**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure staff implemented the care plan to prevent falls for one (1) of three (3) sampled residents, Resident #204. Record review revealed the facility determined Resident #204 required one (1) staff assistance for transfers and toileting and was care planned for staff to assist with transfers and toileting. However, on [DATE] at 4:00 AM, staff found the resident on the floor close to the bathroom, on his/her right side and back, when the resident attempted to go the bathroom unassisted. On [DATE] at 3:15 AM, staff found the resident on the floor when he/she attempted to go to the bathroom unassisted. The resident was sent to the hospital for treatment of injuries and later expired. Review of the Certificate of Death revealed the cause of death was complications from fall. The facility's failure to have an effective system in place to ensure care plans were followed has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ on [DATE]. The State Survey Agency (SSA) verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC) and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Comprehensive Care Plan Guideline, reviewed [DATE], revealed the purpose was to ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Care plan interventions should be reflective of the risk area(s) or disease processes that impacted the individual resident. The comprehensive care plan would be developed with problem areas that should identify the relative concerns, with goals that should be measurable and attainable, and with interventions reflective of the individual's needs and risk influence as well as the resident's strengths. Review of the facility's policy, Fall Management Program Guideline, reviewed [DATE], revealed care plan interventions should be implemented which addressed the resident's fall risk factors. Review of Resident #204's closed clinical record revealed the facility admitted the resident on [DATE], with diagnoses of Pneumonia, Dementia, Muscle Weakness, Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Cardiac Pacemaker. The resident was admitted for rehabilitation, physical therapy, and strengthening. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident required limited assistance of one (1) person for bed mobility, transfers, and toileting, and had no falls prior to admission. The facility assessed the resident with a Brief Interview for Mental Status score of thirteen (13) of fifteen (15) and determined the resident cognitively intact. Review of Resident #204's Care Plan, dated [DATE], revealed the resident was at risk for falls with an intervention to assist the resident with transfers as needed. In addition, the resident was at risk for incontinence and staff was to offer and provide assistance to toilet as needed and/or requested. The resident required staff assistance to complete Activities of Daily Living (ADL) tasks safely with a goal for the resident to have ADL needs met safely by staff. Resident #204 had impaired cognition with associated short-term memory impairment and was at risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness, and staff was to pay attention to basic needs and provide ADL care as required. Review of Resident #204 Physical Therapy (PT) Progress Notes, dated [DATE], revealed the resident made progress with getting up to walk by means of a walker and was able to transfer but forgot a few of the important safety cues while transferring. According to the Progress Notes, dated [DATE], an admission care plan meeting was held with PT, Social Services, MDS, Resident #204, and the resident's daughter and discussed Resident #204 had done well with PT with the exception of the last two (2) days, the resident had tremors and was tired. Resident #204 fatigued easily with Occupational Therapy but was doing well. In addition, Progress Notes, dated [DATE], revealed Resident #204 had become emotional labile and tried to be more dependent on staff. Review of a Fall Event, dated [DATE], revealed on [DATE] at 4:00 AM, staff found the resident on the floor near his/her bathroom. The resident was trying to go to the bathroom unassisted; however, the care plan stated the resident was to have staff assistance for transfers and toileting. The resident lost his/her balance and fell, landing on his/her right side and back causing skin tears to the middle and right fingers of the right hand and upper back. The physician was notified and ordered an x-ray of the swollen and bruised hand. The resident had no complaints of pain or discomfort at that time, but later complained of low back pain and an x-ray of the back was ordered. The facility determined the root cause of the fall was self-transfer to the restroom. The resident was educated on using the call light for assistance with toileting. