**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Numbers MI00131094, MI00135961, and MI00136144. Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive skin assessment and wound care program to ensure ongoing, accurate, and consistent assessment, treatment completion, treatment revision, and documentation per professional standards of practice for two residents (Resident #701 and Resident #707) reviewed, resulting in lack of assessment, treatment, and clear documentation of pressure ulcers (wounds caused by pressure), Resident #707 developing two unstageable DTI (Deep Tissue Injury) pressure ulcers, lack of treatment and assessment for Resident #701's right heel unstageable DTI pressure ulcer, gluteal and sacrum pressure ulcers worsening and infection, unnecessary pain, hospitalization, surgical intervention, and decline in overall health status. Findings include: Review of the facility provided CMS- 672 form revealed there were four Residents in the facility who had pressure ulcers. Of the four Residents with pressure ulcers, two developed at the facility. The CMS- 802 Resident Matrix form included that there were three Residents with pressure ulcers with one being facility acquired. Resident #701: Review of intake documentation, received 3/30/23, revealed Resident #701 had been transferred to the hospital due to wounds, infection, and lack of appropriate care. The intake documentation detailed, (Resident #701) had several wounds on their bottom. The facility never had a wound doctor to look at their wound . The nurses were just changing the dressing but are not trained in any wound care. The wound was starting to smell. The wound is now infected and is green. A week ago, they finally sent (Resident #701) to a wound clinic. The wound was so bad that (Resident #701) was transferred to a hospital. A second intake pertaining to Resident #701, dated as received on 4/24/23. Review of this intake documentation detailed Resident #701 presented with wounds from their waist down, including on their legs and buttocks at the hospital wound care clinic on 3/23/23. Per the intake documentation, The wounds are from neglect as if never turned at the nursing home. It was reported that (Resident #701) refused being moved; however, (Resident #701) commented that they never said this. The wounds are infected with gray ooze/pus coming the wounds. The wounds smell. (Resident #701) bones are visible in some of the wounds . The intake revealed the Resident was transferred to the hospital directly from the wound care clinic due to emergent medical concerns related to the pressure ulcers. An interview was conducted with Wound Care Registered Nurse (RN) A on 6/6/23 at 10:45 AM. When queried regarding Resident #701, RN A revealed the Resident was treated at the Wound Care Clinic three times. When asked, RN A revealed Resident #701 was first seen at the clinic on 3/23/23 and they were sent directly to the hospital ER following the visit due to wound care staff concerns of Resident #701 being neglected at the facility and not receiving appropriate wound care treatment causing the wounds to worsen and Resident #701 developed a severe infection. When queried if the Resident was treated at the wound care clinic after 3/23/23, RN A indicated the Resident was treated one other time and sent to the ER again due to their condition. Review of Resident #701's face sheet revealed the Resident was originally admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (MS), quadriplegia (paralysis of all four extremities), lower extremity contracture, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required extensive to total assistance to complete all Activities of Daily Living (ADL) with the exception of eating, and had three pressure ulcers including one stage four (full thickness tissue loss with exposed bone, tendon, and/or muscle), one unstageable, and one DTI. Review of Resident #701's care plans revealed a care plan entitled, The resident has potential for and actual impairment to skin integrity r/t (related to) . MS, immobility, poor nutritional habits, prefers to lay in bed and resists turning and repositioning and wound care/assessments. R (Right) buttock stage 4 pressure ulcer s/p (status post) surgical closure, L buttock stage 3 ulcer s/p surgical closure, R heel UTD (Unable to Determine) pressure ulcer, DTI to sacrum, scattered scabs to lower extremity in various stages of healing. Often declines to use heel protector boots--prefers floating with pillows. Osteomyelitis of sacrum (Initiated: 1/7/23; Revised: 6/1/23). The care plan included the interventions: - Braden Scale per order (Initiated: 1/7/23) - Encourage good nutrition and hydration in order to promote healthier skin (Initiated: 1/7/23) - Encourage guest to use heel boots while in bed to prevent breakdown. Provide assistance turning as tolerated (Created/Initiated: 5/9/23) - Encourage to consult with the wound clinic (Initiated: 3/8/23) - Follow facility protocols for treatment of injury (Initiated: 1/7/23) - Identify/document potential causative factors and eliminate/resolve where possible (Initiated: 5/9/23) - Monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury (Initiated: 1/7/23) - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (Medical Doctor) (Initiated: 1/7/23) - Obtain blood work . and C&S (Culture and Sensitivity) of any open wounds as ordered by Physician (Initiated: 1/7/23) - Pressure reducing cushion to protect the skin while up in chair (Initiated: 1/7/23) - Resident transfers via hoyer (mechanical device to lift people) and 2 PA (Person Assist) (Initiated and Revised: 1/7/23) - Pressure reducing mattress/ air mattress to protect the skin while in bed (Initiated: 1/7/23; Revised: 4/2/23). Care Plan History detail revealed air mattress was added to care plan on 4/2/23 when it was revised. - Skin Assessments per order (Initiated: 1/7/23) - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface (Initiated: 1/7/23) A second care plan entitled, Resistive/noncompliant with care or treatment (Turning, wound care, wound documentation) r/t (related to) guest stating does not need these interventions performed. Guest often refuses care and acknowledges risk to worsening of wounds and overall health from refusal (Initiated: 3/31/23; Revised: 5/8/23). This care plan included the interventions: - Inform of ADL that is required ahead of time (Initiated: 3/31/23; Revised: 4/25/23) - Provide education about risk of not complying with therapeutic regimen (Initiated: 3/31/23) - Reapproach at a later time (Initiated: 3/31/23) - Offer Choices (Initiated: 3/31/23) - Meet with Social Services 1:1 as needed (Initiated: 3/31/23) An interview was conducted with Resident #701 in their room on 6/7/23 at 9:45 AM. The Resident was in bed, positioned slightly on their right side with the head of their bed elevated at approximately 45 degrees. When queried regarding the level of assistance they require from facility staff, Resident #701 revealed they are unable to walk or move very much without someone helping them. When queried if they have wounds and/or pressure ulcers, Resident #701 confirmed they did. Resident #701 stated, I have drains in my wounds, getting them out today. With further inquiry, Resident #701 revealed they had a doctor appointment with a physician outside of the facility this morning related to their pressure ulcers and were hoping to have the drains removed. When asked why and how long they