Based on observations, interviews, facility policy review, and record review, the facility failed to monitor a resident's bowel movements and initiate the Bowel Regime protocol on shift 7 for 1 of 1 residents reviewed (Resident # [R] 46). This failure resulted in R46 not having a bowel movement for an additional 16 shifts which resulted in R46 screaming out for help and crying because of the pain due to gas buildup and constipation. Findings: The facility's policy, Bowel Regime last revised 3/23 indicated: - Certified Nursing Assistant (CNA) is responsible for accurate documentation of bowel moments in Point Click Care (PCC) [electronic medical record]. - The Licensed Nurse reviews the PCC Clinical Alerts daily for residents in need of the bowel regime. -Residents will have an Medical Doctor (MD) order that reads as follows unless otherwise specified by a healthcare provider: Milk of Magnesium (MOM) 30 cubic centimeter (cc) by mouth (PO) as needed (PRN) if no bowel movement (BM) after six shifts; Dulcolax suppository 10 milligrams per rectum (PR) PRN/ if MOM ineffective; Fleet Enema 1 PR PRN if Dulcolax Suppository ineffective. -The Licensed nurse will review PCC daily for residents in need of the bowel regime and list residents who have not had sufficient BM's within the last six shifts, MOM will be administered per order at the beginning of the 7th shift. If insufficient BM after the MOM is administered, the Licensed Nurse will administer a Dulcolax suppository the following shift. Residents not having results after Dulcolax Suppository will receive enema. R46's care plan, last revised 1/19/25, identified that The resident is at risk for alteration in gastro-intestinal status related to constipation and directed staff to follow the facility bowel protocol for bowel management. On 2/25/25 at approximately 10:30 a.m., a surveyor heard a resident crying out for help saying, please help me, help me. The surveyor observed a CNA enter R46's room and heard the CNA ask R46 what they needed; R46 said, I can't poop, I hurt so bad, I can't push it out. The CNA asked R46 if he/she wanted to try the bed pan and resident said, I can't use that. (R46 has a wound on coccyx). On 2/25/25 at 10:45 a.m., a surveyor again heard R46 crying and observed the resident laying on his/her left side rocking his/her body back and forth, crying and stating, someone please help me. The surveyor observed a medical provider in the room and heard the provider say to a Registered Nurse (RN) that R46 refused a rectal exam and to give fluids and an extra dose of oxycodone (narcotic) to treat the pain and requested an abdominal x-ray. On 2/25/25 at 12:07 p.m., during an interview with multiple staff and a surveyor, CNA1 stated that it was the CNAs responsibility to document the bowel movement. She stated that R46 was calling out and she went into the room. R46 told me to call the police because his/her butt hurts. R46 refused the bed pan and wanted the Doctor. RN1 then stated that R46 was visibly in pain and that she contacted the Doctor and since the resident received his/her scheduled Miralax and Senna plus, the Doctor ordered a suppository (Bisacodyl), which RN1 stated she administered (at 10:47 a.m.). Review of R46's physician orders indicated that R46 was receiving scheduled Miralax daily and Senna plus twice daily. R46's Medication and Treatment Administration Records for February 2025 lacked evidence that R46 had been offered or given PRN Bowel Regime medications or treatments until the Doctor was called on 2/25/25 when R46 was screaming and crying because of the pain and not being able to have a bowel movement. Review of the Physiatry Medical Provider documentation, dated 2/25/25, indicated that R46 had been without a bowel movement, contributed due to a lack of adequate by mouth intake. They have increased Miralax to twice a day, continuing the scheduled Senna twice a day and have ordered a suppository as well as an enema with a plan to give as-needed oxycodone to the patient. Monitor for any changes in bowel habits and adjust interventions as needed to maintain regular bowel function. On 2/25/25 at 12:18 p.m., during an interview with multiple surveyors present, the Director of Nursing (DON) stated that the last documented BM for R46 was 2/17/25 and confirmed that the facility did not initiate the bowel protocol for R46. On 3/10/25 at 3:20 p.m., during an interview with a surveyor, the Administrator reviewed the x-ray results with the surveyor that confirmed non obstructive bowel gas pattern with fecal residue which may corrilate with clinical constipation. On 3/10/25 at 3:55 p.m., during an interview with a surveyor, the DON stated that the bowel protocol for R46 should have started on shift 7 with a suppository because R46 was already receiving Miralax. Review of the bowel documentation provided indicated that R46 had 1 small and 2 medium BMs after bowel treatment intervention on 2/25/25. On 3/11/25 at 11:07 a.m., during an interview, Physiatry Medical Provider stated R46 was having minimal oral intake/mobility as R46 got closer