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 11:50 AM, revealed she cared for Resident #204 on [DATE] when the resident fell. She stated the resident was independent and could make his/her needs known; however, stated he/she did not use the call light, and did not have any alarms to signal staff when he/she got up. Per interview, the nurse could not remember what interventions were in place for the resident and could not remember the last time she had checked on the resident. Review of an Event Report, dated [DATE], revealed on [DATE] at 3:15 AM, staff found Resident #204 on the bathroom floor, alone, with his/her walker in front of him/her. Resident #204 sustained two (2) skin tears on the bridge of the nose and under the left eye, a hematoma around the right eye, and three (3) skin tears to the bilateral lower extremities. Staff contacted the physician and the resident was sent to the emergency room. Interview with LPN #10, on [DATE] at 8:46 PM, revealed she cared for Resident #204 on [DATE] when the resident fell. She stated she was at the desk and heard a thump and found the resident on the floor. She stated the resident required one (1) staff to assist to the restroom and used a walker. The LPN revealed she rounded on residents every two (2) hours and was able to meet the needs of the residents. She stated she could not remember the last time she rounded on the resident. Review of Hospital Records revealed Resident #204 presented to the emergency department on [DATE] at 4:41 AM complaining of a fall that occurred when walking to the restroom. The resident tried to reach his/her walker, missed, and fell. It was the resident's second fall in 24 hours. On exam, Resident #204 was hyperventilating, and had palpable deformities to the left chest, marked facial swelling, and ecchymosis. Computed Tomography (CT) of the chest revealed the resident had three (3) fractured ribs, blood in the right lung base, and possible hemothorax. Resident #204 expired at the hospital on [DATE] at 12:17 PM. Review of the Certificate of Death, dated [DATE], revealed the cause of death was complications from fall. Interview with LPN #1, on [DATE] at 9:49 AM and [DATE] at 3:59 PM, revealed she vaguely remembered Resident #204 and the care plan interventions. She stated if the care plan specified a resident was to have staff assistance, it meant a staff member would need to be present and if not, the resident was not safe. She stated even if the resident presented as independent, staff must assist the resident until the care plan was changed. Interview with the Director of Health Services (DHS), on [DATE] at 1:58 PM and [DATE] at 4:20 PM, revealed the Rehab unit nurse rounded every two (2) hours. The DHS stated staff followed the care plan since Resident #204 was cognitively intact and had assistance available to him/her. Interview with the Executive Director (ED), on [DATE] at 5:53 PM, revealed her overall responsibilities included overseeing the facility, including the nursing staff. She stated if the residents needed assistance of more than one (1) person, the resident was moved to another hall. According to the ED, the nurses were capable of providing every resident's care needs at night. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #204 was discharged on [DATE]. 2. On [DATE], a Quality Assurance and Assessment (QAA) meeting was held to discuss the details of the Immediate Jeopardy and action items contained in the AOC. The Executive Director (ED), Director of Health Services (DHS), Assessment Support, Clinical Support (CS), Divisional [NAME] President, and Medical Director were present. 3. On [DATE], the CS ensured nine (9) residents, who had a fall within the last one hundred and twenty (120) days, were included in the Clinically at Risk (CAR) program. During the weekly CAR meeting, the DHS, Director of Social Services, or Registered Dietitian ensured efficacy of interventions related to the root cause that was identified. The ED will audit CAR meetings to monitor interventions to ensure revisions, monthly. Residents with a fall would be monitored during the weekly CAR meeting up to four (4) weeks to ensure implemented interventions remained effective. All findings will be presented to QAA. 4. On [DATE], the DHS, Assistant Director of Health Services (ADHS), and Minimum Data Set (MDS) Assessment Support reassessed all residents for fall risk. MDS Assessment Support reviewed and revised all care plans as needed and the Certified Resident Care Associate (CRCA) sheets were updated to reflect new interventions if applicable. Fall risk safety interventions for three (3) residents were revised. The DHS, ADHS, Evening Supervisor, or MDS Nurse will conduct random care plan audits on five (5) residents identified at risk for falls four (4) times weekly for eight (8) weeks, then three (3) times weekly for eight (8) weeks, then two (2) times weekly for eight (8) weeks, then monthly for a total of one (1) year. Findings will be presented to the QAA committee. 5. On [DATE], the Corporate Clinical Support educated the Interdisciplinary Team (IDT) on determining root cause of an incident and implementing interventions. The Corporate Clinical Support or Assessment Support will audit up to five (5) falls to ensure the root cause had been determined by the IDT with appropriate interventions implemented weekly for eight (8) weeks, then monthly for one (1) month, and then quarterly for three (3) quarters. All findings will be presented to the QAA committee. 