**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident # 401) of 6 residents reviewed for accidents and falls, resulting in Resident #401 experiencing multiple falls and sustaining several fractures. Findings Include: Resident #401: Accidents: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #401 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, anxiety, depression, arthritis, and history of urinary tract infections. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline with a Brief Interview for Mental Status (BIMS) score of 3/15 and Resident #401 needed assistance with all care. On 12/12/23 at 12:30 PM, Resident #401 was observed lying in bed awake visiting with a family member. The resident smiled but did not answer or respond to questions. The family member, said the resident had encountered several falls at the facility that resulted in multiple fractures. The visitor said the resident now had a mat on the floor beside the bed after the most recent fall with fracture. On 12/14/2023 during a review of five Incident and Accident/I&A reports for Resident #401 the following was identified: 5 reports for falls dated 9/12/23, 10/16/23, 11/3/23, 11/25/23, and 11/26/23. On 9/12/2023 and 11/26/2023 the resident sustained fractures due to the falls: 9/12/2023 2 fractures of the pubic rami and 11/26/2023 a fracture of the right trochanter/hip. The falls are summarized as follows: On 9/12/23 at 1930/7:30 PM: Resident #401 had a fall; found on floor in hallway, head against the wall- complained of/(c/o) left hip pain- resident with multiple c/o hip and knee pain. Resident #401 was yelling out and repeatedly complaining of pain. The staff documented the behaviors of yelling and an order was given for an anti-anxiety medication/Ativan. A CT scan was ordered on 9/18/2023 and was not performed until 9/26/2023 the results were charted on 10/2/2023 and identified 2 pubic rami (pelvic) fractures. A review of a progress note dated 9/13/2023 at 5:03 AM: Complaint of pain in pelvic region . A Fall Risk Evaluation dated 9/13/2023 at 8:12 AM . 1-2 falls in past 3 months . Fall risk score: 12.0. Actioned clinical suggestions: . This was left blank. 9/13/2023 at 10:30 AM, a progress note: Resident noted to be restless, anxious, tearful and yelling out . It hurts . 9/17/2023 at 2:01 PM, a progress note: . resident hollering out in pain . 9/18/2023 at 2:03 PM, a physician progress note: . (patient) still suffer from pain, will check ct of the pelvis and left hip . 9/18/2023 at 3:32 PM, a progress note, . new order for CT scan . 9/20/2023 at 2:07 PM, a physician progress note, (patient) is still in pain . 9/22/2023 at 1:26 PM, a therapy note, . delay in treatment by PT until after CT scan on 9/26/2023 . 9/28/2023 at 7:10 PM, a behavior note, Resident noted to be yelling out and shows increased anxiety . received telephone order to give Ativan . 10/2/2023 at 3:19 PM, a therapy progress note, . received CT scan results of pelvis today . there is two nondisplaced pelvic fractures noted on CT scan . contacted (doctor) . 10/3/2023 at 2:22 PM, a physician progress note, (patient) suffers pelvic fractures, also developed fungal rash on her abdomen . Resident #401 fell on 9/12/2023 a CT scan was ordered on 9/18/2023 and was completed on 9/26/2023. There was no clinical documentation of the results until a therapist documented on 10/2/2023 and contacted the physician. The resident was identified to have 2 pelvic fractures. The resident had been yelling out in pain for 3 weeks and was given Ativan for yelling. On 10/16/2023 at 3:35 PM: Resident #401 had a fall -found on floor in room, lying flat on her back next to a bedside table; an aide heard the resident hollering out. A note on the I&A report revealed, . Writer received order for routine pain medications as pain could be cause of fall, dated 10/17/2023. A review of the physician orders indicated the new order was for a muscle relaxer/Robaxin. The order was initiated greater than 30 days after the resident previously fell and sustained 2 pelvic fractures. The resident had an order for Tylenol 325 mg tablet, Give 2 tablets by mouth two times a day for pain, start date 9/15/2023, but continued to yell out in pain. On 11/3/23 at 12:00 PM: Resident #401 had a fall. The I&A report said the resident was observed on floor near room doorway; I'm hurting. An intervention was enacted: park w/c next to right side of bed. A review of a progress note dated 11/3/2023 at 1:41 PM provided, . resident observed on floor. resident sitting on buttocks with feet out in front and hands behind, near doorway . Resident states, I'm hurting . On 11/25/23 at 10:52 PM: Resident #401 had a fall-on floor next to bed unwitnessed. No new interventions were added until 11/27/2023 (concave mattress)- (the resident fell again on 11/26/2023 and fractured her right hip.) A review of a progress note dated 11/25/2023 at 10:55 PM: Resident observed on floor on right side of bed . has redness on right side of face and above right eyebrow and c/o (complains of) headache . There was no mention of additional interventions to aid in prevention of future falls. On 11/26/23 at 8:00 AM: Resident #401 had a fall out of bed - . resident had fallen out of bed. (Nurse aide) initially heard a loud noise from resident's room and went to check on what had happened. (Nurse aide) reports observing resident to be laying on their right side on the floor in front of wheelchair next to right side of bed. When writer went to see resident, resident was positioned back in bed lying on their back . unwitnessed fall . Resident given routine medications for pain once in bed . 'Tylenol . Ativan . Methocarbamol (Robaxin),' . x-ray is placed for pelvis area. Nursing will continue to follow POC. A review of Resident #401's Medication Administration Record (MAR) for November 2023 indicated the resident was receiving a sedating anti-anxiety medication/Ativan 0.5 mg routinely 4 times a day as well as Robaxin, a sedating medication once a day. From November 1st 2023 to November 18th, 2023 the resident also had an order for diphenhydramine/Benadryl, for itching related to an ongoing rash. The resident had received the medication twice on 11/2/2023 and fell on [DATE]. In all the resident had 6 documented doses of the medication, which can also cause sedation/drowsiness and confusion in elderly persons. A review of the progress notes for Resident #401 revealed the following: 11/26/2023 at 8:52 AM: . (Nurse aide) initially heard a loud noise from resident's room and went to check on what had happened. (Nurse aide) reports observing resident to be laying on their right side on the floor in front of wheelchair . Nursing will continue to follow POC. 11/26/2023 at 9:50 AM: . Resident to be repeating pain in right hip . Writer to place stat x-ray order for pelvis . 11/26/2023 at 2:55 PM: Writer called 911 to report resident needing transportation to hospital for radiology report showing right hip fracture . 11/29/2023 at 2:54 PM: . report from (hospital). Resident had a right hip fracture and (surgical repair) on the 26th . she will come back with a script for Norco (narcotic pain medication) and muscle relaxers . Nurse states she recommended hospice to family . 11/29/2023 at 3:32 PM: . Family inquired about what we would do with resident and current condition . discussed with them how we would monitor her closely . placed a concave mattress to help her with feeling the edge of the bed . A review of the Care Plans for Resident #401 indicated a Safety Care Plan: (Resident #401) is at high risk for falls secondary to her history of a fall x 1 prior to admission [DATE]) decreased safety awareness secondary to Dementia, anxiety, and potential side effects of medications. (Resident) has had falls since admission, and she is currently utilizing a concave mattress to find the edges of the bed, date initiated 6/29/2023 and revised 12/12/2023 to include the concave mattress. There were 4 interventions with the most recent dated 7/21/2023. A review of the Kardex for Resident #401 on 12/14/2023 identified fall mats beside the bed and a concave mattress. There were no dates when enacted. Place resident in Fall prevention program was also undated. During an interview with the Director of Nursing/DON, on 12/15/2023 at 3:20 PM, she was asked about Resident #401's 5 falls. She said the resident had fallen and also sustained several fractures. The DON was asked about the Resident's fall on 9/12/2023, order for a CT scan on 9/18/2023 that was not completed until 9/26/2023 and the lack of clinical documentation of the CT scan results until 10/2/2023, when the therapist documented the results. She said she was aware. Also reviewed that the resident had been yelling out, saying she was in pain and staff were documenting behaviors and the resident was given Ativan. The resident continued to have 4 more falls and suffered another fracture on the last fall 11/26/2023. She was hospitalized and had surgical repair of the fracture. There was not consistent documentation that the resident was being monitored or that additional interventions were enacted to try and prevent continued falls with injury. The DON was asked about the Fall prevention program, and she said it was a policy. A review of the facility policy titled, Fall Prevention and Identification Program, dated reviewed 9/22/2014 revealed, To provide all staff a means to identify and assist residents who have been identifies as frequent fallers. Residents who have been deemed a frequent faller (more than 1 fall in a quarter) by the Interdisciplinary Team, will be place in a Fall Prevention Program . Residents who are in this program will be evaluated for appropriateness every quarter with are conferences, on re-admission and with significant change in status assessments . The policy said the resident would receive an orange dot on their wheelchair and identification bracelet and physician order to identify they are a fall risk. It did not identify interventions to aid in prevention of falls. All residents at the facility are evaluated for falls each quarter with the MDS assessment process, on re-admission and with significant changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Number MI00133837. Based on interview and record review, the facility failed to assess and monitor a resident with a wound infection, urinary tract infection and elevated temperatures for one resident (Resident #1) of three residents reviewed for changes in condition, resulting in hospitalization, wound infection, sepsis, deterioration of health status and wellbeing and subsequent death. