**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement adequate, effective resident specific interventions for a resident with a diagnosis of dementia and a history of a fall, failed to communicate effectively from the therapy staff to the nursing staff and document/implement the safest mode of transferring and ambulation for one (R15) of three residents reviewed for falls, resulting in the resident to have been transferred and admitted to the hospital for a higher level of care, identified to have a right parietal scalp hematoma and laceration that required five staples and an acute right-sided subdural hematoma measuring 0.9 cm (centimeters) in thickness and causing mild mass effect on the subjacent right frontal lobe. Findings include: On 8/22/23 at 9:39 AM, R15 was observed sitting in their wheelchair in the community room watching television. During an interview with R15, the resident mentioned they had a fall that required stitches to the back of their head. Review of the medical record revealed R15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia, repeated falls, difficulty walking and the need for assistance with personal care. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status score of 11 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the preadmission hospital medical record that was provided to the facility upon R15's admission documented in part, . History and Physical . July 09, 2023 . Admitting Diagnosis: Fall . Chief Complaint: Head contusion . presented to the emergency room via EMS secondary to a fall. The patient hit her head on a piece of furniture . The patient was recently discharged from the subacute rehab where her son who is with her right now states that she had fallen in the rehabilitation. The day prior she was discharged home. Son also notes of increased confusion. The patient does have a history of sundowners . Review of the progress notes revealed the following in part: A Nursing note dated 7/18/23 at 2:05 AM, document in part . Resident was witnessed by CNA (Certified Nursing Assistant) when she stumbled backwards, and loss balance before she took a fall to the floor. CNA was assisting resident with toileting before she loss balance while using her 4-wheel walker. Resident hit her head when she landed on the floor. Nurse immediately performed first aid when a one-inch gauge was visually seen with blood leaking out. Nurse applied pressure and wrap head with soft kerlix bandage x2. Blood is pooling through bandage quickly . EMS (Emergency Medical Services) called to the facility. Resident sent out to hospital . A Nursing note dated 7/18/23 at 6:04 AM, documented in part . currently in the ED (Emergency Department) at (hospital name). CT scan done on brain, 0.9 subdural hematoma showed on results . awaiting evaluation from ED Physician . Review of the hospital record documented the following: An Emergency Medicine History and Physical dated 7/18/23 at 2:33 AM, documented in part . presents to the ED following a witnessed fall . Patient is reportedly [NAME] (alert not oriented) x1 at baseline per EMS. She has a history of frequent falls, is not supposed to get up without assistance. The fall was reportedly witnessed by staff there, she had got up, and then shortly after getting up lost her balance and fell backwards . Patient has a laceration, approximately 3 cm on her occiput . Abrasion to the left arm . She is disoriented . CT Head wo (without) Contrast . Acute right-sided subdural hematoma measuring 0.9 cm in thickness and causing mild mass effect on the subjacent right frontal lobe . Right parietal scalp hematoma and laceration without an acute skull fracture . patient should be admitted to the ICU (Intensive Care Unit) . Procedures . Laceration Repair . Scalp . Length (cm): 4 . Number of staples: 5 . Diagnosis . Fall, initial encounter, Subdural hematoma . Laceration of scalp, initial encounter . Review of the progress notes documented that R15 returned back to the facility on 7/19/23. Review of a care plan titled The resident is at risk for falls r/t (related to) debility, history of falls . documented the following interventions . Call light within reach and encourage resident to use (initiated 7/12/23) . Ensure a safe environment with (specify: even floors free from spills and/or clutter; adequate, glare-free light, a working and reachable call light, personal items within reach, handrails/positioning rails as ordered (initiated 7/12/23) . Move to room closer to nurses station for increased visual supervision (initiated 7/13/23) . This indicated R15's fall care plan did not have effective or adequate resident specific interventions to prevent falls for a resident with dementia and a history of falls. Review of a facility policy titled Falls Risk Protocol dated September 2017, documented in part . Falls management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the resident's quality of life . The Nursing Admit/Readmit Assessment and care plan will be initiated within 24 hours of admission . Some risk factors or conditions that may predispose a patient to a fall may include, but are not limited to . Musculoskeletal condition that impair strength, History of falls . Urinary or fecal urgency . Unsteady gait, muscle weakness . Age . Cognitive impairment, dementia . Use of assistive devices . Medications . Physical environment . If upon completion of the Admit/Readmit Assessment the resident is found to be at risk for falls or has a history of falls the physician is contacted for orders, as appropriate; an initial plan of care is developed and individualized interventions are initiated . The interdisciplinary team review the resident's most current fall to determine the resident's present condition or status then a