**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a full body mechanical lift was used per manufacturers recommendations for 1 of 3 residents (R1) reviewed for mechanical lift use. This resulted in actual harm for R1 when staff failed to ensure the lift sling was secured prior to transfer causing R1 to fall from the lift causing pain and a fractured clavicle. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and required assistance with all activities of daily living (ADL)'s. R1's diagnoses included history of glioblastoma multiforme of brain, seizure disorder, hemiplegia of left nondominant side and type II diabetes. R1's care plan dated 6/4/24, directed staff to transfer R1 with a Hoyer lift (a brand name full body mechanical lift) with two staff. R1's progress note dated 7/22/24 at 12:40 p.m., indicated that R1 had a witnessed fall in his room from a mechanical lift at 11:28 a.m., nursing assistant (NA)-A and NA-B were transferring R1 from his bed to his wheelchair when R1 fell out of the sling when the right bottom strap came undone from the lift. R1 had complaints of pain in his left hip and head. R1's progress note dated 7/22/24 at 12:25 p.m., indicated R1 left the facility at 12:25 p.m. via ambulance. R1's emergency department (ED) record dated 7/22/24 identified R1 presented to the ED for evaluation of fall injury after sustaining a fall from a full body mechanical lift earlier that day. R1 injured his left shoulder and had pain with any movement of left shoulder. No history of left shoulder injuries. Imaging identified moderately displaced clavicle fracture. R1 was discharged back to the facility with orders for acetaminophen, ice, and sling. R1's progress note dated 7/22/24 at 6:29 p.m., indicated R1 returned to the facility at 5:00 p.m. via Medicab (medical transportation service). R1's progress note dated 7/28/24 at 2:22 a.m., indicated R1 vocalized a pain rating of 5/10 during transfers and repositioning and 2/10 while at rest. R1 also vocalized that current treatment was minimally effective. R1's progress note dated 7/28/24 at 9:01 a.m., indicated RN-A obtained a new order from the on-call physician for hydrocodone-acetaminophen (Norco) 5-325 milligrams (mg), a narcotic, to be taken twice daily and every 8 hours as needed for pain for 10 days. R1's July 2024 medication administration record (MAR) began monitor pain rating 0-10 every four hours on 7/22/24 after R1 returned from the hospital. R1 first vocalized a pain rating of 2 at 10:00 p.m. There were 67 additional entries ranging from 0-8, with the average being 3/10. From 7/22/24 to 7/31/24 (10 days) there were 7 doses of as needed (PRN) Tylenol (acetaminophen) documented as administered for pain. In addition, there were 7 doses of scheduled Norco administered and 7 PRN doses, for a total of 14 doses. R1's August 2024 MAR indicated pain monitoring with 50 entries of pain rating ranging from 0-8, with the average being 3.5/10. From 8/1/24 to 8/13/24 (12 days) there were 25 scheduled doses of Norco administer (twice daily). No PRN Norco was administered. In addition, there were 2 doses of PRN Tylenol administered for pain. Review of the facility's maintenance logs for the Hoyer mechanical lift A Model #PC450S, Serial #A5955 was inspected bi-annually with the last inspection date of 7/10/2024. The checklist indicated the actuator was greased, castors cleaned and oiled, two back leg bumpers were replaced, battery load test finding was 12.9 with evening spare noted, touch up paint was applied to needed areas, and noted lift is in good condition. Lift A had also been inspected earlier in the year (1/10/24) with similar findings. On 8/13/24 at 3:35 p.m., R1 stated his lack of acceptance of his position here may have led to the fall. R1 stated his feet may have slipped out. R1 denied any concerns about safety, the care that he received, or the staff that provided care to him. R1 no longer had pain from the clavicle fracture. On 8/13/24 at 4:27 p.m., NA-A indicated on 7/22/24 her and NA-B were involved with the transfer that led to R1's fall from the mechanical lift. NA-A stated that she was the initial staff in the room and had placed the sling under R1 while he was lying in bed before NA-B entered room to assist with lift and transfer. NA-A stated it was the right bottom strap that came undone. NA-A stated she can't remember which straps she connected to the lift. NA-A stated that she was the one that was using the controls of the lift. NA-A stated that it happened so fast and that both her and NA-B attempted to protect the resident from hitting his head from the fall. NA-A stated she was not sure of what happened or what could have been avoided. On 8/13/24 at 4:18 p.m., NA-B stated she was called into room to assist with a transfer and when she entered room sling was already in place under R1. NA-B stated she attached and secured the straps on the left side of lift and that NA-A