Based on record review and interview, the facility failed to ensure staff provided adequate supervision to one Resident (#77), out of a total sample of 26 residents, who was identified as a high fall risk and received anticoagulant medication (medication that prevents blood from clotting). Specifically, the facility failed to ensure staff provided adequate supervision and/or implemented adequate interventions in an effort to prevent five falls in one month, one of which resulted in the Resident being transferred to the hospital emergency department for evaluation, and he/she was diagnosed with a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Findings include: Review of the facility's Fall Management Program, dated as last revised 10/13/22, indicated but was not limited to the following: -Policy: To identify, prevent, and treat residents at risk for negative outcomes based on their clinical comorbidities, functional status, cognitive status, and other risk factors that compromise their well-being through a systematic approach. -Purpose: To utilize resident related data to determine which residents are at risk. To minimize resident falls through a systematic approach, implementing individualized interventions based on the resident's assessment, clinical condition, comorbidities, and other related factors. -Procedure: The facility will utilize all resident related information made available on admission to determine resident-at-risk for Fall Status. -A fall risk assessment will be conducted on each resident upon admission, with the quarterly Minimum Data Set (MDS) cycle, when a significant change in status occurs, annually and after a fall. -Residents identified at high risk for falls (score of 10 or higher on the assessment) will have an appropriate fall prevention care plan developed, implemented, and revised as necessary. -Develop a new care plan or update the existing care plan as applicable with new interventions to prevent reoccurrence. -Morning team review will include clinical record review, care plan and Certified Nursing Assistant (CNA) care card update. Interdisciplinary care plans will be revised with a new dated intervention following a resident fall to ensure that all appropriate interventions to minimize recurrence have been included. Resident #77 was admitted to the facility in May 2024 following an extended hospitalization after having two falls at home and a urinary tract infection The Resident had diagnoses including encephalopathy (any brain disease that alters brain function or structure), history of repeated falls, syncope (dizziness) and collapse, muscle weakness and difficulty in walking. Medications included antipsychotic, antidepressant, anticoagulant, and anti-seizure medication (also used for nerve pain). Review of the MDS assessment, dated 5/16/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15, demonstrated inattention and wandering, and required partial to moderate assistance for all walking, and was administered anticoagulant medication. The MDS also indicated Resident #77 had falls prior to admission and had two falls since admission to the facility. Review of May 2024 Physician's Orders included but was not limited to: -Enoxaparin (anticoagulant) syringe 40 milligrams (mg)/0.4 milliliters (mL) subcutaneously (under the skin) twice a day for two months (5/9/24-7/9/24) According to the National Institute of Health (2023), anticoagulants may increase the risk of intracranial hemorrhage associated with falling. Review of a fall risk assessment, dated 5/10/24, indicated Resident #77 had balance problems while walking and had a fall risk score of 10, indicating a high risk for falls. The assessment indicated referrals to Physical Therapy (PT) and Occupational Therapy (OT) were appropriate. Review of the comprehensive care plan for falls, initiated 5/9/24, indicated: Problem: Resident has a history of falling related to weakness and confusion Goal: Resident will remain free from injury (target: 2/28/24) Approach: -Analyze Resident's fall to determine pattern/trend -Give Resident verbal reminders not to ambulate/transfer without assistance -Keep call light in reach at all times -Keep personal items and frequently used items within reach -Leave nightlight on in room -Obtain PT consult for strength training, toning, positioning, transfer training, gait training, mobility devices -Occupy Resident with meaningful distractions: music, companion, crafts -Provide an environment free of clutter Review of the CNA Care Card (undated) indicated but was not limited to: -Mobility/Ambulation: Walks with supervision, monitoring (close supervision) -Mobility device: Encourage rolling walker (RW) -Behaviors: Wanders, anxious, resistive to care -Fall Risk: Yes Review of the medical record and Accident/Incident Report and Investigation Form-Falls indicated Resident #77 sustained five falls between 5/9/24 and 6/1/24, one of which (6/1/24) resulted in a subarachnoid hemorrhage. Fall #1 (5/9/24 at 3:40 P.M.): -Review of the medical record indicated Resident #77 fell off a chair in his/her room witnessed by his/her Health Care Proxy (HCP). No injuries were noted. Interventions/recommendations identified to prevent further occurrence included redirection, encourage diversional activities and therapy to improve