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on 5/23/22, readmission on [DATE] and transferred to the hospital on [DATE]. The Resident had diagnoses that included cerebral infarction (stroke), depression, diabetes, history of falling, anxiety disorder, Alzheimer's disease, difficulty in walking, dysphagia, encephalopathy, gastrostomy status, and pressure ulcer of sacral region. A review of the Minimum Data Set (MDS) assessment, dated 8/18/22, revealed the Resident had severely impaired cognitive skills for daily decision making and was total dependent on staff for bed mobility, dressing, eating, toilet use and personal hygiene. Further review of the MDS revealed the Resident was at risk of pressure ulcers and did not have a pressure ulcer on readmission into the facility. A review of Resident #1's Temperature Summary in the medical record revealed the Resident had a temperature recorded on 10/29/22 at 1:11 PM of 100.5 degrees Fahrenheit; 10/31/22 at 2:32 PM of 99.4 degrees Fahrenheit; 10/31/22 at 5:17 AM of 100.9 degrees Fahrenheit; and 11/1/22 at 12:19 AM of 103.1 degrees Fahrenheit. A review of the Progress Notes revealed no documentation regarding interventions or vital signs with the documented temperature of 100.5 degrees Fahrenheit on 10/29/22 and the next temperature documented on 10/30/22 at 1:01 AM. The Blood Pressure Summary had two listed blood pressures documented on 10/27/22 at 2:59 PM of 132/84 and on 11/1/22 at 12:19 AM of 111/55. The Pulse Summary had two listed pressures documented on 10/27/22 at 2:59 PM of 68 bpm (beats per minute) and on 11/1/22 at 12:19 AM of 100 bpm. A review of the progress notes, dated 11/1/22 at 12:10 AM, revealed the Resident received Tylenol via PEG-Tube (percutaneous endoscopic gastrostomy tube) and dated 11/1/22 at 1:41 AM, temp re check - 99.1 v/s (vital signs) 128/68, P (pulse) 93, 98% (O2 saturation) resp 22, resident had elevated temp 103.1 Rapid Covid test negative at this time. Resident appears to have increase edema. Writer called DTR (daughter) r/t (related to) change dtr requesting resident to be sent to (name of hospital) . Progress note dated 11/1/22 at 1:59 AM, communication with physician, revealed, Situation: elevated temp; Background : possible septic; Assessment (RN)/Appearance (LPN): wound infection completed ABT (antibiotic therapy); Recommendations: Send to (Name of hospital) per DTR request. A review of Resident #1's Medication Administration Record (MAR) revealed an order for Weekly Skin Checks and weekly vital to be completed today every day shift every Thru (Thursday). Completed weekly skin check today and assure that weekly vitals are completed today, with a start date on 10/6/22 and discontinued on 11/8/22. On 10/6/22 and 10/20/22, the MAR was checked as completed but there were no vital signs documented in the vital sign summary or progress notes. On 10/13/22 there was no documentation of completion on the MAR and no vitals noted in the progress notes or on the vital sign summary. A review of Resident #1's wound assessment, completed on 10/24/22 revealed, . Wound measures 4 cm (centimeters) x (by) 5cm x2cm depth. Wound has thick gray slough in the center, with small amount of purulent drainage. Wound base is grey. Periwound is intact with irregular borders and is erythematous. Wound has a strong odor. Dressing performed as ordered. Will continue current treatment as currently ordered. A review of Resident #1's culture and sensitivity for the wound on the coccyx revealed the following: -Gram Stain Many Gram Positive CoccI, Multiple Morphologies Present, Moderate Gram Positive Bacilli, Moderate Gram Negative Bacilli -Isolate 1 few Escherichia coli -Isolate 2 Many Proteus mirabilis -Culture, Anaerobic ***Canceled*** The Resident was started on Ceftriaxone on 10/17/22 to 10/26/22. The progress note on 10/24/22, documented the wound assessment with signs and symptoms of continued infection, .Wound has thick gray slough in the center, with small amount of purulent drainage. Wound base is grey. Periwound is intact with irregular borders and is erythematous. Wound has a strong odor . There was a lack of further evaluation of the wound from 10/24/22 until transfer to the hospital on [DATE]. A review of Resident #1's urinalysis, culture and sensitivity for urine, revealed the following: -Date collected, 10/19/22, date reported 10/21/22. -Urinalysis, with out-of-range test results, included: color dark yellow; appearance turbid; blood-trace; protein present; leukocytes esterase large; and microscopic results with +3 bacteria. -Culture Isolate 1 revealed, greater than 100,000 CFU/NL of Pseudomonas aeruginosa. The document had a handwritten note that stated, Already being Tx (treated) with Ceftriaxone for 10 day for wound infection, was not dated or signed. The sensitivity did not list Ceftriaxone in the list of antibiotics to determine susceptibility to the antibiotic. Further review of the medical record revealed a lack of progress notes indicating assessment of the urinary tract infection development or progress. On 10/21/22 at 7:39 PM, an Alert Note, revealed, Resident ua/cs with culture is completed CrCL (creatinine clearance) 106.0 resident is currently being with ceftazidime which is supectible (susceptible) to infection place on DR board. The Resident was not prescribed ceftazidime. A review of Resident #1's hospital records revealed the following: -Emergency Documentation dated 11/1/22, revealed, .Assessment/Plan 1. Sacral decubitus ulcer, 2. Sepsis, 3. Hyperglycemia, 4. Cellulitis of buttock . History of Present Illness: . Blood sugar noted to be above 600 per EMS (ambulance) .sacral decubitus ulcer with significant surrounding erythema, wound containing apparent necrotic tissue, fetid smell and drainage. Wound is noted to be emanating bubbles of gas upon palpitation . significantly dehydrated and hyperglycemic . -CT Chest/abdomen/pelvis without contrast, dated 11/1/22, Impression: 1. Sacral decubitus ulcer with soft tissue air tracking along the right gluteal musculature and right pelvic floor musculature. Additionally there is osseous demineralization and or erosive change of the underlying sacrum which could relate to osteomyelitis . -Consultation Notes, dated 11/2/22, revealed, .Evaluation of sacral wound on arrival reveals an approximate 15 cm x 20 cm and the sacral bone is visible at the base of the ulcer with necrotic skin subcutaneous tissue and muscle at the edges smelling sacral decubitus ulcer with significant surrounding erythema, wound containing apparent necrotic tissue, fetid smell and drainage -Consultation Notes, date 11/2/22, Addendum, revealed, .size of the decubitus ulcer and the depth making it a stage IV decubitus ulcer 15 x 20 before any debridement and that it will need at least 1 surgical debridement prolonged wound dressing changes eventually the patient will need either a surgical flap done by plastic surgeon or a skin graft and there is a very good chance that the patient might require a diverting loop ileostomy as the patient had a stroke and is not mobile and unable to control her bowel function the diverting stoma is to help with wound care management. The daughter decided to make her mom comfort measures only she stopped the IV antibiotics stop tube feeds and no surgical intervention . On 2/17/23 at 10:05 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #1's facility acquired pressure ulcer and elevated temperatures. A review of vital signs revealed no other vital signs documented on 10/29/22 with the elevated temperature of 100.5 degrees Fahrenheit. When asked about the facility policy with elevated temperatures for a Resident, the DON indicated that the Resident should be rechecked for anything abnormal, recheck temperatures, get a full set of vital signs, contact the Physician and start standing orders for room restrictions, Covid, RSV, Flu A and B testing and reported a lack of documentation that the interventions and assessments had been completed. The DON indicated that there had been a Covid outbreak in the facility and that Covid testing had been done on the 10/27/22 and on 10/31/22, but the Nursing staff should have tested the Resident with the spike in temperature on 10/29/22. When queried regarding the pressure ulcer, the Resident on antibiotics with expected improvement within 72 hours of antibiotic therapy, further review of the medical record revealed a lack of assessment. The DON stated, I am not seeing assessment until the 103 temperature, with mention of wound infection and a set of vital signs prior to transfer to the hospital. On 2/17/23 at 3:35 PM, an interview was conducted with the Infection Control Preventionist (ICP), Nurse H regarding Resident #1's wound and urine cultures and sensitivities and elevated temperatures. When asked about doing wound cultures, the ICP indicated that for a wound culture, usually an aerobic and anaerobic cultures were done and was unsure why the anaerobic culture had been canceled. The ICP indicated that another wound culture would be sent right away. The urinalysis, culture and sensitivity, collected on 10/19 and reported on 10/21/22, and the antibiotic not listed on the sensitivity was reviewed with the ICP. The ICP reported she was out of the building at that time and was unsure what the physician had seen to indicate the Ceftriaxone was appropriate for the urinary tract infection (UTI) and indicated the Unit Manager or the Nurses should be checking with the physician. When asked about ongoing assessments, the ICP indicated Nursing staff should assess and monitor for sepsis with wound infection and UTI. When asked about Resident #1's elevated temperature on 10/29/22, the ICP indicated that usually 100.4 and over an assessment was to be completed to monitor for urinary tract infection by completing a UA (urinary analysis), Covid testing, and assess the wound knowing antibiotics were finished. The ICP indicated that monitoring improvement of infections and reactions to antibiotic use would include documentation of the assessment of the wound, appearance, and drainage, every time they look at the wound. On 2/17/23 at 4:00 PM, an interview was conducted with Unit Manager J regarding Resident #1's pressure ulcer and elevated temperatures. When asked about the elevated temperature on 10/29/22 and assessments, the Unit Manager indicated that the Nurse would treat with Tylenol as needed and continue to monitor, inform the charge nurse, and continue with assessment. When asked about facility protocol for monitoring vital signs, the Unit Manager indicated that vital signs were to be assessed weekly unless otherwise ordered, unless signs and symptoms of anything else as an elevated temperature, wound infection and monitor for more if further issues with the vital signs. The vital signs and wound assessments were reviewed with the Unit Manager. The Unit Manager indicated she was aware there were holes in the weekly assessments that were not done and a lack of wound assessment after the completion of antibiotic to determine change and/or worsening of the wound. A facility policy was requested for Changes in Condition, policy of Vital Sign Monitoring and Sepsis/Infection, but were not received prior to exit. A review of the facility policy titled, Infection Prevention and Control Program Outline, revealed, .1. Surveillance: The RN's and LPN's participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and floor coordinators for notification of changes and inhouse reporting of communicable diseases and infections. Daily Surveillance: . Daily updates on antibiotic therapy, room restrictions, skin and wound documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Number MI00133837. Based on interview and record review, the facility failed to prevent, monitor and treat a facility-acquired pressure ulcer for one resident (Resident #1) of three residents reviewed for pressure ulcers, resulting in the worsening of the pressure ulcer to a Stage IV, infection, sepsis, a deterioration of health and wellbeing and subsequent death. