment on one side, was at risk for falls, and had two falls with injury, and one non-injury fall. The Fall Care Area Assessment (CAA), dated 09/23/24, documented R4 was a high risk for falls, had functional limitations to her left upper extremity, had repeated falls, and muscle weakness. The Fall Risk Assessments, dated 12/24/24, 01/06/25, and 01/13/25 documented R4 was at risk for falls. The Care Plan dated 12/19/24, initiated on 06/07/23, directed staff to use cloth chucks (absorbent pads used to protect surfaces from stains and moisture) on her bed as she may slide off with paper chucks. The update dated 08/08/24, directed staff to encourage R4 to call for assistance to pick up items off the floor. The update dated 08/28/24, directed staff to place a motion detector in her room. The update dated 09/01/14, directed staff to use her wheelchair or long distances instead of using her walker. The update dated 09/05/24, directed staff to encourage R4 to not sit at the edge of her recliner. The update dated 01/14/25, directed staff to not use paper chucks under her as they can be slippery, and she may fall off of her bed. The Fall Investigation, dated 01/14/25, documented R had an unwitnessed fall, and slid off of the bed between her bed and the wall. The investigation documented R4 was placed on the bedpan at 07:15 AM, and at 07:42 AM, staff heard R4 yell for help. R4 was found between the wall and the bed. R4 was leaning on her left hip with her head and left hand on the bed and holding onto the bedrail with her right hand. The investigation documented the root cause of the fall was a paper chuck was placed under the bedpan and when she repositioned, she slid off of the bed. On 01/21/25 at 12:49 PM, observation revealed Consultant HH removed the foot pedals from R4's wheelchair, and Consultant GG placed a gait belt around R4's waist and placed her walker in front of her. Consultant GG and Consultant HH stood beside R4 and had her stand up, pivot, and sit down on her bed. Consultant GG stated therapy staff transferred the resident during the day as part of her therapy which she received five days per week. Consultant GG swung her legs up onto the bed as Consultant HH raised the head of her bed and placed two pillows behind her head. On 01/23/25 at 10:34 AM, Certified Medication Aide (CMA) T stated staff checked on R4 every 15 to 30 minutes, offered activities, and made sure she had anything she needed before staff left her room. R4 liked to get up on her own and not wait for any staff assistance, so a motion detector was placed in her room. CMA T stated her last fall was from sliding off the bed and the intervention was to not use paper on her bed, only cloth. On 01/23/25 at 01:42 PM, Administrative Nurse D stated staff should not leave a resident on the bedpan for longer than 30 minutes and should follow the care plan when assisting her. Administrative Nurse D further stated staff had placed a paper chuck on the bed and a cloth chuck on top of the paper chuck and have continued reeducation on following resident care plans. The facility's Falls and Fall Risk, Managing policy, dated 2001. documented based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If interventions have been successful in preventing falling. Staff would continue the interventions or reconsider whether these measures are still needed if a problem that required the interventions has resolved. If the resident continued to fall, staff would reevaluate the situation and whether it was appropriate to continue or charge current interventions. As needed, the attending physician would help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician would document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. The facility failed to follow R4's care plan of not using paper chucks under the resident, which resulted in R4 sliding off of the bed. This placed the resident at risk for further falls and avoidable injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 36 residents. The sample included 12 residents, with four reviewed for accidents/falls. Based on observation, interview, and record review the facility failed to use an appropriate lift sling during a mechanical lift transfer, which resulted in Resident (R) 6 falling out of a lift sling resulting in a head laceration, hematoma (collection of blood under the skin from an injury), and pain. The facility further failed to implement new interventions to prevent further falls for R14, who had multiple falls. This placed the residents at risk for further falls and fall-related injury. Findings included: - R6's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), osteoporosis (medical condition in which the bones become brittle and fragile from loss of tissue), osteoarthritis (degeneration of joint cartilage and the underlying bone), spinal stenosis (when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), glaucoma (group of eye conditions that can cause blindness), and major depressive disorder (MDD-mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R6 had long term memory problems with severely impaired decision making, one non-injury fall, one minor injury fall, and weight of 159 pounds. The Fall Care Area Assessment (CAA), dated 09/19/22, documented R6 recently admitted on hospice services. Her balance was unsteady; she was only able to stabilize with staff assistance, and she used a wheelchair for mobility. The CAA