had drains in the wounds, Resident #701 revealed they had surgery to try to help heal the wounds and that is when the drains were placed. When asked if they had the pressure ulcers when they were admitted to the facility, Resident #701 stated, I had some when I came. Resident #701 was asked if they had developed additional pressure ulcers at the facility and revealed they were unsure as they could not see the wounds. When queried the location of their pressure ulcers, Resident #701 replied, My bottom and right heel. An alternating air mattress was present on the bed. When asked how long they have had the alternating air mattress, Resident #701 revealed they had a regular mattress when they first arrived at the facility. The Resident was unable to recall the specific date the air mattress was applied but stated, Not that long. When asked if they are able to turn and reposition themselves in bed, Resident #701 indicated they required assistance. Resident #701 was then asked how frequently staff reposition them in bed, Resident #701 revealed it was usually a couple times a shift. Resident #701 was queried regarding more frequent repositioning due to their wounds and indicated it takes two staff members reposition them which makes it more difficult for the staff. Resident #701 had black colored heel boots in place on both of their lower extremities. When asked how long they have had the heel boots, Resident #701 stated, Just got them at the hospital. Resident #701 was queried if staff had kept their heels elevated or used a different type of heel protection device prior to getting the boots from the hospital, the Resident revealed staff would sometimes elevate their legs on a but that they did not have any other boots/devices. Resident #701 was then asked when wound care treatments are typically completed and indicated they are done by the night shift nurses. When asked if the treatments are completed at the ordered frequency, Resident #701 replied, Mostly and indicated their wound care treatments are not always completed. When queried if they ever refused to have the wound dressings changed or to be repositioned in bed, Resident #701 replied, Sometimes because of pain. With further inquiry, Resident #701 revealed they hurt so bad from their wounds and there are times when they just can't take it (pain). When queried if they informed nursing staff about their pain, Resident #701 indicated they had and stated, They want to do it when they have time and that doesn't always work because they are in pain. Resident #701 revealed they wanted the wounds to heal and to get better so they can get into the chair and out of the bed. Review of Resident #701's wound documentation in the Electronic Medical Record (EMR) revealed the Resident had the following Active wounds: - #24 Right Heel: Unstageable Pressure Ulcer - #21 Sacrum: Deep Tissue Pressure - #9 Right Gluteus: Stage 4 Pressure Ulcer - #20 Right Gluteus: Surgical Sutures (9) - #22 Left Medial (inner) Thigh: Surgical Sutures (11) The wound documentation also included the multiple Resolved wounds including: - #14 Right Heel: Unstageable Pressure Ulcer- Last Evaluated on 4/23/23 - #13 Left Heel: DTI Pressure Ulcer - Last Evaluated on 4/23/23 - #12 Left Lateral (outside) Thigh: Stage 2 Pressure Ulcer from Medical Related Device- Last Evaluated on 4/15/23 - #6 Sacrum: DTI Pressure Ulcer- Last Evaluated on 4/23/23 - #23 Right Thigh (front): Open Lesion- Last Evaluated 5/17/23 - #15 Medial Right Foot: Open Lesion- Last Evaluated 4/1/23 - #4 Left Medial Thigh: Pressure Ulcer- Stage 3- Last Evaluated 4/23/23 - #7 Right Lateral Thigh: Open Lesion- Last Evaluated 5/19/23 Resident #701's wound documentation did not clearly identify which pressure ulcers/wounds were present on admission and/or if the Resident developed additional pressure ulcers at the facility. Review of census documentation for Resident #701 detailed the following: - admitted : 1/5/23 - discharged : 3/23/23 - readmitted : 3/31/23 - discharged : 4/26/23 - readmitted : 5/8/23 Review of Resident #701's Discharge- Return Anticipated MDS assessment, dated 3/23/23, detailed the Resident had three pressure ulcers including one stage two, one stage three, and one stage four. Review of Resident #701's Entry Tracking MDS assessment, dated 3/31/23, did not include any information pertaining to Skin Conditions. Review of Resident #701's 5-Day Scheduled MDS assessment, dated 4/6/23, revealed the Resident had six pressure ulcers including one stage two, one stage three, one stage four, one unstageable, and two DTIs. Review of Resident #701's Discharge- Return Anticipated MDS assessment, dated 4/26/23, detailed the Resident had three pressure ulcers including one stage three, one stage four, and one unstageable. Review of Resident #701's 5-Day Scheduled MDS assessment, dated 5/14/23, specified the Resident had one stage four, one unstageable, and DTI pressure ulcers. Review of Resident #701's Health Care Provider (HCP) orders revealed the following active orders: - Check functional status of air pressure mattress two times a day (Ordered: 5/9/23) - Guest to use heel boots while in bed to prevent breakdown. Provide assistance turning as tolerated every 2 hours (Ordered: 5/8/23) - Apply betadine-soaked gauze to right heel wound, apply non-adherent Adaptic gauze, cover with dry 4x4 gauze, ABD pad, wrap with non-compressive Kerlix and reinforce with tape at bedtime for wound care (Ordered: 5/8/23) - Chamosyn Ointment to bilateral buttocks, monitor and notify MD of acute changes two times a day for protection (Ordered: 5/25/23) - Posterior Left Thigh Incisions (with sutures): 1. Cleanse gently with wound cleanser, pat dry. 2. Leave OTA (Open to Air) unless wound has drainage or if clothing causes friction. 3. Monitor for signs of infection, notify MD of acute changes two times a day (Ordered: 5/25/23) - Clean Bilateral JP (Jackson Pratt- wound care drain) drain site with N.S (Normal Saline) pat dry. Monitor for s/s (signs/symptoms) of infection and dislodgment . Record output two times a day (Ordered: 5/8/23) - Clean sacrum with wound cleanser, pat dry, apply aquacel foam dressing as needed (Ordered: 5/25/23) - Clean sacrum with wound cleanser, pat dry, apply aquacel foam dressing in the morning every other day for pressure injury (Ordered: 5/25/23) - Left heel preventative treatment: Apply aquacell foam to left heel for pressure reduction at bedtime (Ordered: 5/8/23) - Right gluteus Incisions (near sutures) Clean with wound cleanser, pat dry, apply medihoney, cover with nonadherent dressing **Only apply medihoney to area with slough** in the morning (Ordered: 5/25/23) Review of Resident #701's Health Care Provider (HCP) orders revealed the following discontinued orders: - APM (Alternating Pressure Mattress) (Ordered and Discontinued: 1/10/23) - Silver sulfadiazine External Cream 1% . Apply to Lower legs topically at bedtime related to cellulitis of right lower . left lower limb (Ordered: 1/5/23; Discontinued: 3/31/23) - Change leg dressings Wash gently with soap and water. Apply Silvadene and Adaptic dressing, cover with gauze wrap and ace bandage at bedtime every Tue, Thu, Sat for wound care (Ordered: 1/24/23; Discontinued: 1/26/23) - Change leg dressings Wash gently with soap and water. Apply Silvadene and Adaptic dressing, cover with gauze wrap and ace bandage in the morning every Tue, Thu, Sat for wound care (Ordered: 1/26/23; Discontinued and Re-ordered: 