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on 5/23/22, readmission on [DATE] and transferred to the hospital on [DATE]. The Resident had diagnoses that included cerebral infarction (stroke), depression, diabetes, history of falling, anxiety disorder, Alzheimer's disease, difficulty in walking, dysphagia, encephalopathy, gastrostomy status, and pressure ulcer of sacral region. A review of the Minimum Data Set (MDS) assessment, dated 8/18/22, revealed the Resident had severely impaired cognitive skills for daily decision making and was total dependent on staff for bed mobility, dressing, eating, toilet use and personal hygiene. Further review of the MDS revealed the Resident was at risk of pressure ulcers and did not have a pressure ulcer on readmission into the facility. A review of Resident medical record of EzGraphs (facility documentation for assessment and measurement of wounds) and Progress Notes regarding wound assessments revealed the following: -Dated 9/12/22, Skin/Wound Note, Writer into resident room and noted on mid lower back 3 cm x 2 cm bruised area with small opening. Writer applied betadine wipe and will place order for betadine wipe for 7 days. Will continue to monitor with daily cares. -Dated 9/14/22, Skin/Wound Note, Writer into resident's room and noted open area on left buttock 1 cm x 2 cm. No drainage or bleeding noted. Writer will place order for z guard to buttock for 7 days. Will continue to monitor with daily cares. -Dated 9/19/22, Skin/Wound Note, CNA (certified nursing assistant) notified writer that resident with an open area to coccyx. Writer in to resident's room to assess. Resident with an open area to coccyx measuring approx. 1.5 cm x 0.5 cm. Wound base is red, peri-wound is erythematous and edematous with blanchable redness and purple discoloration present . Writer did a Ez graph and place on physician board for eval d/t (due to) possible pressure ulcer to coccyx. Nursing will continue to monitor with daily cares. -Dated 10/13/22, Skin/Wound Note, Resident coccyx area Ez graph done. 7 x 12 x 3 cm, [7 cm of eschar tissue with tunneling at noon, 3, & 6] peri wound base is bright red non blanchable. At 6 pm 1.5 slough area, with a foul odor coming from wound/referring to DR (doctor) treatment is Not effective at this time, Will obtain clarification on turn schedule. Possible get OOB (out of bed) schedule. -Dated 10/14/22, Orders-Administration Note, .Writer obtained wound culture from coccyx. [NAME] colored drainage and strong odor noted Writer sent specimen with maintenance. -Dated 10/17/22, Skin/Wound Note, Wound on coccyx has opened up. Writer noted 5.5 cm x 3 cm x 1 cm. Wound has increased odor. Writer noted yellow drainage. Will refer to physician. Nursing will continue to monitor with daily cares. -Dated 10/17/22, Skin/Wound Note, EZ to coccyx. Writer in to assess. Coccyx wound measures 5.5 cm x 5 cm x 1 cm in depth. Undermining measuring approx., 2 cm noted to 7 -9 O clock, and 4 and 5 O clock. Wound base with moderate amount of tan slough, and soft brownish slough toward the coccyx crest. Pink coloration noted undermining edges. Blanchable erythematous and edematous noted to peri wound. Small amount of tan colored drainage to old dressing with strong odor. Resident with no c/o (complaints of) pain or discomfort during treatment. Writer will refer to physician for possible new treatment to area. Wound culture was obtained and result placed on physician board for eval. EZ refer to physician. -Dated 10/24/22, Skin/Wound Note, Writer in to resident's room to assess coccyx wound. Wound measures 4 cm x 5cm x2cm depth. Wound has thick gray slough in the center, with small amount of purulent drainage. Wound base is grey. Periwound is intact with irregular borders and is erythematous. Wound has a strong odor. Dressing performed as ordered. Will continue current treatment as currently ordered. -A review of the Treatment Administration Record (TAR) revealed an order to Perform EZ graph: Coccyx q (every) Monday, every day shift every Mon for Wound, Perform E-Z graph, eval tx (treatment) with a start date on 9/26/22. The EZ graph was not documented as completed on 9/26/22, 10/3/22 or 10/10/22. A review of the TAR of wound treatments for Resident #1's wound revealed the following: -Start Date on 9/12/22 and discontinued on 9/19/22 to apply betadine wipe to lower back open area once daily describe site. In the morning for cleanse mid lower back with betadine wipe once daily. Not documented as completed on 9/12/22 or 9/13/22. Review of the progress notes revealed a lack of daily monitoring documented. The wound description did not indicate the wound was on the coccyx and no EZ graph was found in the medical record. -Start date 9/14/22 and discontinued on 9/14/22, Place z guard on open area on eft buttock twice daily after soap and water wash. Two times a day . Completed on 9/14/22 at 9:00 AM. -Start date on 9/20/22 and discontinued on 9/22/22, Providone Iodine wipe to coccyx [open area] after Saline wipe wash AM [Pressure Ulcer Stage II] every day shift for Wound. Documented as completed on 9/20/22 and 9/21/22 and not documented as completed on 9/22/22. -Start date on 9/23/22 and discontinued on 10/13/22, Providone Iodine wipe to coccyx [open area] after Saline wipe wash cover with 3 x 3 hydrocellular dressing AM [Pressure Ulcer Stage II] every day shift for Wound. Documented as not completed on 9/24, 9/26, 10/3, 10/9, and 10/13. -Start date 10/14/22 and discontinued on 10/18/22, Providone Iodine wipe to coccyx [open area] flush open area with saline, pat dry with gauze, cover with 4 x 4 hydrocellular dressing apply bards wipe at the outer edge of wound bed, AM non stageable every day shift for Wound. Documented as not completed on 10/15 and 10/18. -Start date 10/19/22 and discontinued on 10/20/22, Flush open area on coccyx with Saline then dry thoroughly, cleanse with Betadine Wipe, apply bards wipe at the outer edge of wound bed then cover with 4 x 4 hydrocellular dressing every day shift for Wound, and ordered as needed. -Start date 10/21/22 and discontinued on 10/24/22, Calcium Alginate (opiticel) to fit inside coccyx wound, apply hydrogel, apply protective barrier wipe to peri wound, cover with 6 x 6 hydrocellular dressing every day shift every other day for wound. Not documented as completed on 10/21/22. -Start date 10/25/22, Calcium Alginate (opiticel) to fit inside coccyx wound, apply hydrogel, apply protective barrier wipe to peri wound, cover with 6 x 6 hydrocellular dressing every day shift every other day for wound, and ordered as needed. A review of Resident #1's culture and sensitivity for the wound on the coccyx revealed the following: -Gram Stain Many Gram Positive CoccI, Multiple Morphologies Present, Moderate Gram Positive Bacilli, Moderate Gram Negative Bacilli -Isolate 1 few Escherichia coli -Isolate 2 Many Proteus mirabilis -Culture, Anaerobic ***Canceled*** The Resident was started on Ceftriaxone on 10/17/22 to 10/26/22. The progress note on 10/24/22, documented the wound assessment with signs and symptoms of continued infection, .Wound has thick gray slough in the center, with small amount of purulent drainage. Wound base is grey. Periwound is intact with irregular borders and is erythematous. Wound has a strong odor . There was a lack of further evaluation of the wound from 10/24/22 until transfer to the hospital on [DATE]. A review of Resident #1's Temperature Summary in the medical record revealed the Resident had a temperature recorded on 10/29/22 at 1:11 PM of 100.5 degrees Fahrenheit; 10/31/22 at 2:32 PM of 99.4 degrees Fahrenheit; 10/31/22 at 5:17 AM of 100.9 degrees Fahrenheit; and 11/1/22 at 12:19 AM of 103.1 degrees Fahrenheit. Further review of Resident #1's Progress Notes revealed the following: -Dated 11/1/22 at 1:41 AM, Temp re check - 99.1 v/s 128/68, P (pulse) 93, 98% resp 22, resident had elevated temp 103.1 Rapid Covid test negative at this time. Resident appears to have increase edema. Writer called DTR (daughter) r/t (related to) change dtr requesting resident to be sent to (hospital name) . -Dated 11/1/22 at 1:59 AM, Communication - with Physician, Situation: elevated temp; Background: possible septic; Assessment (RN)/Appearance (LPN): wound infection completed ABT (antibiotics); Recommendations: Send to (hospital name) per DTR request. A review of Resident #1's hospital records revealed the following: -Emergency Documentation dated 11/1/22, revealed, .Assessment/Plan 1. Sacral decubitus ulcer, 2. Sepsis, 3. Hyperglycemia, 4. Cellulitis of buttock . History of Present Illness: . Blood sugar noted to be above 600 per EMS (ambulance) .sacral decubitus ulcer with significant surrounding erythema, wound containing apparent necrotic tissue, fetid smell and drainage. Wound is noted to be emanating bubbles of gas upon palpitation . significantly dehydrated and hyperglycemic . -CT Chest/abdomen/pelvis without contrast, dated 11/1/22, Impression: 1. Sacral decubitus ulcer with soft tissue air tracking along the right gluteal musculature and right pelvic floor musculature. Additionally there is osseous demineralization and or erosive change of the underlying sacrum which could relate to osteomyelitis . -Consultation Notes, dated 11/2/22, revealed, .Evaluation of sacral