**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent falls for 2 of 7 residents (Resident #7 and #56) reviewed for falls, resulting in falls with injuries and fractures negatively affecting the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #7: Review of an admission Record revealed Resident #7 was a male with pertinent diagnoses which included laceration of scalp, traumatic subarachnoid hemorrhage with loss of consciousness (acute brain injury with bleeding in the brain), history of urinary infections, suprapubic catheter (inserted into a hole in abdomen then directly into the bladder), history of falling, and chronic pain. Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 2/19/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15, which indicated Resident #7 was cognitively intact. Review of current Care Plan for Resident #7, revised on 2/22/22, revealed the focus, I am at risk for falls r/t (related to) new admit, hx (history) of falls, Rib fx (fracture), impaired mobility, diagnosis', potential medication adverse effects, Antiplatelet increases risk for bruising/bleeding should fall occur . with the intervention .Staff will remind me and reinforce safety awareness .Need a safe environment with bed kept at knee height, nonskid footwear provided, walker kept in reach, commode used on toilet, safety reminder signs, paddle call light, non skid to recliner .My IDT (Interdisciplinary team) will provide/encourage activities that minimize the potential for falls while providing diversion and distraction .use a fall risk assessment to identify my risk factors . Review of Fall Huddle dated 3/20/22 at 11:20 AM, revealed, .Dining room on 100/200 hallway .Resident was at table with magazines .Resident observed laying on the floor near his wheelchair .Res restless, res was previously in recliner in room scooting down, hollering out constantly, not making sense .Remove high traffic area .Resident to wear leg bag when up .impulsive, poor judgment . Review of (Facility Name) Determination of Reportable Incident/investigation Guide for incident on 3/20/22 at 11:20 AM, revealed, .Immediate intervention: Resident in high traffic area for increased safety, increased monitoring for remainder of shift and staff to call activities to help when resident is anxious or offer to take resident for a walk .Falls committee review: Resident was already in a high traffic area - not going to prevent a possible reoccurrence so intervention removed from plan of care. Also, upon further investigation resident with regular catheter bag and tubing in place. New intervention to change resident to a leg bag when up in his wheelchair to allow for ease with mobility and ambulation . Review of Kardex as of 3/21/22 revealed, .**Please assist me with changing my catheter bag to a LEG BAG when I am up** . Review of Progress Notes dated 5/13/2022 at 11:17 AM, revealed, .At approx. 10:50am writer called to 100 dining room and observed res laying on his left side on the floor in front of the table where he was sitting. W/c to Rt (right) of res. Res alert to himself per his norm stating, I was trying to get to my truck. Res able to move all extremities freely and without difficulty. Staff assisting res off of floor with assist of 3 and a gait belt and placed into w/c. Res able to bear weight with no c/o pain or discomfort when standing. Upon assessment res observed with an area of 5.0x4.0cm swelling to Lt (left) forehead with a 4.0x3.0cm abrasion in the center. Ice applied. Skin tear to Lt upper, outer forearm 3.0x0.5cm. Area cleansed with NS, patted dry, steri-strips applied and covered with tegaderm (waterproof, transparent, sterile barrier to external contaminants). Res also with a 5x4.5cm abrasion to Lt mid back left OTA (open to air). Res talking with staff during assessment. Mood pleasant, smiling at staff. Speech clear, non sensical at times per his norm, continues to make comments of getting home to the farm. PEERL with Lt pupil sluggish. T-97.8 P-80 R-22 BP-152/78 spo2 95% on RA. Res removing his O2 multiple times this AM, spo2 maintaining above 90% with no s/sx of respiratory distress or SOB observed. BG 184. House supervisor made aware of the same . Review of Progress Notes dated 5/13/2022 at 11:28 AM, revealed, .Called to room by wing nurse resident observed sitting in w/c alert per norm with confusion and non sensical speech at times per norm. Large hematoma to Lt forehead, laceration to left elbow and abrasion to left back. Denies dizziness, or nausea. Unable to verbalize whether or not he has blurred vision. Knows that he is in (town residing in). When asked what he was doing he stated he was going to his truck. Rt (right) pupil equal round and easily reactive to light at 3 mm. Lt pupil with small abrasion to outer aspect of eye lid pupil 3 mm and very sluggish. Hand grips weak but equal. (Physician) updated with new order received to transport to ER for Eval . Review of Progress Notes dated 5/13/2022 at 11:40 AM, revealed, .Resident transported to (local hospital) ER via (EMS transport company) with transfer packet, code status, DPOA papers, Meds, labs, progress notes and bed hold policy. Report phoned to (local hospital) ER . Review of Progress Notes dated 5/13/2022 at 3:55 PM, revealed, .Report received from (staff member at local hospital) ER. Res is returning. He does have a bleed. Physician and family aware that it could get worse. Steri Strips placed at facility remain in place. Xray to elbow was negative for fx (fracture). Nystatin has been ordered. Tetanus updated. Physician aware of above . In an email sent on 5/26/22 at 10:30 AM, revealed, .Regarding the fall on (5/13/22) (Resident #7) - review of fall on video showed resident stood and attempted to ambulate getting caught on his catheter. Resident was to have leg bag in place when out of bed. This was the intervention put in place from fall in 3/22. (RN #AA) did not change that in his plan of care. Attached is the warning she received. Education was provided that care plan is to (be) updated immediately . Review of Written Record of Verbal Warning for Registered Nurse (RN) AA dated 5/13/22, revealed, .You failed to change a resident's plan of care that was put in place as a fall intervention . Review of Provider Note dated 5/15/22, revealed, .