**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure comprehensive analysis of falls, accurate documentation, and implementation of meaningful fall prevention interventions for two residents (Resident #2 and Resident #11) of four residents reviewed, resulting in a lack of root cause analysis of falls, inaccurate and incomplete documentation, and a lack of implementation of meaningful interventions following falls. Resident #11 suffered a left shoulder dislocation, fractured the greater tuberosity (head of the humerus bone which rotates in the shoulder joint), and suffered unnecessary pain and the loss of function. Findings include: Resident #2: On 1/19/23 at 10:04 AM, an observation occurred of Resident #2 in their room. The Resident's room was noted to be at the end of the hallway and the furthest from the nurses' station. The Resident was aimlessly wandering within the room independently. When spoke to, Resident #2 made unintelligible grunting sounds. On 1/19/23 at 10:50 AM, loud, indiscernible yelling was heard in the hallway of the facility. Upon inspection, Resident #2 was observed in their room yelling. When asked if they needed anything, Resident #2 stopped yelling but did not respond. The Resident immediately began yelling out again. Record review revealed Resident #2 was originally admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, anxiety, schizophrenia, osteoporosis, and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive, one-person assistance for bathing but was independent with all other Activities of Daily Living (ADL's). The MDS further revealed the Resident displayed behaviors daily both directed and not directed towards others. On 1/20/23 at 2:03 PM, Resident #2 was observed ambulating independently in their room. The Resident repeatedly walked to the doorway, stopped, and then walked back to their bed. The Resident did not respond when spoke to. Review of documentation in Resident #2's Electronic Medical Record (EMR) revealed the following assessments: - 9/16/22: Falls Assessment . History of falls . Location of the fall . medications . Antipsychotics . Antidepressants . Cardiovascular . Fall risk assessed for quarterly assessment, resident remains at risk for falls r/t medications and poor safety awareness . - 1/3/23: Falls Assessment . medications . Antipsychotics . Antidepressants . Cardiovascular . Fall risk assessed for quarterly MDS. Resident at low risk for falls r/t medications and cognition. Resident remains independent for ambulation and ADL's . - 1/14/23 at 12:14 AM: Falls Assessment . Fall Review . Resident was observed on floor in bedroom at foot of bed sitting on bottom wearing only a brief. No footwear in place. Call light not in use. Resident is unable to give description of what happened. Nurse assessed resident for injuries, ROM (Range of Motion), vitals, pain WNL (Within Normal Limits). Resident did have abrasion/discoloration to abdomen extending up to armpit where it appears they slid down the footboard of bed. Resident was incontinent of bladder at time of incident . usually independent for toileting. Resident was assisted from floor and assisted with cleaning up, then back to bed. Care plan was reviewed and updated to encourage resident to wear nonslip footwear while out of bed as allows . IDT (Interdisciplinary Team) met to review resident, care plan was reviewed and updated . Review of Resident #2's care plans included a care plan entitled, SAFETY: risk for falls r/t (related to) hx (history) of falls, medications, cardiac diagnosis, osteoporosis, osteoarthritis, schizophrenia, Alzheimer's disease. recent falls (Created and Initiated: 4/22/17; Revised: 11/4/17). The care plan included the following interventions: - I will wear non-skid footwear for all transfers and walking (Created and Initiated: 4/22/17) - Encourage resident to use nonskid footwear when out of bed as tolerated (Initiated: 1/14/22; Created: 1/17/23) - Unused chair removed from resident's room to reduce trip hazard (Created and Initiated: 7/22/20) - Orient to surroundings - Call light accessible (Created and Initiated: 2/18/20) Review of Resident #2's progress note documentation in the EMR detailed: - 1/13/23 at 11:20 PM: Nurses Note . Resident observed on floor at foot of bed by CAN (Certified Nursing Assistant). Upon observation, resident sitting on buttocks on floor wearing only a brief. Resident independently transferred from bed attempting to self-toilet at approximately 2320 (11:20 PM). Neuro checks initiated . Resident observed with discoloration noted on chest that extended down onto ABD (abdomen), discoloration to left upper arm near elbow, and discoloration to right wrist. Resident without any indication of pain at time of assessment. Resident incontinent of bladder at time of fall. On call NP (Nurse Practitioner) notified . Voicemail left with guardian . Will update CP (care plan) to encourage use of nonslip footwear when out of bed. - 1/14/23 at 12:33 AM: Incident Note . Resident unable to follow commands to observe hand grasps. Resident observed grasping edge of bed to pull self-up along with grasping sheets to cover self. - 1/16/23 at 8:52 AM: Incident Note . No s/s of pain or bruising noted due to recent fall . No additional documentation related to the bruising/abrasions documented following Resident #2's fall on 1/13/23 were noted in the EMR. Review of the facility provided Incident and Accident Report related to the Resident #2's fall revealed, Fall . 