**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to 1.follow the care plan intervention to prevent a fall with a fracture and laceration for one Resident #1.2. implement and develop appropriate interventions to prevent a fall with a fracture for one Resident (#35), 3. complete a fall investigation report after a fall for one Resident (#7), and 4. keep one Resident (#67) free from accidents/hazards after ingestion of lotion with subsequent hospitalization, . 5(a). For Resident #5, the facility failed to implement a scoop mattress intervention in a timely manner (b). have a bed alarm in good working condition out of a total sample of 30 residents. Findings include: Review of the facility policy titled Falls Program Policy, dated 09/2023, indicated the following: - Fall assessment should be completed upon admission, re-admission, quarterly, significant change in resident status and as needed. Identify residents fall risk after completing and reviewing the fall assessment. - Develop individualized care plan. - Review and revise care plan regularly, as needed. - Documentation of falls: complete incident report, fall investigation report and obtain witness statements. Monitor resident vital signs. Monitor neurological checks for any unwitnessed fall. Care plan needs to be updated reflective of resident status. Residents who have had a fall need this information shared with the IDT (interdisciplinary team). Rehab screen to be completed as indicated. Completed incident report and fall investigation report are to be submitted to the DNS or designee for review. 1. Resident #1 was admitted to the facility in July 2023 with diagnoses including wedge compression fracture of the lumbar vertebra, need for assistance with personal care and anxiety. Review of the most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 9 out of possible 15 on the Brief Interview for Mental Status. The MDS further indicated that he/she required extensive assistance of two people for bed mobility and transfers. Review of the care plan related to falls, dated 7/20/23, indicated: -The resident is at risk for falls related to history of falls, acute on chronic low back pain due to acute compression fractures, chronic lumbar/ low back pain, multiple vertebral fractures, muscle weakness, impaired mobility, and dizziness. Intervention date initiated 7/20/23, indicated the following: -Ensure that the resident is wearing appropriate footwear. Intervention date initiated 8/14/23, indicated the following: -Bed/ chair alarm at all times. Review of the current physician orders date initiated 8/16/23, indicated the following: -Bed sensor alarm on when resident is in bed. Check every shift for proper placement and is in good working order every shift. Review of the nursing note indicated: 10/21/2023 at 11:23 P.M.: Nurse's Note: Note text; Patient alert and responsive, was compliant his/her medication. At about 11:15 P.M. this nurse was called in by a nursing aide to see patient was on the floor. This nurse observed that patient was lying face down in a pull of her own blood. This nurse called emergency ambulance for patient to be taken to hospital for further evaluation. The primary physician and the patient's granddaughter were called and a voice mail left. Both calls were not returned by the time this nurse finally handed over to incoming nurse. We will continue to monitor (sic). Review of the fall incident report dated 10/21/23 indicated: -11:15 P.M patient found on the floor of his/her room next to his/her bed, patient found face down in a pull (sic) of blood, wet cloth used to apply pressure and 911 was called. -Nature of injury- Laceration to the face. Review of the fall investigation work sheet included as part of the fall investigation indicated at the time of the fall the following footwear/equipment (at the time of fall), failed to include use of appropriate footwear and use of bed alarm. Further review of the fall investigation worksheet indicated that following the fall the recommendations were implemented to prevent further falls/immediate interventions including: -Floor mats both sides of the bed, bed alarm. Review of written staff statement from staff members indicated the following: -Nurse #1 statement, dated 10/21/23: Last saw resident in bed at 11:25 P.M. Nurse was called in to see the patient who was on the floor in a pull [sic] of blood. -Certified Nursing Assistant (CNA) #5 statement, dated 10/22/23: Last saw resident when doing rounds and found the resident on the floor, did not see anything that would contribute to the fall, alerted the nurse. Further review of the incident report and the witness staff statements failed to include information indicating Resident #1's bed alarm was sounding. Review of fall incident report submitted to the state agency, 10/22/23, indicated that Resident #1 had nothing on his/her feet at the time of the fall. Review of the hospital Discharge summary, dated [DATE], indicated the following: -Resident #1 sustained a right periprosthetic humeral (large bone in the arm) shaft fracture, metacarpal (bone in hand) fractures and eight sutures to the left eyelid laceration On 11/3/23 at 11:24 A.M., the surveyor attempted to interview CNA #5, CNA #5 did not return the request for interview. During a phone interview on 11/8/23 at 8:42 A.M., Nurse #8 said Resident #1 had the alarm on at the time of the fall, but he was not sure if it was functioning. Nurse #8 said he did not hear the alarm sound. During an interview on 11/3/23 at 10:38 A.M., the Director of Nursing (DON) said the alarm for Resident #1 should have sounded when the Resident was found on the floor. The DON and the surveyor reviewed the fall incident report. The DON said that the footwear at the time of the event and the alarm were not checked off as being utilized at the time of the fall but should have been checked of if the alarm was being used. 3(a). For Resident #5, the facility failed to implement a scoop mattress intervention in a timely manner (b). have a bed alarm in good working condition. Resident #5 was admitted to the facility in February 2019 with diagnoses including a history of falls. The most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely/never understood. A review of the Nurses progress notes dated 11/1/23 indicated that Resident #5 had fallen. Further review of the fall care plan indicated a fall intervention created on 11/1/23 indicating the following: *Fall out of bed with bruise to right upper side of forehead. Intervention: Scoop mattress During an