6. On [DATE], the ED, DHS, ADHS, and/or CS initiated in-service education to the licensed nurses and CRCAs. The nurses were educated on the Falls Management Policy, which included determining the root cause, initiating interventions when a resident was identified at risk for falls or had a fall to reduce risk of repeat fall, review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions, and supervision to prevent accidents related to transfers and toileting; and Guidelines for Neurological Checks to evaluate the level of consciousness, evaluate pupil response, motor function, and vital signs that might alert staff for potential for head injury or seizure activity. The CRCAs were educated on the falls management, identification of changes in residents, observation of environment risk, notifying the nurse if the CRCA sheet needed revision, following the CRCA assignment sheets, and importance of reporting immediately any resident changes. Staff had to pass a posttest with a score of 100% and if less than 100%, staff was re-educated. Any nurse or CRCA not educated on [DATE] would not be permitted to work until the training and test were completed. In addition, the MDS Nurses were in-serviced regarding reviewing and revising care plans with interventions for residents identified at risk for falls; and to revise the care plan to include identified root cause with interventions. 7. The DHS, ADHS, MDS Nurse, and/or ED will review newly admitted residents, identified at risk for falls, in the daily Clinical Care Meeting to ensure appropriate interventions were in place. In the daily meeting, the IDT will review falls, determine root cause, and implement interventions related to the root cause with revisions made to care plans as indicated. The DHS, ADHS, MDS Nurse, and /or ED will conduct random audits on five (5) residents identified at risk for falls to verify interventions were in place, observe nursing staff providing assistance with transfers and toileting on varied shifts, and ensure CRCAs were following care plan interventions, four (4) times weekly for eight (8) weeks, then three (3) times weekly for eight (8) weeks, then two (2) times weekly for eight (8) weeks, then monthly for a total on one (1) year. Findings will be presented to the QAA committee. 8. The QAA committee will review results of all audits weekly to ensure 100% compliance and make modifications when necessary. The committee will monitor for any additional educational needs, the effectiveness of the plan, and revise the plan related to areas identified through the audit process. The DHS or ADHS will be responsible to provide additional education as identified during the audits and suggestions made by the QAA committee. The Medical Director will review the progress with the ED (DHS/ADHS in the ED's absence) on a weekly basis. The SSA validated the facility implemented the following actions: 1. Record review revealed Resident #204 was discharged on [DATE]. 2. Record review revealed a QAPI meeting was held on [DATE], with the Medical Director, DHS, ED, Clinical Support, Assessment Support, and the Divisional [NAME] President present. 3. Interview with the ADHS, on [DATE] at 2:10 PM, revealed the CAR met weekly to discuss residents with falls to ensure interventions were effective. Interview with the MDS Coordinator, on [DATE] at 4:51 PM, and the Assistant MDS Coordinator at 5:01 PM, revealed they participated in the CAR and Clinical Care Meeting to ensure interventions were in place and effective. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she attended the CAR meeting to ensure the root cause of falls were discussed and interventions in place. Interview with the ED, on [DATE] at 3:58 PM, revealed she would audit the CAR meetings monthly. Record review revealed residents at risk for falls were reviewed in the CAR meetings, including the nine (9) who had a fall in the last one hundred and twenty (120) days. 4. Interview with the DHS, on [DATE] at 3:07 PM, revealed all resident were reassessed for fall risk and three (3) residents were identified needing additional interventions. She stated she was starting to conduct random audits to ensure care plan interventions for falls were in place and followed. Record review revealed all residents were assessed for fall risk, care plans were reviewed, and three (3) residents' plans were revised. Record review revealed an audit tool the facility was to use to perform the audits. 5. Interview with the ADHS, on [DATE] at 2:10 PM, the DHS on [DATE] at 3:07 PM, and the ED at 3:58 PM, revealed the Clinical Support educated the IDT on determining root cause and implementing interventions. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she trained the IDT on determining the root cause and implementing interventions. Record review revealed the IDT was educated per the AOC. 6. Interviews with CRCA #9, on [DATE] at 2:33 PM, CRCA #10 at 2:50 PM, Certified Medication Technician #2 at 3:08 PM, Licensed Practical Nurse (LPN) #1 at 3:56 PM, LPN #2 on [DATE] at 1:23 PM, Registered Nurse (RN) #1 at 9:39 AM, and RN #2 at 1:42 PM, revealed they were educated per the AOC and completed a posttest. Interview with the MDS Coordinator, on [DATE] at 4:51 PM, and the Assistant MDS Coordinator at 5:01 PM, revealed they were educated on care plan interventions for falls and the root cause analysis. Interviews with Clinical Support, on [DATE] at 5:24 PM, and the ADHS on [DATE] at 2:10 PM, revealed they educated the nurses and the CRCAs per the AOC. The Clinical Support stated staff not educated on [DATE] were educated prior to the working their next scheduled shift, and all staff passed the test with a 100% score. Record review revealed staff was educated per the AOC with posttest completion. 