gait and balance. Review of the OT Evaluation and Plan of Treatment, dated 5/9/24, indicated, but was not limited to: -The patient presents with impairments in balance, gross motor coordination and mobility resulting in limitations and/or participation restrictions in the areas of mobility and self-care. Review of the PT Evaluation and Plan of Treatment, dated 5/10/24, indicated but was not limited to: -The patient presents status post lengthy admission to hospital (one month) with decreased strength in bilateral lower extremities, decreased activity tolerance and decreased standing balance. -Patient with decreased safety awareness demonstrating much confusion. Resident #77's baseline level of functional mobility was partial/moderate assistance (the patient can perform 50% of the mobility task while the caregiver assists with 50%) to walk between 10 feet and 150 feet with no assistive device. -Long term goal: safely ambulate 350 feet using no assistive device on level surfaces with supervision or touching assistance with ability to right self to achieve/maintain balance to increase independence within facility (target: 6/20/24). -Plan of treatment included PT sessions five to six times a week for six weeks (5/10/24 - 6/20/24). Review of an Interdisciplinary Team (IDT) Risk Note, dated 5/23/24, indicated but was not limited to: team reviewed the Resident's fall from 5/9/24 with the following interventions in place: therapy for gait and balance, and encourage diversional activities of choice. Resident very restless and pacing. Medications reviewed and restarted Gabapentin (treats nerve pain) for his/her restless legs. IDT will continue to monitor. Fall #2 (5/26/24 at 9:30 A.M.) -Review of the medical record indicated Resident #77 had a fall in the unit hallway witnessed by a nurse. A Nursing Note, dated 5/26/24, indicated the Nurse saw the Resident walking down the hallway, lose his/her balance and fall. The Nurse indicated she was administering medications some distance away from the Resident and was unable to reach the Resident. No injuries were noted. Fall #3 (5/28/24 at 7:05 A.M.) -Review of the medical record indicated Resident #77 had an unwitnessed fall in the unit hallway. The report indicated a Nurse was at the medication cart and turned around and saw the Resident on the floor. No injuries were noted. Interventions/recommendations identified to prevent further occurrence indicated medication review by the Physician, continue to encourage the Resident to be in supervised area and provide distraction-encourage activity. Review of the PT progress note, dated 5/28/24, indicated Resident #77 had an unwitnessed fall with a recommendation to continue supervision for all mobility. Fall #4 (5/29/24 at 9:30 A.M.) -Review of the medical record indicated Resident #77 had an unwitnessed fall in the unit hallway. The report indicated the Resident's ambulation status was supervised; however, the fall was unwitnessed, and staff found the Resident on the floor in front of the nurse's desk. No injuries were noted. Interventions/recommendations identified to prevent further occurrence indicated to keep hallway clear of obstacles, monitor Resident when in hallway, and attempt to encourage Resident to sit and rest. Review of the medical record indicated Resident #77 was seen by his/her Physician on 5/29/24 and some medications were adjusted. The Physician assessed the Resident using a rolling walker, and said the Resident is to be encouraged to use the walker. Review of an Interdisciplinary Referral and Rehab Screen, dated 5/30/24, indicated but was not limited to a recommendation for staff to provide supervision at all times and to walk with the Resident due to his/her fall risk and decreased safety awareness. The care plan for falls was updated on 5/30/24 with intervention to monitor the Resident for fatigue and offer him/her a chair. Review of an IDT Risk Note, dated 5/31/24, indicated but was not limited to: team reviewed the Resident's falls from 5/9/24, 5/26/24 and 5/29/24 with the following interventions in place: therapy for gait and balance, and encourage diversional activities of choice. Resident very restless and pacing. Physician reviewed medications and made adjustments and said to encourage the Resident to use walker when he/she is ambulating. IDT will continue to monitor. Fall #5 (6/1/24 at 7:45 A.M.) -Review of the medical record indicated Resident #77 was walking in the dayroom without his/her walker and tripped on a walker and fell as he/she was exiting the dayroom. The report indicated the fall was witnessed by Nurse #8. Nurse #8's statement indicated she placed the Resident's walker outside the dayroom to give to the Resident when he/she came out of the room, and she was at the medication cart at the time of the fall. Further review of the incident report indicated four investigation/witness statements from CNAs working on the unit at the time of the fall. None of the CNAs indicated they observed the fall or provided close supervision (according to the fall care plan) while he/she ambulated in the dayroom and failed to indicate any staff encouraged the Resident to use the walker for ambulation as indicated by the Physician on 5/29/24. Further review of the medical record indicated Resident #77 complained