narrative summary of the resident's condition and circumstances surround the even are documented in the resident's clinical record. The care plan is revised as clinically indicated to meet the resident's current needs . Further review of the medical record revealed no documentation of the interdisciplinary team to have reviewed and documented a narrative summary and follow up of R15's fall. Further review of the fall care plan revealed no revision, modifications or new interventions implemented upon R15's readmission to the facility on 7/19/23. Review of a facility Accident/Incident Report dated 7/18/23, documented in part . Resident states I was slipping away! CNA (certified nursing assistant) assisted resident to the bathroom when she lost balance and fell down to the floor . walker with gait belt was used to toilet resident . The CNA that assisted R15 at the time of the fall was later identified as CNA B. Review of CNA B statement documented in part, . was assisted with sitting upright on bed I put shoes on and gait belt around her, walker in front and we both agree <sic> on the count of 3 she will <sic> stand up. We proceed <sic> to walk to the bathroom and when we got in front of the sink, she started to lose balance and fell backward. Her weight was overpowering me, so I kick <sic> the nightstand against the wall and yell <sic> for help as she hit the floor . she was bleeding from the head, the back of the head . Review of the initial Physical Therapy (PT) evaluation dated 7/13/23, documented the following goals in part . Patient will improve ability to roll from lying on back to left and right side and return to lying on back with Partial/Moderate assistance to get in/out of bed . Patient will improve ability to safely transfer to a standing position from sitting in a chair, wheelchair or on the side of the bed with Supervision or Touching Assistance with recognition of safety hazards and with ability to right self to achieve/maintain balance . Patient will safely ambulate on level surfaces 30 feet using two-wheeled walker with Supervision or Touching Assistance with precision of movement, with normalized gait pattern, with continuous steps and with functional posture to prepare for walk to dine for meals . Patient will increase B/L (bilateral) LE (lower extremity) Muscles Strength to 3+/5 in order to facilitate safe transition to next level of care and safely return home . Patient will improve static and dynamic standing balance from poor to Fair to improve ability to do functional task without any difficulty . The assessment also documented the following assistance levels required in part . Lying to sitting on side of bed = Substantial/maximal assistance . Sit to stand = Partial/moderate assistance . Walk 10 feet = partial/moderate assistance . Patient exhibits antalgic gait, abnormalities in posture, shuffling gait, decreased velocity, decreased stride length, narrow base of support and reciprocal movement deficit associated with forward lean of trunk and inadequate hip extension and underlying causes that might be modifiable include: impaired proprioception, muscle instability and muscle paresis/weakness . This initial PT assessment was completed by Physical Therapist personnel (PTP) C. On 8/23/23 at 11:19 AM, PTP C was interviewed and asked to review their evaluation completed on R15 on 7/13/23. PTP C began to review their evaluation from their laptop. PTP C was then asked their directive given to the nursing staff on the safest way to assist R15 from their bed to the bathroom. PTP C stated after they completed their evaluation the safest way to assist R15 from their bed to the bathroom would have been for staff to utilize a gait belt at the resident's waist level, while staff stood to the posterior lateral side of R15. One hand holding the gait belt and one hand on R15's wheelchair while wheeling it behind the resident as they ambulated due to their unsteadiness with their lower extremities and to prevent a fall if they resident fell backwards. PTP C was then asked to read the statement documented by CNA B (from the fall on 7/18/23). After PTP C read the statement, they were asked what was wrong with the documented incident, PTP C replied the staff did not use the wheelchair behind the resident like they were supposed to. PTP C stated . We recommended to roll the chair behind her anytime she is ambulating . When asked how the nursing staff was informed of their directive to use the wheelchair while the resident is ambulating, PTP C explained they verbally told the nurse on the day of the evaluation, and they also wrote it on the communication form that is provided to the assigned nurse after the evaluation is completed. On 8/23/23 at 11:43 AM, the Director of Nursing (DON) was interviewed and asked if they could provide the therapy communication form that was provided to the nursing staff for R15's initial PT evaluation. Review R15's PT evaluation dated 7/13/23 revealed no documentation for the staff to use the wheelchair behind the resident when ambulating. At this time the DON was informed of the interview with PTP C and informed of the concern of the therapy department and nursing communication on the safest assistance level to have been initially implemented for R15. The DON acknowledged the concern. On 8/23/23 at 12:04 PM, CNA B was interviewed and asked about the fall incident with R15 on 7/18/23, CNA B repeated the scenario documented in their statement. When asked if they utilized R15's wheelchair behind the resident when ambulating, CNA B stated they did not. CNA B stated they did not know about using the wheelchair behind R15 while they were ambulating. CNA B stated R15's ambulation assistance level was communicated to them by the previous aide and their