2/28/23; Discontinued: 3/31/23) - Collagenase External Ointment (wound ointment used to remove dead tissue) (250 unit/gm (grams) Apply to Buttock topically at bedtime for Wound care (Ordered: 1/5/23; Discontinued: 3/31/23) - Wound care for wounds #7, #6 and #4 at bedtime every 3 day(s)Cleans wounds with wound cleanser, dry, cover with water-based gel, cover with mepilex (tape) (Ordered: 1/10/23; Discontinued: 2/8/23) - Wound care for wound #9 on coccyx at bedtime Clean with wound cleanser . NS gauze, cover with ABD pad and secure with tape (Ordered: 1/10/23; Discontinued: 2/8/23) - Wound care for wounds #9, #7, #6 and #4 at bedtime every 3 day(s) Cleans wounds with wound cleanser, dry, cover with water-based gel, cover with mepilex (Ordered: 2/8/23; Discontinued: 3/1/23. Re-ordered: 3/1/23; Discontinued: 3/31/23) - Coccyx wound: Cleanse with NS, pat dry, Skin Prep peri-wound Apply TRIAD paste to wound bed, Cover with Aquacel Foam padded dressing Seal edges of dressing with skin prep at bedtime every other day (Ordered: 4/1/23; Discontinued: 5/8/23) - Coccyx wound: Cleanse with NS, pat dry, Skin Prep peri-wound Apply TRIAD paste to wound bed, Cover with Aquacel Foam padded dressing Seal edges of dressing with skin prep at bedtime every 12 hours as needed for if soiled or dislodged (Ordered: 4/1/23; Discontinued: 5/8/23) - Cleanse surgical incision (Coccyx) with NS, pat dry, OTA. Monitor for s/sx of infection at bedtime for wound care (Ordered: 5/8/23; Discontinued: 5/9/23) - Left posterior thigh/buttock wound: cleanse with NS, pat dry skin prep peri-wound place Aquacel Foam dressing Seal edges of Aquacel with skin prep as needed (Ordered: 4/1/23; Discontinued: 4/20/23) - Left posterior thigh/buttock wound: cleanse with NS, pat dry skin prep peri-wound place Aquacel foam dressing Seal edges of Aquacel with skin prep at bedtime for protection (Ordered: 4/1/23; Discontinued: 4/20/23) - Left posterior thigh/buttock wound: cleanse with NS, pat dry skin prep peri-wound place Aquacel Foam dressing Seal edges of Aquacel with skin prep at bedtime every 3 day(s) for protection (Ordered: 4/20/23; Discontinued: 5/8/23) - Left posterior thigh/buttock wound: cleanse with NS, pat dry skin prep peri-wound place Aquacel Foam dressing Seal edges of Aquacel with skin prep every 12 hours as needed for if soiled or dislodged (Ordered: 4/20/23; Discontinued: 5/8/23) - Right and left heel wounds: Swab with Iodine, let dry cover with ABD pad and wrap with kerlix at bedtime . (Ordered: 4/1/28; Discontinued: 4/8/23) - Right and left heel wounds: Swab with Iodine, let dry cover with ABD pad and wrap with kerlix every 12 hours as needed for if soiled or dislodged (Ordered: 4/1/28; Discontinued: 4/8/23) - Monitor heel wounds, notify MD of acute changes two times a day (Ordered: 4/1/23; Discontinued: 5/8/23) - Right and left heel wounds: Swab with Iodine, keep open to air, elevate heels in bed two times a day . (Ordered: 4/8/23; Discontinued: 5/8/23) - Left heel: Apply non-adherent Adaptic gauze, cover with dry 4x4 gauze, ABD pad, wrap with non-compressive Kerlix and reinforce with tape at bedtime (Ordered: 5/13/23; Discontinued: 5/18/23) - Right Buttock wound: Cleanse with NS, pat dry Skin prep to peri-wound loosely pack wound with NS moistened kerlix place ABD pad two times a day (Ordered: 4/1/23; Discontinued: 4/20/23) - Right Buttock wound: Cleanse with NS, pat dry Skin prep to peri-wound loosely pack wound with NS moistened kerlix place ABD pad at bedtime every 12 hours as needed for if soiled or dislodged (Ordered: 4/1/23; Discontinued: 5/8/23) - Right Buttock wound: Cleanse with NS, pat dry Skin prep to peri-wound loosely pack wound with NS moistened kerlix place ABD pad at bedtime every 3 day(s) for wound care (Ordered: 4/20/23; Discontinued: 4/20/23) - Right Buttock and Posterior Left Thigh Incisions (with sutures): 1. Cleanse gently with wound cleanser, pat dry. 2. Leave OTA unless wound has drainage or if clothing causes friction. 3. Monitor for signs of infection, notify MD of acute changes two times a day (Ordered: 5/9/23; Discontinued: 5/25/23) - Right Buttock Incisions (near sutures) Clean with wound cleanser, pat dry, apply medihoney, cover with nonadherent dressing **Only apply to area with slough** in the morning (Ordered and Discontinued: 5/25/23) Review of Resident #701's EMR revealed the following documentation: - 1/5/23 at 9:27 PM: Skin & Wound - Total Body Skin Assessment . Number of New Wounds . Five . The assessment did not identify the location of the wounds. - 1/7/23 at 1:56 AM: Wound Evaluation . #9 Pressure- Stage 3 . Location Not Set .Length: 5.62 cm, Width 4.11 cm . Wound Bed . Epithelial: Yes . Granulation: Yes . Slough: Yes . Eschar: Yes . Evidence of Infection: None . The evaluation included an image of the wound. The wound had visible depth but measurement of the depth of the wound was not included in the evaluation. Note: Wound #9 was later identified as being on the Resident's right gluteus and right buttocks - 1/30/23 at 11:09 AM: Skilled Charting . Dx (diagnoses) cellulitis of right lower limb . - 2/4/23: Wound Evaluation . #9 Pressure- Stage 3 . Right Gluteus . Length: 6.85 cm, Width 5.22 cm . Wound depth not documented. - 3/18/23 at 11:52 PM: Wound Evaluation . #9 Pressure- Stage 3 . Right Buttocks . Length: 7.0 cm; Width: 3.5 cm . Wound Bed . Granulation: Yes . Slough: Yes . Hypergranulated . Exudate: Light . Sanguineous/Bloody . Odor after Cleansing: Moderate . Periwound . Rolled Edges . The image of the wound included on the evaluation showed significant depth to the wound bed, but depth measurements were not included. - 3/21/23 at 11:22 AM: Weight Change Note . Continues to trigger for decrease in weight . Skin: Stage II (L) thigh, Stage III (R) buttock, Deep tissue injury Sacrum, Open Lesion (R) thigh . Will attend wound care clinic weekly . - 4/1/23: Wound Evaluation . #9 Pressure- Stage 3 . Right Gluteus . Length: 5.81 cm, Width 5.81 cm . No depth measurements were included. - 4/1/23 at 7:39 PM: Skilled Charting . readmit . Wound care rendered, bed bath given, family in to visit. - 4/8/23: Wound Evaluation . #9 Pressure- Stage 4 . Right Gluteus . Length: 4.97 cm, Width 4.12 cm, Depth: 1 cm . - 4/11/23 at 7:46 AM: Skilled Charting . Writer contacted provider regarding Resident's wounds d/t (due to) moderate - large, green purulent drainage from the Right buttocks. Per provider order (laboratory blood tests) and place resident in book to be seen by the provider. Resident has several areas of very dry skin on BLE (Bilateral Lower Extremities) that is creating red/irritated and open areas that this writer has requested the provider also evaluate. Writer also informed day shift during report. - 4/13/23 at 10:12 AM: Lab . reviewed and no new orders. - 4/15/23: Wound Evaluation . #9 Pressure- Stage 4 . Right Gluteus . Length: 5.72 cm, Width 3.77 cm, Depth: 2.2 cm . - 4/16/23 at 3:07 PM: eMar - Medication Administration Note . Right and left heel wounds: Swab with Iodine, keep open to air, elevate heels in bed two times a day for protection. Sock stuck to Rt heel. NS (Normal Saline) used to soak sock off. Iodine applied and Rt heel covered with gauze to protect from sock but allow air to heel. - 4/16/23 at 3:09 PM: eMar - Medication Administration Note . Right Buttock wound . Large amt (amount) of sanguineous drainage with small amounts of green purulent drainage noted . - 4/21/23 at 1:36 AM: eMar - Medication Administration Note . Right Buttock