7. Interview with the ADHS, on [DATE] at 2:10 PM, DHS on at 3:07 PM, MDS Coordinator at 4:51 PM, and Assistant MDS Coordinator at 5:01 PM, revealed the IDT reviewed new admissions to ensure fall interventions were in place during the daily Clinical Care Meeting, and determined the root cause of falls to revise the care plans. The DHS stated she was starting to conduct random audits to ensure care plan interventions for falls were in place and followed. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she would be assisting in the falls and care plan audits. Record review revealed falls and care plans were reviewed per the AOC. Record review revealed an audit tool the facility was to use to perform the audits. 8. Interview with the ED, on [DATE] at 3:58 PM, revealed the QAA committee would review the audits to track the data. She stated she would meet with the Medical Director weekly to review the progress of the audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility policy review, and review of the facility's investigation, it was determined the facility failed to have an effective system in place to provide adequate supervision to prevent accidents and injuries for one (1) of three (3) sampled residents, Resident #204. Record review revealed on [DATE] at 4:00 AM, Resident #204 acquired skin tears on his/her right middle and ring fingers and a skin tear along his/her upper back related to an unwitnessed fall. The night shift nurse found Resident #204 in her/his room by the bathroom. Per interviews, staff was aware the resident did not always use the call light to request assistance; however, after the fall, the resident's supervision was not increased and on [DATE], the resident fell again. Continued record review revealed Resident #204 had a second unwitnessed fall on [DATE] at 3:15 AM, when he/she attempted to go to the bathroom unassisted. He/she sustained two (2) skin tears, on the bridge of nose and under the left eye, a hematoma around the right eye, and three (3) skin tears to the bilateral lower extremities. Resident #204 was sent to the hospital for treatment and was found to have three (3) fractured ribs, blood in the right lung base, and possible hemothorax. The resident was admitted to the hospital and later expired. Review of the Certificate of Death revealed the cause of death was complications from fall. The facility's failure to ensure residents were supervised to prevent accidents and injuries has caused or likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE], which alleged removal of the IJ on [DATE]. The State Survey Agency (SSA) verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC) and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Fall Management Program Guideline, review date [DATE], revealed the fall risk assessment identified risk factors to evaluate for the contribution they might have to the resident's likelihood of falling. Should the resident experience a fall, the attending nurse would complete the Fall Event. This included an investigation of the circumstance surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce the risk of repeat fall episodes, and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. Review of the facility's policy, Guidelines for Neurological Checks, review date [DATE], revealed the purpose was to evaluate the level of consciousness, evaluate pupil response, motor function, and vital signs that might alert staff for potential for head injury or seizure activity. Residents having a fall should be evaluated for injury and four (4) neurological checks (recommended every 15 minutes) should be completed. If the resident had a change of condition, (change from baseline) a serial neurological checks would be performed for twenty-four (24) hours. Review of the facility's policy, Assisting Residents to the Bathroom, review date [DATE], revealed the facility would provide residents an opportunity to use the bathroom by providing appropriate assistance to maintain safety and prevent resident falls. Review of Resident #204's closed clinical record revealed the facility admitted the resident on [DATE], for rehabilitation, physical therapy, and strengthening. Resident #204 had diagnoses of Pneumonia, Dementia, Muscle Weakness, Chronic Respiratory Failure, and Chronic Obstructive Pulmonary Disease. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of a thirteen (13) out of fifteen (15) and determined the resident cognitively intact. The facility assessed the resident required physical assistance of one (1) staff for bed mobility, transfers, dressing, personal hygiene, and toilet use. The facility assessed the resident was not steady and only able to stabilize with staff assistance for surface-to-surface transfers, walking, moving from seated to standing position, and moving on and off the toilet. The resident used a walker for mobility. Review of Resident #204's Care Plan, dated [DATE], revealed the resident was at risk for falls with an intervention to assist the resident with transfers as needed. In addition, the resident was at risk for incontinence and staff was to offer and provide assistance to toilet as needed and/or requested. The resident required staff assistance to complete Activities of Daily Living (ADL) tasks safely with a goal for the resident to have ADL needs met safely by staff. Resident #204 had impaired cognition with associated short-term memory impairment and was at risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness, and staff was to pay attention to basic needs and provide ADL care as required. Review