had attached and secured the straps on the right side of lift. NA-B confirmed NA-A was using the lift controls. NA-B stated when R1 was up in the air, the right bottom strap came undone and R1 fell out of sling. NA-B stated that she immediately went to protect R1's head. NA-B stated licensed practical nurse (LPN)-A came in and assessed R1. On 8/13/24 at 4:31 p.m., registered nurse (RN)-A stated that he was called into R1's room following the fall. RN-A stated the lift was found on the right side of R1's bed and the top two straps were still secured and that one of the bottom straps was undone. RN-A stated initially R1 had complaints of hip pain. RN-A stated the strap that came undone must not have been secured under the retainer clip on lift. RN-A stated lift was immediately taken off the floor to be inspected and it was verified that lift was functioning properly, and that sling was also assessed with no defects noted. On 8/14/24 at 9:54 a.m. lift representative (LR)-C stated there are sling retainer clips on each of the hangers to secure the straps of the sling. LR-C stated the only way for the strap to become unsecured is that the strap was not all the way on the hoop as it may have gotten hooked on the top of the hook but not under the retainer clip. LR-C indicated causes for loop to come off included operator error. On 8/14/24 at 11:09 a.m. LPN-A stated the aides notified her of R1's fall, she went and got the RN before entering room to assist with assessment. They entered R1's room and found the sling up in the air with one strap hanging. LPN-A could not recall which strap. LPN-A stated assistant director of nursing (ADON) entered room and instructed LPN-A to go and notify family. LPN-A confirmed that if strap was under retainer clip strap should not have come loose. On 8/14/24 at 11:11 a.m., ADON stated she received call from RN-A to come to R1 room. ADON stated when she entered R1's room, R1 was laying on the floor with the mechanical lift in between bed and R1. ADON stated sling was no longer attached to the lift and/or underneath R1. ADON assessed R1 for injuries and instructed LPN-A to notify doctor and family. ADON stated that they initially thought injury had occurred to left hip as it was longer in length and rotated outward. ADON stated R1 had complaints of hip and head pain at that time. ADON stated she notified the director of nursing (DON) and executive director of fall. ADON stated that maintenance was notified immediately to assess lift prior to it being used again. ADON stated that DON compiled all investigation information to submit a vulnerable adult report and she reviewed prior to submission. ADON stated DON also initiated the retraining material and delegated re-training of staff to RN-B. ADON confirmed that re-training forms that were received were the only training completed. On 8/14/24 at 11:36 a.m., DON stated she immediately spoke with NA-A and NA-B who were involved in the incident and had them complete written statements of the incident. DON stated she completed on the spot retraining with NA-A and NA-B that included verification that straps are secure under the retainer clip prior to transfer of resident. DON stated that maintenance assessed lift to ensure proper functioning and sling was also removed for assessment with no defects noted. DON stated that she had RN-B do random audits of floor staffing performing Hoyer lift transfers to ensure proper technique was being completed. DON stated she placed education sheet in the stand-up binder in each unit to have staff read and sign that they understood. Education sheet included reminder to ensure bed was at the appropriate height when transferring and that staff need to verbalize confirmation of secure connection on straps on their side of lift. DON confirmed that not all staff had been re-trained. DON confirmed that incident was operator error. Volaro Series 4 Lift PC450-HD450 Operator's Manual included the following: Safety Notes: Make sure all four loops from the slip are properly nested in the bottom of the hooks before lifting or transferring a patient or resident. Also make sure all four retainer springs are functioning correctly. Lifting from bed to chair using the divided leg sling: Note: Raise until these is tension on the straps and then double-check to make sure the loops are nested in the bottom of the hooks. The facility policy safe patient/resident handling and movement policy, dated 4/1/2005, indicated employees shall use proper techniques, mechanical lifting devices, and other approved equipment/aids during performance of high-risk patient handling tasks per facility policy and manufacturer's guidelines. This is being issued at Past noncompliance (PNC) after it was verified the facility put the following corrective action in place. -On 7/23/24 education was placed in a binder on each unit that identified When utilizing the full mechanical lift please