**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of MapQuest, and review of the facility's policy, the facility failed to adequately supervise and ensure protection from accidents and injuries for 1 of 20 supplemental and sampled residents, Resident (R) 20. On 10/11/2024, R20 was assisted to bed with two Certified Resident Care Assistants (CRCA) using a mechanical lift. The resident was then re-positioned in bed with one CRCA, CRCA5. CRCA 5 rolled R20 away from her, which resulted in the resident being rolled off the bed and onto the floor. R20 sustained bilateral femur fractures. She was sent to the local emergency room on [DATE]. On 10/16/2024, R20 underwent surgical repair with Open Reduction and Internal Fixation (ORIF) of her bilateral femurs. The facility provided an acceptable Plan of Correction (POC) on 12/17/2024 alleging past noncompliance. The survey team validated the deficient practice was corrected on 11/06/2024, following the facility's implementation of the POC and before the start of the survey. The findings include: Review of the facility's policy titled, Fall Management Program Guidelines, effective 05/31/2017 and reviewed 12/31/2023, revealed the facility would put care plan interventions in place that addressed the resident's risk factors. Review of R20's Face Sheet revealed the facility admitted the resident on 10/31/2022 with diagnoses which included non-ST elevation myocardial infarction (heart attack); hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting the left, dominant side; other paralytic syndrome following cerebral infarction, osteoarthritis in bilateral knees, and morbid (severe) obesity with a body mass index of 50-59. Review of R20's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/19/2024 and the last one done before the 10/11/2024 fall, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating intact cognition. This assessment also revealed R20 was nonambulatory and for mobility used a manual wheelchair which required two to wheel at least 150 feet in a corridor; to roll left and right required substantial/maximum assistance; from sitting to lying and lying to sitting required substantial/maximum assistance; and in a transfer from chair/bed to chair and chair to chair/bed, R20 was dependent, with the helper doing all of the effort. Review of R20's Comprehensive Care Plan (CCP), created on 11/09/2022, revealed the focus for the Care Guide stated she was non-weight bearing and required a mechanical lift. Further review of the care plan category: Falls included interventions, as of 10/11/2024, after the fall, to include assist of two for bed mobility. Prior to that she was one assist for bed mobility. Review of R20's Event Report, dated 10/11/2024, revealed on 10/11/2024 at 8:00 PM, R20 had a BIMS score of 12, which indicated moderate cognitive impairment. Per the report, R20 was assisted to bed via a mechanical lift and two CRCA staff members, CRCA5 and CRCA9. The report stated R20 was identified as someone who would benefit from a bariatric bed and mobility bars to aid with bed mobility, neither of which were in place previously. The report stated R20 was turned in bed and rolled out the other side, resulting in a fall. The report revealed R20 used the word sore when talking about her pain after the fall. Per the report, on 10/13/2024, R20 was asked to go to the hospital. The report stated R20 told staff she did not want to, but she felt it would be better to know if something was wrong with her knees. Per the report, R20 was sent to the local hospital for evaluation and subsequently sent to a larger hospital for further treatment. During an interview on 12/17/2024 at 2:20 PM with the Director of Health Services (DHS), she stated R20's BIMS score of 12, as listed on the 10/11/2024 Event Report was an error. She stated R20 had and continued to have a BIMS score of 15, indicating no cognitive impairment. Review of R20's Progress Note, dated 10/11/2024 at 12:29 AM (actual date was 10/12/2024) by Registered Nurse (RN) 5 revealed a CRCA reported to the staff nurse at 8:00 PM that during incontinence care and assisting R20 to get ready to go to sleep, the resident rolled out of bed onto the floor. Per the note, R20 was assessed and was observed with her head down by the foot of the bed and slightly under the edge of the bed, lying on her back. The note stated, during the physical assessment by RN5, she observed a laceration with a loose skin flap on the lateral side of R20's right great toe, and bleeding from the toe was stopped with pressure held. Per the note, the toe wound site was cleansed, steri-strips were applied to secure the flap, and it was covered with medical foam. The note stated R20 complained of pain, rated at seven out of 10 to bilateral knees, with pain on the left greater than the right. Per the note, as needed oral Tylenol (a pain reliever) was provided at 8:56 PM with R20's bedtime medications. The note stated R20's vital signs and neurological checks were stable. Further review revealed RN5 stated that she, as the staff nurse, educated the staff involved in the incident, CRCA5 and CRCA9 on a change in the plan of care for this resident and the importance of having two persons assisting with care in bed to avoid reoccurrence of the incident. Per the note, R20 