1/13/23 at 23:30 (11:30 PM) . Called into room by CNA to observe Resident sitting on floor in brief at end of bed near footboard. Call light not in use. Feet bare . Resident unable to give description . Injuries observed Abrasion: Abdomen . Other, Specify in Notes . Mental Status: Poor Safety Awareness . Notes: Abrasions noted to chest extending to Abd, LUE (Left Upper Extremity) near armpit and right wrist Injuries Report Post Incident: No injuries observed post incident . Predisposing Physiological Factors: Gait Imbalance .Predisposing Situation Factors: During transfer . Footwear not in place . On 1/24/23 at 10:46 AM, an interview was completed with CNA A. When queried if Resident #2 responds verbally and talks to them, CNA A replied, No, not really. I think it is part of their disease process. When asked if the Resident utilizes the call light, CNA A indicated they did not. An interview was conducted with Resident Care Coordinator Licensed Practical Nurse (LPN) B on 1/24/23 at 2:00 PM. When queried regarding Resident #2 not responding when asked questions and yelling out, LPN B revealed that was normal for the Resident. When queried regarding the Resident's fall on 1/13/23, LPN B indicated they were not working at the time. An interview was conducted with the Director of Nursing (DON) on 1/25/23 at 11:30 AM pertaining to Resident #2's fall on 1/13/23. When queried if the only intervention implemented following the fall was to encourage the Resident to use non-slip footwear when out of bed, the DON reviewed the Resident's EMR and revealed it was. When queried regarding Resident #2 already having an intervention on their care plan for non-slip footwear when that intervention was added and how added the same intervention would help to prevent future falls, the DON verbalized understanding. When queried regarding the documented skin abrasions/bruises documented at the time of the fall and facility policy/procedure for monitoring skin alterations following a fall, the DON indicated there should be documentation in the nursing progress notes. The DON reviewed Resident #2's EMR and indicated the areas were resolved per the note on 1/16/23. No further information was provided. Resident #11: On 1/19/23 at 10:40 AM, Maintenance Director C was observed in Resident #11's room placing a positioning device on the footrest of their wheelchair. An interview was completed with Resident #11 on 1/19/23 at 10:42 AM following Director C exiting the room. Resident #11 observed was sitting in a regular wheelchair with bilateral leg rests in place. A padded positioning device was present on the right footrest. When asked, Resident #11 revealed Director C had placed the positioning device on the footrest of their chair. Resident #11 was queried regarding the reason for having a padded position device on only one footrest and revealed it was due to pain. Resident #11 stated, I fell and hurt my feet and left shoulder. When queried regarding the fall, Resident #11 revealed they fell at the facility and broke their shoulder. When asked if they had recovered from the fracture, Resident #11 revealed they had pain and decreased ROM following the fall. When asked if they were able to move their left shoulder, Resident #11 lifted their arm from their lap forward and to their side less than 90 degrees. Record review revealed Resident #11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epilepsy, falls, schizophrenia, and greater tuberosity of left humerus fracture. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively intact and required extensive to total assistance to complete all ADL's with the exception of eating. The MDS further revealed the Resident had one-sided, impaired upper extremity Range of Motion (ROM). Review of prior MDS assessment documentation of Resident #11's Functional Limitation in ROM revealed Resident #11 had no ROM limitations in any extremity until 8/31/22. Review of the CMS-672 Resident Census and Condition Form revealed the facility had three Residents with contractures including one facility-acquired contracture. The DON was queried regarding the Residents with contractures including the facility-acquired contracture on 1/19/23. The DON replied via email on 1/19/23 at 4:24 PM and revealed Resident #11 had a facility-acquired contracture. Review of Resident #11's EMR revealed the following documentation: - 2/23/22 at 10:35 AM: eInteract Change in Condition Evaluation . Falls . Skin Evaluation . Face: Laceration . Chest: Abrasion . Pain (rating not documented) . Pain Location: Not applicable/Not assessed . - 2/24/22 at 11:08 AM: Nurses Note . Abrasion to forehead