Based on review of medical records and other pertinent documentation, observations, and interviews, it was determined that the facility failed to ensure adequate supervision to prevent falls as evidenced by: 1) Failure of the geriatric nursing assistant (GNA) to remain with a resident who, due to a stroke and resulting muscle weakness and cognitive impairment, required total assistance with bathing during a shower. The resident sustained an unwitnessed fall during the shower. This fall resulted in a leg fracture, transfer to the hospital and subsequent surgical repair. 2) Failure of the GNA to provide supervision to a resident with severe dementia, who required extensive assistance with mobility, after assisting the resident to the toilet. The resident subsequently got off the toilet, started to walk and fell. This fall resulted in a fracture to the resident's nose. 3) Failure to ensure a resident who was dependent on staff for turning and positioning was turned in bed in a manner to prevent the resident from falling out of bed during care resulting in abrasions, bleeding, pain, and a change in mental status which required a transfer to an acute care hospital. All three of these falls resulted in actual harm to the residents. This was found to be evident for 3 (Residents #14, #114, #501 ) out of 15 residents reviewed for accidents during the survey. The findings include: 1.) On 10/12/22 at 2:29 PM, during an interview, an observation of Resident #14 revealed the resident had an abrasion on the top of his/her nose. At that time, Resident #14 indicated that s/he had sustained the abrasion when s/he fell out of bed and hit his/her head. On 10/20/22 at 1:40 PM, a review of Resident #14's medical record was conducted.There was a care plan, Resident #14 has had an actual fall and remains at risk for falls: weakness, ESRD, had the intervention Staff educated to positioning when providing care, which was added to the care plan on 9/19/22. The intervention did not indicate how the resident was to be positioned during care. Also, there was a care plan, Resident #14, requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting, initiated on 7/12/22, which included the interventions, provide resident with extensive assist of 2 for bed mobility, and provide extensive assist of 1 for bathing. There care plan had not been updated to reflect the resident was totally dependent, requiring 2 person physical support for bathing. Review of Resident #14's quarterly assessment with an ARD (assessment reference date) of 7/18/22 documented the resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating the resident had moderate cognitive impairment. The assessment documented Resident #14 was dependent on staff for ADLs (activities of daily living) and required extensive assistance with 2 person physical assist for bed mobility, and 1 person physical assist for bathing. The resident's quarterly assessment with an ARD of 10/4/22 documented Resident #14 required 2 person physical assist for bed mobility and was totally dependent with 2 person physical support for bathing. In a Change of Condition note, on 9/16/22 at 9:30 PM, the nurse documented Resident #14 had a fall off the bed during a bed bath and was observed lying on his/her left side, face down, bleeding from open wounds on the forehead and bridge of his/her nose bridge and the resident was sent to the emergency room for further assessment and management. In a telehealth evaluation note, with an effective date of 9/16/22 at 10:32 PM, and date of service of 9/16/22, 9:15 PM, the physician documented Resident #14 was on Eliquis (anticoagulant) (blood thinner), had a fall from his/her bed with a head injury, and was bleeding from his/her nasal bridge, right and left forehead, and right chin. The physician further documented Resident #14 was witnessed to have hit his/her head hard against the ground, was acutely confused, and the resident was unable to answer questions, and gave the disposition to transfer the resident to the emergency department. On 10/23/22 at 11:25 AM, a review of ED (emergency department) documentation revealed on 9/16/22 at 11:12 PM, in an ED provider note, the physician documented Resident #14 presented to the ER (emergency room) for trauma following a fall, that the resident reported he/she fell face forward while getting a bath and, per EMS (emergency medical services) the resident was on Eliquis. The physician also wrote that Resident #14 was reporting diffuse (widespread back pain), and per nursing home staff, the resident had a change in mental status. The physician documented Resident #14 had an abrasion to the right forehead, an abrasion on the bridge of the nose, an abrasion to the right knee and the resident had tenderness to palpation (method of examination by feeling with the fingers or hands) below the paraspinal (around the spine) area in the C-T (cervical, thoracic) and L-spine (lumbar) spine. The ED documentation indicated Resident #14 underwent CT (computerized tomography) scans (used to visualize parts of the body to diagnose disease or injury) of his/her head, spine, facial bones, chest, abdomen, and pelvis and documented the results of the scans. In a Medical Decision Making and Plan of Care, in the ED note, the physician wrote that the Resident #14 had presented to the emergency room as a code trauma (trauma patient requiring trauma