**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent implement effective interventions to prevent falls for two (Resident #3 and Resident #5) of five reviewed for falls, resulting in a fall with major injury and repeated hospital transfers (Resident #3) and repeated falls and the potential for major injury (Resident #5). Findings include: Resident #3 (R3) Review of an admission Record revealed Resident #3 (R3) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included nondisplaced intertrochanteric fracture of left femur, difficulty in walking, multiple fractures of pelvis, dementia, history of falling, unspecified fracture of the lower end of right radius, traumatic hemorrhage of cerebrum, and major depressive disorder. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/3/23, reflected R3 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). An admission MDS with an ARD of 3/17/23 revealed R3 was independent with one-person physical assist for ambulation, transferring, and eating. R3 required limited assistance of one person to toilet, dress, and for personal hygiene. In an observation on 5/17/23 10:55 AM, R3 was observed resting in her bed, turned toward the fall, with her eyes closed. R3's bed was against the wall and in the lowest position. In an interview on 5/18/23, Family Member E reported that he had a phone call conversation with R3 on 3/4/23. During that conversation R3 was able to speak to Family Member E, stating that R3 was in good spirits and was able to converse with the family member. Family member E reported that he had visited R3 on 4/22/23. During the visit, R3 had a bruise above her eyebrow, was in a groggy state and was not able to carry on a conversation with the visiting family members. When inquiring with staff regarding R3's current state, Family Member E reported that R3 had fallen three times and hit her head and was transferred to the hospital. Review of the Care Plan revealed that R3 had a risk for falls section initiated on 8/27/23 related to diagnoses including but not limited to recent falls, history of dementia, poor short-term memory and ability to follow cues, and poor safety awareness. Some interventions included assist resident to keep her clothing off the floor and in her closet and dresser, bed against the wall, medication review by pharmacist, nightlight in room to help orient resident, put concave mattress on bed, and PT (physical therapy) screen for strength and ambulation. A Nurse's Note dated 1/2/2023 at 8:00 PM revealed R3 was discovered on the floor of her room. R3 reported to staff that she was attempting to get something for her roommate and slipped. R3 sustained a bump on her head. An Incident Report dated 1/2/23 at 9:27 PM revealed the Interdisciplinary Team determined that R3 stated she was attempting to help her roommate per request and got weak on her way back to her bed. As an intervention, R3 and her roommate were educated on call light use. A Nurse's Note dated 2/26/23 at 12:29 AM revealed R3 was observed sitting on the edge of her bed and scooted down to the floor onto her bottom. Two-hour checks were initiated as an immediate intervention. An Incident Report dated 2/2/6/23 at 4:02 AM revealed the Interdisciplinary Team determined that it was possible that R3 was disoriented at the time of the fall, so a nightlight was placed in R3's room. A Nurse's Note dated 3/1/2023 at 12:39 AM revealed R3 was discovered in another resident's room sitting on the floor. R3 stated that she got tired and sat down. R3 was assisted up and back into her room. An Incident Report dated 3/1/23 revealed the Interdisciplinary Team determined that prior to this incident, R3 was ambulating around the unit. It is likely she got confused as to where her room was . will refer to therapy . she is getting out of her room more and walking around so perhaps she needs strengthening . The immediate intervention was to reorient R3 to her room when she was observed wandering the unit. In a Nurse's Note dated 3/21/2023 at 5:38 PM, R3 had left hip pain after sustaining a fall however, details regarding the fall were not revealed in the Nurse's Note. An Incident Report dated 3/21/23 at 2:20 PM revealed R3 was observed laying on her left side next to her bed, between bed and bedside dresser. When asked what happened, R3 stated that she did not know. It is under suspicion that the resident lost her balance as there was nothing obstructing the walkway . The Interdisciplinary Team determined that the nurse had been in the residents room approximately 2 minutes prior to the fall. At that time, R3 was observed sitting on her bed. R3 is independent with bed mobility and transfers. The fall intervention for R3 was to place a recliner in her room to allow her to sit in a chair to rest instead of her bed. It was unsure if R3 rolled out of bed or fell while ambulating in her room. In a Nurse's Note dated 4/2/2023 at 1:04 PM, R3 was discovered laying on a floor face down. Blood on floor noted. Resident was alert and un oriented upon assessment. Resident had blood coming from laceration to right side of head above the eyebrow. Resident