shows no sign of infection. - 2/25/22 at 12:33 AM: Incident Note . Resident skin tear above eye area well approximated with no s/sx (signs/symptoms) of infection or swelling noted or reported. - 2/25/22 at 8:22 AM: Incident Note . Resident with skin tear above eyebrow with no s/s of infection noted. Goose egg to forehead has decreased with bruising to area. Resident with bruising and scrap (sic) to right side and up under breast. - 2/25/22 at 6:21 PM: Nurses Note . resident alert and easy to arouse . no injuries, bruising, skin intact. Resident with no s/sx (signs/symptoms) of pain or discomfort post fall . -2/25/22 at 11:52 PM: Nurses Note . alert, resting in bed, has one steri strip over left eye . -2/27/22 at 11:07 PM: Nurses Note . resting in bed, no distress, has one steri strip over left eye, has purple bruising to both eye corners. no further injuries noted from fall . - 3/2/22 at 11:37 AM: Social Service Note . Resident's new glasses arrived at facility today . Note: Resident #11's MDS detailed the Resident did not wear corrective lenses. - 8/30/22 at 1:25 PM: eInteract Change in Condition Evaluation . Falls .Skin Evaluation . Contusion . Discoloration . left side of forehead . Is the Resident cognitively able to rate their pain: Yes . (pain rating not documented) . Pain location: Headache . Abrupt onset of progression of severe headache . change in mental status, or focal neurological abnormalities . location of pain . left side of forehead . left arm/shoulder . Resident was found on floor in room after attempting to self-transfer from wheelchair. C/o (complain of) right arm/shoulder pain - 8/30/22 at 1:30 PM: Nurses Note . Writer called to resident's room by CENA staff after resident was discovered on floor in room. Resident admits was attempting to self-transfer from wheelchair at time of incident. Resident was assessed and transferred from floor to bed via Hoyer lift by staff. Large raised purple contusion apparent to left side of forehead on initial assessment by writer. She also c/o (complain of) left arm pain, MD notified. No further abrasions/skin tears, etc. noted at this time. Pain reported and PRN (as needed) Tylenol administered. Resident is currently resting comfortable in bed at this time . - 8/30/22 at 2:10 PM: Nurses Note . Nurse reported resident fall in room and new orders for left arm Xray r/t pain following fall. Writer went into assess resident, who was laying in bed awake at that time. Resident's left elbow was bent with hand laying near left shoulder, when writer asked resident if could straighten arm said no. No bruising or swelling was observed on hand, wrist, forearm, or elbow. Writer lifted resident's short sleeve shirt to assess shoulder and it appeared shoulder was dislocated. Contacted physician to verify if we should obtain Xray at facility or send to ER for possible dislocation, physician ordered to send to ER for evaluation . - 8/31/22 at 5:01 AM: Incident Note . Resident has bruise to left forehead and right shoulder is painful post relocation. PRN (as needed) Tylenol given for a PAINAD (Pain Assessment IN Advanced Dementia- scale used to assess and determine pain level in individuals with dementia and/or other cognitive impairments who are unable to verbally communicate pain levels) of 4 for right (sic) shoulder . - 8/31/22: Physician's Note Late Entry . Fall with resultant shoulder dislocation unfortunately on the left side with a left femoral (sic) fracture for which was sent to the emergency room . They have put on a sling and then requested her to follow with orthopedic surgeon which we will arrange . does have discomfort and pain which is actually being controlled with the help of pain medication . Exam . 1. The patient actually is in the sling at the present time . 2. Left femur fracture . - 9/1/22 at 12:22 AM: Nurses Note .resting in bed, Tylenol given for c/o pain in shoulder, with noted effect. sling in place. bruise above left eye . - 9/2/22 at 12:14 AM: Nurses Note . resident resting in bed, assisted with meals, left arm in sling, bruise remains above left eye, denies c/o pain at this time . - 9/2/22: Physician's Note Late Entry . Follow-up on a recent event . fall with left humeral fracture. We are waiting for orthopedic evaluation for this patient . pain control seems to be adequate . was transferred to the hospital . had a shoulder displacement which was put in place in the ER but unfortunately sustained a humeral fracture also, for which is in a sling . - 9/6/22 at 3:46 PM: Nurses Note . Resident returned from f/u (follow up) appt with (orthopedic physician) this shift. Suggestions include PT/OT, NWB to left hand, finger, wrist with ROM to be completed in therapy. Sling to worn AAT (at all times) when not in therapy . - 10/10/22 at 12:11 PM: Nurses Note . Per ortho follow-up, resident may discontinue non-weight bearing status to LUE and discontinue sling use to left arm at this time. Weight bearing as tolerated to left arm . - 11/29/22 at 12:16 PM: Physician's Note Late Entry . Follow-up on fracture of the greater tuberosity of the humerus . continues to require some pain control . Impression/Plan .In addition for the non-displaced fracture of the greater tuberosity of the humerus, will continue to require pain control . Review of Resident #11's hospital medical record documentation revealed the Resident's dislocated shoulder was reduced (put back in place) in the ER. Diagnostic imaging reports dated, 8/30/22 at 5:21 PM detailed, XR (X-Ray) Shoulder Complete 2+ Views Left . Reason . fall, pain, trauma . Findings . 