observation on 11/3/23 at 8:42 A.M., the surveyor observed the Resident sleeping in bed on an air mattress. During an observation and interview with Certified Nurse's Assistant (CNA) #4 on 11/3/23 at 8:51 A.M., she said the Resident was sleeping on an air mattress and not a scoop mattress. During an interview with the Unit Manager #2 at 11/3/23 at 9:34 A.M., she said the Resident had a fall on 11/1/23, interventions were added to his/her fall care plan to get him/her a scoop mattress, she said when fall interventions are added, they should be implemented immediately. During an interview with the Director of Nurses on 11/3/23 at 9:46 A.M., he said he expects fall interventions added after a fall to be implemented immediately. (b). Resident #5 was admitted to the facility in February 2019 with diagnoses including a history of falls. The most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely/never understood. A review of the November physician's orders indicated the following: * Bed sensor alarm on when resident is in bed. Check every shift for proper placement and is in good working order. Start date 11/1/23. During an observation on 11/3/23 at 8:42 A.M., the surveyor observed the Resident sleeping. The Resident was observed moving around the bed in his/her sleep, there was no sound from the bed alarm. During an observation and interview with Unit Manager #2 on 11/3/23 at 9:34 A.M., Resident # 5 was observed out of bed in a broda chair. Unit Manager #2 removed the bed alarm placed under the Resident's bed sheets, she repeatedly tried to press the alarm but there was no sound, she checked the battery port, there were only two batteries, she said the alarm should have three batteries so it can work properly. During an interview with the Director of Nurses on 11/3/23 at 9:46 A.M., he said bed alarms should be always functional, staff should be checking every shift for proper placement and making sure the alarm is in good working order. 2. Resident #35 was admitted in 03/2023 with diagnoses including depression and hypertension. Review of the Minimum Data Set (MDS), 9/27/23, indicated that Resident #35 is rarely/never understood. Resident #35 requires extensive assist with toilet use, personal hygiene, bed mobility, and transfers. Review of the care plan, dated 3/30/23, indicated the following: - The resident is at risk for falls related to confusion, deconditioning, gait/balance problems < s/p falls, R-humerus fracture, UTI, confusion Review of the activities of daily living flow sheets for April 2023 indicated that toileting every 2 hours was in place at the beginning of April. Review of the fall incident reports indicated that Resident #35 had the following falls and interventions: - On 4/8/23 at 11:35 P.M., Resident #35 was observed sitting on the floor in his/her room going to the bathroom. The intervention put in place after the fall was toileting every 2 hours. - On 4/28/23 at 5:45 A.M., Resident #35 was observed lying on the floor in his/her room after attempting to go to the bathroom. The intervention put in place after the fall was to toilet every 2 hours and offer to toilet on 11-7 shift. - On 9/4/23 at 9:45 A.M., Resident #35 was observed in his/her bathroom on the floor after hitting the top of his/her head on the toilet paper dispenser. The intervention put in place was to educate and ensure Resident #35 is not carrying liquids when ambulating. - On 10/7/23 at 10:45 P.M., Resident #35 was found on the floor on left side in the bathroom after falling head first while reaching for toilet paper. The Resident sustained a laceration with 5 sutures to his/her left eye. The intervention was to offer toileting to Resident #35 after breakfast. Review of the care plan indicated that the last intervention updated was on 3/30/23. During an interview on 10/20/23 at 10:12 A.M., the Director of Nursing said that he doesn't usually like the 2 hour toileting and is usually a quick intervention that you put in place. The DON said that the 2 hour toileting intervention should have been re-evaluated because if the Resident is still falling then it means the intervention is not working. The DON said that the interventions should be appropriate for the fall and address the reason for the fall. He said that the intervention to not carry liquids when ambulating should have been related to the fall. 3. Resident #7 was admitted in February, 2018 with diagnoses including dementia and heart failure. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #7 scored a 1 out of a possible 15 on the Brief Interview for Mental status (BIMS), indicated severe cognitive impairment. Resident #7 requires limited assistance with toilet use, bed mobility, and transfers. During an observation on 10/17/23 at 10:32 A.M., Resident #7 was found on the floor by the surveyor. The surveyor notified the nurse on duty and the nurse responded. Vitals were taken on the Resident and the Resident was put back into bed. On 10/18/23, review of the fall incident reports did not indicate that a fall investigation had been started on the incident that occurred on 10/17/23. During an interview on 10/19/23 at 12:37 P.M., the Director of Nursing said he was not made aware of the fall that occurred with Resident #7 and that he did not have an investigation for the fall. 4. Resident #67 was admitted in March, 2023 with diagnoses including dysphagia and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #67 scored a 1 out of a possible 15 on the Brief Interview for Mental status (BIMS), indicated severe cognitive impairment. Review of the MDS indicated that Resident #67 requires extensive assistance with all activities of daily living and is independent with eating. Review of the clinical record indicated that on 10/13/23, Resident #67 was observed in his/her room ingesting a bottle of lotion. Resident #67 was sent out to the hospital for further evaluation. Review of the care plan did not indicate that Resident #67 had any interventions put in place after the incident occurred. During an observation on 10/19/23 at 8:26 A.M., Resident #67 had a tube of polygrip (a denture adhesive cream) in his/her bedside table. During an observation on 10/20/23 at 7:45 A.M., Resident #67 had a tube of polygrip in his/her bedside table. During an interview on 10/20/23 at 7:40 A.M., the Director of Nursing said that Resident #67 should not have any non-food items within reach after an incident of ingestion. He also said that a care plan should be put in place with interventions to prevent ingestion of non-food items.