understanding was that it was safe to ambulate with R15 while using the gait belt and the resident's walker. On 8/24/23 at 8:39 AM, a follow up interview was conducted with the DON, when asked why R15, a resident with dementia and a history of falls did not have effective or adequate resident specific interventions implemented to prevent further falls, the DON stated the facility does the least restrictive interventions during the time that they were getting to know R15. The DON stated the facility did move R15's bedroom when they identified the resident was more confused. No further explanation or documentation was provided before the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes: MI00129000, MI00130149 and MI00130248. Based on interview and record review the facility failed to implement interventions as documented by the Interdisciplinary team, review the effectiveness of fall interventions (R24), and provide adequate bathing assistance for (R34) two of four residents reviewed for falls, resulting in R34 being transferred to the hospital and receiving multiple stitches from a large laceration over the forehead and scalp. Findings include: R34 Review of the medical record revealed R34 was admitted to the facility on [DATE] with a readmission date of 6/15/22 and diagnoses that included: Syncope and collapse, hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side, muscle weakness, chronic kidney disease stage 3 and type 2 diabetes mellitus. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and requiring staff assistance for all Activities of Daily Living (ADLs). Review of a facility Accident/Incident Report dated 2/9/22 at 12:00 AM, documented in part . Location . Resident Room . Type Of A/I (Accident and Incident) . Slid out of chair . Resident Statement . I slid out of chair, knelt down + I sit down. I don't hurt myself. Outline Sequence of events leading up to fall . Watching TV while in chair . Denies pain . Skin (abrasion, reddened or opened area) . none noted . Interventions Implemented at time of incident . Neuro check done, Bed monitored in low position . IDT (Interdisciplinary Team) Review/Comments . Resident was found sitting on the floor next to her bed . Non-skid surface added to w/c (wheelchair) seat. Therapy to eval (evaluate) . On 8/10/22 at 10:28 AM, Rehabilitation Director (RD) B was interviewed and asked to provide the Therapy evaluation completed regarding R34's February 9th fall. RD B stated they would look into it and follow back up. At 12:39 PM, RD B returned and stated the resident was not evaluated by the therapy department as documented on the Interdisciplinary report. Review of an Accident/Incident Report date 6/13/2022 at 8:50 PM, documented in part . Location . Resident Room . Shower . Type of A/I . Fall . Resident Statement . Resident states she passed out and fell out of her shower chair . Outline sequence of events leading up to fall (Blank) . Resident denied pain following her fall . Sent out 911 . Head injury, skin tear L (left) lower forearm . Review of a written statement by Certified Nursing Assistant (CNA) G dated 6/13/22, documented in part . Monday June 13, 22, Shower was being given on an alert and oriented patient as reported by a facility nurse at the start of shift. Pt (Patient) was showering and staff was in the room area. Pt said she was ready, as staff started to entering <sic> bathroom, staff heard a thud. Staff opened shower curtain found pt on the floor forward facing. Pt said she was fine, but blacked out after she said she was ready to get out. Staff pulled called <sic> light for help, and then got help from the rest of staff . On 8/9/22 at 2:15 PM, a telephone interview was conducted with CNA G who identified themselves as an agency CNA and stated the day of R34's fall (June 13, 2022) was the first time they had ever worked in the facility. CNA G stated in part, . I got the report that she (R34) was a standby assist and I was in her room and I just heard her fall . They (the facility) put two agency staff together (themselves and the nurse they were assigned with that day were both agency per CNA G) . It was like the blind leading the blind . We didn't know about the residents . It should have been more information given to us . CNA G confirmed they were not in the shower room assisting R34. CNA G stated they were in R34's room on standby. Review of a care plan titled (R34 name) has an ADL self-care performance deficit r/t (related to) weakness, and history of CVA (Cerebrovascular Accident) with left sided weakness impaired ROM (Range of Motion) LUE (Left Upper Extremity)/LLE (Left Lower Extremity). She prefers to be independent, but needs assist peri-care and transfers. Refuses care at times (Revised 6/16/22) documented the following intervention . BATHING/SHOWERING: The resident requires extensive assistance by one staff member for showering/bathing. Use shower chair with arm rests for additional support in shower . Date Initiated: 05/21/2021 . This intervention was the same intervention that was supposed to be implemented on the date of R34's June 13th, 2022, fall. The facility failed to follow the intervention they implemented for R34 to have extensive assistance by one staff member for showering/bathing. Review of hospital documents dated 6/13/2022 at 9:53 PM, documented in part . Patient presented to ED (Emergency Department) from (facility name) facility 2/2 (secondary to) loss of consciousness and fall . According to the patient she was taking a shower after <sic> facility. Since she cannot stand she sits on a bench underneath the shower. Patient had completed a ho <sic> water shower after which she felt dizzy while sitting on the bench and lost consciousness. She fell forward, headfirst hitting the ground. She