**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Numbers MI00119459, MI00119621 and MI00113949. Based on observation, interview, and record review the facility failed to complete post fall assessments for two residents (Resident#1 and Resident #2) and follow care planned interventions for bed mobility for one resident (Resident #4), resulting in Resident #1 and Resident #2 sustaining multiple falls without proper post-fall assessments and interventions. In addition, Resident #4 rolled off the bed during incontinence care and fractured his left hip requiring surgical intervention. The incontinence care was being provided by one Certified Nursing Assistant (CNA), when the care plan dictated a two-person assist. The facility was cited at Past Non-Compliance with a Compliance Date of [DATE]. Findings Include: Resident #4: On [DATE] at 11:50 AM, Resident #4 was observed watching television in his room. He was observed to have three, large healing skin tares on his left forearm that were sustained in his fall. Resident #4 reported he fell while he was at the hospital and scrapped his arms underneath the bed and broke his hip. On [DATE] at 12:02 PM, Nurse A and Nurse B reported Resident #4 readmitted to the facility about 10 days ago and has recently returned to his baseline. They reported he did contract COVID and was moved into an isolation room shortly before his fall and that is why he believes he fell at the hospital. Nurse A and B added his skin tares are healing wonderfully as they were sustained during his fall. On [DATE] at approximately 12:20 PM, a review was completed of Resident #4's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia, Diabetes, Heart Disease and Kidney Disease. Further review was completed of his medical record and the following was found: Care Plan: I require 2 staff extensive assist to re position and turn in bed . revised on [DATE] but initially added to his care plan on [DATE]. Bedside [NAME]: Transferring: I am dependent with staff assist x2 with the mechanical maxi lift for all transfers. Toileting: I am dependent x2 to use toilet with use of mechanical life. Dressing: I require 2 staff extensive assist to dress . Mobility: I require 2 staff extensive assist to reposition and turn in bed . Progress Notes: [DATE] at 21:00: Patient has been discharged from the facility and sent to the hospital after a fall. Patient c/o back pain and it is noted that he is bleeding from multiple places. He will be further evaluated and treated in the ER. [DATE] at 00:29: Resident noted lying on the floor, next to his bed - resident thought back was broken- resident was bleeding multiple places from b/l arms and right foot. pain level 10- notified PCP- order to send to ER for eval. [DATE] at 15:17: IDT reviewed report of resident lying on the floor next to his bed that occurred on [DATE] @ 1900. The CNA was providing care to the resident when the resident rolled out of bed. The nurse entered resident's room and resident was lying on the floor next to his bed, resident had skin tears to left outer ankle, left forearm, and right forearm. Resident stated I think my back is broken, complaints of 10/10 pain. PCP and resident's wife notified. [DATE] at 15:09: Resident admitted at 1440 from Covenant on stretcher via MMR, Resident is alert and happy to be back, Dx left hip fx (fracture) . On [DATE] at 3:18 PM, an interview was conducted with CNA D regarding Resident #4's fall. CNA D reported there was an assist light on and she and another aide went down the hall and found a fall had occurred. Once they entered the room, they saw Resident #4 was on the floor in between the wall and bed, but was facing toward the door. CNA D explained both of his arms were skinned and there was a copious amount of blood. She reported where Resident #4 fell, there was a wooden cover over the pipe and they think the resident hit the ledge of the covering when he fell, as the covering was no longer affixed to the wall. CNA D stated they were moving him as gently as they could and as they were assisting him to sit up they heard a pop and assumed it from his hip. CNA D reported Resident #4 is a two person assist and has been that level of assistance for some time. On [DATE] at 4:17 PM, an interview was conducted with CNA C regarding her involvement with Resident #4's fall. She reported another aide alerted her to the fall and she informed the nurse. Resident #4 was on the COVID unit, so they had to don appropriate PPE (Personal Protective Equipment) prior to entering his room. CNA C observed Resident #4 on the floor between the bed and the window and his body was positioned oddly. Resident #4 had three skin tares on his left arm from his elbow to the wrist and there was a lot of blood from those injuries. Resident #4 was complaining of back and knee pain and they moved the bed out the way to provide more room for them to assess and assist him. CNA C explained she used her body to help support Resident #4 after they sat