to end of life care and has had history of constipation, therefore it was regular for R46 to go several days without BMs. This is why on the 19th, I recommended to continue the current regiment and recommended to make adjustments if continued constipation. I did not see this patient again until 2/25, and there were no nursing complaints prior to this time. This is where I became concerned regarding lack of BM and change in behaviors as this was not normal for R46. I then brought this to the primary team's attention, and made several changes myself to R46's regiment as soon as I saw R46 including increasing miralax, addition of suppository and other regiment per Doctor's recommendations. In the past if patients did not have a bowel movement and there was nursing concern there are standing orders that can be ordered such as fleet enema, MOM and suppositories as stronger agents if without BM or call out to Third Eye (off hours physician service). This did not occur from the last time I saw R46 on the 19th until I saw R46 again on the 25th. On 3/11/25 at 11:09 a.m., during an interview, Nurse Practioner stated Nursing never brought to our attention that she was constipated or hadn't had a BM in a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Facility Reported Incident report, facility's investigation, facility's policies and procedures, record review, and interviews, the facility failed to follow their own policy and procedures for Transfer Techniques, Fall Prevention Program, Accident/Incidents and failed ensure that care plan interventions for the use of a gait belt during transfers were followed for 1 of 2 sampled residents (#1). This failure to use a Gait Belt resulted in a distal femur fracture. Finding: Review of the Facility's Reported Incident form, dated 4/13/23 and the 5 day follow up report, dated 4/17/23, stated on 4/11/23 resident sustained an injury while two students and one CNA were transferring. The resident had an x-ray and right femoral fracture was found. Review of the facility's 5 day follow up report, dated 4/17/23, indicates Resident #1 was lowered to the floor during the transfers due to becoming very weak. Resident #1 was then placed in the whirlpool chair with the assistance of a Certified Nursing Assistance (CNA) and CNA student. Once in the whirlpool, [Resident #1] complained of right knee pain. He/she was removed from the whirlpool, provided ice and remained comfortable throughout the afternoon. The following morning the resident was seen by the provider, complaining of some pain and swelling of the right knee, an X-ray of the knee found a right distal femur shaft fracture with malalignment. Review of the facilities investigation contained statements from the witnesses: CNA Student #1 witness statement, dated 4/13/23 at 8:44 a.m.: On 4/11/23 during clinical .resident was brought in on his/her wheelchair by the CNA. The CNA was transferring him/her to the Whirlpool chair by herself. [Resident #1] was weak and started to lower to the floor. CNA guided him/her down to the floor, and I noticed residence leg was in an awkward position on the floor. [Resident] was in distress at the time and he/she appeared in pain. The other CNA student I was with, assisted CNA to get [Resident #1] from the floor to the Whirlpool chair. [Resident #1] was then lifted into the whirlpool by CNA . as the other CNA student and I were helping [resident] in the Whirlpool. [Resident] began crying and complaining of leg pain. This was reported to the CNA instructor who then got the nurse. CNA Student #2 witness statement, dated 4/13/23 at 8:44 a.m.: On 4/11/23 during clinical .The CNA went to transfer [resident] from his/her wheelchair to the whirlpool chair lift but resident was not strong enough to stand so CNA lowered him/her to the floor. I helped the CNA lift [resident] from the floor to the whirlpool lift chair. During the whirlpool [resident] complained of pain in his/her knee and was crying so I went to get my instructor. CNA Student #3 stated dated 4/13/23: when I came into the area where {Resident #1] was, the CNA was in the middle of transferring the patient from his/her wheelchair to the whirlpool chair when the patient couldn't hold his/her weight. CNA was still holding on to him/her and slowly brought him/her down to the floor. The patient's leg on the right side was at an awkward angle. CNA then asked one of the CNA students to help her transfer [resident] into the whirlpool chair. On 4/18/23 at 10:16 a.m., during an interview Resident #1 stated, That day I slipped out. It was a total accident, and when I did my leg bent backwards. I screamed, my leg my leg . I slipped out of the CNA 's hands .I slipped out of their hands and when I fell my knees went back from my thigh. On 4/18/23 at 11:38 a.m., during an interview with the involved CNA, the CNA stated if she's unaware of what assistance a resident needs, I usually ask it in report and then there's also the [NAME], which I did not check for [Resident #1] transferring. She was told by another CNA that Resident #1, was just a stand pivot which