**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake M100132402. Based on interview and record review, the facility failed to operationalize policies and procedures, appropriately assess, monitor, notify pertinent parties, implement meaningful care plans, and thoroughly investigate falls, for 1 (Resident #1), resulting in an inappropriate root cause analysis and interventions that lead to subsequent falls causing harm, serious injury and death. Findings include: Resident #1 (R1) Review of a Face Sheet revealed R1 is an [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses of dementia, cognitive communication deficit, falls and Parkinson's disease. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed R1 was moderately cognitively impaired and required extensive assistance of 1 staff for transfers, toileting, and personal hygiene. She was not steady without human assistance and had limited range of motion on one lower extremity. R1 had a history of falls upon admission and had falls since admission with a non-major injury. She was not on a toileting program and was frequently incontinent of urine and always incontinent of stool. Review of the Significant Change of Condition MDS dated [DATE] revealed R1 was severely cognitively impaired and required extensive assistance of 1 staff for transfers, toileting, and personal hygiene. She was not steady without human assistance and had no range of motion impairments on any extremity. R1 had falls since admission that consisted of one fall with no injury and one fall with injury. Review of a Fall Prevention Program policy last revised 1/1/22 revealed: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. 3. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 5. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a.) Interventions will be monitored for effectiveness. 6. When any resident experiences a fall, the facility will: .d) Notify physician and family. e) Review the resident's care plan and update as indicated. f) Document all assessments and actions. g) Obtain witness statements in the case of injury. Review of a Falls - Clinical Protocol policy last revised 1/1/22 revealed: 1. As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling . 2. Based on the assessment an initial plan of care will be developed and implemented to address identified risk. This will be revised as necessary. 3. The Minimum Data Set (MDS) and subsequent CAAs (Care assessment areas) will be utilized to develop the comprehensive plan of care to minimize fall and injuries from falls. 5. Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include Resident's abilities and deficits, Balance (sitting/standing), Adaptive equipment needs, Proper use of . bathroom safety. 6. In addition, interventions for direct care givers should be placed on the CNA care card or similar format. 8. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. Review of a Nursing admission Evaluation dated 1/11/22 for R1 indicated the resident was at high risk for falls. Review of the Physical Therapy (PT) Evaluation and Plan of Treatment document for R1 revealed she started care on 1/12/22 for strain of muscle, fascia and tendon of left hip as well and abnormal gait and mobility. The resident could walk 10 feet with supervision and not attempted to walk 50 feet with two turns due to being in an isolation room and unwilling to do laps in her room. The resident was unable to stand without support as needed for 10 seconds and was able to sit unsupported for 30 seconds with no back support. Patient could not stand without upper extremity support with AD as needed for 10 seconds. She was moderately impaired for decision making ability for routine activities. Review of a Practitioner Progress note date 1/12/22 for R1 revealed: Per notes, she has had multiple falls over the last month. Provide a safe and supportive environment. Remind patient to call for help before ambulation. Review of an Incident Report dated 1/17/22 at 10:00 PM revealed R1 had an observed fall when she was found standing with her walker in front of her bathroom and fell backwards when the Certified Nursing Assistant (CNA) stepped towards her. There is suspicion her head was impacted. R1 did not know what happened and was documented as last observed at 9:45 PM sleeping. No documentation indicating other staff who worked this day were interviewed. Another resident name is documented as interviewed but no statement provided. The investigation results indicated the resident was self-ambulating and did not call for assistance. The resident had an abrasion, neurological checks were started, and all notifications were completed. Interventions included encouraging the resident to wear nonskid footwear when out of bed. The physician was notified and the Power of Attorney (POA). The Director of Nursing (DON) and Nursing Home Administrator (NHA) were not notified. Review of an Incident Report dated 1/23/22 at 9:00 PM for R1 revealed she had an observed fall while being toileted. She had a syncope (blacking out or fainting) episode and unable to transfer to the wheelchair and was lowered to the floor. The Environmental Factors documented reports the resident was being transferred to the bathroom when she became weak. She was last seen at 8:30 PM in bed. Immediate interventions were for a Physical Therapy (PT) referral and to wear nonskid footwear. The investigation results documented the resident was being toileted and was noted to sycopole (sic) episode and was lowered to the floor. The resident was noted to have an injury and denied pain/discomfort. The resident had a PT referral and encouraged to wear nonskid footwear while up. The only statement noted is from an unidentified staff member that revealed the Resident being toileted and had syncope episode. She was in and out of being awake and fell asleep. CNA and myself tried to transfer her to wheelchair once she came to, but she was dead weight and difficult to move. We laid her down