him up as the nurse was completing her assessment. CNA C stated CNA F was visibly upset about what occurred. CNA F informed her she went to reach for wipes at the foot of the bed and he rolled off. CNA C reported Resident #4 has always been a two person assist with Maxi lift since she has been employed at the facility. On [DATE] at 4:50 PM, an interview was conducted with Nurse E regarding Resident #4's fall on [DATE]. Nurse E was assigned to the COVID unit, she received report and began to pass her medications. Soon after someone they had a fall and simultaneously Nurse H came over and asked if she needed any assistance. Nurse E asked Nurse H if she could handle the fall as she did not expect the resident would need to be sent out. Nurse E continued to pass her medications and then checked in with Nurse H and was informed Resident #4 had to be sent to the Emergency Room. Nurse E reported she contacted the physician, paramedics and brought the treatment cart. Nurse E reported she did ask CNA F what occurred and was informed as she was reaching for wipes, he rolled off the bed. Nurse E reported Resident #4 was a two person assist and she did inform the CNA of this when she told her what occurred. On [DATE] at 8:30 AM, an interview was conducted with CNA F regarding Resident #4's fall. CNA F stated she arrived to work and was assigned to the COVID unit and had about 9 residents. About 6:15 PM/6:30 PM CNA F was caring for Resident #4's roommate (completing vitals and cleaning up the resident). Resident #4 informed CNA F as she was still providing care to his roommate that he needed to be changed and was somewhat upset and demanding she provide care to him at that moment. CNA F assured Resident #4 she would take care of him as soon as she finished with his roommate. She added even the resident she was providing care for chimed in and told Resident #4 that she (CNA F) was doing the best she could. CNA F reported once she finished with the roommate, she decided to check Resident #4 and change him to satisfy him in that moment as she knew they were busy that evening. CNA F reported she pulled down Resident #4's brief as he was laying flat in bed as he stated he had a bowl movement. She then turned him slowly toward the window to prepare to change and clear his coccyx, with her left hand lightly holding him and as she reached for the wipes he was not able to sustain his own bodyweight and he rolled off the bed and onto the floor. CNA F explained as he fell, he hit the wooden board (that protrudes from the wall) first and then the floor. She continued the board was already loose and hanging from the wall and other staff were aware of this. CNA F was aware Resident #4 was a 2 person assist for transfers but not bed mobility. She admitted she did not look at the care card prior to doing care and stated Resident #4 was persistent and she wanted to meet his needs timely. CNA F stated as he was being assessed by the nurse, they heard a pop and all assumed it was his hip. On [DATE] at 9:00 AM, this writer and Maintenance Director G observed room [ROOM NUMBER] (the room Resident #4 fell in). The room is currently occupied by another resident who was observed watching television during the observation of the room. On the wall by the window, next to the register was a wooden box cover for the HVAC pipe that was hanging off the wall with nails exposed. Director G reported he was unaware it was not attached to the wall as he never received a work order for it. He reported they built those boxes to protect the HVAC pipes and added he is not sure if the condition of the box occurred before or after Resident #4 fell. The resident reported since he moved into the room the pipe cover was not affixed to the wall. The resident moved into the room on [DATE], 5 days after Resident #4 fell and sustained a hip fracture. The condition of the HVAC cover was not discovered until this writer observed the room in the presence of Maintenance Director G. On [DATE] at 11:00 AM, an interview was conducted with Nurse H regarding her involvement with Resident #4's fall. Nurse D reported she took some medications over to Nurse E and asked if she could assist with anything. Nurse E informed her Resident #4 fell and asked if she could handle that for her. Nurse H reported she did not think much of it as she did not anticipate him needing to be sent out to the hospital. Nurse H walked in, and Resident #4 was on the floor between the bed and window. She assessed the resident as he was responding normally but his arms were bloody from large skin tares. She reported two aides assisted in sitting him up and they supported his bodyweight while she assessed him further, once he was sitting up he expressed pain and stated he thought he broke his hip. Nurse H reported she stuck her head out the door and asked Nurse E to bring the treatment cart and to contact paramedics and physician. Nurse H reported she cleaned up his arms and wrapped them prior to EMS