he/she was supposed to be with a gait belt and I didn't know that. Surveyor asked the CNA if she used a gait belt during the transfer. CNA stated, no, no gait belt was used. CNA confirmed she attempted to stand pivot Resident #1 stating, The first time I stood [him/her] up and I just had the student pull his/her brief out, and resident stated oh, I got to sit. So, I sat resident down in his/her wheelchair .I stood resident up again and then he/she just wouldn't stand, like he/she just like deadweight . So, we lowered resident to the ground CNA then confirmed that both her and student CNA picked the resident up off the floor and placed him/her on the whirlpool chair without the use of a Hoyer lift and then transferred him/her to the tub. CNA stated when she asked the resident if he/she was ok, resident replied, I think I might have twisted my knee. The CNA went to get the nurse, however, was redirected by answering call bells. When she talked to the nurse, the Nurse stated, he was already made aware by the CNA student's instructor of the residents twisting of the knee and had already evaluated the resident knee pain. At this time, the CNA stated she did not notify the nurse of the resident being lowered to the floor/fall stating, I also didn't know that qualified as a fall. I had been told before that if a staff was present and they were lowered, it doesn't qualify. Obviously, I was still going to tell the nurse but I didn't get him right then and there, and I should have. I should have left him/her on the floor. On 4/18/23 at 12:29 p.m., during a telephone interview with the involved Licensed Practical Nurse (LPN #1), he stated on 4/11/23 the CNA and the students put Resident #1 in the tub, when he/she was getting in he/ she hurt his/her leg. At the time of the report the LPN was not told of the resident being lowered to the floor. He stated, he had given Resident #1 Tylenol and he/she was sleeping approx. 45 mins later. He went back after an additional hour to look at the resident's leg, as soon as I touched it, he/she cried out with pain, said it hurt terrible. I put a call out to PA (physician assistant). Stating, he filled out an SBAR (Situation Background Assessment and Recommendation) and the Physician Assistant (PA) did not call back during his shift. He reported off to the oncoming LPN #2 what had happened with Resident #1 and that there was a call out to the PA and he left the facility at 6:30 p.m. On 4/19/23 at 9:00 a.m., during a telephone interview with LPN #2, she stated, it was reported that 2 CNA 's transferred him/her in a stand pivot and his/her knee twisted the opposite way and he/she bumped his/her knee. Upon evaluation of Resident #1's knee was very swollen and [resident] and I talked about the fact [resident] already had surgery on that knee. So, I iced it, I gave him/her Tylenol .I checked on resident all night . made sure report in the morning said I think his/her knees should be X-rayed just to rule out the possibility of a new fracture on an old site. The knee was where he/she had the pain .she told me she had a fall, that sounded not good. On 4/18/23 Resident #1's care plan, with a revision date of 8/18/22, under the Focus area of Activities of Daily Living (ADL) self-performance deficit, contained an intervention that directed staff that Resident #1 was a Squat pivot transfers in/out of bed with 1 assist and gait belt. Nurse note, dated 4/11/23 at 10:13 a.m., states, Late entry, this writer in to check on resident who had been asleep. Upon awaking he/she had c/o pain 7/10 in RLE (right lower extremity). attempts to move leg causes resident to cry out. Right LE (lower extremity) continues with 0 redness or edema. Placed call to provider to question need for X-ray with no answer. Message left to return call. Nurse note, dated 4/11/23 at 10:31 a.m., states, upon transfer with 2 asst to shower chair res c/o twisting his/her knee Nurse note, date 4/11/23 at 9:45 p.m., states patient complained of pain right knee. The knee is swollen, tender . unable to move leg without pain to knee. Ice applied per request x 10 minutes. with patient stating some relief. states that this knee is also the one he/she injured requiring surgery years ago. Bruising noted below the knee, with patient stating that's where he/she landed when he/she fell. Will continue to monitor and leave note for oncoming and MD. Dated 4/12/23 at 4:08 p.m., states resident seen by provider today for pain and swelling in right knee. And X-ray was ordered, showing fracture of distal femur shaft . family notified by (PA) . resident will be NWB (non-weight bearing) and no Hoyer lift to be used. Provider notes, dated 4/12/23, patient did have a whirlpool yesterday and with this he/she slipped onto the ground affecting his/her right knee with increased edema and discomfort .pain in right knee. s/p fall to the floor hitting his/her right knee. History of right total knee arthroplasty many years ago. We'll check X-rays of right knee to rule out fracture. Will place patient on Tylenol 650 mg (milligrams) 3 times Daily x 5 days. Will