remained safe with her needs met and the call bell within reach. The note stated staff would continue to monitor the resident. During an interview on 11/26/2024 at 11:50 AM with R20, she stated she did not think she would need to go to the hospital at first, but she was hurting worse and worse. Then, she stated, by Saturday, when the CRCAs tried to turn her, the pain had increased to more than she could handle, and she started to cry. She stated she told RN2 she wanted to go to the hospital, so she was sent to the local Emergency Department (ED). She stated she was told both of her femurs were fractured, and she had surgery to fix them at a larger hospital. During an interview on 11/26/2024 at 9:15 AM with CRCA9, she stated she was asked to help transfer R20 to bed using the mechanical lift. She stated once she had done that she left the room to finish a task she had started in another room. She stated she was called back to R20's room by RN5 because R20 had rolled onto the floor. She stated RN5 assessed R20, and she saw blood coming from R20's right toe. CRCA9 stated that she, along with other staff, assisted R20 back to bed with the mechanical lift. She stated R20 appeared to handle it well During an interview on 11/26/2024 at 10:04 PM with RN5, she stated on 10/11/2024 at approximately 8:00 PM, CRCA5 requested CRCA9 to assist in using a mechanical lift to place R20 in the bed. She stated once the task was complete, CRCA9 left the room, and CRCA5 started to provide incontinence care to R20. She stated R20 was care planned for one assist for bed mobility. She stated R20 rolled to the side of the bed, using the edge of the mattress to pull herself and rolled too far, falling off the side of the bed. RN5 stated she evaluated R20 and determined R20 had a skin tear to her toe, and first aid was applied. RN5 stated there was no deformity, redness, or edema, and R20 rated her pain at a 5 out of 10. RN5 stated she gave R20 Tylenol and documented the decreased pain, as manifested by the resident falling asleep. RN5 stated she was off for the next few days after that, and when she returned, she was surprised R20 had been admitted to the hospital. Review of R20's Progress Note, dated 10/13/2024 at 4:37 PM, revealed RN2 documented (a late entry on 10/14/2024 at 2:08 PM) R20 requested to go to the hospital due to pain in her legs, especially when moving, with the left more painful than the right. The note stated R20 was now crying when moving her left leg, and it was painful to palpation approximately two palms widths above the knee, but she was unable to determine if the left leg was shorter than the right leg due to R20's inability to move legs well. The note stated the APRN was notified by RN2, and Emergency Medical Services (EMS) accepted R20 for transport to the local hospital emergency department (ED, located eight miles from the facility per mapquest.com) for evaluation and treatment. Review of R20's hospital Discharge Summary, from the second and larger hospital, located approximately 33 miles from the facility per MapQuest.com, revealed R20 was admitted on [DATE], after an X-ray of her legs showed left and right femur comminuted (a fractured bone that had shattered into multiple pieces which could be caused by a serious fall) and displaced distal femur diaphysis fracture (the area of the femur just above the knee joint). The X-rays also showed surrounding soft tissue edema and vascular calcifications. The left and right knee radiology reports revealed severe tricompartmental joint space narrowing (indicated cartilage loss and severe osteoarthritis) and the femur fractures. Further review revealed on 10/16/2024, R20 had a surgical repair of her fractures with an open reduction and internal fixation (ORIF) of bilateral femurs. Per the record, R20 had no complications and was discharged back to the facility on [DATE] in stable condition. Review of R20's Progress Note, dated 10/19/2024 at 3:53 PM, revealed R20 was returned to the facility via private EMS, with an assist of four to transfer the resident from the stretcher to her bed. Per the note, R20's surgical dressings were clean, dry and intact. The note stated R20 rated her pain a six out of 10, and Tylenol was given per order. The note stated a follow-up was scheduled for 11/01/2024 with the orthopedic surgeon. During an interview on 11/27/2024 at 10:17 AM with RN2, she stated she worked with R20 during the day shift on 10/12/2024 and 10/13/2024. She stated, on 10/12/2024, R20's pain was a 7 out of 10, and RN2 provided Tylenol per order and topical Biofreeze. On 10/13/2024 at 4:37 PM, RN2 stated R20 was in tears and had increased pain. RN2 stated the Nurse Practitioner was notified, and an order was obtained to send R20 to the ED for evaluation and treatment. During an interview on 11/26/2024 at 2:59 PM with the Physician and the Nurse Practitioner, the Physician stated he was aware of R20's fall, and it had resulted in bilateral femur fractures. During an interview on 11/27/2024 at 1:47 PM with the Assistant Director of Health Services (ADHS) and the Director of Health Services (DHS), the DHS stated she expected an immediate intervention to be put in place after a fall. During an interview on 12/17/2024 at 2:24 PM with the Executive Director, when asked what she had