arriving. Prior to them arriving he expressed increased pain and began to dry heave, when EMS arrived, they administered Ketamine for pain management. Nurse H reported the resident cannot hold himself up and is a two person assist. Further review was completed of Resident #4's medical record and the following was found: Discharge Summary: Fall, left hip fracture .patient presented to the ED following an unwitnessed fall from bed at (Nursing Home). Following the fall the patient complained of severe left hip pain. (EMS) was called and patient was given 20mg Ketamine for the pain .XR hip was completed showing a mildly displaced left intertrochanteric fracture . On [DATE] at approximately 10:30 AM, a review was completed of the facility FRI (Facility Reported Incident) investigation regarding Resident #4's fall with hip fracture. At the time of the investigation the facility was unaware that while Nurse E was assigned to Resident #4 that evening, Nurse H assessed, monitored, and provided treatment to the resident immediately following his fall. The following was reviewed: 5 Day Report .On [DATE], around 1900 long term resident, (Resident #4) requested that he needed his brief changed while (CNA F), was in the room caring for his roommate. Once finished caring for the roommate, (CNA F) went to assist (Resident #4). (CNA F) rolled (Resident #4) onto his right side in the bed and reached to grab a wipe and began providing care., At that time (Resident #4) rolled out of bed onto the floor, landing on his left side. (CNA F) attempted to sop him from rolling off the bed but was unable. (CNA F) immediately called for assistance. (Nurse E), assessed resident and observed skin tares to his right arm and right foot. (Resident #4) had complaints of pain 10/10 to his back, stating, I think my back is broken. (CNA C) reports she entered the room at roughly 1900 and observed resident laying on the floor between the bed and wall with skin tears on his arms and complaints of pain all over .On [DATE] at 0815 . notified DON that resident had a mildly displaced left intertrochanteric fracture that would require surgery .Resident underwent surgery on [DATE] for an Open Reduction Internal Fixation Left Intertrochanteric Hip Fracture .After full investigation the facility has determined that (Resident #4) is dependent and requires two-person assistance with toileting, bed mobility, and dressing and the plan of care was not followed. (CNA F) was immediately educated at the time of the occurrence and a final discipline was issues on [DATE] . Statement from CNA F: On [DATE] I was taking vitals and answering call lights. Upon entering room [ROOM NUMBER], resident in bed 1 said he needed his pants off so he could use the bathroom. I took bed one's vitals. Resident in bed two (Resident #4), began to holler that he needed to be changed. I assured him that I would help him as soon as I was done helping bed one. (Resident #4) repeated that he needed assistance. When I finished with bed one, I went to check on (Resident #4) and his brief needed to be changed. I rolled him over to check his bottom. While I had him rolled over I reached for wipes, cleared his bottom, and he just rolled out of the bed. I tried to grab him but he kept rolling out of the bed toward the window. I put the call light on and moved the bed. Then I went to the door and called for help stating a resident was down on the floor . On [DATE] at 12:10 PM, an interview was completed with the DON (Director of Nursing) and Consultant Nurse I regarding Resident #4's fall that resulted in a hip fracture. The DON was contacted once Resident #4 was stabilized and being transported to the emergency room for treatment. The DON was informed Resident #4 rolled out bed as CNA F was providing care alone. It was expressed the resident has always been a two-person assist and the aide used inappropriate assistance when completing incontinence care. The DON stated they were informed the next day Resident #4 fractured his hip and required surgery to repair it. She reported Resident #4 had just moved to isolation because he had COVID and was demanding and yelling for CNA F to change him. The aide admitted she did not look at his [NAME] prior to providing care for him. The CNA was immediately educated by the nurse prior to them initiating education to all facility staff. The DON and Consultant Nurse I reeducated all facility staff on checking the care plan prior to providing care and their nurses complete random audits of aides while they are providing care to ensure they follow the appropriate level of assistance. They have seen staff are communicating more with one another about assistance level required. We further discussed that Nurse H was not interviewed during their FRI investigation and they explained they were not aware she was the nurse who provided aid to Resident #4 after his fall. During the abbreviated survey the facility was found to be out of compliance with their regulatory requirement. But