utilize biofreeze every 2 hours as needed pain. Patient is essentially bed bound and does not ambulate or place weight onto his/her legs at this point. Provider notes, dated 4/13/23, seen today for increased pain secondary to right femur fracture . the day before yesterday patient was going for a whirlpool and after discussion with CNA what was found is that patient had a 2 person assist from his/her wheelchair to the whirlpool chair while they were doing this patient became dead weight and fell to his/her right knee in an awkward angle to his/ her leg. Staff helped lower him/her to the ground and he/she did complain of right knee pain at that time and was noted to have swelling. Patient did have X-rays yesterday that did show a femur fracture distally above his/her total right knee replacement on the right side . we will place a long brace right leg on at all times. Patient is non weight bearing and no Hoyer lift at this point. Facility Transfer Technique Policy and Procedure, issued 10/2019 states, Purpose: To ensure that all resident transfers are completed in a safe and efficient manner for both the resident and the person and/or persons performing the transfer. Policy: Based on the residence needs, a gate belt may be used. All residents must be lifted or transferred according to the determined procedure. Transfer status will be documented on the resident's care plan, CNA [NAME]/assignment. prior to transferring the resident, the staff member will check the transfer status on the [NAME]/assignment to determine the proper transfer technique for the resident. Review of the facility's Accident/Incident policy and procedure with a revision date of 1/2023, directs staff to notify the nursing supervisor/licensed nurse when an incident occurs . The licensed nurse or the nursing supervisor will complete and document the evaluation of the residence condition. This evaluation is to include but not limited to: type of injury with location on body . the health care provider will be notified with the date and time of notification documentation in RMS (risk Management System) in nurses notes. Document any new orders or recommendations made by the health care provider. If unable to reach the healthcare provider in a timely manner, call the medical director .The responsible party will be notified by the licensed nurse/designee with the date and time of notification documented in RMS and nurses' notes. Review of the facility's Fall Prevention Program with a revision date of 3/23 states, A fall: an observed or unobserved, unexpected drop to a lower level or loss of erect position and directs staff to includes fall prevention measures on the CNA [NAME]/assignment .Follows directions for care as indicated on the resident care flow sheets. If a fall occurs, keeps the resident in mobile until resident is examined and determined to be free from fractures. Review of the No lift expectations: Eastside Rehabilitation Center is a no lift facility if any resident falls they must be Hoyer lifted back to a chair or bed, it is never acceptable to lift a resident up off the floor. On 4/18/23 at 1:47 p.m. the surveyor discussed with the Administrator, the Director of Nursing and the Regional Director of Operations that the CNA did not use the gait belt during this transfer that resulted Resident #1 sustaining a distal femur fracture, staff did not to use a manual lift to get the resident off the floor and staff did not to notify the nurse immediately of the fall. At this time, the Administrator notified the surveyor that the facility had identified and acted upon these findings on 4/13/23 (2 days) after the resident was lowered to the floor to prevent future occurrences. See list below for actions facility initiated. As a result of the facility's investigation, the following corrective actions were initiated on 4/13/23: - Wrote a plan of action for this event which included, care plan for transferring not followed, resident experienced a fall and nurse was not notified. - Resident care plan was reviewed for how to transfer resident safely - Audit care plans to see who is supposed to be transferring with a gait belt and ensure there is one available in the room. - Review residents who transfer with gait belt with therapy to ensure this is how the resident should be transferring. - Created audits for monitoring transfers being completed per care plans - All clinical staff will be education on the fall policy and procedures as well as accidents in injuries policy and procedure. - Clinical staff will be educated that facility is a no lift facility. Staff involved in the incident will be educated prior to working again including a gate belt competency. - CNA involved was provided education on gait belt application and techniques, utilizing a Hoyer lift if resident is on the floor, resident and the facility, accident/incident policy and fall prevention policy and procedure. - 2 Audits have been completed since fall. - Results will be reviewed in Quality Assurance Performance Improvement meetings until 3 months of compliance have been reached.