the most concern with regarding this incident, she stated the occurrence of the fall and that the staff was educated on how to prevent one like it in the future. The facility provided an acceptable Plan of Correction on 12/17/2024 alleging past non-compliance of the deficient practice and a date of compliance of 11/06/2024 with corrective actions as follows verbatim: 1. Corrective actions for identified resident(s) affected by the deficient practice. a. On 10/11/24 at 8pm, The resident was immediately-assessed post incident by RN #1 (RN5). The RN #1 (RN5) noted no obvious injuries except a laceration to right great toe and treatment was initiated. The residents' pain level was monitored post incident and Tylenol was administered as needed. Tylenol was effective after each administration bringing pain level to baseline. Residents' average pain level is a 3 on a 0/10 scale due to chronic pain to bilateral knees related to diagnosis of osteoarthritis to bilateral knees and osteoporosis. The Physician was notified of the fall on 10/11/24 post incident. b. On 10/11/24, RN #1 (RN5) provided one on one education to CNA #1 (CRCA5) immediately by RN #1 (RN5) to ensure two assist with care in bed to avoid reoccurrence. c. On 10/13/24 at 4:37pm, RN#2 assessed resident and noted increased pain with movement and resident requested to be sent to ER. APRN was notified of the resident's condition. Resident was sent to ER. d. On 10/19/24 at 3:53pm, resident returned to facility with post-surgical intervention and resident expressed she was glad to be back home. Order for PT, OT and is non-weight bearing and follow up with ortho on 11/1/24. e. On 11/1/24, the resident returned from her ortho appointment with satisfactory condition post-surgical follow up. The resident remains non-weight bearing status. f. On 10/15/24, the IDT (Interdisciplinary Team) reviewed and revised the residents care plan to include 2 assist with bed mobility, per the RN#l (RN5) immediate intervention. 2. Identification of other residents who may be affected by the deficient practice and corrective actions that will be put in place to ensure the deficient practice does not reoccur. a. All residents requiring extensive to maximum assist with bed mobility could potentially be affected. b. A one-time audit of 100% health center residents was reviewed by [NAME] President of Clinical Operations and MDSC (Minimum Data Set Coordinator) on 10/23/24 reviewing the resident's most recent MDS section GG and ensuring care plan was appropriate for assist status. Any concerns that were identified were corrected immediately. 3. Measures put in place and systemic changes you will make to ensure that the deficient practice does not reoccur. a. On 10/14/24 education was initiated by DHS and ADHS regarding falls and care plans. Education was provided to licensed nursing staff and CRCAs. On 10/23/24 additional education from [NAME] President of Clinical Operations was provided to DHS, ADHS, MDS (MDSC), ED to include on rolling resident toward the care giver, ensuring profiles are completed on admission, following care plans, and notifying DHS or ADHS of all falls (injury or non-injury). This additional education was then provided to licensed nursing staff and CRCAs. Education concluded on 10/24/24. After 10/24/24, any newly hired staff will be educated through orientation by DHS and/or ADHS. Campus does not use agency staff. b. Starting on 10/24/24, as part of the facility's ongoing quality improvement plan the DHS, ADHS, SDC (Staff Development Coordinator), and/or clinical support will observe a total of 3 staff members completing bed mobility to ensure care plan/care profile is being followed weekly x 4 weeks, then 2 staff members weekly x 4 weeks, then 1 staff member weekly x 4 weeks, then 1 staff member monthly x 3 months. This will ensure staff members have retained the education provided on standards of care related to bed mobility. c. The findings of this audit will be presented to the Quality Assurance and Performance Improvement Committee (QAPI) consisting of the Executive Director, Director of Health Services, Assist director of health services, and medical director monthly. 4. Describe the Quality Assurance & Process Improvement Program that will be put into place. a. An Ad Hoc Quality Assurance meeting was held on 10/14/24 regarding the incident on 10/11/24 regarding resident fall with injury and the facility's corrective action, the facility QAPI Committee to review the findings of audits plan of correction to ensure the plan is effective. b. The findings of this audit will be presented to the QAPI committee consisting of ED, DHS, ADHS, MD (Medical Director), MDS will review monthly. The QAPI meetings will determine when compliance is achieved or if ongoing monitoring is required. The State Survey Agency (SSA) validated the facility's Plan of Correction for past noncompliance which determined the facility had corrected the deficient practice for F689 on 11/06/2024 as alleged. 