wound on arrival reveals an approximate 15 cm (centimeter) x 20 cm and the sacral bone is visible at the base of the ulcer with necrotic skin subcutaneous tissue and muscle at the edges smelling sacral decubitus ulcer with significant surrounding erythema, wound containing apparent necrotic tissue, fetid smell and drainage -Consultation Notes, date 11/2/22, Addendum, revealed, .size of the decubitus ulcer and the depth making it a stage IV decubitus ulcer 15 x 20 before any debridement and that it will need at least 1 surgical debridement prolonged wound dressing changes eventually the patient will need either a surgical flap done by plastic surgeon or a skin graft and there is a very good chance that the patient might require a diverting loop ileostomy as the patient had a stroke and is not mobile and unable to control her bowel function the diverting stoma is to help with wound care management. The daughter decided to make her mom comfort measures only she stopped the IV antibiotics stop tube feeds and no surgical intervention . On 2/17/23 at 10:05 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #1's facility acquired pressure ulcer. A review of Resident #1's medical record with the DON revealed question as to the origination of the pressure ulcer with the documentation on 9/12/22 of mid lower back 3 cm x 2 cm bruised area with small opening or on 9/14/22 of open area on left buttock 1 cm x 2 cm and no Ez graph completed with further location and description. When asked if the Resident had multiple wounds, the DON was unsure. When asked about the order, dated 9/12/22, to monitor site daily, the DON, after review of the medical record, indicated a lack of assessments and EZ graphs. Treatment changes and treatments documented as not completed were reviewed with the DON. When asked about the change in the dressing on 10/21/22 of Calcium Alginate, hydrogel, barrier wipe and cover with 6 x 6 and the assessment of the wound to signifying the need to change the dressing, the DON stated, I don't see anything but on 10/17 for the physician to review. The wound culture was reviewed with the DON. The culture documented results reported on 10/16/22 at 10:30 AM, but the physician had not ordered the antibiotic until 10/17/22. When asked if the physician had been contacted on 10/16/22 of the culture results, the DON indicated that staff would have to log into the lab portal to get the results and did not know why the physician had not been called on 10/16/22. The DON was queried regarding the infected pressure ulcer, the Resident on antibiotics with expected improvement within 72 hours of antibiotic therapy, and further review of the medical record revealed a lack of assessment after the completion of the antibiotic therapy. The DON stated, I am not seeing assessment until (11/1/22) the 103 temperature, with mention of wound infection and a set of vital signs prior to transfer to the hospital. On 2/17/23 at 3:35 PM, an interview was conducted with the Infection Control Preventionist (ICP), Nurse H regarding Resident #1's facility acquired pressure ulcer. When asked about doing wound cultures, the ICP indicated that for a wound culture, an aerobic and anaerobic cultures were done and was unsure why the anaerobic culture had been canceled. The ICP indicated that another wound culture should be sent right away. The ICP Nurse indicated she was not made aware that the Anaerobic culture had been canceled. When asked about ongoing assessments, the ICP indicated Nursing staff should assess and monitor for sepsis with wound infection. When asked about Resident #1's elevated temperature on 10/29/22, the ICP indicated that usually 100.4 and over an assessment was to be completed to monitor for urinary tract infection by completing a UA (urinary analysis), Covid testing, and assess the wound knowing antibiotics were finished. The ICP indicated that monitoring improvement of infections and reactions to antibiotic use would include documentation of the assessment of the wound, appearance, and drainage, every time they look at the wound. On 2/17/23 at 4:00 PM, an interview was conducted with Unit Manager J regarding Resident #1's pressure ulcer and elevated temperatures. The Unit Manager indicated she was aware there were holes in the weekly assessments that were not done and a lack of wound assessment after the completion of antibiotic to determine change and/or worsening of the wound. A review of the facility policy titled Pressure Ulcer Monitoring Protocol, revealed, . 4. Weekly the Charge nurse will assess the pressure ulcer by measuring it using the clear size graph which is part of the 2 part EZ graph system. Once the wound is traced on the graph and assessed, the plastic backing will be peeled off the back of the graph and then placed onto the paper part of the EZ graph. The nurse will complete the wound assessment sheet in its entirety by filling out the EZ graph paper part of the system . 6. ICN (Infection Control Nurse) compiles a list of all residents with current pressure ulcers and distributes this list weekly to the interdisciplinary team. Each team member will review the resident's current pan of care as it relates to their specialty and make any necessary changes. 7. Monitoring of progress: A clean pressure ulcer with adequate intervention and blood supply should show evidence of some healing within 2-4 weeks. If no progress can be demonstrated, the physician should reevaluate the adequacy of the overall treatment plan as well as staff and resident adherence to this plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physical restraints were not utilized for staff convenience and to unnecessarily inhibit freedom of movement for one resident (Resident #85) of two residents reviewed, resulting in failure to comprehensively assess, classify, and document restraint use, application and utilization of a restraint for a cognitively and physically impaired resident, lack of informed consent, and the likelihood for knowledge deficiency related to risks, physical discomfort and psychosocial distress utilizing the reasonable person concept. Findings include: Resident #85: Record review revealed Resident #85 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included anxiety, hearing loss, repeated falls, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood, displayed no behaviors, and required limited to total assistance to perform Activities of Daily Living (ADLs) with the exception of being independent with eating. The MDS assessment further revealed the Resident had two falls, one without injury and one with injury, and bed and chair alarms were utilized daily but did not have a restraint. During entrance conference with the facility Administrator on 9/19/22 at 10:59 AM, State survey staff were notified the facility had transitioned to a new Electronic Medical Record (EMR) system on 9/1/22 and resident medical records were located in both the prior and new EMR systems. On 9/19/22 at 12:24 PM, Resident #85 was observed sitting in their wheelchair at a table in the dining room area of the unit. Multiple residents were in the area waiting for lunch service. A chair alarm and lap buddy (firm foam device attached to the wheelchair and positioned in front of the abdomen and over the legs) were noted on the wheelchair. A soft cervical collar brace was present on the Resident's neck. While the Resident was sitting at the table, Licensed Practical Nurse (LPN) O was observed administering the Resident's medications but did not assess the lap buddy. After passing medications, LPN O exited the locked facility unit leaving one staff member (Certified Nursing Assistant [CNA] P) on the unit. At 2:23 PM on 9/19/22, Resident #85 was observed sitting in their wheelchair in the same position, with the chair alarm and lap buddy in place, at the table in the dining room. The Resident had a soft cervical collar brace in place. An interview was completed with Certified Nursing Assistant (CNA) P at this time. When queried regarding Resident #85's soft cervical brace, CNA P revealed (Resident #85) fell and broke their neck. When queried why the Resident had the lap buddy on their wheelchair, CNA P replied, So they won't get up. CNA P was then asked if the Resident was able to remove the lap buddy independently, CNA P replied, (Resident #85) won't. They are 104 (years old). On 9/20/22 at 8:00 AM, Resident #85 was observed in their room in bed. The Resident was positioned on their right side with their eyes closed. Their soft cervical brace was visibly soiled and sitting on the windowsill in the room. Resident #85's wheelchair was sitting in the room and was observed to have a pommel cushion (cushion with a square, raised wedge in the front keeping legs separating and limiting forwarding motion) on the seat. The lap buddy was next to the wheelchair. A paper [NAME] (bedside care guide), toileting schedule, and turning schedule were present on the end of the Resident's bed. Review of the bedside [NAME] revealed the following: - Safety: Lap Buddy; release, toilet, shift position/ROM (Range of Motion) every two hours (specify) [sic] - Orthotic to: May remove soft C-Collar (cervical brace) for bathing, eating, or laying still in bed. Must wear if up walking - Pommel cushion to wc (wheelchair) with posey grip (anti-slip material) above and below cushion The bedside turning schedule did not include documentation of repositioning/ROM and/or releasing the lap buddy when the Resident was up and not in bed. Review of the bedside toileting schedule for Resident #85 detailed: - 9/14/22: 9:30 AM- Dry - 9/15/22: 12:00 AM- Void, 2:00 AM: Void, 4:00 AM: Dry, 6:00 AM: Dry, 9:00 AM: Dry/BM - 9/16/22: 6:30 PM- Dry/BM/Bathroom, 9:30 PM- Dry/Bathroom - 9/17/22: 12:00 AM- Incontinent/Void, 2:00 AM: Incontinent/Void, 9:30 AM- Dry - 9/18/22: 4:00 AM- Incontinent/Void, 9:45 AM: Incontinent/Void/BM, 9:30 PM- Incontinent/Void - 9/19/22: 4:00 AM: Incontinent/Void At 9:07 AM on 9/20/22, a care observation for Resident #85 occurred. CNA R was assisting the Resident to sit up in bed and ambulate with their walker at this time. CNA R did not place the cervical collar on the Resident prior to assisting them to sit up. CNA R asked the Resident to reach for and hold the walker handles and to stand without the cervical collar in place. At this time, CNA R was stopped and queried regarding the Resident's level of assistance required and required assistive devices including the soft cervical collar. CNA R indicated they were attempting to get the Resident situated prior to putting the collar on. CNA R proceeded to look in the Resident's drawers before