team response expected) following a fall at the nursing home with a change in mental status, that he/she arrived boarded and collared (spine immobilized with a cervical neck collar and backboard) and a trauma scan was ordered as the resident was on Eliquis. The images showed no acute traumatic injuries, the resident was stable and discharged back to the facility. On 10/24/22 at 10:13 AM a review of the facility's fall investigation revealed on 9/17/22 at 12:56 AM the nurse documented that a GNA (geriatric nursing assistant) was attempting to change Resident #14 and complete ADL care, the resident was on his/her right side, with the GNA on the left side of the bed, when the resident fell off the bed during the bed bath. The nurse indicated the GNA witnessed the fall, and the nurse observed the resident lying on the left side, face down, bleeding from open wounds on forehead and nose bridge. In an undated, handwritten incident report, Staff #39, GNA wrote that after giving Resident #14 a bed bath, in an attempt to dress the resident, Staff #39 rolled the resident away from him/herself and the resident flipped over the bed onto the floor, hitting his/her head and face. On 10/25/22 at 4:00 PM, during an interview, Staff #39, GNA indicated that on the evening of 9/16/22, he/she was giving Resident #14 a bed bath when the resident fell out of bed. Staff #39 stated that after cleaning the resident, he/she turned the resident away from her, onto his/her side to put a brief under him/her, when the resident rolled out of bed. Staff #39 indicated the height of the bed was in a position that allowed the GNA to give care. Staff #39 indicated the bed did not have side rails and the resident was on an air mattress. Staff #39 stated he/she thought the mattress may have partially come off the bed because the incident happened so fast and there was a floor mat, but the resident flipped over and hit his/her head on the floor. Staff #39 stated that following the incident he/she was given an education and told to roll the resident towards him/her, not away, and, if the resident could not assist in turning, Staff #39 was to call another person to assist with turning the resident. On 10/26/22 at 2:56 PM, during an interview, Staff #40, LPN, stated that at the time of Resident #14's fall, the GNA came out of the resident's room and told Staff #40 that he/she had been giving Resident #14 a bed bath and the resident had rolled out of bed. Staff #40 stated that when he/she went to the room, the resident was observed lying on the floor, next to one side of the bed, with the wash basin on the opposite side of the bed, and indicated Resident #14 fell when the GNA rolled the resident away from him/herself. Staff #40 stated that at that time, Resident #14 was bleeding on the bridge of the nose and forehead, that he/she tried to stop the bleeding, and when the bleeding stopped, the resident was assessed, and the resident was alert and talking. Staff #40 stated 911 was called, and because Resident #14 was on a blood thinner and hit his/her head, the resident was sent to the hospital to be evaluated. Staff #40 stated he/she was familiar with Resident #14, and the resident could follow directions, however, the resident needed help with everything except eating or drinking. Staff #40 stated the resident was on an air mattress and indicated the resident needed 2 people to assist in turning. On 11/2/22 at 11:00 AM, the above concerns were reviewed with the Nursing Home Administrator and the Director of Nurses. 2.) On 11/7/22 review of Resident #114's medical record revealed the resident was admitted to the facility with diagnosis that included but not limited to a stroke with related right sided hemiplegia (muscle weakness or paralysis). The resident received occupational, physical and speech therapy during this admission. Review of the admission Minimum Data Set Assessment (MDS), with an Assessment Reference Date of 10/15/19 revealed the resident had unclear speech with slurred and mumbled words (B0600), was able to sometimes make self-understood, with this ability being limited to making concrete requests (B0700). Regarding understanding others, the resident was assessed as sometimes understands - responds adequately to simple, direct communication only (B0800). A Brief Interview for Mental Status (BIMS) was not conducted due to the resident rarely/never understanding. The staff assessment for mental status revealed both short- and long-term memory problems and that the resident had severely impaired cognitive skills for daily decision making. Further review of the admission MDS revealed the Resident #114 had functional limitations in range of motion that interfered with daily functions or placed the resident at risk of injury on one side for both upper and lower extremities. This assessment coincides with the diagnosis of hemiplegia. The resident was also assessed as being totally dependent on staff for taking a shower. Review of the care plan addressing the resident's requirement for assistance with activities of daily living revealed the following intervention, which was initiated on 1/7/2020: Provide resident/patient with total assist of 1 for bathing. During an interview with the unit nurse manager (#10) on 11/15/22 at 9:39 AM, when asked about expectations of GNA supervision during a shower for a resident with hemiplegia, the unit