of Daily Physical Therapy (PT) Notes, dated [DATE], revealed Resident #204 safely demonstrated transferring back and forth requiring contact guard assistance due to unsteadiness. Resident #204 made slow progress and Pneumonia had inhibited the progress. On [DATE], the resident received therapy to include seated bilateral lower extremity exercise to increase lower extremity strength needed for improving transfers and gait, standing activities with rolling walker to improve stability, and ambulation with staggering gait. Per the PT note, nursing staff was aware Resident #204 had increased fatigue and nausea and required contact guard assistance for all functional transfers. Review of Daily Occupational Therapy (OT) Notes, dated [DATE], revealed Resident #204 required supervision when performing dressing, toileting, and hygiene, and fatigued with minimal exertion. On [DATE], Resident #204 participated in therapy; however, she/he experienced a feeling of nausea and fatigue. Resident #204 was educated on using the call light for transfers but required supervision for safety. Review of an Event Report, dated [DATE], revealed on [DATE] at 4:00 AM, Resident #204 had an unwitnessed fall. Licensed Practical Nurse (LPN) #9 found Resident #204 on the floor by the bathroom in his/her room. LPN #9 reported Resident #204 was going to the bathroom but did not have on his/her oxygen, his/her oxygen saturation (blood oxygen level) had dropped, he/she lost his/her balance and fell. Resident #204 landed on his/her right side and back causing skin tears to the right middle and ring fingers and a skin tear along the upper back spine. LPN #9 completed two (2) neurological checks (4:00 AM and 4:15 AM) which Resident #204 presented as lethargic/drowsy, had weak upper and lower left and right extremity movements, and speech was unclear. Documentation revealed the resident exhibited a change in mental status with new onset of lethargy and slurred speech. The fall risk re-assessment listed the resident had cognitive or memory impairment that effected safety and judgement, he/she required assistance to ambulate safely, and he/she refused to comply with safety measures such as call light use and appliances. Immediate intervention was for the bed to be in the lowest position. Further review revealed LPN #9 failed to complete the third and fourth follow-up neurological checks, per the facility's policy. The Physician was notified and orders obtained for an x-ray to the resident's swollen and bruised right hand. Later in the shift, LPN #1 notified the physician Resident #204 complained of low back pain related to the fall and obtained an order to add x-ray of the back. X-ray results revealed degenerative changes and scoliosis noted to the lumbar, and the wrist had a scapholunate dissociation, dorsal tilt to the lunate. The physician was notified and no new orders were given. Telephone interview with LPN #9, on [DATE] at 11:46 AM, revealed she requested not to work the Rehab unit (where Resident #204 resided) because there was never a Certified Resident Care Associate (CRCA) on third shift, and sometimes she was not able to meet all of the residents' care needs being the only one on the unit. LPN #9 expressed her concerns to the Director of Health Services (DHS). She recalled Resident #204 completed things independently and had been educated several times on using the call light to ask for assistance and had stop signs posted in his/her room. LPN #9 stated on [DATE], the resident got up with his/her walker and tripped going to the bathroom because he/she did not have on his/her oxygen and became dizzy and confused. She found the resident in front of her/his bathroom with skin tears on the hand, finger, and back, and hurt his/her wrist. LPN #9 believed the fall was unwitnessed and neurological checks were completed on unwitnessed falls for one (1) hour every fifteen (15) minutes. She stated Resident #204 would sometimes take the oxygen off and did not use the call light. She stated the resident was checked on every two (2) hours and after the fall, the intervention put into place was to have the bed in the lowest position, she could not remember if more supervision was added. LPN #9 revealed if a resident needed two (2) person assistance, the resident was transferred to another part of the facility as soon as possible. Review of the Interdisciplinary Team's (IDT) evaluation of the root cause of the [DATE] fall for Resident #204 revealed the IDT agreed the root cause was due to self-transfer to the restroom. The immediate intervention was to put the resident's bed in the lowest position and changed to obtain a bedside commode. Review of an Event Report, dated [DATE], revealed on [DATE] at 3:15 AM, Resident #204 had an unwitnessed fall. LPN #10 rushed into the resident's room when she/he heard a strange thump and found the resident on the bathroom floor with his/her walker in front of him/her. Resident #204 sustained two (2) skin tears on the bridge of the nose and under the left eye, a hematoma around the right eye, and three (3) skin tears to the bilateral lower extremities (BLE). Four (4) neurological checks were completed and found the resident alert, with weak upper and lower right and left extremity movement, and with clear speech. The fall risk re-assessment listed the resident required assistance to transfer, required assistance to ambulate safely, required use