wound .Dressing loose and soaked with drainage. Drainage noted to be green tinted with foul odor . - 4/21/23 at 1:38 AM: eMar - Medication Administration Note . Left posterior thigh/buttock wound . Dressing saturated with serosanguinous drainage. Wound cleansed per orders and new dressing applied. - 4/23/23 at 9:22 PM: Wound Evaluation . #14 - Pressure - Unstageable (Slough and/or eschar) . Right Heel . Length 3.64 cm; Width 4.94 cm . Wound Bed . Eschar . Scab . Progress: Resolved. Notes: Edge of eschar loosening and bleeding coming from edge of eschar that is loose. Note: The wound was documented as resolved but the image in the evaluation clearly showed a non-healed unstageable pressure ulcer. - 4/23/23 at 9:26 PM: Wound Evaluation . #6 - Pressure Deep Tissue Injury . Sacrum. Resolved- 4 months ago . Length 4.2 cm . Width 1.28 cm . Wound Age: 1 week . Exudate . Light . Serous . Treatment: Turning/repositioning program . Progress: Resolved . The image attached to the evaluation showed two distinct open wounds with apparent depth over Resident #701's sacrum and the surrounding skin was reddened and excoriated. The wounds were notably larger than 4.2 cm by 1.28 cm and it is unclear what was measured from the evaluation documentation. Additionally, the evaluation did not include wound depth measurements. - 5/8/23 at 2:24 PM: Wound Evaluation . #21 - Pressure- Deep Tissue Injury . Sacrum . Length 8.39 cm; Width 7.48 cm . Wound Bed . Epithelial: Yes . Granulation: Yes . No dressing applied . The wound image revealed the pressure ulcer was in the same place as wound #6 had been documented previously and per the image, the pressure ulcer appeared to be improved and healing in comparison to the documentation and image on 4/23/23. - 5/8/23 at 2:25 PM: Wound Evaluation . #22 -Surgical - Sutures (11) . Left Thigh Medial .Length 6.61 cm; Width 0.96 cm . New . - 5/8/23 at 3:15 PM: Skilled Charting . Guest admitted from Hospital post-surgical debridement and closure of coccyx wound, placement of JP (Jackson Pratt - type of wound drain) drains x 2, and colostomy. Guest has PICC (Peripherally Inserted Central line - used for longer term IV therapy) line in place for IV antibiotics. Guest oriented to room and cleaned with the assistance of nurse aid. JP drains have minimal drainage noted to be bright red per report. Foley catheter in place . - 5/8/23 at 4:15 PM: Wound Evaluation . #24 Pressure- Unstageable . Right heel . New . Length: 4.97 cm . Width . 1.74 cm . Wound Bed . Epithelial . Eschar . Progress: New . - 5/9/23 at 11:52 AM: Physician Progress Note . s/p (status post) hospitalization for osteomyelitis (infection in the bone) of sacrum due to pressure injuries. Pt with functional quadriplegia . Pt reports pain is not well controlled with current oxy dose at this time. Requesting oxycodone (narcotic pain medication) to be increased; discussed options of pain management . discussed risk of dependence and side effects. Will schedule pain management at this time . Continues on IV abx for osteomyelitis . Skin: Inspection and palpation: Multiple surgical incisions to bil (bilateral) buttocks, + JP drains to surgical sites, + serosanguinous drainage. Pt with bil. Heel wounds, Unstageable . Patient with pressure ulcer closure on 5/5; monitor surgical incisions, monitor drains. Follow up with surgeon. Continue wound care to incisions and bil. Heel wounds. Monitor for s/sx of infection . - 5/13/23 at 3:22 AM: Skilled Charting . During wound care, left hip surgical wound with JP drain: noted drain to still be in place and suture remains intact. Also noted that tip of the white internal part of drain is visible at the puncture site. This was not visible during wound care last night. Drain continues to produce output and Guest denies any changes in pain to area. On call provider notified. - 5/18/23 at 3:01 PM: Physician Progress Note . pt seen and examined . Multiple surgical incisions to bil buttocks. + JP drains to surgical sites, + serosanguinous drainage. Pt with bil. Heel wounds, Unstageable . Note: There was no documentation of a current left heel pressure ulcer in Resident #701's wound evaluations/assessments. - 5/19/23 at 6:27 AM: Skilled Charting . Guest continues on IV abx for osteomyelitis . Surgical incisions to right and left buttock areas both well approximated with stitches intact. Scant amt of serosanguinous drainage noted when cleansing incisions. JP drains to both areas intact. Left side JP drain continues to have minimal output 5mL (milliliters) or less of dark brownish red fluid . Right side JP drain continues to have decreasing drainage approx. 10-15 mL per shift of dark brownish red fluid . continues to have excoriated periwound skin and also open pressure area to sacrum . Clear yellow drainage noted at times on bed pad, unable to determine source, as when cleansing wounds, no yellow drainage noted to any of the wounds . Wounds to bilateral heels remain dry and without drainage. Guest tolerating all dressing changes well. This nurse timing dressing changes to coincide with administration of scheduled analgesic. Reassurance given often of wound conditions. Guest expresses many concerns r/t the healing of wounds . - 5/19/23 at 7:47 AM: eMar - Medication Administration Note . Guest to use heel boots while in bed to prevent breakdown. Provide assistance turning as tolerated every 2 hours. - 5/19/23 at 7:47 AM: eMar - Medication Administration Note . Chamosyn Ointment (non-prescription moisture barrier cream) to Sacrum DTI . two times a day for protection - 5/19/23 at 1:40 PM: Skilled Charting . had a scheduled follow up appointment with Infectious Disease physician for evaluation of wounds, treatment orders, and continuation of IV antibiotics. Upon transportation arrival stated . would not like to go today due to the fact that would be in too much pain during the transportation . - 5/23/23 at 11:36 AM: Skin & Wound Evaluation . Pressure . Deep Tissue Injury . Sacrum . Present on admission . How long has the wound been present? New . Length: 6.7 cm . Width: 4.7 cm . Depth: 0.1 cm . Wound Bed . Eschar . 10% of wound filled . Image included with evaluation displayed a large, irregularly shaped, open wound. The wound bed was beefy red in color with minimal eschar. The tissue surrounding the wound was not intact, excoriated, and discolored. - 5/23/23: Wound Evaluation . Pressure . Stage 4 . Right Gluteus . Length: 2.08 cm . Width: 2.09 cm . Width: 1.24 cm . - 5/23/23 at 11:50 AM: Skin & Wound Evaluation . Surgical . Sutures . 11 . Left Thigh Medial . Present on admission . New . Length: 5.1 cm . Width: 3.5 cm . - 5/23/23 at 5:32 PM: eMar - Shift Level Administration Note . Updated buttock wound assessment, noted changes. Educated and encouraged guest to turn and reposition from side to side to offload pressure and promote healing with verbalized understanding. Educated guest on the repercussions of pressure injury since just had surgery at the wound clinic. Assisted this afternoon with wound care and positioned guest to right side . - 5/24/23 at 3:38 PM: Skin & Wound Evaluation . Pressure . Unstageable . Right Heel . Present on admission .