ensure that you have the bed at the appropriate height so that the lift does not have to raise all the way up. Please ensure that you are pausing to double check loops are attached appropriately as well prior to lifting the resident up. Please verbalize double checks when utilizing lifts. Make sure we are double checking our partners work to make sure slings are clipped in all the way. All staff interviewed confirmed that they had seen this training. -Management conducted 16 random audits to confirm staff were utilizing the lifts properly. -On 7/22/24 maintenance inspected the lift for function and safety. Additionally checked the sling for any issues. -On 7/22/24 the executive director (ED)-A emailed requesting bids for all new mechanical Hoyer lifts through a different vendor. On 8/1/24 ED-A received approval to purchase all new EZ-way mechanical lifts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to comprehensively assess fall risk and implement individualized interventions to reduce the risk of falls for 2 of 3 residents (R1, R3) reviewed for accidents. This resulted in actual harm for R1 who sustained fractures and for R3 who sustained a subdural hematoma after repeated falls and whom both required medical treatment or services. Findings include: R1's Inpatient Discharge summary, dated [DATE], identified R1 fell three times prior to her hospital admission in which she sustained nasal fractures, left great toe fracture, distal right fibula fracture, and a left wrist fracture. She was discharged to the facility in stable condition with a good rehab potential and was expected to require services for less than 30 days. R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 admitted to the facility on [DATE]. She was severely cognitively impaired and received extensive physical assist for most cares. R1 relied on a wheelchair for locomotion and did not walk. She required staff assist to stabilize during transfers. R1 was diagnosed with a right fibula (lower leg) fracture, muscle weakness, urinary tract infection (UTI), dementia, anxiety disorder, and repeated falls. R1 lacked condition(s) or chronic disease(s) which resulted in a life expectancy of less than six months. R1's baseline care plan, dated 11/16/22, identified R1 to be at risk for falls related to her impaired mobility, multiple fractures, and history of falls in which R1 would be safe and free from falls. The care plan directed staff to orient R1 to her room and call light system and to provide R1 with reminders as often as necessary, along with reviewing fall prevention with R1's representative on admission and to follow physical therapy (PT) and occupational therapy (OT) instructions for mobility function. The care plan identified R1 was non-weight bearing to her right leg, was not to ambulate, and required full assist for transfers and further directed staff to assess for incontinence every two hours and as needed (PRN). R1's discharge goal was to turn to her prior living facility. R1's medical record identified the following entries and identified information: -A progress note, dated 11/17/22, at 9:00 p.m. R1 was found on the floor. Per R1's statement, she tried to reach the door and slipped from the wheelchair (w/c). R1 was educated to use her call light and ask for help. -A progress note, dated 11/18/22, at 3:52 a.m. R1 was checked on every 30 minutes throughout the shift to prevent falls. -A progress note, dated 11/20/22, at 9:15 p.m. R1 required assist of 2 staff with a standing mechanical lift, was non-compliant with non-weight bearing transfer orders, and self-transferred during shift. -A progress note, dated 11/21/22, at 1:26 a.m. R1 self-transfers most of the time. [R1] should be monitored every 30 minutes for fall risk. -A progress note, dated 11/21/22, at 1:40 a.m. R1 was checked every 15 to 30 min[utes] to ensure she was not self-transferring or unstable. R1 was very confused and writer stayed with [R1] throughout the shift as it was unsafe for [R1] to leave her alone in her room. -A progress note, dated 11/21/22, at 10:41 a.m. R1 was found seated on the floor by her doorway around 7:10 a.m. R1 stated she got herself up from the bed and lowered herself to the floor as no one came when she needed help. An associated, same day, Risk Management (incident report) identified an intervention for anti-roll back breaks to be applied to her w/c. R3's care plan identified, on 1/9/23 (over a month and a half later), anti-roll breaks were initiated. -A progress note, dated 11/22/22, at 12:59 a.m. R1 self-transferred into her w/c from her bed. R1 was kept in one of the day rooms since she felt anxious in her room. Music was played for her which helped calm her. R1 will be monitored closely. A Fall Review Evaluation, locked 11/23/22, identified R1's prior falls and identified the following factors which contributed to R1's fall risk: psychotropic drug use, memory loss, occasional