has bump to backside top of head with noopen [sic] areas noted. Resident was unaware of what happened and was unable to inform staff of incident . R3 was transported to the Emergency Department for further evaluation. An Incident Report dated 4/2/23 at 12:00 PM revealed resident was observed in her room on the floor face down there was blood noted to resident's face and the floor around her head. Immediate assessment noted a laceration above her right eyebrow and a lump on the back of her head. Resident was unable to tell staff what had occurred . during the investigation it was noted that there were some clothing items strewn about the living area. It was not confirmed whether these items may have played a role in the fall . an order was given to send resident to (ED) Emergency Department for evaluation . intervention for fall was to assist resident to keep her clothing off the floor in her closet and dressers. In a Nurse's Note dated 4/8/23 at 4:30 AM, R3 was lying on the floor in another resident's room. She attempted to ambulate throughout facility independently and fell onto the floor . was transferred by two staff back into her room into bed. She did c/o (complain of) pain of left thigh during transfer into bed .Pain seems to be only with movement . An Incident Report dated 4/8/23 at 4:36 AM revealed a Physical/Occupational therapy request was made for R3. The Incident Report stated that the pain seems to be only with movement resident denied pain at first but had complaints of pain with transfer into bed. 15-minute checks were also initiated. In a Nurse's Note dated 4/8/23 at 9:58 AM R3 had a witnessed fall out of bed. R3 was discovered on her back/right side . Total body assessment done, resident is reporting left side thigh pain, resident was assisted into bed with help of another LPN (Licensed Practical Nurse) and a CNA (Certified Nursing Assistant). Positioned farther toward wall in bed to avoid falling off the edge. [Physician H] notified, said to continue neuro checks, no need for an x ray . In a Nurse's Note dated 4/8/23 at 12:35 PM, R3 was being assessed for neurological checks when R3's left leg was observed to be shorter than right and slightly turned out. When asking resident to move that leg she stated she can't. Extremely painful to the touch. Upon visual inspection left hip has some swelling. Imaging was ordered for R3's left leg. A Nurse's Note dated 4/8/23 at 4:33 PM revealed Resident in bed this shift restless, asked if she was in pain said yes but couldn't rate it .Resident was extremely painful when log rolled to be changed .They (Imaging company) arrived at 1415 (2:15 PM) to do x-ray, at 1455 (2:55PM) received results .Received order to send to ER (Emergency Department) .ambulance at 1620 (4:20 PM). Review of Hospital Discharge Paperwork dated 4/12/23 revealed R3 sustained an acute intertrochanteric proximal left femur fracture Ground level fall with history of frequent falls. At time of presentation in the Emergency Department presents today due to fall. Patient has dementia and is unable to provide history. Guardian called but unable to reach. Patient brought in from [Facility] by EMS (Emergency Medical Services). Per chart review, patient had ground level fall last night and had left hip pain . Of note, patient was recently seen in ED (Emergency Department) on 04/02 for a fall with head injury. CT (Computed Tomography) brain with no acute fractures and patient was discharged back to facility. She had injury above right eyebrow and hematoma of posterior aspect (back) of head that was stable.Left hip XR (x-ray) with Acute comminuted intertrochanteric proximal left femur fracture . As a result of her injuries, R3 underwent hip surgery for repair of the fracture. In an interview on 5/22/23 at 9:09 AM, Certified Nursing Assistant (CNA) F reported that R3 enjoyed ambulating around but would often go into other resident's rooms. Staff tried to keep an eye on her when R3 was up ambulating about. CNA F stated that R3 had a problem with falling out of her bed. In an interview on 5/22/23 at 11:39 AM, Registered Nurse (RN) D reported that after a resident sustains a fall an assessment of the resident is completed. Regarding assessment of the resident's extremities, complaining of pain would be the basis for getting an x ray. If a resident were to complain of pain, especially pain with range of motion, a stat (immediate) x ray would be ordered. RN D also reported that R3 would fall out of bed. This could be attributed to R3's habit of laying awkwardly on the bed or lay to more to one side of the bed than the other. In an interview on 5/22/23 at approximately 11:00 AM, Registered Nurse (RN) C reported that the process for falls included assessing the resident and performing any necessary first aid. If a resident did not have proper range of motion, best practice was to leave them. RN C reported that part of the assessment does include a pain assessment. If they can't move that extremity or grimacing or has pain, at that point we tell the doctor that they need an x-ray. RN C reported that R3's x-ray was not ordered when R3 