of an assistive device and/or often forgot to use, and he/she refused to comply with safety measures such as call light use and appliances. LPN #10 contacted the physician and the resident was sent to the emergency room. Interview with LPN #10, on [DATE] at 8:46 PM, revealed on [DATE], Resident #204 had an unwitnessed fall. The resident seemed a little bit more confused than usual. LPN #10 heard a thump and found the resident on the floor. Resident #204 received a hematoma right above the eyes and the resident's head was a major concern so the emergency medical services were called along with the physician and relative. She remembered Resident #204 needed one (1) person assistance and used a walker. Resident #204 had been educated on using the call light for assistance and had stop signs in his/her room. LPN #10 stated the Rehab unit was full and she completed rounds every two (2) hours and was able to meet the needs of the residents. Review of the IDT's evaluation of the root cause of the [DATE] fall for Resident #204 revealed the IDT agreed the root cause was due to self-transfer to the restroom. The IDT agreed with the immediate intervention to transfer the resident to the emergency room. No acute injuries were noted. Review of Hospital Records revealed an Emergency Department Encounter, dated [DATE], which revealed Resident #204 presented to the emergency department on [DATE] at 4:41 AM complaining of a fall that occurred when walking to the restroom. The resident tried to reach his/her walker, missed, and fell. It was the resident's second fall in 24 hours. The resident complained of rib pain, denied neck, abdominal, and lower back pain. Review of the Emergency Department Provider Notes, dated [DATE], revealed the resident arrived to the emergency department due to an unwitnessed fall. The resident complained of rib pain with multiple facial and bilateral knee skin tears. On exam, Resident #204 was hyperventilating, and had palpable deformities to the left chest, no flail segment. The resident had marked facial swelling and ecchymosis. Resident #204 was admitted on [DATE] for palliative care related to his/her respiratory status. Computed Tomography (CT) of the chest revealed the resident had three (3) fractured ribs, blood in the right lung base, and possible hemothorax. Final diagnoses were Acute Respiratory Failure with hypoxia (body deprived of oxygen) and hypercapnia (condition of excessive carbon dioxide in the bloodstream), Trauma of Chest, Contusion of Face, and Periorbital Ecchymosis (Bruising around the eyes). Resident #204 expired at the hospital on [DATE] at 12:17 PM. Review of the Certificate of Death, dated [DATE], revealed the cause of death was complications from fall. Interview with LPN #1, on [DATE] at 9:49 AM and [DATE] at 3:59 PM, revealed she vaguely remembered Resident #204 and his/her fall interventions. She stated if a resident fell with no apparent reason, then a urine culture was sent out for possible urinary tract infection. If the care plan specified a resident was to have assistance of one (1), then a staff member needed to be present and if not, the resident was not safe. LPN #1 reviewed the neurological checks dated [DATE], and stated the nurse should have done the checks every fifteen (15) minutes for one (1) hour, and if baseline changes were noted, then they were done for seventy-two (72) hours to watch the resident intensely. If a resident presented with symptoms of lethargy, dizziness, weakness, and did not have his/her oxygen on, she would call the physician and give a detail description of the resident so the physician could make an informed decision. In addition, she would have increased supervision for more frequent checks than every two (2) hours. LPN #1 stated Resident #204 needed more supervision during night shift. Interview with the MDS Coordinator, on [DATE] at 11:51 AM, revealed Resident #204 had short-term memory impairment and needed assistance of one (1) staff. The MDS stated neurological checks were incomplete for the [DATE] fall, as only two (2) of four (4) were completed which was against policy. The nurse would not know if Resident #204 was swaying from the baseline to implement effective interventions from the unwitnessed fall, which could cause the resident harm. Interview with the DHS, on [DATE] at 4:20 PM, revealed the standard for rounding for nurses was every two (2) hours unless the physician ordered more frequent checks, or the care plan was changed. Even if a resident experienced a fall, after the neurological checks were completed the resident went back to the two (2) hour rounding. The DHS stated resident care needs were met when the call light was answered; however, staff interviews revealed Resident #204 did not use the call light. Per interview, the IDT determined the root cause and made changes and/or approved interventions for Resident #204's [DATE] and [DATE] falls. She stated staff could have checked on Resident #204 every five (5) minutes and he/she still could have fallen. According to the DHS, Resident #204 had a BIMS of thirteen (13) and had a choice to use the call light or not to get assistance. Interview with the Social Worker, on [DATE] at 11:37 AM, revealed a BIMS score of thirteen (13) - fifteen (15) indicated a resident was cognitively intact and typically alert and oriented; however, Dementia could impair a resident's decision-making. Interview with the