nurse manager responded that those residents were at higher risk of falling, sliding out of the chair and that those were residents you would want to stay with. When asked about expectations for supervision for cognitively impaired residents when in the bathroom, she indicated that they were always a minimum assist of 1, or to give privacy, the GNA can stay outside the [bathroom] door but remain within eyeshot. Review of the initial facility report for MD00150076 revealed that, on 1/11/2020 at 12:15 PM, Resident was in the bathroom receiving a shower by GNA. Resident requested to wash their face and perineal area independently. GNA handed [him/her] supplies, made sure shower chair was locked and stepped to the door as the resident started washing [his/herself]. GNA speaking with the nurse through the door, but not leaving the doorway, heard a bang. GNA immediately turned around and observed shower chair tipped over sideways towards [his/her] right side with the resident completely out of shower chair laying on [his/her] right side. Resident stated that [she/he] was trying to stand up to the GNA . Nurse immediately assessed the resident. No signs of injuries to the head. Resident complained of right hip discomfort. Nurse notified MD [medical doctor], 911 to transport to [name of hospital] ER for evaluation. Review of the final report regarding this incident revealed clarifications regarding some of the above statements. These included: Resident requested to wash their face and perineal area independently. Clarification-GNA said to [him/her], 'here is your washcloth to wash your face and [s/he] was agreeable resident who was handed washcloth by GNA and washed [his/her] face and front area. Resident stated to the GNA that [she/he] was trying to stand up. Clarification- GNA asked [him/her] what were you trying to do and the resident responded in two words, stood up. Review of the witness statement, signed on 1/13/2020 by the Occupational Therapy Assistant #69, revealed she saw Resident #114 for therapy. Her statement revealed Sitting in wheelchair [s/he] can wash [his/her] face, brush [his/her] hair and turn the water on [His/Her] environment is the cue which means if [s/he] has supplies given to [him/her] on in front of [him/her], [s/he] will perform the task in the right room (example bathroom). I do not need to be there the entire time. I could walk out of the room to get a towel and cup of water and return and [s/he] would still be working on self-care task. If [s/he] was in the shower the cue would be wash. [S/he] has never attempted to stand independently, however [s/he] has picked cones off of the floor with therapy from a sitting position with cueing. According to the Occupational Therapy Assistant's statement, the resident never attempted to stand independently. Further review of the investigation documentation revealed a witness statement, signed by GNA #68 on 1/13/2020, that revealed she had transferred Resident #114 to a shower chair using a hoyer lift and that the resident had a mesh hoyer pad under [him/her] during the shower. The GNA washed the areas the resident could not reach as well as the resident's hair. The GNA then handed the resident the washcloth and while the resident was washing the GNA went to the door to talk to the nurse. A hoyer lift is a mechanical lift used to transport a resident from one surface to another. It requires a pad to be placed under the resident and then the pad is hooked to the lift to facilitate a transfer from a bed to a chair or vice versa. Review of the care plan revealed the resident required total assist of 2 for transfers using the hoyer lift. Further review of the final report submitted by the facility revealed the following statement: Noted GNA was in the room standing at the doorway to speak with the nurse quickly while the resident was washing. Bathroom door is directly diagonal from the main door (50 inches apart) - You can see the bathroom shower from standing at the door. Observations made during the survey of the rooms on the unit where the resident resided confirms that the bathroom was directly diagonal from the main door to the room. However, to open the door to the hallway and speak to someone in the hall, one would have to physically leave the bathroom. Further review of GNA #68's witness statement revealed the following: What did you see? I did not see [him/her] fall, I just heard bang. Review of the Fall Investigation documentation, completed by Nurse #70, revealed this was an unwitnessed fall. Additionally: Activity during incident: slid from shower chair; Was fall related to seating/positioning: Yes; Explain: when resident attempting to wash perineal area could have slid from seat on shower chair while attempting to move self in chair. Summary of Investigation: Root cause/conclusion: Resident slid from shower chair. Review of the witness statement, signed on 1/13/2020 by Nurse #70 revealed: I was standing [at the] medication cart passing medications and GNA [name of GNA #68] was standing at the doorway quickly telling me with the door open talking to me about showers she was given and this was her last shower . Further review of the investigation documentation failed to reveal documentation to indicate why GNA #68 left the resident unattended in the shower other than to inform the nurse about showers she had provided. No documentation was