[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Numbers MI00133898 and MI00134745. Based on observation, interview and record review, the facility failed to operationalize policies and procedures for fall prevention including analysis for two residents (Resident #703 and Resident #708) of three residents reviewed resulting in lack of implementation of meaningful and planned implementation of interventions, lack of thorough analysis of falls to determine root cause, Resident #703 experiencing fractured ribs from a fall, Resident # 708 falling and suffering a fracture of their right humeral neck (bone in upper arm), emergency medical treatment/care, unnecessary pain, and the likelihood for decline in overall health and well-being. Findings include: Resident #703: An interview was completed with Witness I on 6/6/23 at 11:18 AM. When queried, Witness I revealed Resident #703 had a fall with injury in February 2023 at the facility. Witness I revealed the Resident suffered two broken ribs from the fall. When asked what occurred, Witness I responded, (Resident #703) was getting up to go to the bathroom and their walker wasn't in reach. With further inquiry, Witness I revealed the Resident is very unsteady without their walker and facility staff do not put it next to them when they are in bed. When asked if that had spoke to staff about the walker not being next to the Resident, Witness I revealed they spoke to staff multiple times, but the walker was still not next to the Resident when they visited. Witness I was queried regarding staff response when they spoke to them regarding their concern and replied, They say it's (walker) in the way. Witness I then stated, (Resident #703) ended up there (facility) because they fall and broke their hip at home and the staff were aware the Resident was at risk for falls. When queried what interventions were in place to prevent falls prior to the Resident falling and fracturing their ribs, Witness I replied that the walker was supposed to be next to them. When queried what interventions were implemented following the Resident's fall in February, Witness I stated, They put up signs in the room about the walker. Record review revealed Resident #703 was most recently admitted to the facility on [DATE] with diagnoses which included macular degeneration, left eye glaucoma, hypotension (low blood pressure), Chronic Obstructive Pulmonary Disease (COPD), diabetes mellitus, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited to extensive, one-person assistance for all Activities of Daily Living (ADLs) with the exception of eating. The MDS specified the Resident had zero falls since admission, reentry, or prior assessment. On 6/6/23 at 4:12 PM, Resident #703's room door was closed. This Surveyor knocked on the door and heard sounds but was unable to discern what the Resident was saying. Upon opening the door slightly, Resident #703 stated they were in the bathroom. When asked if there was a staff member in the room, Resident #703 replied, No. When queried if they needed staff assistance, Resident #703 indicated they were okay and just in the bathroom. There were no facility staff present in the hallway. Review of Resident #703's care plans revealed a care plan entitled, Risk for falls r/t related to x (diagnoses) of Right femur fracture . HX (history): Falls, incontinence, weakness, impaired mobility (Initiated: 6/14/21; Revised: 5/23/23). The care plan included the interventions: - Ambulation order: 1 PA (person assistance) using a walker (Initiated: 6/14/21; Revised: 9/3/21) - Evaluate lab tests (Initiated: 2/2/21) - Evaluate X-rays (Initiated: 2/2/21) - Keep walker next to bed in front of med cabinet (Initiated: 2/2/23) - Orders made to make sure guest has walker next to bed at all times (Initiated: 2/1/23) - Reinforce need to call for assistance (Initiated: 2/2/21) - Resident transfers via 1 PA (Initiated: 8/21/21; Revised: 2/1/23) - Weight Bearing Status: WBAT (Weight Bearing As Tolerated) (Initiated: 2/2/21) On 6/8/23 at 8:40 AM, Resident #703 room door was closed. After knocking and entering the room, Resident #703 was observed in bed, positioned on their back with the room lights off. The TV was off, and the room was quiet and dim. Resident #703's walker was positioned approximately three to four feet away from their bed, directly against the wall next to the bathroom door. Their push pad call light was clipped to the sheet, positioned above their head, and not within the Resident's line of sight and/or feel. An interview was completed at this time. Resident #703 was pleasantly forgetful. When queried where their call light is if they need help from staff, Resident #703 began looking and feeling all around their bed and stated, I can't find it, never can find it. I don't know where they put it. Resident #703 then stated, Will you help me find it? When asked if staff assist them to get up to go to the bathroom, Resident #703 replied, No. I don't know where they are. They aren't coming in here. When queried if they had fallen at the facility, Resident #703 revealed they don't remember. Review of progress note documentation in Resident #703's Electronic Medical Record (EMR) revealed: - 2/1/23 at 1:56 PM: Skilled Charting . Guest was found on the floor by a nurse bringing lunch to room. Guest was sitting on the floor, leaning up against the bed with feet out in front of them. (Resident #703) said tripped and fell and did not hit head. Guest is complaining of right hip pain 5 out of 10, I notified provider and recommended a STAT x ray of the right hip. Guest was wearing appropriate footwear and non-slip socks. Room was free of clutter and well lit. Notified family of incident. Vital signs right after fall . 154/99 (1230 PM [elevated]) with pulse of 70 . (Authored by Registered Nurse [RN] L) - 2/1/23 at 3:08 PM: eINTERACT SBAR Summary for Providers . Situation . Falls . Outcomes of Physical Assessment . Functional Status Evaluation: Fall . Pain Status Evaluation: Does the resident/patient have pain? Yes . Neurological Status Evaluation: (Blank) . Nursing observations, evaluation, and recommendations are: (Blank) . Primary Care Provider responded with the following . Recommendations: Complete x-ray, family insisted on resident going to ED . Out to ED . (Authored by RN K) - 2/1/23 at 4:17 PM: Skilled Charting . Investigation Summary Note: Guest had a noted fall on 2/1/23. Nurse description of the event is reported as: Guest was found on the floor by a nurse bringing lunch to room. Guest was sitting on the floor, leaning up against the bed with feet out in front of them. (Resident #703) said they tripped and fell and did not hit head. Guest is complaining of right hip pain 5 out of 10, I notified provider . recommended a STAT x-ray of the right hip. Guest was wearing appropriate footwear and non-slip socks. Room was free of clutter and well lit. Notified family of incident. Vital signs right after fall . 154/99 (12:30 PM- elevated) with pulse of 70, not her vital signs are 117/71 (1400- 2:00 PM) with pulse of 68 . After hip x-ray guest complained of rib pain and the family wanted to resident to be evaluated at (hospital) ED. Guest was sent to ED. Root cause has been determined to be transferring without assistance/misunderstanding of limitations. IDT met and care plan has been reviewed. New intervention added to keep walker next to bed and a sign on the medication cabinet to keep walker there. - 2/3/23 at 6:33 PM: eMar - Shift Level Administration Note . Guest expresses is experiencing pain, post fall. A review of facility provided employee list revealed neither RN K nor RN L were listed as facility employees. Upon request of Incident and Accident (I and A) report and any related investigation document to Resident #703's fall in the facility on 2/1/23, the Administrator provided the following: - I and A form, dated 2/1/23, which detailed, Fall . Nursing Description: Guest was found on the floor by a nurse bringing lunch to room. Guest was sitting on the floor, leaning . feet out in front of them. (Resident #703) said tripped and fell and did not hit head. Guest was wearing . non-slip socks. Room was free of clutter and well lit . Resident Description: (Resident #703) said tripped and fell and did not hit head . complaining of right hip pain 5 out of (10) . Resident Taken to Hospital: Y (Yes) . Injuries Observed at Time of Incident . Unable to determine . Right trochanter (hip) . Level of Pain . 