fell the first time because she did not complain of pain. RN C reported that the x-ray was not ordered until 12:51 PM, hours after the first and second fall R3 sustained on 4/8/23. RN C stated that x-rays should be ordered when a resident has complaints of pain, pain with movement, or swelling. A Nurse's Note dated 4/30/23 at 6:32 AM revealed R3 was discovered lying on the floor of her bedroom laying on her right side. An Incident Report dated 4/30/23 at 6:00 AM revealed resident was observed lying on her right side on the floor with her right arm under her body . LPN (Licensed Practical Nurses) states that resident chooses to lie close to the edge of her bed and suspects that she rolled out of bed. Suggested to place perimeter mattress on bed to provide boundary . falls have occurred when resident tries to sit down on edge of bed slides off bed becomes weak when walking and sets down . Resident was given a Broda chair (wheelchair with tilt and recline abilities) and given graded papers to occupy her time as R3 was a retired schoolteacher. R3 had not sustained any further falls after the 4/30/23 fall. Resident #5 (R5): Review of the medical record reflected R5 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the left dominant side, muscle weakness and vascular dementia. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/2/23, reflected R5 had short-term and long-term memory problems, did not walk and required limited to total assistance of one to two or more people for activities of daily living. The MDS was coded for two or more falls without injury. On 5/18/23 at 10:41 AM, R5 was observed lying in bed, with the bed height in a low position. The head and knees of the bed were elevated, and a perimeter mattress was in place. What appeared to be a pillow, was beneath the sheet on his right side. The left side of the bed was against the wall. A pillow boot and blanket were observed on the floor at the right bedside. R5's eyes were closed, and he was observed to be intermittently moving in bed. Upon knocking on the room door, no response was received from R5. R5 did open his eyes briefly but did not verbalize. R5's medical record reflected he required staff assistance for transfers. Review of R5's Incident Reports since 1/1/23 reflected falls on 1/27/23, 2/8/23, 2/20/23, 2/26/23, 3/2/23, 3/10/23, 3/15/23, 4/15/23, 4/27/23 and 5/1/23. R5's Progress Notes reflected an additional fall on 5/10/23. An Incident Report for 1/27/23 at 2:10 AM reflected R5 was observed lying on his back, perpendicular to the bed. R5 stated he went to sit down, and the chair moved out from underneath him. The left brake on his wheelchair was not engaged, and the anti-rollback brakes were not functioning properly. The root cause analysis note reflected when R5 attempted to self-transfer from his bed to the wheelchair, his wheelchair moved backwards, causing him to slip out of the front. There was no documentation as to why R5 was self-transferring. The report reflected he was assisted into his wheelchair and with toileting. A facility-wide audit for anti-rollback brakes was put in place. Review of a facility document reflected an anti-rollback audit was conducted on 1/27/23, and R5's anti-rollback brakes were adjusted. An Incident Report for 2/8/23 at 9:49 AM reflected R5 reported entering his bathroom that morning and attempting to self-transfer to the toilet. The floor was wet with water, and he slipped, fell and landed on the garbage can. Upon inspection of the commode, it was plugged and leaking water onto the floor. The water was cleaned up and maintenance was notified of the needed repair. The root cause analysis note reflected R5 entered the bathroom, the floor was wet with water, and he slipped. R5 landed chest first on the garbage can. There was no intervention to address R5 transferring to the bathroom unassisted. During an interview on 5/22/23 at 12:34 PM, Director of Nursing (DON) B indicated the root cause of the fall on 2/8/23 was related to the floor being wet, causing R5 to fall. The immediate intervention was to wipe the water and notify maintenance for repair of the leaking toilet. When asked if there was an intervention pertaining to R5 self-transferring to the toilet, DON B stated it did not look like there was an intervention for that. An Incident Report for 2/20/23 at 4:10 AM reflected R5 was observed sitting on the floor, in front of his bed. The left wheelchair brake was not locked. R5 reported he was trying to get into the chair and it moved. The root cause analysis note reflected R5 was attempting to self-transfer into his wheelchair and only locked the right brake. R5 stood, the wheelchair moved, and he lost his balance. R5's wheelchair was taken out of service for inspection of the brakes and anti-rollback brakes. The note reflected the wheelchair passed inspection. There was no documentation as to why R5 was self-transferring. The report reflected he was assisted to his wheelchair and with toileting. R5 was educated to take his time and double check that all safety measures were engaged before using his chair. R5's medical record did not reflect