found to indicate the GNA needed supplies or assistance. No documentation was found to indicate the resident had requested privacy. Review of the Minimum Data Set assessment, with an Assessment Reference Date of 1/11/2020 revealed the resident continued to have short term memory problems (C0700) and severely impaired cognitive skills for daily decision making (C1000). This assessment also revealed continued total dependence on staff for showering. Further review of the final report from the facility revealed documentation that an audit was conducted on all the shower chairs with no noted concerns. Further review of the facility documentation revealed GNA #68 received one on one in-service that included: Do not leave patient unattended during shower. Residents need direct supervision while in shower. If a resident requests privacy, then make sure the resident is safe and report to the nurse. Continue plan of care regardless of where resident is being discharged to. The facility also provided documentation of training to staff in January 2020 regarding shower fall prevention. This training included but was not limited to: Don't leave resident unattended during a shower; and report to nurse if resident wants privacy with shower. Review of the Change in Condition Evaluation, with an Effective Date of 1/11/2020 at 12:15 PM and completed by Nurse #70, revealed the resident was in pain but was not cognitively able to rate their pain on a pain scale. The nurse completed assessment questions to evaluate the cognitively impaired resident. This documentation included: Repeated troubled calling out. Loud moaning or groaning. Crying. Facial grimacing. Tense. Distressed pacing. Fidgeting. Distracted or reassured by voice or touch. Further review of the final report revealed a notation that Resident noted with fracture involving the proximal right femoral shaft [right thigh]. On 11/07/22 at 3:58 PM, surveyor reviewed with the Director of Nursing the concern that the fall resulted in harm to the resident. On 11/15/22, review of the hospital emergency department report, dated 1/11/2020 revealed documentation of expressive aphasia (inability to express yourself verbally) and R hemiparesis. This report also revealed: tenderness over the right hip and contusions (bruises) on right lateral thigh. Further review of the emergency department report revealed: .The pt [patient] was put on a shower chair and left unattended. Then [s/he] fell over onto [his/her] R [right] side Pt is a limited historian due to expressive aphasia. Review of the hospital discharge summary revealed: .Work-up with x-ray was noted with fracture involving the proximal right femoral [thigh bone] shaft patient underwent a right hip peritrochanteric nailing [a surgical repair] for subtrochanteric fracture . On 11/15/22 at 11:47 AM, the surveyor informed the Administrator that review of the hospital records confirmed that the resident sustained a fracture after the fall at the facility. 3.) 2) On 11/7/22, review of Resident #501's medical record revealed the resident was admitted to the facility in 2019 with diagnosis that included but were not limited to dementia and repeated falls. Review of the resident's care plan addressing activities of daily living (ADL), with a revision date of 10/22/19, revealed the following interventions: Provide resident/patient with extensive assist of 1-2 for transfers using a pivot transfer; and Provide resident/patient with extensive assist of 1-2 for toileting. Review of the Minimum Data Set (MDS) assessment, with an assessment reference date of 11/2/19, revealed that Resident #501 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 4 out of 15. The MDS assessment also revealed that Resident#501 required extensive assistance, with staff providing weight bearing support, for transfers, walking in the room and toileting. This assessment also revealed the resident had sustained at least two falls since admission, but with no injuries related to the falls. Review of facility report MD00151194 revealed the following occurred on 2/7/2020 at 8:30 AM: Resident was in the bathroom using the toilet and GNA was approximately 7 feet in the room gathering chair. Another GNA was coming into the room to assist and observed the resident standing up attempting to walk. Resident made several steps and fell forward to the ground. GNA was unable to reach the resident. Nurse immediately assessed the resident. Compression applied to the nose. Nurse notified MD [medical doctor], 911 to transport to [name of hospital] ER [emergency room] for evaluation. Review of the final report submitted 2/11/2020 revealed: X-ray noted comminuted fracture of the anterior nasal bone [broken nose]. Resident returned to the facility with an order to follow up with ENT (ear, nose and throat). During an interview with the unit nurse manager (#10) on 11/15/22 at 9:39 AM, when asked about expectations of GNA supervision for cognitively impaired residents when in the bathroom, she indicated that they were always a minimum assist of 1, or to give privacy the GNA could stay outside the [bathroom] door but remain within eyeshot. Review of the Witness Interview Record signed by GNA #55 on 2/7/20 revealed the following: On 2/7/20 I went to take [his/her] breakfast tray and [s/he] said [s/he] had to go pee, [s/he] was sitting on the side of the bed. I laid [him/her] back down