woke up a few sec after . She did notice blood coming out of her head. Facility workers came to help her sit onto the bench. And Called EMS (Emergency Medical Services). Upon Arrival of the EMS patient's blood sugars were noted to be in the 50s. She was brought to the ER since she was bleeding from her forehead and for further work-up for the loss of consciousness . Review of a hospital Internal Medicine document dated 6/14/22 at 4:54 AM, documented in part . The patient was evaluated in the ER . She has a large laceration over the forehead and scalp with crusting of blood . Review of an admission Summary note dated 6/16/22, documented in part . Resident admitted from (hospital name) at 7:57 PM via stretcher accompanied by EMS. Admitting diagnosis of closed head injury . Resident has stitches to forehead . Review of a June 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented in part, . Monitor sutures to forehead. Report changes to MD every shift for skin alteration . Start Date 06/17/2022 . On 8/9/22 at 2:45 PM, the Director of Nursing (DON) was interviewed and asked why R34 was left in the shower room alone to bathe themselves on June 13, 2022, prior to their fall if their care plan documented for the resident to receive extensive assistance by one staff for showering/bathing? The DON stated they know the resident usually request privacy while showering, however facility staff should never leave anyone unattended. The DON stated they would look into it more and follow up. On 8/10/22 at 10:03 AM, the DON presented Unit Manager (UM) D and stated UM D would be able to share more details surrounding the fall with R34 on 6/13/22. When asked if R34 should have had a staff member assisting during the whole duration of their shower, considering the resident's care plan documented extensive assistance by one staff. UM D stated someone should have been assisting for the whole shower. UM D stated she is very familiar with the resident and the resident does not like others present when they shower. When asked about the safety of the resident and the intervention documented in the resident's care plan for extensive assistance by one staff for showering, UM D replied that means someone should be there the whole time when she showers. On 8/10/22 at 1:40 PM, the DON was interviewed and asked why the resident was not evaluated by therapy as documented by the IDT team as an intervention after the residents 2/9/22 fall. The DON stated they would look into it. No further information or documentation was provided by the end of survey. R24 Review of the medical record revealed R24 was admitted to the facility on [DATE] with a readmission date of 4/15/22 and diagnoses that included: dementia, spinal stenosis, cognitive communication deficit, legal blindness, heart failure and chronic kidney disease stage 3. A MDS assessment dated [DATE] documented a BIMS score of eight indicating moderately impaired cognition and requiring staff assistance for all ADLs. Review of Incident and Accident reports for falls revealed ten documented falls from December 2021 until the date of survey (August 2022), which revealed the following: On 12/23/21 at 7:30 PM, the resident fell in their room. An intervention was documented of educating the resident to use the call light if help is needed and wait for care. A second intervention for therapy to screen for anti-roll back device to wheelchair was documented. The resident has a diagnosis of dementia and moderately impaired cognition, reeducating the resident to use the call light would not be an effective intervention for this resident. On 2/12/22 at 11:50 PM, the resident fell in their room. An intervention was documented to have educated the resident on using the call light for help, to have metabolic workup and to continue working with therapy for strengthening. The education of the call light is a repeated and ineffective intervention. On 2/18/22 at 8 AM, the resident fell in their room. An intervention to remind patient to not transfer by their self and to have shoes and/or gripper socks on was documented. Educating a resident with dementia to not transfer by themselves is not an effective intervention. The intervention to have shoes or gripper socks applied was not documented on the resident's care plan for staff to implement. On 4/13/22 at 4:30 PM, the resident fell in their room. An intervention to encourage to lay down after lunch was documented. This fall required the resident to be transferred to the hospital. Review of a hospital document dated 4/13/22 at 6:14 PM, documented a right orbital floor fracture. On 4/30/22 at 8:15 AM, the resident fell in their room. An intervention for therapy to evaluate the wheelchair for modifications, offer to lay down after dinner and a room change was documented. Review of the census report revealed the resident room was not changed after this fall. On 8/10/22 at 10:30 AM, the Rehabilitation Director (RD) B was interviewed and asked if therapy evaluated and made modifications to the resident's wheelchair, RD B stated they would review their records and follow up. RD B returned and stated therapy did not evaluate the resident's wheelchair and no modifications was made to the wheelchair by the therapy department. On 8/10/22 at 1:42 PM, an interview was conducted with the DON. The DON was asked about the multiple interventions that were documented by the IDT team and never implemented and the repeated ineffective interventions. The DON stated the IDT was supposed to meet this week (week of survey) to discuss more aggressive fall interventions for the resident, however the State Agency walked in to complete the survey and the meeting was postponed. No further explanation or documentation was provided by the end of survey.