1. Record review of R20's progress notes, incident report, discharge summary, internal investigation with witness statements, and the medication administration record (MAR), revealed R20 was immediately assessed post-incident by RN5, who noted no obvious injuries except a laceration to her right great toe and treatment was initiated. R20's pain level was monitored post incident, and oral Tylenol and Biofreeze were administered as needed. Tylenol was effective after each administration bringing R20's pain level to her baseline pain level of three. On 10/11/2024, immediately after the incident RN5 provided education to CRCA5 to ensure a two-person assist for R20 with care in bed to avoid recurrence. On 10/15/2024, the IDT reviewed and revised R20's care plan to include a two-person assist with bed mobility, per RN5's immediate intervention. 2. Record of two residents identified as potentially at risk to be affected were reviewed, R27 and R30. Record review for R27 revealed the current care plan and profile care guide was last reviewed on 11/27/2024, updated on bed mobility with assist x 1, with a start date of 10/23/2024; and transfers: assist x 2; mechanical lift. Further review revealed the resident profile and the care plan matched. Record review for R30 revealed the current care plan and profile care guide was last reviewed on 11/27/2024, updated on bed mobility with assist x 1, with a start date of 10/23/2024; and transfers with assist x 2; mechanical lift. Further review revealed the resident profile and the care plan matched. In interviews with CRCA3 on 12/18/2024 at 8:49 AM; CRCA13 on 12/17/2024 at 3:35 PM; and CRCA16 on 12/17/2024 at 3:27 PM, they stated they knew how to look at the profile care guide to verify the level of assist needed for residents and verbally described how they would always ensure they rolled the resident toward them and never away from them. Review of the letter dated 10/23/2024 revealed the Vice-President of Clinical Operations (VPCO) and the Minimum Data Set Coordinator (MDSC) conducted a one-time audit on 100 percent (%) of the facility's most recent MDS section on functional ability to ensure residents' care plans were appropriate to residents' assist status. The letter was signed by the VPCO and the MDSC. 3. Review of sign-in sheets for mandatory fall education performed by the DHS and ADHS that included fall policy and educations on following the care plan; profiles completed upon admission and following fall; notify DHS/ADHS regardless of injury; if one assist, roll resident toward staff and not away from staff, revealed all active nursing staff employees, licensed nurses and CRCAs, completed the education. Review of the provided employee list to check for education revealed 47 out of 47 active nursing staff employees received the previously listed fall education as of 10/24/2024. In an interview with the Executive Director on 12/17/2024 at 4:08 PM, she stated, on the provided employee list, the names that had a slash mark through them on the sign-off sheet were employees that were no longer employed at the facility. Review of the Audit Tool, dated October 2024, revealed the DHS, ADHS, Staff Development Coordinator (SDC), and/or Clinical support would observe a total of three staff members completing bed mobility. Further review revealed audits were performed on 10/24/2024 and 10/31/2024. Review of the Audit Tool, dated November 2024, revealed audits were performed on 11/07/2024, 11/14/2024, 11/21/2024 (2 staff members observed), and 11/28/2024 (2 staff members observed). Review of the Audit Tool, dated December 2024, revealed audits were performed on 12/5/2024 (2 staff members observed) and 12/12/2024 (2 staff members observed). The audit results indicated that all observed clinical staff members had no problems identified with providing correct bed mobility to residents. 4. Review of the meeting minutes of the Ad Hoc QAPI meeting on 10/14/2024 included the initiation of education, provided by the DHS and ADHS to all health center nursing staff on following the care plans, completing resident profiles upon admission and following resident profiles and a schedule of systemic monitoring for the assurance of retraining and education. The QAPI meeting on 11/05/2024 included the Executive Director (ED), DHS, Business Office Manager (BOM), MDS, Director of Social Services (DSS), Corporate Clinical Support (CCS), Pharmacist, Medical Director, and Nurse Practitioner and revealed the total falls, falls with major injury, trend versus target fall rate for 90 days prior, as well as root causes were reviewed. The QAPI meeting on 12/12/2024 included the ED, DHS, ADHS, MDS, DSS, CCS, Pharmacist, Medical Director, and Nurse Practitioner, and revealed a discussion of the investigation of R20's root cause of her fall; measures put in place to make her a two-person assist; notification to the DHS/ADHS for all falls, with or without injury; education, care plan, resident profile on admission; systemic monitoring; audit reviews; and falls tracking. In an interview with the Executive Director, DHS, MDS, BOM, and DSS on 12/18/2024 from 12:12 PM to 12:30 PM, they all stated they attended QAPI meetings, and they discussed R20's fall, the root cause, and staff would utilize a two person assist with R20 in bed mobility; the education of CRCA5 and all nursing staff on how to assist residents with bed mobility so that residents would roll toward the staff; audits would be done per schedule observing staff providing care with resident bed mobility, and these audits would be and were reviewed in the meetings.