(Resident #7) fell. He was sent to the hospital. He had a small left frontal cutaneous laceration and also, he has a small left frontal subdural hematoma measuring 8 mm .Impression: Closed head injury with a small abrasion and laceration of the left frontal scalp with a small, 8 mm, subdural hematoma . According to Medline Plus, a subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain .most often the result of a severe head injury . https://medlineplus.gov/ency/article/000713.html. Review of Progress Notes dated 5/17/22 at 3:16 PM revealed, .BIMS done with resident today. He could not recall the month or the day and had trouble with recall as well. While asking questions he asked what this had to do with the cows. Unable to hold a meaningful conversation and would revert back to the farming he had to get done . Review of Progress Notes dated 5/24/2022 at 10:52 PM, revealed, .Res sitting in w/c by fish tank when he leaned over and fell out of w/c onto left side. Writer heard fall with other staff. Res had a cut to left side of head that was bleeding. Staff applied pressure to wound and then assessed res. Res able to verbalize that he was trying to unhook a trailer when asked what he was doing. Res denied pain, PERRL (pupils are equal, round and react to light), ROM (range of motion) intact to all extremities, and no drooping noted to face. V.S. T:99.0, P:88, R:28, B/P:177/96, SpO2:96@RA. BG:274. House supervisor made aware . Review of Progress Notes dated 5/24/2022 at 6:46 PM, revealed, .(Physician) made aware of res fall, laceration to head, Neuros WNL per res . No new orders received . In an interview on 5/24/22 at 3:09 PM, Director of Nursing (DON) B reported (Resident #7) had a fall with a hematoma and the facility had sent him to the hospital and he received stitches to his head. DON B reported for all falls the IDT team reviews and talks about the falls every day, discuss care plans and interventions and if any changes were needed. Review of Orders dated 5/25/22, revealed, .Monitor laceration on L side of head apply CDD (clean dry dressing) if drainage noted q (every) 1 shift and PRN as needed. Cleanse with NS (normal saline) an apply CDD is draining . Review of Orders dated 5/25/22, revealed, .Monitor abrasions to L knee every day and evening shift . During an observation on 5/26/22 at 9:26 AM, CNA D assisted by CNA JJ assisted resident from his wheelchair to his bed in his room. CNA D reported she felt more comfortable with another staff to assist with resident, he was normally a one assist, as he hasn't been standing very good. CNA D reported he had an incident yesterday and was going this afternoon for an x-ray. Resident #56: Review of an admission Record revealed Resident #56 was a male with pertinent diagnoses which included anxiety, urgency of urination, dizziness and giddiness, stroke, ulcer of [NAME] of left foot, chronic pain syndrome, and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #56, with a reference date of 4/21/22 revealed a Brief Interview for Mental Status (BIMS) score of 00 out of a total possible score of 15, which indicated Resident #56 was severely cognitively impaired. Review of current Care Plan for Resident #56, revised on 10/27/2020, revealed the focus, .I need assistance with my ADL's. AEB: Needs assistance with bed mobility, transfer, walking .toilet use . with the intervention .My toileting ability is: Assist x 1-2 based on level of arousal. Go slowly when I stand as I become dizzy easily . Review of Progress Notes dated 5/17/2022 at 8:49 PM, revealed, .At approx. 1900 writer called to resident bathroom. Resident was lowered to floor in bathroom after knees buckled during peri care. Resident did not hit head, Neuros WNL (within normal limits) PEERL (pupils are equal, round and react to light) WNL. 2 abrasions to L knee measuring 1.5cm x 0.5cm and 0.4cm x 0.3cm, areas cleansed with NS, patted dry and left OTA (open to air) due to no drainage. No c/o pain or discomfort at that time. BP-107/72, P-61, R-16, T-98.2, SpO2-97% and BG 128. House supervisor made aware . Review of Fall Huddle dated 5/17/22, revealed, .Exact Location of Incident: Room - Bathroom .Describe exactly what you saw: When staff standing resident to provide care after toileting res. knees gave out and staff lowered res on to knees .List causes or potential causes: Gait belt use was not performed by staff .Any other information or specific factors that may have contributed to this fall? No gait belt use .Describe Injuries: Abrasions to L (left) knee . 1.5 x 0.5 and 0.4 x 0.3 .Intervention: Staff education: Education provided to (CNA #II) about gait belt use . Review of Progress Notes dated 5/18/2022 at 10:43 PM, revealed, .Fall on 5/17/2022 reviewed at Fall Committee. All Safety Interventions in place per plan of care and continues to be appropriate at this time. Staff education provided . Review of Progress Notes for Resident #56 revealed no documented refusals by resident to wear a gait belt during ambulation. During an observation on 5/24/22 at 10:36 AM, observed a paper on the door to Resident #56's room, upon further review, the document was a form for 15-minute checks for Resident #56. In an interview on 5/24/22 at 10:37 PM, CNA D reported the form hanging on the outside of the door were for 15-minute checks for Resident #56. CNA D reported she was to make note of what the resident was doing every 15 minutes and she would sign it. Once it is completed, it would go in the chart. CNA D reported the form for 15-minute checks was replaced every day. During an observation on 5/25/22 at 3:15 PM, review of the 15-minute form on the door for Resident #56 revealed missing documentation for a 15-minute check for 2:30 PM and 2:45 PM. Also, no initials were in the time slots for 1:25 PM, 1:30 M, and 1:45 PM for this date.