locating the cervical brace on the windowsill. CNA R then placed the cervical collar on the Resident. CNA R was asked why the Resident had both a pommel cushion and a lap buddy. CNA R revealed Resident #85 had the pommel (called saddle) cushion on their wheelchair for a while, but the lap buddy was new. When queried how the lap buddy worked, CNA R revealed the device was not easy to place as the foam on the edges had to be fit in between the metal sides/arm rests of the wheelchair. When asked why Resident #85 had the lap buddy, CNA R indicated the Resident tries to get up by themselves and the lap buddy stops them. When asked if Resident #85 was able to ambulate, CNA R revealed the Resident was able to ambulate with a walker and one assist. CNA R was then asked if the Resident was receiving therapy and/or restorative services and revealed they were unsure. Review of Resident #85's current care plan in the new EMR system revealed the Resident did not have a care plan in place related to use of a lap buddy. A care plan entitled, Care Tasks (Initiated: 8/5/22) was present in the EMR. This care plan included the following interventions: - Ambulate: One assist with gait belt and Four wheeled walker (Initiated: 8/5/22) - Anti roll back device to W/C (Wheelchair) (Initiated: 8/5/22) - Anti tip bars to W/C (Initiated: 8/5/22) - Concave mattress to bed for positioning (Initiated and Revised: 8/5/22) - Gripper socks: On when in bed, shoes on when up (Initiated and Revised: 8/5/22) - Gripper strips at/to: Right side of bed, middle of bed. Bathroom in front of sink, toilet and shower (Initiated and Revised: 8/5/22) - Please keep closet door locked with child lock at all times (Initiated and Revised: 8/5/22) - Pommel cushion to w/c with posey grip above and below cushion (Initiated and Revised: 8/5/22) - Speak loudly and clearly to residents' ear as is hard of hearing (Initiated and Revised: 8/5/22) - Toilet seat with bilateral arms (Initiated: 8/5/22) - Transfer bar to right side of HOB (Head of Bed) (Initiated: 8/5/22) - Transfer: One assist with gait belt with two wheeled walker (Initiated and Revised: 8/5/22) Review of Resident #85's ADL / Safety Care Plan in the prior EMR included the following approaches/ interventions and dates: - Toilet seat with bil. (bilateral) arms for support (11/3/14) - Gripper Socks on when in bed , shoes on when up (6/6/16) - Gripper Strips at/to: Right side of bed, middle of bed and in bathroom in front of sink, toilet and shower (3/21/18) - Chair Alarm to all chairs with posey grip above and below pad Change pad annually and prn (as needed) (4/15/19) - Anti tip bars to w/c (wheelchair) (3/5/21) - Anti roll back device (3/11/21) - Bed Alarm set @ 1 second interval Change pad annually and prn (5/26/21) Review of Resident #85's Progress Notes in the EMR's revealed the following: - 3/20/22 at 10:02 AM: FAMILY/RESPONSIBLE PARTY notified . of 2nd fall last night, (family) asked writer why resident would keep falling from wheelchair and if they had been restless, writer notified (family) that although writer was not here at the time of the incident it is noted resident was restless and attempting to stand up, (family) asked the writer 'since (Resident #85) is so confused, for their safety, is there any way you can kind of strap them into it?' Writer educated (family) on the inability to strap (resident) in d/t (due to) that being considered a restraint which we cannot do, writer did educate (family) on the option of a lap buddy or an alarming Velcro seatbelt for which resident has an eval in place for from therapy to eval if that is appropriate for the resident, (family) said would discuss it further with (Resident son) later this afternoon. Writer notified (family) that we would be completing a UA (urinalysis) as well to r/o (rule out) infectious process as a cause for restlessness . - 8/8/22 at 9:44 AM: Interdisciplinary Care Conference Review . Reviewed plan of care . Resident is . alert, confused . Resident is a participant in some unit activities, is cooperative and pleasant . requiring extensive to total assist with ADL functions, transfers and ambulates with 1 assist, gait belt and 2 wheeled walker . also has a w/c for long distances had a fall on 7/8/22 no apparent injury reported, has a bed alarm and chair alarm in place due to attempts to get up on own and falls . - 9/9/22 at 9:00 PM: Health Status Note: Resident returned to facility from visit post fall. Resident noted to have order for c collar to be in place at all times and off only to wash No further nurses' notes in either EMR systems addressed the lap buddy. The EMR did not include any nursing assessments related to implementation, utilization, and/or assessment of the lap buddy. Further review of Resident #85's EMR's revealed no documentation of consent for lap buddy/restraint use and/or advance directives/legal representative. Review of Resident #85's Health Care Provider Orders revealed the active orders in the new EMR system, Renew any previously signed restraint orders which have not been discontinued (7/8/22) Review of Resident #85's CNA POC (Point of Care) Response History documentation for the past 30 days revealed the task, Lap Buddy; release, toilet, shift position/R.O.M. every 2 hours (Specify) (sic). The task began on 9/12/22. Detailed review revealed the following documentation of completion: - 9/12/22 at 6:42 PM - 9/13/22 at 2:30 PM, and 7:23 PM - 9/14/22 at 2:52 AM, 2:19 PM, and 9:44 PM - 9/15/22 at 12:50 AM, 2:22 PM, and 6:25 PM - 9/16/22 at 11:52 AM and 9:30 PM - 9/17/22 at 1:07 AM, 11:44 AM, and 8:38 PM - 9/18/22 at 12:20 AM, 10:51 AM, and 8:20 PM - 9/19/22 at 5:47 AM, 1:46 PM, and 8:55 PM - 9/20/22 at 12:49 PM An interview was conducted with Social Services Director U on 9/21/22 at 9:44 AM. When queried regarding Resident #85's cognition and advance directives, Social Services Director U revealed they had worked at the facility less than two weeks and would need to review the EMR. Director U stated they would follow up with requested information. On 9/21/22 at 10:50 AM, Resident #85 was observed in the TV room of the unit. The Resident was sitting in their wheelchair with the soft neck brace in place and the lap buddy restraint in place in their wheelchair. An overbed table was in front of the Resident and they were eating ice cream. No staff were present in the area. When asked questions, Resident #85 made eye contact but did not provide appropriate and/or related responses. At 11:05 AM on 9/21/22, an observation of Resident #85 occurred in the TV/Dining room area of the unit. The Resident was sitting in their wheelchair with the lap buddy and chair alarm in place. There were no staff visible in the area. Resident #85 was pleasantly confused when asked questions. When asked if they could remove the lap buddy on their wheelchair, Resident #85 responded Yes but did not remove the lap buddy. This Surveyor then pointed to the lap buddy and asked Resident #85 if they would remove it, Resident #85 replied, Yes and began touching the lap buddy. The Resident proceeded to touch the lap buddy. The Resident brushed food crumbs off the top and then reached to the zipper on the edge and unsuccessfully attempted to unzip the waterproof nylon style cover. Resident #85 then began pulling at the sides and pulling up on the lap buddy but was unable to remove the restraint. An interview was completed with Therapy Director X on 9/21/22 at 12:14 PM. When queried if Therapy services typically evaluate use of assistive devices including pommel cushions and lap buddies, Director X replied, Yes. When queried regarding Resident #85's pommel cushion, Director X reviewed the EMR and stated, Recommended on 5/31/22. When queried regarding the reason for the pommel cushion, Therapy Director X indicated it was recommended due to positioning. When queried regarding Resident #85's lap buddy, Director X revealed Therapy had not evaluated the Resident for the appropriateness of a lap buddy and stated, Not referred to us (therapy). When queried why Therapy would not evaluate for appropriateness, Director X was unable to provide an explanation. With further inquiry regarding Resident #85's lap buddy, Director X stated, We should not use them (lap buddy) as restraint. On 9/21/22 at 3:37 PM, a second interview was completed with Social Services Director U. When asked about Resident #85, Social Services Director U stated, (Resident #85) has not had a legal decision maker in place since admission. Director U was asked to clarify if they were saying the Resident had not had any type of legal representation for medical decisions in place since their initial admission date in 2013, Director U verbalized confirmation. When asked if the Resident was cognitively intact when they were originally admitted to the facility, Director U revealed the Resident had been severely cognitively impaired since admission in 2013. When queried, Director U indicated the Resident was unable to make their own medical decision. When asked who was making medical decisions for the Residents as they had a DNR (Do Not Resuscitate) order in place, Director U revealed facility staff had been contacting one of the Resident's children who was listed as an emergency contact. Director U revealed they contacted one of Resident #85's emergency contacts (one of their children) to inform them that legal representation needed to be established and that the Resident's code status had been changed to a full code. An interview was conducted with the facility Administrator and Director of Nursing (DON) on 9/21/22 at 4:39 PM. When queried if Resident #85 would be able to remove the lap buddy due to their cognitive status, both the DON and Administrator stated the Resident would not. When asked if the lap buddy was a restraint, the DON and Administrator both confirmed the device was a restraint. The Administrator stated, (Resident #85) does not have the (cognitive) capacity to remove (the lap buddy). When queried regarding facility policy/procedure related to consent for restraint use and legal representation for residents who are unable to make their own medical decisions, the Administrator verified Resident #85 should have a consent but did not. The Administrator stated, Does not have a consent and did not have a legal guardian (representative) to sign one. The Administrator revealed the situation would be corrected but were unable to provide further explanation. An interview and record review were conducted with the Director of Nursing (DON) on 9/22/22 at 8:46 AM. When queried regarding the reason Resident #85 had the lap buddy implemented and lack of actual order in the EMR, the DON reviewed the EMR and Incident and Accident Reports for the Resident. The DON stated the lap buddy was implemented on 9/12/22 following the Resident's fall with cervical spinal fracture (neck). An interview was completed with Registered Nurse (RN) T on 9/22/22 at 8:46 AM. When queried regarding Resident #85, RN T revealed they had been working when the Resident fell and suffered a fracture. When asked, RN T revealed Resident #85 was a high risk for falls. RN T was queried regarding interventions in place to prevent falls. RN T revealed the Resident had alarms in place and stated, (Resident #85) also had the pummel cushion to stop them from getting up. When asked about the lap buddy, RN T revealed that was implemented after the fall to stop the Resident from getting up by themselves. A facility policy/procedure related to restraints was requested from the facility Administrator on 9/20/22 at 4:29 PM but not received by the conclusion of the survey. Review of facility provided policy/procedure entitled, Resident Rights & Responsibilities (Revised 1/20/19) revealed, Policy . 