Nurse Practitioner (NP), on [DATE] at 11:00 AM, revealed Resident #204 would get up without assistance and nursing staff would get upset with her/him and educated the resident on using the call light. The NP stated Resident #204 got tired easy and was weak because of his/her respiratory condition and he/she had Pneumonia. She stated the CRCAs checked on the resident often because the resident was on diuretics (increases urine); however, per interviews, there was only one (1) nurse on the Rehab unit at night. Interview with the Executive Director (ED), on [DATE] at 5:53 PM, revealed if a resident needed assistance for more than one (1) staff, the resident was moved to another hall. Resident #204 had a BIMS of thirteen (13) and she/he was teachable to the call light in order to receive assistance. She further stated the facility consulted with the physician and determined Resident #204's falls were unavoidable. The ED revealed the minimum requirement for rounding was every two (2) hours and staff was not required to document every time they rounded so it was unclear how often Resident #204 was supervised. Interview with Resident #204's Daughter, on [DATE] at 8:15 AM, revealed Resident #204 had been educated on using the call light; however, she stated the resident had been diagnosed with associated short-term memory impairment and Dementia. She stated Resident #204 had lived with her prior to admission to the facility and required assistance with some of his/her daily needs. She stated when she saw Resident #204 at the hospital after the fall, she did not recognize the resident due to the swelling and bruising on his/her face, and the resident was in a lot of pain. The Daughter stated the hospital was going to transfer the resident to a trauma center; however, she stated the resident's oxygen dropped and he/she passed away. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #204 was discharged on [DATE]. 2. On [DATE], a Quality Assurance and Assessment (QAA) meeting was held to discuss the details of the Immediate Jeopardy and action items contained in the AOC. The Executive Director (ED), Director of Health Services (DHS), Assessment Support, Clinical Support (CS), Divisional [NAME] President, and Medical Director were present. 3. On [DATE], the CS ensured nine (9) residents, who had a fall within the last one hundred and twenty (120) days, were included in the Clinically at Risk (CAR) program. During the weekly CAR meeting, the DHS, Director of Social Services, or Registered Dietitian ensured efficacy of interventions related to the root cause that was identified. The ED will audit CAR meetings to monitor interventions to ensure revisions, monthly. Residents with a fall would be monitored during the weekly CAR meeting up to four (4) weeks to ensure implemented interventions remained effective. All findings will be presented to QAA. 4. On [DATE], the DHS, Assistant Director of Health Services (ADHS), and Minimum Data Set (MDS) Assessment Support reassessed all residents for fall risk. MDS Assessment Support reviewed and revised all care plans as needed and the Certified Resident Care Associate (CRCA) sheets were updated to reflect new interventions if applicable. Fall risk safety interventions for three (3) residents were revised. The DHS, ADHS, Evening Supervisor, or MDS Nurse will conduct random care plan audits on five (5) residents identified at risk for falls four (4) times weekly for eight (8) weeks, then three (3) times weekly for eight (8) weeks, then two (2) times weekly for eight (8) weeks, then monthly for a total of one (1) year. Findings will be presented to the QAA committee. 5. On [DATE], the Corporate Clinical Support educated the Interdisciplinary Team (IDT) on determining root cause of an incident and implementing interventions. The Corporate Clinical Support or Assessment Support will audit up to five (5) falls to ensure the root cause had been determined by the IDT with appropriate interventions implemented weekly for eight (8) weeks, then monthly for one (1) month, and then quarterly for three (3) quarters. All findings will be presented to the QAA committee. 6. On [DATE], the ED, DHS, ADHS, and/or CS initiated in-service education to the licensed nurses and CRCAs. The nurses were educated on the Falls Management Policy, which included determining the root cause, initiating interventions when a resident was identified at risk for falls or had a fall to reduce risk of repeat fall, review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions, and supervision to prevent accidents related to transfers and toileting; and Guidelines for Neurological Checks to evaluate the level of consciousness, evaluate pupil response, motor function, and vital signs that might alert staff for potential for head injury or seizure activity. The CRCAs were educated on the falls management, identification of changes in residents, observation of environment risk, notifying the nurse if the CRCA sheet needed revision, following the CRCA assignment sheets, and importance of reporting immediately any resident changes. Staff had to pass a posttest with a score of 100% and if less than 100%, staff was re-educated. Any nurse or CRCA not educated on [DATE] would not be permitted to work until the training and test were completed. In addition, the MDS Nurses were in-serviced regarding reviewing and revising care plans with interventions for residents identified at risk for falls; and to revise the care plan to include identified root cause with interventions. 