documented an 08/29/22 Health Status Note documented staff found the resident on the floor with a large bump to the left side of her forehead. The Quarterly MDS, dated 11/07/22, documented R6 had short- and long-term memory loss, with severely impaired decision making. The MDS documented R6 required limited assistance of one staff for eating, extensive assistance of two staff for toileting, hygiene, dressing, bed mobility, and total assistance of two staff for transfers. The MDS documented R6 had no range of motion impairment, she used a wheelchair, and had one minor injury fall. The MDS lacked a weight, pain assessment, and balance testing. The Fall Care Plan, dated 08/12/22, documented staff moved R6 closer to the nurse's station after the 08/29/22 fall. Other fall interventions included remind her to not pick up her room tray and to ask for assistance with this and placed a motion sensor in the resident's room. Staff would ensure the resident's call light was within reach and staff would encourage her to use it for assistance as needed. Staff would know R6 might need reminders that she had a call light and education on how to use it. Staff would ensure her walker was at bedside when going to bed. The ADL Care Plan, dated 11/11/22, directed staff to provide total assistance of two staff for transfers with the full mechanical lift and large combi sling. The 09/27/22 care plan update directed staff as follows: Do NOT use a hygiene sling (designed specifically for toileting and allows the user to have easy access to the perineal area) for transfers. Fall risk assessments of 2022 were completed for R6 quarterly and after each subsequent fall and documented R6 at high risk for falls. The Fall Note, dated 08/29/22 at 11:31 AM, documented staff notified the nurse the resident was on the floor, and upon assessment the nurse found a large bump to the left side of R6's forehead. The note documented the nurse notified the physician who instructed her to send the resident to the emergency department (ED) due to her condition. The Progress Note, dated 08/29/22 at 07:24 PM, documented R6 sustained an abrasion the length of her nose and bruising above her left eye. A motion detector was set up in the resident's room. The Transfer Data Collection, dated 09/14/22, documented the resident may require a full mechanical lift at times. The care plan lacked an update regarding this information. The Fall Note, dated 09/24/22 at 09:34 AM, documented at 08:35 AM, a Certified Nurse Aide (CNA) called the nurse to the resident's room where he found R6 on her back on the floor in front of the mechanical lift. The nurse documented staff stated R6 slipped out the bottom of the lift sling. R6 was bleeding from the back of her head with a 2 centimeter (cm) laceration noted to the lower left side of her head and a hematoma. The nurse assessed R6, applied a pressure dressing to stop the bleeding, and notified an on-call physician. The physician instructed staff to keep a pressure dressing on the resident, monitor for continued head bleeding, monitor for any change in cognition, and to monitor for any signs of further injury. The note documented the resident reported head pain and staff offered an ice pack, which the resident declined. The nurse changed the pressure dressing and noted some blood on the gauze pad. Neurological checks were within normal limits for the resident. The Fall Investigation, dated 10/04/22, documented staff attempted to transfer the resident with the Hoyer (total/mechanical) lift and did not use the correct sling. As a result, the resident fell through the bottom of the sling and hit her head on the lift and her right hip on the floor. The investigation stated all hygiene slings were removed until the facility provided staff education. The facility reported the incident to the state agency. The Staff Education Meeting, dated 10/13/22, covered use of lift and slings. On 12/28/22 at 11:07 AM, observation revealed CNA M and CNA N, with Licensed Nurse (LN) G in the resident's room, providing incontinence care. R6 anxiously stated my baby, where's my baby. When LN G asked R6 if she was in pain, R6 replied she was in pain but did not know where. The staff used the total mechanical lift with a medium sling to transfer R6 from her bed to her wheelchair. On 12/28/22 at 11:08 AM, LN G stated the facility had two full body lifts and 2-3 residents on each side who used them. She stated the facility had two medium slings, two large slings, and three extra slings in the offices. On 12/29/22 at 11:22 AM, CNA M stated on 09/24/22 the resident hollered out and when they wanted to transfer R6 to her wheelchair, they could not find the total lift sling. They found the night shift had put it in the soiled laundry and it needed washed. CNA M stated he looked on the other side of the facility for a total lift sling but could not find a clean one. CNA M stated when they put the hygiene sling under her and lifted her off the bed it was ok, but when they moved R6, she swung a little and dropped through the bottom of the sling onto the floor. He stated R6 used to use a walker before the previous fall, but now used a total lift for transfers. On 01/04/23 at 08:43 AM, Administrative Nurse D stated when a sling became soiled staff were to place it in the laundry and there were spare slings on the units. Administrative Nurse D said in order to use a hygiene sling, the resident should