5. Respect and dignity. The resident has a right to be treated with respect and dignity, including a. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #113: On 09/19/22 at 10:35 AM Resident #113 was observed in her room sleeping in bed. Nasal cannula was noted on resident's face. Room was clean, no excess clutter or furniture was noted. 09/20/22 at 09:45 AM Resident #113 was observed in her room sleeping in bed, positioned flat on her back. Call light in reach. A record review of the Face Sheet and MDS assessment indicated the Resident #113 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses: Cerebral infarction (stroke), Dysphasia (difficulty swallowing) following cerebral infarction, Hypertension, Asthma, Type 2 Diabetes Mellitus, Atrial Fibrillation, Anemia, Acute respiratory failure with hypoxia, gastrotomy status, History of falling, Alzheimer's disease, Muscle weakness, Convulsions, presence of cardiac pacemaker. The MDS admission assessment dated [DATE] indicated Resident #113 had severely impaired cognitive abilities, with BIMS score 3/15, and needed assistance with daily care, transfers, and toileting. On 09/21/22 at 11:23 AM during interview with Unit Manager, Registered Nurse L, she was asked about Resident #113 and her stay in a facility. Nurse L stated that resident had a change in condition on 07/19/22 after she suffered a fall from a wheelchair. Resident had to be hospitalized . After resident returned from hospital on [DATE], she had to be hospitalized again on 07/23/22 with a diagnosis of stroke. Resident #113 returned to facility on 08/10/22 with a significant decline in condition. Resident is staying in bed all the time and is hard to arouse. She is totally dependent on staff assistance for moving and repositioning. Review of Resident #113's record revealed the following documentation: Nursing note dated 06/11/2022- Type of Event: fall. Description of event: Writer called to Northeast Hall from North Hall. Observed resident on floor, in front of couch, legs out in front or resident, back partially against couch, no c/o (complaints of) pain, no injury noted, resident was attempting to sit on couch, slipped, hit back of head on a table, and fell to the floor. Injury: no apparent injury. Range of motion check: moves all extremities, no c/o pain. Neuro checks: (immediately after) Bilateral hand grasp firm, due to light unable to assess pupil dilation, checked in 10 minutes with position change, PERL, Neuro's remained WNL (within normal limits), remained of shift. Care Given/ First Aide Given: Ice offered; resident refused. Vitals: Immediately After: Blood Pressure 184/98 Pulse 85 Respirations 18 Temperature 98.5 SPO2 99 % Via RA Blood Sugar 143. 3 minutes after: Blood Pressure 158/76 Pulse 95 Respirations 20 Temperature 98.5. 10 minutes after: Blood Pressure 128/80 Pulse 80 Respirations 18 Temperature 98.5 Nursing note dated 07/18/22- Resident #113 has history of fall prior to admission to facility. Staff charting resident can be oriented and disoriented at the same time. Possible increase in tiredness with sliding off the couch and chair. Could be increased weakness. Resident is working with skilled PT and OT (physical and occupational therapy) at this time, may see increase in in strength and endurance, will continue to monitor with cares. Nursing note dated 07/19/22 at 11:41 PM- Resident #113 was sitting in a wheelchair in hallway watching TV and staff observed resident on the floor. Resident was in prone position in front of the wheelchair. Writer noted blood on the head and floor. Resident stated, get me up. Resident with complaints of pain but would not answer writer when asked where pain was. Resident noted to have 4 cm crescent-shaped skin tear on top of right hand. Writer noted above right eye resident with edema and bruising. Writer cleansed blood on head. No catastrophic reaction. Resident was sent to hospital and when EMS attendant assisted resident up resident complained of pain to right leg. Nursing re-admission note dated 07/22/22 at 01:30 PM had the following: Patient is an [AGE] year-old female with a history of dementia. Patient is at neurologic baseline, but unable to provide history. Patient was found on a ground (In a nursing facility), was found to have swelling over the right eye and shortened rotated right leg, unknown downtime. Patient brought into emergency room. Patient had a complete work-up which included CT (computer technology to produce images of the inside of the body) of the head and CT of the spine which were negative for any acute processes. Chest x-ray did not reveal any acute processes. Laboratory work-up revealed hyponatremia (low levels of sodium in the blood). X-ray of the right hip revealed committed intratrochanteric (break of the femur between the greater and the lesser trochanters) fracture of her femur. Patient was being admitted for further evaluation management and possible ORIF (open reduction internal fixation surgery). On 07/20/22 patient (Resident #113) underwent intramedullary rodding (orthopedic surgery during which a metal rod inserted through the canal of the femur along the femoral shaft to stabilize femur fracture) , tolerated the procedure well and without complication. Postoperatively, she was evaluated by physical and occupational therapy, SNF (skilled nursing facility) was recommended. She was otherwise stable for discharge. There was a return to facility note dated 07/22/22 at 04:38 PM: Via EMS at 4 PM resident placed in bed. She is essentially unconscious, only groaning with repositioning. There is no response to voice and minimal response to gentle tactile stimulation. Primary surgical dressing located on right hip. Nursing note dated 07/23/22 at 11:49 PM had the following: Writer down to resident's room for assessment and noted resident to be lethargic with shallow breathing. Writer also noted resident to have death rattle heard by writer and other staff. Resident has had no oral intake this shift and was reported to have none on day shift. Writer went into resident's hard chart to look at advanced directives and noted resident to be a Full Code status. At that time writer attempted to place a call to resident's daughter x 3 with no answer. Writer placed call to physician who gave orders to send resident to Emergency room. EMT arrived to take resident to the hospital. On 08/10/22 Resident #113 returned from the hospital. Nursing note dated 08/10/22 at 02:50 PM had the following documented: Resident returned to facility after she was admitted to hospital with CVA (stroke) affecting her right side. Resident returned to facility with PEG tube, which she is not tolerating well. Resident also returning with following diagnosis: acute encephalopathy (inflammation of the part of the brain), dysphasia (inability to swallow), acute hypoxic failure, acute cystitis, tube feed intolerance, anemia, and A-fib (atrial fibrillation). Review of Resident #113's Care Plan revealed the following: 06/06/2022 PROBLEMS/STRENGTHS Potential for falls or injuries secondary to History of falling, Osteoarthritis, Gout, Mod disorder, Major depressive disorder, Alzheimer's, and Dementia with potential for cognitive decline and the effects this may have on safety awareness. STANDARDIZED APPROACHES section was not filled. GOAL(S): Will not experience serious injury from fall. Eval q (every) 3 months STANDARDIZED APPROACHES section was not filled. No other goals/interventions were documented regarding resident's risk for falls in ADL/Safety Care plan. No updates to Care Plan or new interventions were found after Resident #113's falls on 06/11/2022 and 07/19/22. Fall Risk Assessment Policy revised on 02/01/18 was provided and reviewed. Policy indicated the following: To provide staff an appropriate assessment of a fall risk on admission, thus decreasing the possibility of fall incidents for all residents when possible. Policy Interpretation and Implementation 1. On admission, the Interdisciplinary Team headed by the Floor Coordinator, will obtain a medical history, medication profile, and a fall history from the resident and/or family during their admission review meeting. The Physical Therapist, and/or Occupational Therapist, along with the Restorative Nursing R.N. Supervisor and the Charge Nurse and/or Floor Coordinator will screen the resident for transfer and ambulation abilities and any safety needs and develop a plan of care based on their assessment. These orders will be obtained in accord with their written assessment. 2. Then, Quarterly and with any Significant Change in Status assessment thereafter, the MORSE fall risk assessment will be completed in ECS by the Restorative Nursing R.N. Supervisor on every resident. 3. The assessment will be scored as directed under each topic area of risk. 4. When completed and saved the total will be calculated automatically and the assessment including score will be saved into the resident's chart as well as the neuromuscular/skeletal care plan. 5. A score of 0-24 indicates no risk, 25-50 is low risk and 51 or higher represents high risk for falls. An individualized, preventative plan of care will be developed and initiated for each resident regardless of score. Resident #47: On 9/21/22, at 8:50 AM, Resident #47 was sitting in the dining room eating breakfast. Resident #47 had numerous dry scabbed skin tears to their bilateral hands. Resident #47 lifted their sleeve and stated, I did have a real big one up here and then pulled their sleeve down trying to cover the skin tears on their right hand. On 9/21, at 1:30 PM, a record review of Resident #47's electronic medical record revealed an admission on [DATE] with diagnoses that include Dementia with behavioral disturbances, Epilepsy, and chronic kidney disease. Resident #47 has severely impaired cognition and required extensive assistance with Activities of Daily Living. A review of the incident and accident reports, physician orders and progress notes provided by the facility revealed the following: 05/10/2022 Type of Event: skin tear laceration . 