and told [him/her] I was going to be right back and went to go get another GNA. I immediately went back to [his/her] room and the resident was sitting up on the side of the bed again but this time trying to stand up. The GNA that was coming to help stated she would be there shortly and had to run something. Since [s/he] was trying to stand and walk I walked [him/her] into the bathroom, holding under arms behind [him/her] guiding [him/her] to the bathroom. I sat [him/her] down on the toilet. [S/he] was going to the bathroom and I went to grab [his/her] chair at the foot of the bed. I was pulling the chair over, the other GNA came in and observed the resident on the floor in the bathroom. [S/he] was laying on her belly with her face to the side. They did not make a noise. I did not hear him/her try to get up-[s/he] will usually yell when ready like 'mom', I was in the room while [he/she] was sitting on the toilet. Review of the Witness Interview Record signed by GNA #54 on 2/7/2020 revealed the following: .When I arrived at the room, when opening the door I had to move the resident's chair as it was in front of the doorway to the bathroom at that time. The bathroom door was opened and as I turned to go into the bathroom I saw [name of resident #113] standing close to the bathroom door and [s/he] just fell forward. I was unable to reach [him/her] quick enough to help prevent the fall. Observations made during the survey of the rooms on the unit where the resident resided revealed the bathroom door was directly diagonal from the main door to the room. When entering the room, one walks past the bathroom prior to reaching the area of the room with the resident's bed. According GNA #54's statement the resident's chair was already outside of the bathroom door when the resident fell. GNA #55's statement indicated she was not with the resident because she was getting the chair. No documentation was found to indicate the discrepancy between the two GNA statements was clarified. Review of the medical record revealed a progress note, with an effective date of 2/7/2020 at 3:35 PM and written by Nurse #44, which revealed the following: GNA in to resident room to help with ADL care - requested assistance from second GNA. Upon assessment resident attempting to self transfer out of bed, staff at bedside. Resident reported that [s/he] needed to use restroom. GNA assisted [name of Resident #501] ambulate to toilet with one assist. GNA then went to grab residents chair from bedside to bring closer to resident for transfer off of toilet. [name of Resident #501] independently stood and attempted to independently walk with pants/brief at ankles. 0830 Second GNA entered room and noted [name of Resident #501] was close to the bathroom door. GNA was unable to reach resident before resident became unsteady and fell to the ground in bathroom doorway. GNA immediately called for nurse assistance. Nurse to room .Gauze/towels held in place to nose - bleeding noted and skin break to bridge of nose. Did report pain to nose .EMS [emergency medical service] arrived at 0850 and transported [name of Resident #501] via stretcher to [name of hospital] .CT of head without contrast completed at [name of hospital] - conclusion: moderately sized right frontal scalp hematoma [bruise] .CT of facial bones without contract conclusion: comminuted fracture of the anterior nasal bone [broken nose]. Nose not set at hospital r/t [related to] swelling. Returned from [name of hospital] approximately 1430 [2:30 PM] .Apply ice q [every] shift to nose x 20 minutes. ENT [Ear, Nose and Throat] consult to be scheduled for follow up. Resident to have assistance at all times when in restroom/shower room. Further review of the medical record revealed a nursing note with an effective date of 2/8/2020 at 1:17 PM which revealed the following: .Nose remains slightly swollen, bruising to bil [bilateral] eyes, nose and rt [right] wrist area. Small dry abrasions to above upper lip and bridge of nose . Further review of the medical record revealed a nursing note with an effective date of 2/9/2020 at 1:05 PM which revealed the following: .Bruising continues to facial areas. Nose remains slightly swollen . On 11/07/22 at 3:58 PM surveyor reviewed with the Director of Nursing the concern that the fall resulted in harm to the resident. Further review of the facility provided documentation revealed One-On-One in-service training was provided to GNA #55 on 2/11/2020 regarding Fall prevention, safe resident handling and fall prevention in resident with dementia. Additionally, an Individual Performance Improvement Plan was established for GNA #55 on 2/11/2020 to address Unsatisfactory job performance, violating safety rules or contributing unsafe conditions. The facility also provided documentation of training to staff in February 2020 regarding fall prevention-bathroom. The Brief Description of the Presentation stated: BIMS - Brief interview for Mental Status, residents with scores 12 or below cannot be left in the bathroom or shower. Further review of the care plan addressing fall risk, which was initiated in July 2019, revealed the following intervention was added on 2/7/2020: Assistance at all times when in shower room/bathroom. On 11/15/22 at 4:55 PM, surveyor reviewed the concern with the Director of Nursing regarding the failure to prevent accidents for Resident #501 and #114.