**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DPS B: Based on observation, interview, and record review, the facility failed to implement ordered devices to prevent accidents/falls for 1 resident (Resident #31) of 2 reviewed for accidents, from a total sample of 19, resulting in the risk for falls and potential for injury. Findings include: Review of the medical record reflected that Resident #31 (R31) was readmitted to facility 4/18/2023 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, ataxia following cerebral infarction, repeated falls, difficulty in walking, unsteadiness on feet, lack of coordination, other abnormalities of gait and mobility, and weakness. Review of the Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 8/18/23 reflected that R31 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive impairment). Section G of the same MDS reflected that R31 required one-person extensive assist with bed mobility, transfers, and toilet use, and supervision for eating after set up. In an observation and interview on 10/9/23 at 1:11 PM, R31 was observed sitting in wheelchair, in room, with left arm positioned on wheelchair tray table and left leg on wheelchair foot pedal. R31 was observed with a soft palm protector positioned in left hand and a tennis shoe and sock on left foot. R31 stated that she had history of a stroke that affected her left side, could not walk but could stand on legs, and transferred from wheelchair with assist of one staff member. R31 further stated that her ability to stand and transfer had become more difficult as her left leg brace had been gone for quite some time. Per R31, brace had broken at least a month ago, was removed from room and believed taken to therapy, had never been returned, and had heard nothing about it since. R31 stated that she now just wore her tennis shoe on her left foot, that she had less control and felt more unsteady when she stood to transfer as the foot and ankle were not supported as they had been with the brace and feared that her foot may be injured, or ankle may give out and that she would fall. R31 stated that she transferred from wheelchair to toilet or bed multiple times daily. In an observation and interview on 10/10/23 at 12:01 PM, R31 was observed sitting in wheelchair, in dining room, awaiting lunch. R31's left lower extremity (LLE) was positioned on wheelchair foot pedal with gray knee-high sock and tennis shoe noted to left foot. No brace was observed at LLE with R31 stating that therapy had not brought it back yet. Review of R31's electronic medical record completed with the following findings noted: Order dated 4/18/23 stated, Lt (left) foot AFO (Ankle Foot Orthosis-brace, splint, or boot used to reduce, prevent or limit movement of the lower leg and foot by supporting weak muscles) to be worn when out of bed- assess skin prior to application and after removal every day and night shift. Review of the electronic Treatment Administration Record dated 10/1/2023 - 10/31/2023 reflected order for left foot AFO and was observed to be signed out by both day and night shift nurses from 10/1/23 through 10/10/23 day shift. Review of all progress notes from 9/11/23 to 10/10/23 included no documentation reflecting R31's broken AFO. Physical Therapy Evaluation and Plan of Treatment dated 8/19/23 indicated within Initial Assessment/Current Level of Function & Underlying Impairments section, Precautions: Fall Risk, Left Hemiplegia with Hand Splint and LE (lower extremity) AFO. Fall Risk assessment dated [DATE] indicated score of 50 (high risk for falling). Care Plan Focus with a 11/27/19 date of initiation and 11/28/19 date of revision stated, The resident is at risk for falls r/t (related to) CVA (cerebrovascular Accident-stroke) with left sided hemiparesis, history of multiple falls, diabetes, depression, left upper and lower extremity contractions with an associated intervention indicating, AFO to left foot to be worn when out of bed dated 11/28/19. [NAME] (tool used by the Certified Nurse Aide to guide them as to the care needs of a specific resident) indicated, Left foot AFO to be worn out of bed-assess skin prior to application and removal and TRANSFERS: extensive assist x (times) 1-2, pivot on right. Use gait belt and Left foot AFO to be on . In an interview on 10/10/23 at 12:09 PM, Certified Nurse Aide (CNA) I confirmed familiarity with R31 and that she was her assigned CNA that date. Per CNA I, R31 required one-person extensive assist with most activities of daily living including bed mobility, dressing, transfers, and toilet use. Per CNA I, R31 had a soft palm protector that she wore in her left hand during the day and a wrist/hand splint that was placed on the same hand at night. CNA I further stated that R31 used to wear a brace to her left leg whenever she was out of bed, that the brace had broken approximately 1 month ago, had been taken to therapy and had never been returned. CNA I stated that she now just placed a tennis shoe on R31's