08/10/2022 . skin tear . 08/17/2022 . noted resident propelling w/c (wheelchair) and getting stuck between peer w/c . 08/29/2022 . skin tear right forearm and top of right hand . 08/31/2022 . abrasion left wrist . A review of both electronic medical record care plans for falls/injuries revealed the following: PROBLEMS/STRENGTHS Potential for falls or injuries secondary to ANXIETY DISORDER, BIPOLAR DISORDER, OSTEOARTHRITIS, EPILEPSY, DORSAGLIA, DEMENTIA WITH POTENTIAL COGNITIVE DECLINES CAUSING DECREASED SAFETY AWARENESS. GOAL (S): Will not experience serious injury from fall . APPROACHES Monitor for changes in transfer ability which may indicate either more independence or more support from staff . Keep call light within easy reach for resident . Focus Care Task Date Initiated: 08/08/2022 Goal To remain at my highest functional ability as possible and to continue with my plan of care in the safest manor possible Date Initiated: 08/08/2022 Target Date: 09/14/2022 Interventions . Transfer: Two assist standup lift Date Initiated: 08/08/2022 . There were no interventions initiated to aide or protect in residents hands and arms from the skin tears and abrasions. On 9/22/22, at 09:26 AM, an observation of CNA Y assisting Resident #47 with toileting was conducted. CNA Y propelled Resident #47 into the bathroom in their wheelchair then stopped and read the bedside care plan. CNA Y then left out of the room and returned with an easy lift and commode. CNA Y hurriedly assisted Resident #47 into the easy lift sling and moved the easy lift machine into place in front of the resident. CNA Y removed the Velcro seat belt and began to lift the resident while the resident had a hold of their wheelchair wheels. Resident #47 began yelling STOP! STOP! You're breaking my arms. CNA Y stopped the lift and assessed the sling placement, seat belt and motioned that they were going to begin lifting the resident again. CNA Y was asked to stop as the resident was still holding onto the wheels. CNA Y then placed Resident #47's bilateral hands on the grab bars on the easy lift, lifted the resident onto the commode. Once the resident was sitting on the commode, CNA H entered and offered their assistance. CNA H assisted CNA Y with placing Resident #47 back into their wheelchair. CNA H was asked if Resident #47 required one or two persons assist with the easy lift and CNA H stated, she tends to get agitated so two people are required. CNA Y was asked why they used the easy lift alone and CNA Y stated, that the resident was new to them. On 9/22/22, at 12:28 PM, the Director of Nursing (DON) was interviewed regarding Resident #47's incident and accident reports. The DON was asked if they implemented any intervention to aide in the decrease of the amount of skin tears Resident #47 had sustained and the DON stated, she has lotion ordered for her skin. The DON was asked if they had ever considered protecting her hands with gloves or having her wear longer sleeved clothing and the DON stated, maybe she would do good with geri-sleeves (protect the upper extremities from abrasions, bruises, snags and tears throughout the day) or derma sleeves (protects fragile skin and reduces shear) . The DON stated, they would implement the intervention and place the order. The DON was alerted of the easy lift transfer with CNA Y and was asked regarding the transfer status and the DON offered that we have people that are a 2 assist transfer to protect them. The DON further offered the CNA Y needs to be reeducated. A review of the Stand up Lift Use Policy Revised: 12/04/2019 revealed . Explain the procedure to the resident . Have the resident hold the lift handles . Resident #121: A review of Resident #121's medical record revealed an admission into the facility on 8/10/22 with diagnoses that included cerebral atherosclerosis, fracture of left femur, cerebral atherosclerosis, dementia, anxiety disorder, depression, pain in left hip, retention of urine, constipation, low vision right eye, blindness left eye and history of falling. A review of the Minimum Data Set assessment, dated 8/17/22, revealed, the Resident had severely impaired cognition and needed extensive assistance with activities of daily living that included bed mobility, transfers, dressing, and personal hygiene and needed two-person physical assist with extensive assistance for toilet use. On 9/19/22 at 12:52 PM, an observation was made of Resident #121 sitting in her wheelchair in the dining area. When asked questions, the Resident did not answer questions well and did not converse in appropriate conversation. A review of Resident #121's progress notes, the Resident had a fall on 9/4/22, was found in the bathroom and the Resident had reported to staff that she had crawled there. On 9/21/22 at 4:39 PM, an interview was conducted with Unit Manager, Nurse A regarding Resident #121's falls. The Unit Manager reviewed the fall and indicated she had the fall on 9/4/22 and that the Resident was found in the bathroom by staff, it was unwitnessed, the Resident had an alarm that was sounding that alerted staff to the room and reported there were no injuries documented. The Unit Manager was asked if neurological checks were to be completed. The Unit Manager reviewed the medical record and reported that it was an unwitnessed fall and indicated neurological checks were to be performed with an unwitnessed fall for a disoriented Resident, with neurological checks starting with every 15 minutes for the first hour and initiated right after the occurrence of the fall. The Unit Manager was unable to find the neuro checks in the medical record for 9/4/22 and reported an order to start on 9/7/22. The Unit Manager indicated he was off and did not come back until 9/6/22 and upon review, the neuro checks had not been ordered. When asked if the care plan had been updated, the Unit Manager indicated that the care plan had not been pulled over from the old system and that nothing in the old system would have been put into place after 9/1/22. The Unit Manager reviewed the medical record and indicated there was not a care plan for falls in the new charting system. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure adequate staffing levels and appropriate assessment and monitoring per professional standards of practice to prevent and mitigate falls including falls with injury, appropriate transfers, and ensure implementation of interventions to prevent skin tears for four residents (Resident #47, Resident #85, Resident #113, and Resident #121) of six residents reviewed, resulting in a lack of adequate supervision to prevent falls, lack of assessment and monitoring following falls, lack of investigation and documentation of falls with injury, Resident #113 suffering a fractured hip, Resident #85 experiencing a fractured cervical spine, and Resident #27 suffering a fractured hip, unnecessary pain, and the likelihood for decline in overall health status. Finding include: Resident #85: Record review revealed Resident #85 was originally admitted to the facility on [DATE] and most recently returned on 9/9/22 with diagnoses which included anxiety, hearing loss, repeated falls, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood, displayed no behaviors, and required limited to total assistance to perform Activities of Daily Living (ADLs) with the exception of being independent with eating. The MDS assessment further revealed the Resident had two falls, one without injury and one with injury, and bed and chair alarms were utilized daily but did not have a restraint. On 9/19/22 at 12:24 PM, Resident #85 was observed sitting in their wheelchair at a table in the dining room area of the unit. Multiple residents were in the area waiting for lunch service. A chair alarm and lap buddy (firm foam device attached to the wheelchair and positioned in front of the abdomen and over the legs) were noted on the wheelchair. A soft cervical collar brace was present on the Resident's neck. At 2:23 PM on 9/19/22, Resident #85 was observed sitting in their wheelchair in the same position, with the chair alarm and lap buddy in place, at the table in the dining room. The Resident had a soft cervical collar brace in place. An interview was completed with Certified Nursing Assistant (CNA) P at this time. When queried regarding Resident #85's soft cervical brace, CNA P revealed (Resident #85) fell and broke their neck. When queried why the Resident had the lap buddy on their wheelchair, CNA P replied, So they won't get up. On 9/20/22 at 8:00 AM, Resident #85 was observed in their room in bed. The Resident was positioned on their right side with their eyes closed. Their soft cervical brace was visibly soiled and sitting on the windowsill in the room. Resident #85's wheelchair was sitting in the room and was observed to have a pommel cushion (cushion with a square, raised wedge in the front keeping legs separating and limiting forwarding motion) on the seat. The lap buddy was next to the wheelchair. A two wheeled walker was also present in the room. A paper Kardex (bedside care guide), toileting schedule, and turning schedule were present on the end of the Resident's bed. Review of the bedside Kardex revealed the following: - Safety: Lap Buddy; release, toilet, shift position/ROM (Range of Motion) every two hours (specify) [sic] - Orthotic to: May remove soft C-Collar (cervical brace) for bathing, eating, or laying still in bed. Must wear if up walking - Pommel cushion to wc (wheelchair) with posey grip (anti-slip material) above and below cushion - Anti-roll back device to wc - Anti-tip bars to w/c - Concave mattress to bed for positioning - Gripper socks: On when in bed, shoes on when up - Ambulate: One assist with gait belt and four wheeled walker - Transfer: One assist with gait belt and two wheeled walker At 9:07 AM on 9/20/22, a care observation for Resident #85 occurred. CNA R was assisting the Resident to sit up in bed and ambulate with their walker. CNA R did not place the cervical collar on the Resident prior to assisting them to sit up. CNA R asked the Resident to reach for and hold the two wheeled walker handles and to stand without