bladder incontinence, use of assistive device(s), and decrease in muscle coordination. The evaluation summary identified R1 was at risk for falls related to her fracture diagnoses, muscle weakness, UTI, dementia and history of falls, her required assist for transfers and the use of a mechanical lift, and her non-ambulation status. The summary interventions directed staff to orient her to her room, the call light system, and to give reminders. In addition, anti-roll back breaks were to be added to her wheelchair and staff were to ensure R1 wore non-slip footwear at all times as she allowed. R1 also worked with physical and occupational therapy to improve her mobility. The evaluation lacked identification of R1's numerous self-transfer attempts, observed anxiety, and/or analysis related to the falls on 11/17/22 and 11/21/22. R1's progress notes, dated 11/23/22 through 11/28/22, identify each day R1 displayed self-transfer actions. Falls Care Area Assessment (CAA), dated 11/29/22, identified R1 was at risk for falls related to her fall history and casts, antipsychotic and antidepressant medications, wandering behavior, infection, incontinence, anxiety disorder, and dementia in which R1 was pleasantly confused. The CAA's Care Plan Considerations section indicated the care plan objective was to avoid complications with the hopes R1 would be able to return to her assisted living facility after she worked with therapy. The CAA lacked details of R1's 11/17/22 and 11/21/22 falls or her self-transfer habits. The CAA lacked evidence staff completed a comprehensive fall assessment and/or analysis or individualized intervention(s) identification based on R1's fall risk. A review of R1's comprehensive care plan demonstrated a lack of additions and/or adjustments to fall risk related problems, goals, and/or interventions after the 11/29/22 CAA process. In addition, R1's care plan lacked R1's self-transfer actions. R1's subsequent medical record identified the following entries and identified information: -An incident report, dated 12/14/22, at 7:00 a.m. R1 was found sitting on the floor in her room's entryway with a sustained skin tear on her lower leg. Her locked w/c was next to her bed. R1 stated she wanted to get up for the day and fell. R1's symptoms were reviewed with her provider, and she tested positive for a UTI. -A progress note, dated 1/3/23, R1 was found sitting on the floor in her room's doorway at 5:35 p.m. Her locked w/c was next to her bed. R1 stated she tried to get out of bed. The incident report identified to offer afternoon activity. R1's care plan lacked the intervention. -A progress note, dated 1/12/23, R1 was found sitting in her room's doorway: her w/c in the bathroom (BR). R1 self-transferred frequently this night and utilized the [BR] many times. The incident report identified R1 stated she fell in the BR and pushed herself toward the door. R1 was reminded to utilize her call light and wait for staff assistance (despite this intervention have not been effective and R1's diagnosis of severely cognitively impaired). -A progress note, dated 1/20/23, at 3:00 a.m., on 1/19/23, at 11:30 p.m. R1 informed staff she fell in the BR. Staff identified a left elbow bruise. In addition, R1 was found sitting on the therapy room floor at 1:30 a.m. R1's w/c was in her BR turned upside down. R1 stated her left rib hurt and she had new bruising to her left leg and breast. The incident report identified R1 was provided with a snack and placed within sight of staff for about an hour and then assisted into bed. -A progress note, dated 1/23/23, R1 was found sitting on the floor in her room's doorway at 11:50 a.m. Her w/c was behind the door. R1 stated she tried to walk out to look around. The incident report identified R1's care plan was updated to keep R1's w/c next to her bed with the breaks locked at all times when R1 was in bed. The care plan lacked the intervention. -A progress note, dated 2/8/23, R1 was found sitting on the hallway floor outside of her room at 3:00 a.m. R1 was toileted and assisted back to bed. The incident report identified an intervention for Actogram (sleep/wake cycle monitoring) watch to be performed for three days and reviewed upon completion. R1's medical record lacked documented evidence the Actogram recording period from 12/8/22 to 12/13/22 was reviewed and/or followed up on. -A progress note, dated 1/25/23, R1 demonstrated urinary frequency and urgency, increased confusion, and noted to have multiple falls recently. Orders provided to test R1's urine for infection. A subsequent progress note, dated 1/26/23, identified positive urine results and an antibiotic was started. -A progress note, dated 1/27/23, at 8:57 p.m. R1 was found scooting on the floor coming out of her room with an abrasion on her forehead. The incident report identified R1 stated she tried to go to the BR and fell. Staff followed up with therapy about an