be capable of holding arms down to side and be cognitive. Staff used a large hygiene sling and should not have used the hygiene sling with R6. Administrative Nurse D stated she provided all nursing staff education on lift use. The facility's Using a Mechanical Lift policy, dated July 2017, documented at least two staff are needed to safely move a resident with a mechanical lift. Staff must be trained and demonstrate competency using the specific devices used in the facility. Before using a lift device staff were to assess the resident's physical and cognitive condition, measure the resident for proper sling size and purpose, and select a sling bar appropriate for the resident's size and the task. After placing the sling under the resident, staff were to visually check the size to ensure it was not too large or too small. The policy directed staff to lift the resident two inches from the surface to check the fit of the sling and weight distribution, slowly lift the resident, and gently support the resident as he/she was moved. The policy directed staff to disinfect slings between residents, wash and sanitize according to manufacturer's instructions. The facility failed to use an appropriate transfer lift sling during a full-body mechanical lift transfer. As a result, R6 slipped out of the sling, fell to the floor, and sustained a head laceration, a hematoma, and pain. - R14's Electronic Medical Record (EMR) documented diagnoses of fracture of neck of left femur (thigh bone), cerebral aneurysm (bulge or ballooning in a blood vessel in the brain), diabetes mellitus (disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and anxiety. The Quarterly MDS, dated [DATE], documented R14 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R14 required supervision for eating and limited staff assistance for transfers, walking, toileting, dressing and hygiene. R14 had unsteady balance, used a walker or wheelchair, and had one minor injury fall since prior the MDS. The Fall Care Plan, dated 11/4/22, directed staff to ensure sure her call light was within reach and encourage her to use it for assistance as needed. The resident needed prompt response to all requests for assistance. Staff would provide a safe environment with even floors free from spills and clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; and personal items within reach. The 09/05/22 fall update (initiated 10/07/22) directed staff to provide a call light pendent for R14. The update for the fall 09/19/22, (initiated 9/22/22) directed staff to provide a motion alarm as R14 could not remember to call for assistance. The update after the 10/19/2022 fall (initiated 10/26/22) directed staff to provide a call light pendant (repeated from 10/07/22). The Fall Risk Assessments from 09/01/22 to 10/27/22 all documented R14 at high risk for falls. The Fall Note, dated 09/5/22 at 04:30 PM, documented staff heard the resident yell for help and found her on the floor just outside the bathroom door. R14 stated she was going back to bed. Bruises were noted to bilateral wrists and the back, right side of her head. The nurse notified the physician of the fall and the resident complaints of left leg/hip pain. The resident's head hurt, and she has a bruise to the back of her head. The physician ordered staff to send the resident to the hospital for evaluation. The hospital report, dated 09/05/22, documented diagnoses of contusion (bruise) of head and left hip from fall and the X-ray of R14's left hip documented no fracture. The re-admission from the hospital assessment, dated 09/12/22, documented R14 had a left hip fracture, and a motion alarm was in place related to resident confusion and hallucinations. The Fall Note, dated 09/19/22 at 03:25 PM, documented staff found R14 on the floor, laying on her right side, knees slightly bent. The resident was assessed with no obvious injury noted, but complained her tailbone hurt. The Fall Note, dated 10/19/22 at 10:30 AM, documented a dietary aide was passing menus to residents when she saw R14 attempt to sit down, but sat on the arm of the chair, lost her balance and fell to the floor. A standing floor alarm was in place and active. The resident fell onto right side of her body and hit the right side of her head. The physician ordered staff to send R14 to the emergency room as she was on blood thinners. On 12/29/22 at 07:53 AM, observation revealed R14 in bed and a motion alarm on. Certified Nurse Aide (CNA) M put her shoes on, used gait belt and walker with contact assistance to assist her to the toilet. R14 took small steady steps. Observation revealed non-skid strips on the floor in front of the toilet, carpet in bedroom, and a toilet riser with hand bars. On 01/04/23 at 08:50 AM, Administrative Nurse D verified the lack of new appropriate fall prevention interventions after the 09/05/22 and 10/19/22 falls, placing R14 at risk for further falls. The facility Fall Managing policy, dated March 2018, documented staff would identify fall interventions based on previous evaluations and current data related to the resident's specific risks and causes to try to prevent falls. If falls recurs despite initial interventions staff would implement additional or different interventions or indicate why the approach remained relevant. The facility failed to provide relevant fall interventions to prevent further falls for R14, placing the resident at risk for falls with injury.