left foot, continued to transfer her as a one assist as had never been told otherwise by therapy or nursing, and confirmed that R31 transferred from wheelchair to toilet or bed several times during her shift. In an interview on 10/10/23 at 12:41 PM, Licensed Practical Nurse (LPN) H confirmed familiarity with R31 as was the routine nurse on the unit where R31 resided. Per LPN H, R31 had left sided paralysis (loss of ability to move) due to history of a stroke, had both a soft palm protector and plastic wrist/hand splint that she wore to left hand depending on the time of day, but stated that she could not recall if R31 had a LLE splint or brace. Upon referencing R31's medical record, LPN H confirmed that R31 had an order for a LLE AFO, stated that R31 should have the brace on whenever she was out of bed, was uncertain as to whether she had the brace on that date, and should not have signed out that the brace was in place for that date as stated that she had not placed or verified that it was in place. LPN H also acknowledged that she had signed out R31's order for the AFO on the previous shifts that she had worked (10/2, 10/3, 10/4, 10/6, 10/7, 10/8) as was unaware that R31's AFO was broken until that date. In an interview on 10/10/23 at 12:50 PM, Occupational Therapist (OT) J stated she was familiar with R31, that she had recently participated in occupational therapy with goals to have included improving transfers, had been discharged from services on 9/14/23 with ongoing use of LLE AFO, and confirmed that R31's AFO was in good repair at the time of the occupational therapy discharge. OT J denied prior awareness that R31's AFO was broken, stated that there was a broken AFO in the therapy gym across the hallway that may be R31's but could not say with certainty as was not labeled with a name, that the orthotic representative had been at facility the prior Thursday and was asking questions about R31 so was under the impression that he may be ordering her a new AFO, and that she was currently trying to contact him for additional information as Nursing Home Administer (NHA) A had came to the therapy gym just prior to inquire about the status of R31's AFO. In an interview on 10/10/23 at 1:00 PM, Physical Therapist (PT) K confirmed familiarity with R31, stated that she had recently participated in physical therapy as bathroom transfers had become more difficult and unsafe for resident and staff with goal of improving dynamic and static standing balance with ongoing use of LLE AFO. Per PT K, R31 had left foot drop (difficulty lifting the front part of foot which may cause it to drag during transfer or walking) due to left sided paralysis making standing difficult with AFO needed for support. PT K stated that R31's AFO was utilized prior to and during the most recent therapy treatment and was in good repair at the time of R31's 9/15/23 therapy discharge. PT K further stated that transferring R31 without LLE AFO in place would be concerning, would not be a safe transfer, and was unsure as to why physical therapy was not notified that there was an issue with R31's brace so that therapy could have followed up with recommendations. On 10/10/23 at 2:15 PM, NHA A entered conference room, stated that she had been approached by OT J that date, that she had authorized the therapy department to order a new AFO for R31, and that therapy provided R31 with a temporary AFO to wear until new AFO was available. On 10/10/23 at 2:17 PM, entered R31's room in presence of NHA A with R31 observed to be sitting in wheelchair with blue AFO in place at LLE. R31 stated that someone had just placed the brace and had informed her that she could use it until the new one that was just ordered arrived. In a follow-up interview on 10/10/23 at 2:19 PM in presence of NHA A, CNA I confirmed that R31's LLE AFO had been broken for several weeks, that she had provided broken brace to and communicated directly with therapy department regarding brace but had not communicated to any individual in the nursing department that R31's brace was broken. Review of the facility policy titled Fall Prevention with an 7/11/18 adopted date stated, Policy: It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents .Purpose: 1. To identify residents at risk in a timely manner. 2. To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. 3. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls . This Citation Has Two Deficient Practice Statements A and B. DPS A. Based on observation, interview and record review the facility failed to investigate and identify root causes for falls and implement interventions as identified on incident and accident reports and physician orders, thus failing to prevent a series of falls for one resident (#52) of three residents reviewed for falls, resulting in a fall with a left hip fracture that required surgical repair. Findings include: Resident #52 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 52 (R52) was a [AGE] year old female admitted to the facility with a diagnoses of dementia, R52 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Section G of MDS reflected R52 required extensive assistance from 2 staff for transfers, toileting, bed mobility and had lost the ability to walk. R52 was observed in the dining room/lounge area of the facility's secured dementia unit. R52 was observed in a regular wheelchair without anti tip Review of incident and accident reports pertaining to R52's falls for 2023 reflected R52 fell on [DATE] from her recliner because she was trying to get up. The incident report does not reflect if the fall was witnessed, it does not identify why R52 was trying to get up ; bathroom, get something eat, reposition etc . intervention was to but strips on the floor in front of recliner/bed. There was no indication of what time the fall occurred or when R52 was last visualized by staff. Of note, resident R52's room was observed not to have strips in front of the bed throughout the survey. Incident report dated 04/02/23 (time unknown) reflected R52 was observed sitting on the floor in front of her bed, there was no injury noted. Multiple blankets were on the bed and the intervention listed on the incident report was remove some of the blankets. It was unclear what time this occurred, the last time R52 was toileted, or the last time she was visualized by staff, there was no documentation that determined if R52 was tangled up in the blankets or intentionally tried to get out of bed. Incident report dated 04/06/23 (time unknown) reflected R52 was observed sitting on the floor in front of her recliner, no injury noted but R52 did complain of foot pain. There was no documentation that revealed time of day, last time she was visualized by staff, or where R52 was trying to get up and go to, i.e.: bathroom, get a snack, leave her room to socialize. The intervention listed on the incident report was to remove the recliner. Incident report dated 06/26/23 reflected R52 tripped over her shoe while leaving the dining room. Intervention was to ensure her shoes are on correctly. The report does not reflect if R52's shoes were untied, on the wrong foot, ill fitting or need to be replaced. R52 sustained swelling and bruising to the left side of her face as a result. Incident report dated 08/24/23 0006 reflected R52 was observed on the floor in front of her bed and complaining of left hip pain. R52 yelled out when left leg palpated and reported to License Practical Nurse (LPN) O that she had hit her head. R52 was transferred and admitted to the local hospital where she was admitted with a left hip fracture and underwent surgical repair. The intervention was to add a perimeter mattress. The incident report did not contain information such as the time of the fall, what R52 was attempting to do i.e. go to bathroom, get a snack reposition etc the new intervention listed on the incident report was to send to the hospital and add a perimeter mattress. Review of the October 2023 monthly Physician orders reflected an physician order that was written on 8/30/23 High back reclining [sic] w/c (wheel chair) with seat cushion and rear anti-tippers for Positioning and Locomotion. Of note, R52 was observed sitting throughout the survey in a regular (non high back, not reclining) wheelchair without rear anti-tippers. Review of the MDS dated [DATE] reflected a BIMS of 3 - section G prior to the 8/24/ 23 fall , R52 required supervision with the assist of one staff person for bed mobility, transfers, and ambulation, and toileting no mobility devices were needed. R52 was coded as being continent of bowel and bladder. Post 8/24/23 fall with left hip fracture was when R52 became dependent with the assist of two staff persons for transfers, toileting, bed mobility, was no longer able to walk and became occasionally incontinent of urine. Incident report dated 10/06/23 R52 was observed sitting in front of her wheelchair foot rests, R52 reported R52 slid out of the chair. There was no injury and the intervention was to add a non-slip pad to the chair. Review of R52's fall risk assessments dated 01/03/23, 04/06/23, 06/26/23, 08/24/23, 08/28/23 and 10/06/23 all identified R52 as High Risk for falls Review of R52's fall care plan reflected the Physician ordered high back reclining wheelchair with rear anti-tippers were never added or implemented despite the Physician order written on 08/30/23. On 10/11/23 at 10:00 AM, Certified Nursing Assistants (CNA)C and P were both CNAs reported working on the dementia unit for several years and both reported they were familiar with R52, CNA P reported prior to R52's fall with fracture hip in August, R52 was ambulatory, walked up and down the halls with no assisted devices, CNA C stated R52 wore pull ups and for the most part toileted herself. Neither CNA could recall use of a high back wheel chair with anti tippers and both reported strips on floor have been gone for awhile. Neither CNA recalled the use of floor mats being used, hipsters, or