of pain to his/her right hip and was sent to the emergency room for evaluation. Review of emergency room Physician documentation, dated 6/1/24, indicated but was not limited to Resident #77 being evaluated after sustaining a fall at the facility with a question of a head strike. Imaging of the pelvis and both hips were negative for fracture. However, on the computed tomography (CT) scan of the brain, there was a finding of a trace right frontal subarachnoid hemorrhage. A repeat scan performed four hours later confirmed the presence of a subarachnoid hemorrhage and that it was unchanged from the initial scan. Review of a CT scan of the brain performed during a prior hospitalization, dated 4/11/24, failed to indicate Resident #77 had a subarachnoid hemorrhage or any other type of bleeding in the brain. The care plan for falls was updated on 6/2/24 with interventions to occupy Resident with meaningful distractions (repeated intervention); PT notified and recommends not using walker- he/she does not recognize the device; provide close supervision for safety as needed (6/3/24). Review of the CNA Care Card failed to indicate it was updated to reflect PT's recommendation to not use a walker as the Resident does not recognize it. Review of a Physician's Progress Note, dated 6/3/24, indicated the Resident had a recent fall with subarachnoid hemorrhage. Continue fall precautions, supportive care, monitor for any motor or sensory deficits, follow up with neurology as needed. Review of an IDT Risk Note, dated 6/6/24, indicated but was not limited to: team reviewed the Resident's falls from 5/9/24, 5/11/24, 5/26/24, 5/29/24, and 6/1/24 with the following interventions in place: therapy for gait and balance, and encourage diversional activities of choice. Resident very restless and pacing. Physician reviewed medications and made adjustments and encouraged resident to use walker when he/she is ambulating. On 6/3/24, Resident was assigned a CNA with very close supervision at all times. IDT will continue to monitor. Review of a Nursing Note, dated 6/3/24, indicated but was not limited to Resident #77 was placed on 1:1 supervision with a CNA and a gait belt worn every shift to prevent any falls. During an interview with the Rehabilitation Director and Physical Therapist #1 on 7/16/24 at 7:42 A.M., the Rehab Director said Resident #77 has had a lot of falls since admission and can be impulsive and uncooperative. The Rehab Director reviewed PT documentation and said supervision by staff means when the Resident is up and ambulating, the resident should always have someone right there with him/her. Physical Therapist #1 said she agreed with the Rehab Director and said supervision of the Resident is when someone has eyes on the Resident and standing right with him/her to assist. During an interview on 7/16/24 at 9:31 A.M., CNA #3 said Resident #77 used to walk around the unit independently, and after the Resident fell and was sent to the hospital, he/she has been on a 1:1. She said now she walks alongside the Resident with her hand ready on the gait belt if he/she needs to be redirected or guided to turn or avoid obstacles so he/she doesn't trip. During an interview on 7/16/24 at 9:50 A.M., CNA #4 said she has worked with Resident #77 as his/her 1:1 a few times. She said the Resident has never fallen while she was his/her 1:1, but he/she has fallen with other CNAs. She said she saw the Resident fall at the nursing station (5/29/24) and she did not see a CNA supervising him/her. During an interview on 7/16/24 at 10:30 A.M., Nurse #8 said Resident #77 wanders constantly and has had a lot of falls since being admitted to the facility. She said on 6/1/24 (fall with injury), she didn't actually see the Resident fall (contrary to the incident report). She said she heard a noise, turned around and saw the Resident on the floor and no CNA was with him/her. She said after that fall, she was glad that they put him/her on a 1:1 because she was so nervous the Resident would fall and get hurt. During an interview on 7/16/24 at 10:48 A.M., CNA #2 said when Resident #77 was first admitted to the unit, he/she was very confused, unsteady with walking and impulsive. He said the Resident needed someone watching him/her 24/7. During an interview with the Director of Nursing (DON) and Regional Clinical Specialist #2 on 7/16/24 at 11:10 A.M., they said Resident #77's ambulation status is very different than his/her last admission. They said the Resident is very impulsive and gets up and walks in a moment's notice. Regional Clinical Specialist #2 and the DON said close/constant supervision of the Resident was not practical and they did not implement 1:1 supervision until the Resident returned from the hospital after sustaining a subarachnoid hemorrhage from the fall on 6/1/24. During an interview on 7/17/24 at 10:55 A.M., Resident #77's Responsible Person (RP) said Resident #77 was taken to the emergency room on 6/1/24 after having a fall and was told by the doctor that there was some bleeding in his/her head. He said the Resident had CT scans of his/her head before, and the Resident never had any bleeding in his/her brain before. He said the Resident has had several falls since admission to the facility and is relieved he/she now has a 1:1 to keep him/her safe.