they recognized the deficient practice, completed a process change, education, and audits prior to survey entry and during the survey they were found to be currently compliant. Therefore, Past Noncompliance will be granted with the compliance date [DATE]. On [DATE] at 1:00 PM, a review was completed of the facility policy entitled, Turning a Dependent Resident Away from the Caregiver, revised [DATE]. The policy stated, .Using a draw sheet adjust the residents position by pulling resident as close to caregiver as possible before turning resident on their side. 6. Cross the residents' arms over chest, Cross the leg nearest to you over the leg farthest from you, unless contraindicated .7. Place one hand under the residents' shoulder and the other under the hip. Using good body mechanics roll the resident gently and smoothly away from you. Maintain contract with resident to ensure resident is securely positioned . Resident #1: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's dementia, anxiety, arthritis, depression, heart disease, atrial fibrillation, pulmonary hypertension, history of falls with history of left hip fracture. The MDS assessment dated [DATE] indicated the resident had a memory problem and needed assistance with all care. The resident died on [DATE]. A review of a Facility Reported Incident (FRI) indicated Resident #1 complained of right-sided abdominal pain with facial grimacing and guarding of the right abdomen on [DATE] at 5:05 AM. The resident was assessed by nursing with all vital signs normal except for an elevated heart rate of 105 beats per minute and her oxygen saturation rate was 93% (the lower end of normal). The resident was transferred to the hospital at 1:48 PM on [DATE]. The FRI investigation revealed the resident returned from the hospital on the same day [DATE] with diagnosis of a fracture of one rib (the fourth) on the right side. At that time, Resident #1 also was identified to have- purple bruising on the left anterior leg, right breast, under the right arm, right mid-back, and right upper buttock. The resident began receiving Morphine as needed, a Lidocaine patch and Tylenol. Per the investigation, the resident was assisted out of bed at approximately 5:00 AM on [DATE], by Nurse P and Certified Nursing Assistant/CNA O with no complaints of pain. Then at approximately 8:50 AM she began to complain of pain to Nurse B with guarding of the right side. After lunch [DATE] she yelled Help and when assisted to bed by Nurse B and CNA Q, the resident screamed out in pain, and stated, I feel like I'm going to get sick and yelled out Help me. A review of an Incident and Accident Report for Resident #1 dated [DATE] at 1805 (6:06 PM) indicated the resident fell, Patient was observed on the floor by kitchen staff. The incident occurred in the dining room and the resident had been sitting in her wheelchair prior to falling. She obtained a skin tear to her left temple. On the Incident and Accident Report dated [DATE], the heading List any interventions that can be added that may prevent further occurrence was blank. The Interdisciplinary team made documented a recommendation to Move table in dining room to prevent chair from getting stuck. There was no mention of other interventions. Dietary Aide R's statement [DATE] at 1805 (6:05 PM), I was bussing (tables) in the front of the main dining room when I heard some one say Ouch. I turned around and she (Resident #1) was on the floor. I ran to get nurses. A review of the fall assessments for Resident #1 revealed a Fall Risk Assessment was completed on readmission [DATE] and the resident was assessed to be High Risk for falls with a score of 20. The next Fall Risk Assessment was completed on [DATE] with the Quarterly MDS assessment. Resident #1 was again assessed to be High Risk for falls with a score of 17. The [DATE] Fall Risk Assessment asked History of Falls within last six months: 'Multiple Falls,' was checked. The section titled, Medication Use only had Antihypertensives checked. The resident also received routine narcotics and psychotropic medications, but they were not checked on the assessment form. In addition, the resident was receiving Reglan, a medication that can cause many side effects in elderly residents including, drowsiness, loss of strength or energy, muscle pain or weakness, restlessness and unusual weak feeling. There was no Fall Risk Assessment completed after Resident #1 fell on [DATE] and obtained a skin tear to her left temple. A review of the progress notes revealed the following: [DATE] at 4:27 PM, Patient was found on the floor in the dining room. Patient did not state what she was doing, and the fall was not witnessed. Patient has a 0.9 cm skin tear to the left side of her forehead . [DATE] at 11:21 AM, . resident's glasses were broken from her fall yesterday. Notified POA to contact residents eye doctor to order a new pair. [DATE] at 3:57 PM, a provider note, Seeing patient today after a fall she had on [DATE]. Patient does have a bruise to the left eyebrow area with small skin tear . A review of the Care Plans for Resident #1 identified the following: I have a risk for falling r/t (related to) confusion, fluctuating cognition, wandering, self-transferring, deconditioning, gait/balance problems, incontinence, medication, psychoactive medications, unaware of environmental factors . date initiated [DATE] and revised with cancellation on [DATE]. The interventions were not updated after the resident fell and injured her forehead on [DATE]. A post-fall Fall Risk Assessment was not completed after Resident #1 fell on [DATE] and the Care Plan was not updated. Resident #2: A record review of the Face sheet and MDS assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: Dementia, heart failure, history of respiratory failure, and hypertension. The MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment and needed 2-person assistance with transfers and 1-person assistance with toileting and ambulation. The resident died on [DATE]. A review of a Facility Reported Incident (FRI) investigation indicated Resident #2 fell on [DATE]. She was observed on the floor of her room and complained of pain in her left hip. She was assessed and had a bruise on her left hip and left hip. An x-ray of the left hip was ordered on [DATE] and completed on [DATE] with results of a left hip fracture. A review of the progress notes revealed the following: [DATE] at 4:53 PM, Patient reported to therapy that she had fallen last night and got herself back up and into bed . A bruise measuring 1.5cm x 1.5cm x 0 was observed to her left knee . [DATE] at 8:40 AM, CNA (Certified Nursing Assistant) observed resident on the floor . observed to be laying on her back by the end of the first bed . was persistent on her left hip hurting and later turned into her let groin . bruise was found to left elbow and left hip . a few hours later patient became very anxious and in pain to where she was constantly calling out, asking staff to sit with her, she didn't want to be alone . she couldn't get comfortable and was in pain . [DATE] at 9:32 AM, a note by the provider, . fell last night and broke her left hip . [DATE] at 2:33 pm, received order to increase morphine . also received order for Norco 5-325 mg every 6 hours for pain management . [DATE] at 3:34 PM, a note indicated Resident #2 had died. A record review of the Incident and Accident Reports for Resident #2 indicated the resident had fallen twice after she was admitted to the facility: [DATE] and [DATE]. The Incident and Accident Report dated [DATE] revealed, Patient stated she was trying to get into bed and slipped and fell. There were no witnesses, and she obtained a left knee bruise measuring 1.5 cm x 1.5 cm x 0. Patient stated she was in her wheelchair . Self-transfers frequently. Rearrange room, moved across from nurse's station. A review of the Fall Risk Assessments for Resident #2 identified one completed on admission [DATE]. There was no completion of Fall Risk Assessments after the resident fell on [DATE] to aid in preventing additional falls; Resident #2 fell again on [DATE] and fractured her left hip. There was no fall risk reassessment after the fall with fracture on [DATE]. A review of the Care Plans for Resident #2 revealed, I have a risk for falling related to confusion, fluctuating cognition, wandering . gait balance problems, incontinence, Medication . date initiated [DATE] and updated after discharge [DATE]: Interventions updated [DATE],For my safety, I require a room close to the nurses station, date initiated [DATE]; [DATE] updated Offer to toilet me at the start of shift and at the end for my safety, as I am known to self transfer . On [DATE] at 12:50 PM, the DON and Corporate Clinical Nurse were interviewed related to the lack of a reassessment of fall risk after Resident #2 fell on [DATE] and incurred an injury (change of condition), the Corporate Clinical Nurse Resident #2 should have had a completed Fall risk assessment after the fall. Also discussed the fall Resident #2 had on [DATE] when she sustained a left hip fracture. The Corporate Clinical Nurse was asked why the facility waited until the resident had fallen twice and sustained injuries both times to provide an intervention to toilet the resident. In the Care Plan it was noted on [DATE] that she attempted to transfer self and was incontinent. On the [DATE] Incident and Accident Report it noted, Due to my cognition, I sometimes self-transfer without assistance . There was no explanation why a toileting plan was not initiated sooner. A review of the policy titled, Fall Management Guidelines, dated revised [DATE] provided, Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls . Residents will be assessed for fall risk upon admission, quarterly, annually and with a change of condition . Residents identified at risk for falls will have a care plan developed and implementation of appropriate fall prevention interventions .