5 (out of 10) . Mobility: Ambulatory with Assistance . Mental Status: Orientated to Person . Injuries Report Post Incident . No Injuries Observed Post Incident . Predisposing Physiological Factors: Confused . Weakness . Gait Imbalance . Impaired Memory . Predisposing Situational Factors . Ambulating without Assist . Predisposing Situational Factors . Using [NAME] . (Authored by RN K) Review of Resident #703's Hospital diagnostic testing reports dated 2/1/23 revealed: - 2/1/23: CT Chest/Abd (abdomen) Pelvis . Impression: Acute fractures of the lateral right 11th and 12th ribs . - 2/1/23 XR (x-ray) Hip Right . Impression: Partially healed incomplete nondisplaced periprosthetic fracture proximal right femur. No evidence of acute injury . An interview was completed with Certified Nursing Assistant (CNA) J on 6/8/23 at 1:24 PM. When queried regarding Resident #703's required level of assistance for ambulation and to use the bathroom, CNA J indicated the Resident requires one assist but gets up on their own. When queried if the Resident ever uses their call light for assistance, CNA J replied, Sometimes. When queried if the Resident is confused, CNA J revealed they were. When asked if the Resident was cognitively able to utilize the call light when it is within their reach, CNA J stated, Yes and continued that the Resident's family is usually present and assists with care. CNA J was queried regarding the signs in Resident #703's room specifying their walker needed to be next to the bed and the reason for the signs. CNA J replied the [NAME] needed to be by their bed was so they could use it when they get up. When queried why they were getting up without one person assist if that is what they require, CNA J did not provide an explanation. When queried regarding the call light not being in reach and the walker not being next to the bed during observation on 6/8/23 at 8:40 AM, a reasonable justification was not provided. When asked if the Resident is able to be left unattended in the bathroom, CNA J reiterated the Resident will get up on their own. When queried regarding observations of Resident #703's room door being closed and the reason the door is closed when care is not being provided, CNA J disclosed resident doors are closed for privacy and to maintain a home-like feel. When queried regarding Resident #703 getting up on their own, risk for falls, and how staff observe the Resident when they are in the room with their door closed, CNA J did not provide an explanation. Additional review of Resident #703's care plans revealed the following care plans revealed the following: - Alteration/at risk for musculoskeletal problems r/t HX (history) of right femur fracture (Initiated: 6/14/21; Revised: 5/23/23). The care plan included the intervention, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance (Initiated: 2/2/21). - Actual ADL/Mobility deficit, hx of Right femur fracture, Alzheimer's dementia . HX: Falls, incontinence, weakness, impaired mobility . Guest unable to utilize call light related severe cognition impairments. Staff to anticipate needs (Initiated: 8/30/21; Revised: 5/23/23). Review of Resident #703's EMR revealed the current active order, Hydrocodone-Acetaminophen (Norco- narcotic pain medication for severe pain) Oral Tablet 5-325 mg (milligram) . Give 1 tablet by mouth every 6 hours for pain due to recent FX (fracture) of ribs (Start Date: 2/20/23). Per the Resident's Medication Administration Record (MAR) for June 2023, they were still receiving the medication for rib pain from their fall with fracture. An interview and review of Resident #703's fall was completed with the Director of Nursing (DON) on 6/9/23 at 11:55 AM. When queried what intervention was implemented following the fall with subsequent rib fracture, the DON replied, Keep walker next to bed. When asked where the Resident's walker was in the room when they fell on 2/1/23, the DON was unable to provide a response. When queried the last time the Resident had been observed by staff prior to finding them on the floor, the DON was unable to provide a time. When queried if Resident #703 is supposed to have assistance from staff to transfer and ambulate, per their orders/care plan, the DON confirmed they are. The DON was then queried regarding the root cause of the fall, per the investigation summary note, being transferring without assistance, and how the intervention was going to ensure the Resident received the required staff assistance, the DON did not elaborate. When queried regarding observation of the Resident, in bed with the door closed, call light not in reach, and walker not next to them, the DON denoted they were unaware. When queried if the facility had any additional investigation information pertaining to the Resident's fall, the DON revealed they would check. Resident #708: Record review revealed Resident #708 was most recently re-admitted to the facility on [DATE] with diagnoses which included dementia, kidney disease, intracerebral hemorrhage (brain bleed), stroke, weakness, difficulty walking. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively intact and required limited one person assistance for transferring, dressing, and toileting. The MDS further indicated the Resident had one with no injury and one fall with major injury. On 6/8/23 at 11:15 AM, Resident #708 was observed sitting in a wheelchair at an empty table in the dining room of the facility. When spoke to, Resident #708 was pleasantly confused and unable to provide meaningful responses to questions asked regarding falls in the facility. At 1:15 PM on 6/8/23, Resident #708 was observed sitting at the same table as previously observed in the dining room. The Resident was eating their lunch at this time. Review of Resident #708's care plans revealed a care plan entitled, Risk for falls r/t dementia, intracerebral hemorrhage . poor safety awareness (Initiated: 4/13/22; Revised: 2/2/23). The care plan included the interventions: - During transfers, remind/encourage guest to change positions slowly 1/31/23 (Initiated: 2/2/23) - Frequent rounds on resident when in room to make sure needs are met (Initiated: 2/2/23) - Neuro checks per protocol (Initiated: 4/13/22) - Reinforce need to call for assistance (Initiated: 4/13/22) - Resident transfers via 1pa ambulation with 1pa 2WW (two wheeled walker) (Revised: 2/1/23) - Set Guest on dining table while sitting on wheelchair when in dining room for meals (Initiated: 8/23/22) - Use shower chair when giving a shower (Initiated: 2/3/23) - Wear gripper socks at all times as resident allows (Initiated: 10/17/22) The care plan also included the discontinued intervention, Resolved: Requires 2PA for ambulation (Initiated: 4/13/22; Revised and Resolved: 2/1/23) A second care plan entitled, Actual