the cervical collar in place. At this time, CNA R was stopped and queried regarding the Resident's level of assistance required and required assistive devices including the soft cervical collar. When asked why the Resident had both a pommel cushion and a lap buddy, CNA R revealed Resident #85 had the pommel (called saddle) cushion on their wheelchair for a while, but the lap buddy was new and indicated they were to prevent the Resident from getting up so they would not fall. CNA R revealed the Resident tries to get up by themselves and the lap buddy stops them. When asked if Resident #85 was able to ambulate, CNA R revealed the Resident was able to ambulate with a walker and one assist. When asked if the Resident was supposed to have a two wheeled or four wheeled walker, CNA R gestured towards the walker in the room and indicated that was the only walker they were aware of the Resident using. CNA R was then asked if the Resident was receiving therapy and/or restorative services and revealed they were unsure. Review of Resident #85's current care plan in the new EMR system revealed the Resident did not have a care plan specifically related to falls and/or safety. A care plan entitled, Care Tasks . To remain at my highest functional ability as possible and to continue with my plan of care in the safest manor (sic) possible (Initiated: 8/5/22) was noted. This care plan included the interventions: - Ambulate: One assist with gait belt and Four wheeled walker (Initiated: 8/5/22) - Anti roll back device to W/C (Wheelchair) (Initiated: 8/5/22) - Anti tip bars to W/C (Initiated: 8/5/22) - Concave mattress to bed for positioning (Initiated and Revised: 8/5/22) - Gripper socks: On when in bed, shoes on when up (Initiated and Revised: 8/5/22) - Gripper strips at/to: Right side of bed, middle of bed. Bathroom in front of sink, toilet and shower (Initiated and Revised: 8/5/22) - Please keep closet door locked with child lock at all times (Initiated and Revised: 8/5/22) - Pommel cushion to w/c with posey grip above and below cushion (Initiated and Revised: 8/5/22) - Speak loudly and clearly to residents' ear as is hard of hearing (Initiated and Revised: 8/5/22) - Toilet seat with bilateral arms (Initiated: 8/5/22) - Transfer bar to right side of HOB (Head of Bed) (Initiated: 8/5/22) - Transfer: One assist with gait belt with two wheeled walker (Initiated and Revised: 8/5/22) Review of Resident #85's Progress Notes in the EMR's revealed the following: - 2/23/22 at 10:47 PM: Incident . Type of Event: Observed on Floor . Writer was in the hallway with back turned to the resident caring for another resident. Writer heard thump and turned around to observe resident laying on the floor next to wheelchair by the couch in the front of the hallway . lying on her left side in the fetal position. Writer got help and immediately got resident back into chair. Proceeded to do vitals and neuro checks. Contacted nurse supervisor who came and assisted in cleaning and applying steri strips to the wound on the back of the left hand about 5.5 cm across the back of hand. Skin was approximated into place with steri strips and covered. Head was looked at and no bumps or bruises were noted. Injury: skin tear Range of motion check: moves all extremities no c/o (complaints of) pain Neuro checks . - 2/26/22 at 1:52 AM: Follow up . Injury noted from fall . fall from 2/23 . Writer noted 4 cm (centimeter) x 6 cm bruise to middle of resident's forehead. Writer noted all of resident's neuro checks have all been WNL (Within Normal Limits) . also noted 7 cm x 8 cm bruise to top of resident's left hand. Steri-strips covering 6 cm skin tear to top of left hand . - 3/19/22 at 7:28 PM: Incident . fall . Writer was sitting in hallway with residents, resident was self-propelling self in wheelchair in hallway and stating wanted to go home. Resident wheeling self around, then resident abruptly leaned forward in wheelchair in attempt to stand but went forward instead, appearing to land on knees and then land on left shoulder. Resident did not hit head. Chair alarm did sound. ROM and neuro's normal. Resident yelling out Get me up! Get me up! Hospitality aide informed CNA to come down hall and assisted writer to help resident into wheelchair . no apparent injury . - 3/19/22 at 9:48 PM: Incident . fall . Writer notified by CNA that resident was on the floor. Writer down hall and notes resident in hallway, laying on left side near back door of hallway. Resident had been sitting near back door asking for it to be opened, resident appeared to have attempted to stand from wheelchair and fell. CNA was answering other alarm in room, and other CNA was in hallway with other residents. Resident with other fall just 2 hours prior, resident propelling self in w/c and stating needs to go home. Resident not agitated but very set on opening the door. Resident denies pain and denies hitting head, writer notes no redness to head. Left shoulder with some redness, left elbow with a red/light purple bruise starting to form 3 cm x 4 cm. Small abrasion noted to left hip 1 cm x 0.2 cm. Some redness to outer left calf noted . ROM and neuro checks normal. Injury: bruising scrape . - 3/20/22 at 3:25 AM: Skin Comments . Writer notes that left outer elbow with a bump formed and bruise darkened since several hours prior d/t fall, resident with pain on touch but not with ROM (Range of Motion) . - 3/20/22 at 10:02 AM: FAMILY/RESPONSIBLE PARTY notified . of 2nd fall last night, (family) asked writer why resident would keep falling from wheelchair and if they had been restless, writer notified (family) that although writer was not here at the time of the incident it is noted resident was restless and attempting to stand up, (family) asked the writer 'since (Resident #85) is so confused, for their safety, is there any way you can kind of strap them into it?' Writer educated (family) on the inability to strap (resident) in d/t (due to) that being considered a restraint which we cannot do, writer did educate (family) on the option of a lap buddy or an alarming Velcro seatbelt for which resident has an eval in place for from therapy to eval if that is appropriate for the resident, (family) said would discuss it further with (Resident son) later this afternoon. Writer notified (family) that we would be completing a UA (urinalysis) as well to r/o (rule out) infectious process as a cause for restlessness . - 5/8/22 at 5:40 PM . Incident . fall . Writer was on north hall in the dayroom and heard chair alarm start to go off on east hall, looked through partially opened divider to see resident in process of falling from slight standing position to floor. Resident landed on left hip and left elbow. Resident was just trying to stand from wheelchair. Resident did not hit head . redness to left hip, and redness to left elbow. Resident has minor bleeding from under fingernail of right middle finger. Resident denies pain. When asked what was trying to do stated I was trying to fix my pants. Injury: scrape, just redness on left elbow and left hip Range of motion check: moves all extremities . - 5/10/22 at 7:11 PM: BEHAVIOR: Writer notified that resident becoming agitated after dinner, resident stating needs to go home, attempting to stand from wheelchair multiple times. Resident raising voice at staff, attempting to hit at staff. Staff attempting food/fluids, toileting and redirection. Resident attempting to go to doors and yelling I gotta go home!. Writer spoke with (family) and asked about residents nighttime Xanax (anti-anxiety medication) being given, resident then did receive this and (family) stated Geri chair (wheeled reclining chair) could be used to prevent fall as resident trying to stand repeatedly . stating if Xanax not successful then she is fine with Ativan (antianxiety medication) SO (standing order) being used . - 7/8/22 at 11:02 PM: Incident . fall . Writer responded to chair alarm just in time to witness go from standing to falling on left side . did not hit head . states was trying to go home . - 8/2/22 at 9:44 AM: Interdisciplinary Care Conference Review . Reviewed plan of care . Resident is . alert, confused . Resident is a participant in some unit activities, is cooperative and pleasant . requiring extensive to total assist with ADL functions, transfers and ambulates with 1 assist, gait belt and 2 wheeled walker . also has a w/c for long distances had a fall on 7/8/22 no apparent injury reported, has a bed alarm and chair alarm in place due to attempts to get up on own and falls . - 9/9/22 at 9:00 PM: Health Status Note: Resident returned to facility from visit post fall. Resident noted to have order for c collar to be in place at all times and off only to wash Note: There was no assessment and/or progress note in the EMR indicating the Resident had fell. - 9/14/22 at 6:59 PM: Orders - Administration Note . Perform Weekly Skin Assessment . Resident with greenish/yellow bruising to middle of forehead. Resident with an recent fall and skin injuries already reported . - 9/18/22 at 2:12 AM: Skin/Wound Note . CNA called down writer to check out resident's scab . has a scab from a fall noted earlier in the week, scab has redness surrounding the entire area about 2 cm out from the scabbing . Review of Resident #85's health care provider orders did not include an order for transfer to the hospital following their fall on 9/9/22 nor were any hospital records from the transfer noted in the EMR. Review of Resident #85's clinical census documentation did not indicate the Resident left the facility. On 9/21/22 at 10:50 AM, Resident #85 was observed in the TV room of the unit. The Resident was sitting in their wheelchair with the soft neck brace in place and the lap buddy restraint in place in their wheelchair. An overbed table was in front of the Resident and they were eating ice cream. No staff were present in the area. When asked questions, Resident #85 made eye contact but did not provide appropriate and/or related responses. At 11:05 AM on 9/21/22, an observation of Resident #85 occurred in the TV/Dining room area of the unit. The Resident was sitting in their wheelchair with the lap buddy and chair alarm in place. There were no staff visible in the area. Resident #85 was pleasantly confused when asked questions. Resident #85's facility provided fall Incident and Accident (I and A) reports revealed the forms completed prior to September 2022 included the nurses note present in the EMR but did not incorporate an analysis of the fall nor did they detail interventions implemented to prevent future falls. Review of the I and A's for September 2022 revealed the following: - 9[TRUNCATED]