to the floor and hoyered her to her bed. She was smiling and said she couldn't remember what happened. A brief objective description of the alleged incident revealed Resident had syncope episode on toilet and had to be laid to floor in order to be hoyered. Report is conflicting about the resident being toileted in the bathroom or being transferred to the bathroom. No neurological checks post fall noted. The name of the physician allegedly notified has a first name written with (on call) next to the name. Review of the Electronic Medical Records (EMR) for R1 revealed no progress notes dated for 1/23/22 indicating the resident had a fall and any follow up. No Neurological checks noted. Review of a Practitioner Progress Note dated 1/24/22 for R1 revealed the resident was seen for a follow up of medical conditions and physical therapy progression. This is a frail, elderly individual. She is currently lying in bed resting. She reports mild pain to her left hip. Assessment and Plan: . Frequent falls: Provide a safe and supportive environment. Remind patient to call for help before ambulation. Debility: Encourage participation with therapy as tolerated. Continue to assist with ADLs as needed and provide a safe environment. No documentation acknowledging R1 fell on 1/23/22 or the practitioner was aware. Review of a Practitioner Progress Note dated 2/4/22 for R1 revealed: . 4. Frequent falls: She continues to have episodes of weakness with nursing staff and therapy. Provide a safe and supportive environment. Monitor vital signs. 5. Debility: Assist with ADL's as needed and provide a safe environment Review of a Practitioner Progress Note dated 2/7/22 at 10:32 AM for R1 revealed: She has had episodes of weakness periodically where she loses her balance. This afternoon, she got up from the toilet unassisted and fell forward, hitting the back of her head on the door frame. She did not lose consciousness. She has a laceration about two inches in length on the back of her head that will need stitches. She will be sent to the hospital for this. Review of an Incident Report dated 2/7/22 at 3:30 PM for R1 revealed she had an unobserved fall when she transferred herself off of the toilet and fell. Immediate intervention was to add grip tape to the floor and a physical therapy referral. One staff members' name was written down as interviewed but no statement provided from that staff member or any other staff who worked. The results from their investigation included: Res was observed on the floor of her bathroom by staff with (wheelchair) next to her footwear in place, call light (within) reach (not) in use. There is a laceration to back of head (with two) staples placed (at emergency room). (No) further (complaints of) pain/discomfort at this time. At baseline res is A&O (alert and oriented) X 1-2 with poor safety awareness and syncopale (sic) episodes. At this time res is to have grip tape placed to floor and Pt referral made. Will continue to monitor through [NAME]-charting, neuro-checks, (vital signs) and SOC (standard of care). No documentation reflecting how the resident ended up on the toilet and was documented as last seen at 3:30 PM which is the time of this incident. Review of a Hospital emergency room Discharge summary dated [DATE] at 4:34 PM for R1 revealed the resident arrived with a laceration to the back of her head after a ground level fall while transferring to the toilet. It is unclear whether it was witnessed or not . paramedics reported that she fell in the bathroom while trying to transfer from the toilet. The resident received staples to the 2-centimeter laceration on her scalp. Review of a Nursing Progress note dated 2/17/22 for R1 revealed the daughter of R1 had concerns the resident keeps slipping down in the wheelchair and a request for a wedge cushion. PT recommended a (dycem) to be applied the residents seat on the wheelchair. Review of a Standard of Care (SOC) progress note dated 2/24/22 for R1 revealed: New Fall/Follow-Up: IDT (interdisciplinary team) met to discuss week 2 after recent fall 2/18/22 and assess interventions currently in place. Situation (where/when/what/who): Res was observed on the floor of her bathroom with (wheelchair) next to her and call light within reach and not in use. Injury/No injury: Laceration to head was healed with no recent (complaints of) pain. Bruise right hip that has healed as well. Factors involved (acute condition/environment, ect.): Resident is alert and oriented x 1-2 with poor safety awareness and chooses not to put her call light on for transfers. Notifications: Resident, family, and facility aware at this time. Analysis of intervention to implement new interventions include grip tape was added to the floor and resident has not had another fall since 2/18/22. Referrals: Resident was signed on with Hospice since fall. No incident report provided for 2/18/22 fall. Review of an Incident Report dated 2/26/22 at 6:30 PM for R1 revealed she had an unobserved fall and was found on her left side by her wheelchair in the dayroom. The physician documented as notified is on call. The resident reported she tried to walk or stand to go back to her room. The immediate interventions were to keep her comfortable through the transition process. No staff statements provided. Investigation results are the resident was in the dayroom and wanted to go back to her room after dinner. No complaints of pain initially so resident was assisted to wheelchair with the hoyer lift and then into her bed. When resident was in her bed she complained of pain in left hip/thigh. Xray ordered and showed a non-displaced left femoral neck fracture. Resident has a history of dementia and poor safety awareness and does not remember to ask for assistance with transfers. Declination to transfer to hospital due to hospice status and implemented comfort measures. Review of a Radiology Report dated 2/26/22 at 9:49 PM for R1 revealed she had a nondisplaced left femoral neck fracture. Review