7. The DHS, ADHS, MDS Nurse, and/or ED will review newly admitted residents, identified at risk for falls, in the daily Clinical Care Meeting to ensure appropriate interventions were in place. In the daily meeting, the IDT will review falls, determine root cause, and implement interventions related to the root cause with revisions made to care plans as indicated. The DHS, ADHS, MDS Nurse, and /or ED will conduct random audits on five (5) residents identified at risk for falls to verify interventions were in place, observe nursing staff providing assistance with transfers and toileting on varied shifts, and ensure CRCAs were following care plan interventions, four (4) times weekly for eight (8) weeks, then three (3) times weekly for eight (8) weeks, then two (2) times weekly for eight (8) weeks, then monthly for a total on one (1) year. Findings will be presented to the QAA committee. 8. The QAA committee will review results of all audits weekly to ensure 100% compliance and make modifications when necessary. The committee will monitor for any additional educational needs, the effectiveness of the plan, and revise the plan related to areas identified through the audit process. The DHS or ADHS will be responsible to provide additional education as identified during the audits and suggestions made by the QAA committee. The Medical Director will review the progress with the ED (DHS/ADHS in the ED's absence) on a weekly basis. The SSA validated the facility implemented the following actions: 1. Record review revealed Resident #204 was discharged on [DATE]. 2. Record review revealed a QAPI meeting was held on [DATE], with the Medical Director, DHS, ED, Clinical Support, Assessment Support, and the Divisional [NAME] President present. 3. Interview with the ADHS, on [DATE] at 2:10 PM, revealed the CAR met weekly to discuss residents with falls to ensure interventions were effective. Interview with the MDS Coordinator, on [DATE] at 4:51 PM, and the Assistant MDS Coordinator at 5:01 PM, revealed they participated in the CAR and Clinical Care Meeting to ensure interventions were in place and effective. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she attended the CAR meeting to ensure the root cause of falls were discussed and interventions in place. Interview with the ED, on [DATE] at 3:58 PM, revealed she would audit the CAR meetings monthly. Record review revealed residents at risk for falls were reviewed in the CAR meetings, including the nine (9) who had a fall in the last one hundred and twenty (120) days. 4. Interview with the DHS, on [DATE] at 3:07 PM, revealed all resident were reassessed for fall risk and three (3) residents were identified needing additional interventions. She stated she was starting to conduct random audits to ensure care plan interventions for falls were in place and followed. Record review revealed all residents were assessed for fall risk, care plans were reviewed, and three (3) residents' plans were revised. Record review revealed an audit tool the facility was to use to perform the audits. 5. Interview with the ADHS, on [DATE] at 2:10 PM, the DHS on [DATE] at 3:07 PM, and the ED at 3:58 PM, revealed the Clinical Support educated the IDT on determining root cause and implementing interventions. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she trained the IDT on determining the root cause and implementing interventions. Record review revealed the IDT was educated per the AOC. 6. Interviews with CRCA #9, on [DATE] at 2:33 PM, CRCA #10 at 2:50 PM, Certified Medication Technician #2 at 3:08 PM, Licensed Practical Nurse (LPN) #1 at 3:56 PM, LPN #2 on [DATE] at 1:23 PM, Registered Nurse (RN) #1 at 9:39 AM, and RN #2 at 1:42 PM, revealed they were educated per the AOC and completed a posttest. Interview with the MDS Coordinator, on [DATE] at 4:51 PM, and the Assistant MDS Coordinator at 5:01 PM, revealed they were educated on care plan interventions for falls and the root cause analysis. Interviews with Clinical Support, on [DATE] at 5:24 PM, and the ADHS on [DATE] at 2:10 PM, revealed they educated the nurses and the CRCAs per the AOC. The Clinical Support stated staff not educated on [DATE] were educated prior to the working their next scheduled shift, and all staff passed the test with a 100% score. Record review revealed staff was educated per the AOC with posttest completion. 7. Interview with the ADHS, on [DATE] at 2:10 PM, DHS on at 3:07 PM, MDS Coordinator at 4:51 PM, and Assistant MDS Coordinator at 5:01 PM, revealed the IDT reviewed new admissions to ensure fall interventions were in place during the daily Clinical Care Meeting, and determined the root cause of falls to revise the care plans. The DHS stated she was starting to conduct random audits to ensure care plan interventions for falls were in place and followed. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she would be assisting in the falls and care plan audits. Record review revealed falls and care plans were reviewed per the AOC. Record review revealed an audit tool the facility was to use to perform the audits. 8. Interview with the ED, on [DATE] at 3:58 PM, revealed the QAA committee would review the audits to track the data. She stated she would meet with the Medical Director weekly to review the progress of the audits.