1. Anterior inferior dislocation (uncommon dislocation) of the humeral head in relation to the glenoid. 2. Acute displaced fracture (broken bone pieces do not line up) involving the greater tuberosity of the humeral head. Questionable irregularity of the underlying glenoid (hallow socket in the shoulder blade where the head of the humerus sits) which may also represent fracture . On 1/20/23 at 2:13 PM, Resident #11 was observed in their room, in bed. When queried if they had gotten out of bed today, Resident #11 replied, No. With further inquiry, Resident #11 revealed they were having pain. Review of Resident #11's Pain Level Summary documentation in the EMR revealed the last documented pain level was on 10/29/22. Review of Resident #11's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2023 revealed no documentation of pain level assessment. Review of the facility-provided Incident and Accident (I and A) reports for Resident #11 revealed the Resident had two similar unwitnessed falls while sitting in their wheelchair in their room. The I and A details included: - 2/23/22 at 10:35 AM: Fall . Resident's room . Nursing Description: Called to resident room by activities staff, observed resident laying on floor on right side with CNA holding head up. CAN stated they entered the room, resident was laying face down next to bed with wheelchair flipped on top of them and foot pedals wedged between resident chest and floor. Prior to fall, resident was sitting in chair next to bed . Call light not in use. Footwear was in place. Laceration and bruising noted to residents left eyebrow. Large bruise and goose egg noted to resident's mid forehead. Abrasion and bruising noted to resident's right chest where foot pedal was wedged. Small abrasion noted to left pointer finger . Resident Description: Resident stated . was trying to get self to stand up but legs didn't work . Immediate Action Taken . Assessed resident for injuries . Neuros WNL although resident's pupils were not reactive. Laceration and bruising noted to residents left eyebrow. Large bruise and goose egg noted to resident's mid forehead. Abrasion and bruising noted to resident's right chest where foot pedal was wedged. Small abrasion noted to left pointer finger. Resident was cleaned up and assisted off the floor . Injuries Report Post Incident: No Injuries Observed Post Incident . Predisposing Environmental Factors: (Blank) . Predisposing Physiological Factors . Weakness/Fainted . Predisposing Situational Factors . Call light not used . Other Info: Resident attempted to self-transfer, although has not been ambulatory since admission . The I and A did not detail if Resident #11's call light was located within reach at the time of their call, if the wheelchair brakes were locked, the position of the footrests prior to the fall, and/or interventions implemented to prevent future falls. - 8/30/22 at 1:25 PM: Fall . Resident's Room . Nursing Description . Writer called to resident's room by CNA staff at 1325 (1:25 PM) to report resident found on floor . Upon entering room . observed resident lying on left side on the floor in front of wheelchair that was tipped in the forward position. Resident was lying on left shoulder/arm and left side of face was on the floor. Call light was not in use . Resident Description: Resident states . was getting up & 'trying to find out what was going on.' At the time of the incident, fire alarm test was performed and was attempting to get up and see what was happening, following door being closed during test . Immediate Actions Taken: Resident assessed . Large purplish contusion observed to left side of forehead and potential shoulder separation/dislocation noted following residents c/o pain to left arm/shoulder area . No further abrasions or known issues noted . Orders received transfer to hospital for further eval . Resident taken to hospital: N (No) . Injuries Report Post Incident: No Injuries Observed Post Incident . Predisposing Environmental Factors: (Blank) . Predisposing Physiological Factors . Drowsy . Impaired Memory . Incontinent . Predisposing Situational Factors . Ambulating without Assist . Notes . IDT met to review resident, front anti-tippers added to wheelchair and care plan. Tilted seat ordered for wheelchair . Review of Resident #11's care plans revealed a care plan entitled, Risk for falls r/t epilepsy, hx falls, muscle weakness, medications . (Created and Initiated: 8/19/19; Revised 2/18/20). The care plan included the interventions: - Call light accessible (Initiated: 8/19/19) - Make