that he was independent for transfers. R5 required staff assistance. During an interview on 5/22/23 at 10:33 AM, Registered Nurse (RN) C reported once a resident with anti-rollback brakes stood from their wheelchair, the wheelchair was not supposed to move back. When their weight was moved off the seat, the wheelchair could not be pushed back. During an interview on 5/22/23 at 12:34 PM, when asked how the wheelchair moved if the anti-rollback brakes were functioning, DON B reported she did not know about the function of anti-rollback brakes. The Incident Report for 2/26/23 at 10:25 AM reflected R5 was observed on the bathroom floor by the Certified Nurse Aide (CNA). He was crawling on the floor, and his wheelchair was tipped on it's side. The report reflected R5 had been toileted about 30 minutes prior. He did not use his call light before taking himself to the bathroom unassisted. R5 reported he tried to go to the bathroom, grabbed the bar and slipped. His wheelchair fell over, and he hit his head. The root cause analysis note reflected R5 had a strong desire to be independent and did not always use his call light. A sign was to be posted on the bathroom door to cue R5 to ask for assistance to use the bathroom. An Incident Report for 3/2/23 at 6:25 AM reflected R5 was sitting on the floor, in front of his bed. R5 reported he stood to change his pants, leaned on the chair, the cart moved away from him and he sat on the floor. The report reflected his anti-rollback bars were assessed and were in working order. The root cause analysis note reflected when standing to change his pants, he held onto the wheelchair, and it rolled away from him. R5 sustained an abrasion to the right leg and a bruise to the left inner/upper arm. The intervention reflected staff was to offer to assist R5 with morning care and dressing for the day during the final rounds of third shift. R5's falls on 1/27/23, 2/20/23 and 3/2/23 reflected instances of his wheelchair moving, causing him to fall during transfers. R5's Care Plan reflected an intervention of anti-rollback brakes was initiated on 10/28/22 and revised on 10/31/22. During an interview on 5/22/23 at 1:49 PM, Director of Maintenance (DM) I reported they installed a lot of anti-rollback brakes and tested them when they were installed. They did not follow-up on them unless told by the nurses or CNAs that they were not working properly. What he corrected the most, was when the arms that stuck out over the wheels got caught on something, bent and were knocked out of adjustment. MD I reported anti-rollback brakes were mechanical and could fail. MD I reported having to work on R5's anti-rollback brakes several times. Maintenance Assistant (MA) J and MD I agreed they usually found that R5 knocked his anti-rollback brakes out of adjustment. They reported they may have been able to look in their tracking system to see if they had any requests to look at R5's anti-rollback brakes. No additional documentation pertaining to evaluation and/or repair of R5's anti-rollback brakes was provided during the survey. An Incident Report for 3/15/23 at 7:29 AM reflected R5 attempted to get out of bed at 2:40 AM and fell to the floor. R5 was incontinent at the time of the fall. The immediate intervention reflected the Plan of Care was updated with a toileting schedule. The Interdisciplinary Team (IDT) note reflected R5 had been restless and had difficulty sleeping after returning from the hospital after a possible stroke. Sleep tracking was initiated. An Incident Report for 4/27/23 at 7:00 PM reflected R5 was observed on the floor and stated he slid from his wheelchair and laid on the floor. The report reflected R5 was wet and soiled and incontinent of bowel and bladder at the time. The IDT root cause note reflected to assist R5 to the toilet upon waking, after supper and upon request to promote a toileting pattern. An Incident Report was not received for R5's fall on 5/10/23. A Progress Note for 5/10/23 at 7:59 AM reflected R5 was observed lying on the floor and sustained a skin tear to the left elbow. He was assisted back to bed via hoyer lift and instructed to call for assistance with reaching for things. During an interview on 5/22/23 at 12:34 PM, DON B was queried about bowel and bladder tracking in attempt to establish a toileting schedule and reported they would maybe do it for a fall, depending on the situation. When asked about a situation when they might do that, she reported if a resident was incontinent and kept falling at the same time and each time they were incontinent. Regarding R5's fall on 5/10/23, DON B reported he was not able to tell staff about the incident and was incontinent of bowel and bladder at the time of the incident. New interventions were to include a 72 hour sleep study and a bladder incontinence journal. When queried what a bladder incontinence journal was, DON B reported she could ask the Clinical Care Coordinator, and it would be on a separate form. Review of R5's MDS history since admission to the facility reflected occasional to frequent urinary incontinence, without the trial of a toileting program.