ADL/Mobility deficit d/t . RUE (Right Upper Extremity) fx (fracture) (Initiated: 4/13/22; Revised: 2/2/23) was noted in the Resident's EMR. This care plan included the Resolved intervention, Sling to RUE at all times (Initiated: 2/2/23; Resolved: 3/26/23). Review of Resident #708's progress note documentation in the EMR revealed the following: - 8/23/22 at 6:29 PM: Skilled Charting .Resident observed sitting on floor near table in dining room, no injuries. Resident states . was trying to get out of chair back into wheelchair. Assist off floor with 2-person assist . Will continue with plan of care . - 8/23/22 at 7:05 PM: Skilled Charting . Observed on floor in dining room near table. Resident states . was trying to get out of chair to get back into wheelchair. Assist off floor with 2-person assist . Will continue with plan of care. - 8/23/22 at 9:14 PM: Incident Note . Investigative Summary r/t incident on 8/23/22. Nurse was called by staff to dining room, upon arrival, nurse observed Guest on floor in dining room near table. Resident states was trying to get out of chair to get back into wheelchair. Nurse assist Guest off floor with 2-person assist . Root cause: guest self-transferred from dining chair to w/c (wheelchair) without assistance. Intervention: Guest will be assisted on dining table on w/c ensuring no dining chair is closed to guest. - 10/14/22 at 8:15 AM: Skilled Charting . LATE ENTRY . (CNA) notified nurse that guest was found on the left side of the bed (bed in lowest position) sitting on the floor . was wearing socks and shoes and the room was free of clutter. Guest was helped into bed and relaxed for a little while before being assisted into chair . Guest was found to have high blood pressure and I notified provider on call, they recommended giving guest scheduled blood pressure medications and to recheck blood pressure in an hour. Blood pressure was rechecked in an hour and blood pressure in now WNL (Within Normal Limits) . Guest is resting in chair . Guest said . slipped out of bed and hit head but is only complaining of 3 out of 10 left shoulder pain. Remind guest to call for help for assistance. - 10/17/22 at 11:28 AM: Skilled Charting . Investigation Summary . Resident was found next to bed with regular socks on, care plan updated to have the resident wear gripper socks at all times as allowed. - 1/31/23 at 7:08 PM: Incident Note . Certified Nursing Assistant [CNA] N) called for help, and (Licensed Practical Nurse [LPN) O] went in to help . asked for more assistance. All the nurses went in to assist. Guest was laying in the shower on the floor on belly and left side. The CNA stated that (Resident #708) stood up from the shower bench to transfer to wheelchair and fell slowly down as (CNA) tried to brace them. The CNA stated that (Resident #708) did not hit their head. (Resident #708) said . did hit head. Neuros were started and a complete head to toe assessment was completed . had minor scratches to Left thigh and knee . complaining of left hip and right shoulder pain. 8/10 . no bruising or swelling to area. Guest has active ROM. Guest able to squeeze nurse's fingers and hold when nurse pushes back and forth. VS taken. BP: 78/48 (low), HR: 95, RR: 15. Guest complains it hurts more with movement. All nurses safely assisted guest to wheelchair. Once in wheelchair guest vomited and had a BM . safely assisted back to bed. On-call (Provider) called and notified . said to continue neuros and get an x-ray of right shoulder and left hip . - 2/1/23 at 12:15 AM: Skilled Charting . Nurse called x-ray and they stated that it was dispatched out so someone would come out and do it before 6am. Tylenol was given earlier for pain . (Resident #708) is able to squeeze my fingers and hold steady while I push and pull. Complaining more of pain with movement. No swelling or bruising to area . - 2/1/23 at 6:53 AM: Skilled Charting . X-Ray still has not showed up. Called them and they said they pushed it to morning. (Resident #708) is able to squeeze my fingers and hold steady while I push and pull. Complaining more of pain with movement. No swelling or bruising to area . On call (Provider) aware . - 2/1/23 at 8:34 AM: Skilled Charting . Waiting on x-ray to arrived (sic) around 9:40AM to Xray R shoulder and L hip. Doctor is aware that we are waiting until x-ray gets here to x-ray patient. once results are in, will notify on call provider for further instruction. - 2/1/23 at 9:00 AM: Skilled Charting . Incident notes: Guest is still complaining of pain. We got the results back from x ray . sending guest to the hospital . - 2/1/23 at 10:50 AM: Skilled Charting . Results came in for right shoulder x ray and relayed results to on call provider. Guest will be transferred to the hospital per doctor . - 2/1/23 at 9:41 PM: Skilled Charting . Guest returned tonight from Hospital via an ambulance with a fractured right humerus post fall wearing a sling. Guest needs to wear the sling at all times for good healing and only take a sponge bath until seen by the doctor . - 2/3/23 at 2:01 PM: Skilled Charting . Investigation Summary Note: Guest had a noted fall on 1/31/23. Nurse description of the event is reported as: (CNA N) called for help, and LPN (LPN) O went in to help. (LPN O) then asked for more assistance. All the nurses went in to assist. Guest was laying in the shower on the floor on belly and left side. The CNA stated that (Resident #708) stood up from the shower bench to transfer to wheelchair and fell slowly down as (CNA) tried to brace them. The CNA stated that (Resident #708) did not hit their head. (Resident #708) said . did hit head. Neuros were started and a complete head to toe assessment was completed . had minor scratches to Left thigh and knee was complaining of left hip and right shoulder pain. 8/10. There was no bruising or swelling to area. Guest has active ROM. Guest able to squeeze nurses fingers and hold when nurse pushes back and forth. VS (Vital signs) taken. BP: 78/48, HR: 95, RR: 15. Guest complains it hurts more with movement. All nurses safely assisted guest to wheelchair. Once in wheelchair guest vomited and had a BM . assisted back to bed. On-call called and notified . said to continue neuros and get an x ray of right shoulder and left hip . X-ray later showed a hairline fracture non-displaced, resident sent to (Hospital) ED. Guest was given a sling and to attend a follow up appointment with orthopedics. Root cause has been determined to be transferring without assistance/misunderstanding of limitations. IDT met and care plan has been reviewed. New intervention added to use shower chair when giving a shower . - 2/3/23 at 12:14 AM: Skilled Charting . Incident notes . Guest rated pain 5/10 - 2/3/23 at 6:30 PM: eMar - Shift Level Administration Note . Guest is not getting up out the bed like normal, states is in pain. - 2/4/23 at 3:00 PM: Nursing Progress Note . Subjective: Fall from bed . Objective: Patient had a fall from bed, patient was lying in bed prior to the fall, no room clutter noted, patient had nonslip socks on, provider and family to be notified, no new orders at this time. Assessment: No apparent injury noted, and patient has full ROM. Plan: No new orders at this time. - 2/4/23 at 4:40 PM: Physician Progress Note . Pt (patient) sp (status post) left (sic) up (upper) ext (extremity) fracture . Pt instructed needs to ask for help when trying to transfer. ER paperwork reviewed. X Ray reviewed. Ortho consult ordered by ER . - 