sure my brakes are locked before every transfer (Initiated: 8/19/19) - Encourage and assist resident to lay down after meals (Initiated: 9/13/20) - Dycem to between pants and total lift sling and coccyx cushion and total lift sling in wheelchair to prevent sliding (Created: 3/25/21; Initiated: 3/24/21) - Therapy eval r/t fall (Created: 2/24/22; Initiated: 2/23/22) - Front anti-tippers to high back wheelchair (Initiated: 8/30/22) - Drop (tilted) seat to wheelchair (Initiated: 9/12/22) Review of Resolved interventions in the care plan revealed there were no additional interventions implemented and discontinued following Resident #11's falls. An interview was conducted with the DON on 1/25/23 at 11:10 AM. When queried regarding Resident #11's falls, the DON confirmed the Resident had two unwitnessed falls in their room while sitting in their wheelchair. The DON was queried regarding the injuries Resident #11 sustained from their fall on 8/30/22 and revealed the Resident had dislocated and fractured their left shoulder. When asked about inconsistent documentation of which shoulder was painful/injured and Physician documentation indicated the Resident had fractured their femur (leg), the DON replied, They did not fracture their femur and indicated the documentation was in error and would need to contact the Physician to have them fix it. When queried what happened when the Resident fell, the DON stated it was right after a fire drill and revealed the Resident had attempted to get up out of their wheelchair by themselves. When queried if the Resident was made aware a fire drill was occurring and the reason for their door being closed, the DON replied, No and indicated staff and Residents are not alerted of upcoming drills for preparedness. When asked if staff tell residents the reason their doors have to be closed and if they provide any additional instructions, the DON did not provide a response. The DON was then queried what interventions were implemented following the fall and replied, Front anti-tippers and tilted seat (to wheelchair). When queried regarding Resident #11's fall on 2/23/22, the DON indicated the Resident had fell out of their wheelchair in the room but did not sustain any major injuries. When queried regarding the Resident's head laceration and if any diagnostic testing had been completed, the DON indicated the Resident was treated in the facility. When asked about the inconsistent documentation pertaining to the injuries including a note detailing the resident did not have any bruising or injuries, the DON was unable to provide an explanation. When queried regarding the Physician/Health Care Provider not assessing the Resident following the fall until 3/18/22 and not addressing the fall in their documentation, the DON did not provide an explanation. The DON was then asked what interventions were implemented following the fall in February to prevent future falls and injury. The DON reviewed Resident #11's EMR and stated, Referred to therapy. The DON was then queried regarding the location of the call light at the time of the fall, if the wheelchair brakes were locked, location of other items in the room, when the Resident had last been observed, and/or the position of the wheelchair foot pedals for both falls. The DON indicated the Resident would have been visualized by staff when they shut the room door for the fire drill on 8/30/22 but were unable to provide a specific time. No additional explanation was provided. When asked if they had any additional information regarding the falls and if an investigation had been completed, the DON indicated they did not think there was any additional information but would look. An interview was completed with Certified Occupational Therapy Assistant (COTA) Therapy Director E on 1/25/23 at 1:32 PM. When queried regarding Resident #11's fall on 2/23/22 and referral to therapy services, Director E indicated they were not employed on a full-time basis until recently and were not familiar with the Resident's falls and/or treatments. Resident #11's therapy documentation including the evaluation following their fall on 2/23/22 was requested at this time. Review of Resident #11's provided therapy documentation included the following: - Evaluation and discharge documentation from 6/16/20 to 7/3/20 treatment certification period - 3/21/22: Occupational Therapy (OT) . Evaluation and Plan of Treatment . Prior Equipment . w/c with high back, elevating leg rests and side support . Safety Awareness = Impaired . RUE (Right Upper Extremity) ROM WFL (Within Functional Limits) . LUE ROM = WFL . Has Patient fallen in past year? Yes; How many times? = Exact number unknown; Was patient injured from fall? Yes; Injury description: minor injuries . Reason for Therapy . Pt. (patient) also has difficulty maintaining seated position in w/c and often has slid out of w/c secondary to becomes lethargic and unable to maintain upright position . - 8/31/22: Occupational Therapy (OT) . Evaluation and Plan of Treatment . Reason for Referral / Pt was referred to OT