of a Hospice Progress Note dated 2/26/22 for R1 revealed Fall Event. A call was placed to Hospice on 2/26/22 at 11:20 PM to notify them the resident had an unwitnessed fall in her room around 6:30 PM. they found pt on the floor, it appears that she had tried to get up from her wheelchair. Pt was complaining of hip pain, so facility did X-rays and found a non-displaced fracture. Also advised that in the future it is best to call near time of fall and before X-rays so they can be discussed with our provider. Review of a Hospice Progress note dated 2/27/22 at 10:15 AM for R1 revealed the Nurse from the facility notified hospice that the resident is reporting nausea and started to vomit and is shaky. She fell and broke her hip yesterday. Review of a Care Plan for R1 revealed on 1/12/22 she is to be toileted with the assistance of one staff member and personal hygiene. On 1/11/22 she is to transfer with the assistance of one staff with walker and gait belt. On 1/12/22, reposition/ambulate as tolerated. On 1/25/22, Up in wheelchair for meals and by the nurses station for supervision and cues. On 1/28/22 a focus for the residents impaired cognitive function was initiated. On 1/28/22, the Resident uses wheelchair to move around room and facility. Review of the Respiratory Care Plan for R1 revealed she has altered respiratory status/difficulty breathing related to chronic respiratory failure with hypoxia initiated 1/12/22 Review of a fall care plan initiated on 1/11/22 revealed: The resident is at risk for falls related to history of multiple falls while at home, chronic respiratory failure, muscle strain, contusion of left hip, Parkinson's, history of right knee replacement, spinal stenosis, anemia, resident will attempt self-transferring without calling for assistance, resident will excuse staff for privacy while in the bathroom. Interventions as follows: 1/11/22- Encourage rest periods as needed to avoid overtiring. 1/12/22- Physical Therapy/Occupational Therapy to evaluate and treat as ordered or as needed. 1/12/22- Provide activities of interest. 1/12/22- Provide activities of daily living such as incontinence care, transfers, ambulation, as written in the activities of daily living plan of care. 1/12/22- anticipate and meet the resident's needs based on nursing assessments. 1/12/22- Determine causative factors of fall and resolve or minimize. 1/12/22- Use gait belt for transfers and walking. 1/12/22- Review information on past falls and attempt to determine cause of falls 1/17/22- Bed in low position when not providing care. 1/17/22- Bed wheels locked at all times, unless transporting or moving. 1/18/22- Encourage resident to wear nonskid footwear on when out of bed. 2/7/22- Grip tape to bathroom floor. Review of a Death Certificate dated 3/4/22 for R1 revealed the cause of death is from a) Medical decompensation following left femur fracture b) fall approximate interval between onset and death was 1 week. Manner of death is Accident from 2/26/22 at unknown time from an unwitnessed fall from standing height. In an interview on 11/29/22 at 1:51 PM, Licensed Practical Nurse (LPN) G reported that on 2/26/22 at 6:30 PM she was first coming to the unit to start working that evening. She remembers being frustrated that the facility left R1 in the day room behind the nurses' station alone because she needed supervision. R1 was so confused and would keep trying to get up from her wheelchair. R1 would try to stand up and walk. She remembers she heard some noise coming from the room behind the nurses' station and when she went to see what the noise was, she saw R1 laying on the floor. LPN G reported she made sure she was alright and then used a mechanical lift to get her off the floor. Then gave her pain medication and put her in bed. When queried if she notified the physician the day of 2/26/22 when R1 fell, LPN G reported she thinks she made several calls to the on call practitioner but not sure if she got a call back, which may be why she just wrote on call under the name of the physician notified. She does remember calling the residents daughter discussing whether or not to do x-rays as well as the Unit Manger who is no longer working at the facility. In an interview on 11/29/22 at 3:30 PM, the Director of Nursing (DON) reported R1 had 19 visits from their practitioners for various reasons from 1/12/22 to 2/9/22. She was having hypotensive episodes and her diuretics and blood pressure medications were discontinued or adjusted. On 1/17/22 she had a witnessed fall, and she was seen by therapy for falls and encouraged to wear nonskid socks. On 1/23/22 the resident had a syncope episode and did not consider lowering the resident to floor as a fall. On 2/7/22, based on the progress note, the resident's niece was present, but did not include that in the fall investigation. This day she went to the hospital and encouraged her wheelchair to be close and in a locked position. Grip tape was also added to the floor and the Nurse Practitioner made some medication changes as well. When asked to clarify the actual events, the DON reported she needed to call the Certified Nursing Assistant (CNA) to find out what actually occurred. No statements from the staff were provided. The DON reported the resident excused the staff from the bathroom for privacy while in the bathroom. When asked to clarify if residents who were high risk for falls could be left alone in the bathroom when they are care planned to be a one person assist, she answered yes. On 2/26/22 the resident was observed in the day room behind the nurses' station on the floor around 6:30 PM and was last seen at 5:55 PM during her meal. The DON expects the staff to call hospice, the physician, and family after a fall incident within a reasonable time. The resident did not complain of pain right away but did have pain after she went to bed. No documentation in the EMR indicating R1 was assessed and educated with comprehension about how to use a call light.