2/7/23 1:14 PM: Skilled Charting . Investigation Summary Note: Guest had a noted fall on 2/4/23. Nurse description of the event is reported as: Patient rolled out of bed and landed on knees with no apparent injury and no hitting of head, patient has no change to range of motion . placed back into bed and updated care plan. Neuros WNL PERRLA, vitals WNL, ROM WNL with fracture shoulder. Patient had a fall from bed, patient was lying in bed prior to the fall, no room clutter noted, and patient had nonslip socks on . Assessment: No apparent injury noted, and patient has full ROM. Root cause has been determined to be transferring without assistance/misunderstanding of limitations. IDT met and care plan has been reviewed. New intervention added to keep bed in lowest position . - 2/7/23 at 10:11 PM: Skilled Charting . Incident note . Guest is complaining of 5/10 pain in shoulder . Resident #708's care plans were reviewed again. No active and/or resolved care plan and/or intervention were present related to maintaining the Resident's bed in the lowest position. Review of Resident #708's Health care provider orders revealed the following active and discontinued orders: - Discontinued . Transfers 2PA with walker Ambulation therapy only (Discontinued: 2/1/23) - Transfers 1 PA Ambulation 1 PA with 2WW (Ordered: 2/1/23) Review of Neuro Assessment documentation for Resident #708 revealed the form contained a section titled, Neurological Assessment . A1. Which Neurological Schedule is being performed? 1) Q (every) 15 min. x 1 hour 2) Q hour x 4 hours 3) Q 2 hours x 4 hours 4) Q shift x 24 hours . Neuro assessment documentation following their fall on 1/31/23 revealed neuro assessments were not completed four times for the first hour following the fall. Neurological assessments were completed on 1/31/23 at 7:20 PM, 7:35 PM, 7:50 PM, 8:50 PM, 9:50 PM, 10:50 PM, and 11:50 PM and 2/1/23 at 1:50 AM, 3:50 AM, 8:30 AM, and 9:55 PM. Review of Resident #708's Fall Risk Assess documentation dated 2/1/23 detailed, Reason for Assessment Request . Recent Falls . History of Falls within last six month . 1-2 times . Memory and Recall Ability: In the last 7 days: recalls three out of four of the following: current season, that he/she is in a nursing home, location of room, staff names/faces . Sometimes . Confined to a Chair: If resident cannot walk even when assisted by staff are they . Confined to a chair and oriented . Gait Analysis . Requires hands-on assistance to move from place to place . Uses an assistive device . Intervention/Comment: Remind guest to call for help for assistance . Upon request for all I and A forms and documentation for Resident #708 since the last annual, the Administrator provided the following: - 10/14/22, I and A form: Fall . Nursing Description: CNA notified nurse that gues was found on the left side of the bed . wearing socks and shoes . Resident Description . slipped out of bed and hit head but is only complaining of 3 out of 10 left shoulder (pain) . Injuries Observed at time of Incident: No injury Left shoulder (rear) . Level of Pain: 3 . Mental Status: Orientated to Person .Orientated to Situation . Notes: Guest claims . has 3 out of 10 pain in left shoulder, no visible injury, ROM (Range of Motion) intact . Predisposing environmental Factors . Other . Predisposing Physiological Factors . Weakness . Guest said slipped out of bed, bed was in lowest position . No Witnesses . - 1/31/23, I and A form: Fall . Nursing Description: CNA N called for help, and LPN O went in to help . then asked for more assistance . Guest was laying in the shower on the floor on belly and left side . fell slowly down as (CNA) tried to brace them. Resident Description: I tried to move over by myself and I fell . Immediate Action Taken: Neuros started . guest found at baseline . minor scratches Complaining of left hip and right shoulder pain 8/10 . no bruising or swelling to area . Taken to Hospital: N (No) . Injuries Observed at time of Incident: Abrasion: Left thigh . Abrasion: Left knee . Level of Pain: 8 . Mobility: Wheelchair bound . Mental Status: Orientated to Person . No Injuries Observed Post Incident . Predisposing environmental Factors . Wet floor . Predisposing Physiological Factors . Weakness . Gait Imbalance . Impaired Memory . Predisposing Situational Factors . Ambulating without Assist . During Transfer . - 2/4/23 at 2:15 PM, I and A form: Fall . Nursing Description: Guest found on knees next to bed with no apparent injury and denies hitting head . Resident Unable to give Description . Immediate Action Taken . Guest assessed for signs of injury and denies any pain at this time . assisted safely into bed. ROM intact . updated care plan . Injuries Observed at time of Incident: No injury . Mental Status: Orientated to Person . Predisposing Physiological Factors . Weakness . Impaired Memory . Predisposing Situational Factors . Ambulating without Assist . No Witnesses Review of Resident #708's Radiology Results Report dated 2/1/23 at 10:23 AM and reviewed 2/1/23 at 1:51 PM detailed, Shoulder Complete . 2V (2 View) . Reason for Study . Pain in Right Shoulder . Findings . There is a hairline, nondisplaced surgical neck fracture of the right humerus . Visualized right hemithorax (collection of blood between the chest wall and lung) is clear . Conclusion: Acute surgical neck fracture right humerus . On 6/9/23 at 7:55 AM, Resident #708's room door was closed. Upon knocking and entering, Resident #708 was observed on their back in their bed with their eyes closed. The right side of the bed was positioned directly against the wall and their overbed table was positioned next to the left side of the bed. The bed was approximately waist high and not in low position. An interview and review of Resident #708's falls was completed with the Director of Nursing (DON) on 6/9/23 at 11:55 AM. The DON was queried regarding Resident #708's fall on 10/14/22 and interventions implemented following the fall. The DON reviewed the Resident's EMR and stated the intervention implemented following the fall was, Gripper socks. The DON was asked if the Resident was wearing socks and shoes when they fell and confirmed they were. When queried how gripper socks were different than shoes for fall prevention, the DON was unable to provide an explanation. When asked the rationale and appropriateness of that intervention related to the fall, given the Resident was wearing shoes, the DON replied, I agree. It doesn't make sense. When asked why the IDT Investigation note following the fall indicated the Resident was wearing regular socks when the nurses note and I and A specified the Resident was wearing shoes and socks, the DON was unable to explain the discrepancy. When queried if wearing non-slip footwear including gripper socks and/or shoes was a standard intervention for fall prevention, the DON confirmed it was. When queried if the Resident was at risk for falls prior to falling, the DON verified they were. The DON was then asked why the intervention was not already in place, the DON did not elaborate. The DON was then asked to clarify what time Resident #701 fell on 1/31/23, the DON was unable to provide a specific time. When queried what occurred when Resident #708 fell on 1/31/23 and fractured their humerus, the DON revealed the Resident had just finished receiving a shower when the fall occurred. When asked if the CNA was present when the Resident fell, the DON replied, Yes.&quo[TRUNCATED]