services secondary to falling out of w/c when fire drill went off. Pt was sent to hospital and was found to have dislocated L shoulder and L non-displaced fx of L greater tuberosity and large contusion on forehead . Pt does not have any orders for weight bearing and ROM precautions. will default to no ROM at shoulder and NWB (Non-weight Bearing) of LUE . RUE ROM = WFL; LUE ROM = DNT (Do Not Treat) (fx); Clinical Reason(s) = Severe fracture (Greater tuberosity and shoulder dislocation. However pt returned from hospital with no ROM or weight bearing orders. Building attempting to get pt in to see ortho and get further instructions) . Does Patient worry about falling? = Yes . Pt has poor safety and judgement and can be impulsive at times . Clinical Impressions/Reason for Skilled Services: Pt recently had a fall and it resulted in L shoulder dislocation and fx of greater tuberosity. Pt is Dependent with bed mobility and having difficultly feeding and oral hygiene secondary to unable to use LUE . - 9/26/22 (signed date): Skilled Interventions Provided: PROM (Passive Range of Motion)/ AAROM (Assisted Active Range of Motion) with LUE. Pt has difficulty following ROM and weight bearing restrictions . able to complete AAROM with therapist present to provide appropriate positioning of LUE . Pt was participating with therapy services however was sent out to hospital . - 10/3/22: Occupational Therapy (OT) . Evaluation and Plan of Treatment . Pt is resident of this facility and was recently on OT/ST services prior to going to hospital. OT was looking into Fx UE . was found to have aspiration pneumonia . has returned to this facility from hospital . Reason for Therapy . still under precautions for L shoulder restrictions. NWB of LUE and no Shoulder ROM. Pt was in sling however unable to locate sling upon return . - 10/27/22 (date signed): OT Discharge Summary . Assessment and Summary of Skilled Services . Direct, hands-on care with patient this reporting period focused on the following skilled interventions . now WBAT (Weight Bearing as Tolerated) and can use arm as appropriate . No documentation for therapy evaluation/treatment following the Resident's fall on 2/23/22 was provided. On 1/25/23 at 4:35 PM, an interview was completed with Clinical Care Coordinator (CCC)/Staff Development Registered Nurse (RN) D. When queried if Resident #11 was evaluated and treated by Therapy in February 2022, RN D revealed they would need to check. A follow-up interview was completed with RN D on 1/25/23 at 4:42 PM. RN D revealed they had spoke to Therapy and reviewed the EMR. RN D stated, Therapy did not do an evaluation in February because (Resident #11) was already on Speech Therapy. No further information was provided. On 1/25/23 at 4:47 PM, a second interview was completed with the DON. When queried why Resident #11 was not seen by Therapy services following the fall on 2/23/22, the DON revealed they were not aware the Resident had not been seen. The DON proceeded to review the EMR and indicated the Resident was seen by therapy as part of their quarterly (MDS) screen but did not receive services/treatment. The DON was then asked if any other interventions, including nursing interventions, had been implemented to prevent future falls and revealed no interventions had been implemented. When asked if the nursing staff had implemented any immediate interventions to ensure Resident #11's safety, the DON replied, No immediate interventions. With further inquiry, the DON revealed they would be working with staff regarding the importance of implementing immediate interventions following falls. When queried regarding investigation to identify potential causes of the falls in order to implement appropriate and meaningful interventions, the DON indicated falls are discussed in the IDT meetings. No additional investigation documentation was provided. When queried why the interventions implemented following the fall on 8/30/22 including front anti-tippers and a tilted seat to Resident #11's wheelchair were not implemented following the fall on 2/23/22, the DON was unable to provide an explanation. Review of facility provided policy/procedure entitled, Falls Reduction Program (Revised 9/25/16) revealed, Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall- related injury . Procedure . 2. Implement and indicate individualized interventions on Care Plan/Kardex . 3. If fall occurs Charge Nurse to complete the following: Physical assessment of resident and observation of environment . Immediate interventions as identified by physical assessment and environmental observation . 3.1. Initiate safety interventions and update care plan as applicable . 3.2. Charge nurse to monitor for delayed consequences of incident utilizing the following . Physical assessment and documentation . Neurological Assessment per directions, as applicable . 3.3. IDT to review each incident to complete root cause analysis . 3.4.2. Complete/review Fall Assessment . Discuss and determine root cause . Summarize IDT analysis in the incident[TRUNCATED]