increased supervision as a post fall intervention for R52. On 10/11/23 at 10:53 am during an interview with LPN O who was on duty in August when R52 fell and fractured her hip, LPN O stated she could not exactly recall much without looking at her notes, when queried LPN O stated she thinks R52 fell at about midnight, she stated R52 was crying out in pain and looked scared. LPN O stated she didn't think the fall was witnessed but couldn't say for sure (incident report does reflect witnessed or not) LPN O stated she 'might have seen R52 right before the fall but was not sure, thinks R52 might have been asleep and fell out of bed, but didn't really know. LPN O did report R52 was known not to sleep well at night and would frequently get up, come out into the hall for a snack or out to socialize with her, LPN O also stated R52 was known to get up and use the bathroom independently . When queried last time the assigned CNA checked on R52 and asked about toileting or an evening snack, LPN O stated she did not know. On 10/11/23 at 11:01 AM, during an interview with Unit Manager/LPN D reported falls were discussed by the interdisciplinary team, Unit Manager?LPN D stated sometimes she attends the meetings and sometimes she doesn't, but the purpose is to implement interventions. When the incident and accident reports for R52 for the 2023 year were reviewed , Unit Manager/LPN D acknowledged that a root cause analysis was not done or discussed in the meetings. When queried how the team determined what intervention to use without identifying a root cause, Unit manager LPN D stated she would have to talk with other members of the disciplinary team. When queried why R52 was observed throughout the survey in a regular wheel chair opposed to the high back reclining chair with anti-tippers ordered by the physician , Unit manager LPN D stated she wasn't sure. When queried why there weren't bed strips on the floor next to the bed as described to be implemented on the incident and accident report Unit manager LPN D stated when the recliner was removed maintenance also removed the strips by the bed last April. When queried if the non-skid strips were in place in August when R52 fell and fractured from her bed would it have prevented the fall. Unit Manager LPN D stated possibly, but nobody will know for certain. On 10/11/23 at 12:27 PM, during a follow up interview with Unit Manager LPN D she reported she thinks the root cause of R52's fall was dementia. When queried if it was discussed or determined or identified if R52's dementia led to an unmet needs such as socialization, hunger, repositioning, thirst, toileting? Unit manager/LPN D reiterated the root cause of R52's falls was dementia. When queried if interventions such as hipsters, matt on floor at the side of the bed or increased supervision was ever discussed or implemented at any of R52's post fall meeting or if the interdisciplinary team discussed patterns, such as time of day or location of falls, Unit Manager/LPN D stated No. According to the facility policy titled Fall Prevention dated 07/11/2018. POLICY: It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by an RN/LPN to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department and if appropriate, a fall prevention protocol will be initiated. PURPOSE: 1. To identify residents at risk in a timely manner. 2. To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. 3. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls. 4. To evaluate outcomes. PROCEDURE: 1. A licensed nurse will complete a Fall Risk Assessment within 24 hours of admission to determine the resident's risk factors associated with the potential for falls. 2. A Fall Risk Assessment will be completed on a quarterly basis and as needed thereafter (i.e., a fall has occurred or a change in condition etc.). The Fall Risk Assessment will be maintained in the resident's permanent record. 3. The results of the Fall Risk Assessment will be scored to identify the resident's risk category. 4. The Interdisciplinary Team will be responsible for reviewing the Fall Risk Assessments, if assessed to be a high risk and/or is appropriate they will initiate fall prevention interventions. 5. The Director of Nursing/designee will be responsible for tracking resident falls. 6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place as well as current assessments and documentation reflecting notification of applicable disciplines, resident's physician and resident's family/responsible party. 7. The Director of Nursing/designee will conduct a weekly Fall Committee Meeting consisting of Interdisciplinary Team members. They will review the falls for the week to identify issues and/or trends. The minutes of all Fall Committee meetings will be documented on the FALL COMMITTEE MINUTES. The Fall Committee Meeting minutes will be maintained in the Fall Committee Manual. 8. The QA&A Team will meet monthly, and as needed, to review fall occurrences and give recommendations as deemed appropriate.