ambulation program (per a progress note, this follow-up occurred on 1/30/23); however, therapy deemed it inappropriate due to safety concerns. Instead, staff were to utilize as needed (PRN) essential oils on her pillow to encourage rest and relaxation. R1's care plan identified, on 2/2/23 essential oil use was added. -A follow-up progress note, dated 1/27/23, at 9:09 p.m. causal factors for R1's 1/27/23 fall were determined to be R1's current UTI, toileting needs, and that R1 failed to use her call light to ask for assistance. R1 had a history of multiple falls. Interventions included bowel and bladder evaluation and aromatherapy. -R1's treatment administration records (TAR), dated 1/23, identified PRN essential oil aromatherapy orders initiated on 11/16/23. The TAR lacked evidence R1 was provided with essential oil aromatherapy on 1/27/23 through 1/31/23. -A progress note, dated 1/28/23, at 12:24 a.m. R1 was found sitting on the hallway floor outside of her room at 11:00 p.m. R1's unlocked w/c was in her BR. R1 stated she attempted to go to the BR. The incident report, identified R1's provider and dietary were consulted (per a progress note, dated 1/30/23, this consult occurred) to add a nutritional supplement to promote adequate caloric intake to help reduce falls if R1 possibly experienced discomfort due to hunger and inability to communicate hunger (per a progress note, dated 1/31/23, the order was provided). -A progress note, dated 1/31/23, at 12:00 a.m. identified R1 was found on her BR floor. Her unlocked w/c was in the BR doorway. R1's left shoulder was assessed to be more distended out of place than her right and R1 complained her shoulder and left hip hurt. Per a follow-up note, at 2:58 a.m. R1 was sent to the emergency room (ER). R1's care plan identified on 2/2/23 intervention implementation that directed staff to review information on past falls and attempt to determine the cause of the falls with recording of possible root causes, removal or alter any potential causes if possible, and to educate R1/family/caregivers/interdisciplinary team. R1's medical record lacked evidence such a review was completed. R1's Inpatient Discharge summary, dated [DATE], identified R1 was diagnosed with failure to thrive with recurrent falls and fall injuries of a left shoulder dislocation, L1 and L2 lumbar spinal fractures, 12th rib fracture, left sacral (base of spine) fracture, and left pubic rami (pelvic) fractures. R1's physical condition at discharge was terminal and hospice end of life/comfort care was ordered. A progress note, dated 2/7/23, identified R1 displayed restlessness, yelled out 'help me,' and was observed to sit up in bed four times. A Fall Review Evaluation, dated 2/10/23, identified R1 was at risk for falls related to fractures, muscle weakness, UTI, dementia, and history of falls. R1 was unresponsive and bedbound in which comfort care and safety while in bed continued. A progress note, dated 2/10/23, identified R1 passed away at 12:15 a.m. R1's medical record identified R1's fall risk was assessed on 11/23/22 and 2/10/23 based on the MDS process; however, the record lacked comprehensive fall risk assessments and/or analysis were completed after R1's multiple falls in order to develop, adjust, and/or monitor for effectiveness, individualized care plan interventions to mitigate R1's fall and/or fall injury risk. When interviewed on 2/13/22, at 2:47 p.m. trained medication aide (TMA)-A stated she would find fall interventions in the resident's care plan or on the Kardex. TMA-A explained R1 constantly utilized the BR and did not sleep well at night. Staff assisted R1 to bed and a minute after staff walked away R1 would self-transfer. Once R1 returned from the hospital, R1 often requested the bedpan and she witnessed R1 lean forward in bed. TMA-A stated she heard in report R1 was observed seated edge of bed when she was not supposed to. TMA-A explained that prior to R1's hospital stay being around people was overall the only thing that calmed R1. She indicated R1's status upon her return was a shock as R1 was making progress in her prior recovery and staff talked about R1's return to her previous facility. TMA-A denied involvement in a comprehensive analysis of R1's falls and she stated she lacked knowledge of any new fall risk interventions for R1 once she returned from the hospital. When interviewed on 2/14/23, at 10:50 a.m. R1's nurse practitioner (NP)-A stated R1 was a ball of anxiety when she was admitted in which she had a history of falls. Despite this, R1's discharge plan was for her to rehab and return back to her previous facility. R1's anxiety and impulsiveness improved with medication changes; however, she continued to have significant poor safety awareness. NP-A acknowledged other than trying to settle [R1's] mind to keep her from going so fast, she was unaware of R1's care planned fall interventions. She verbalized she was unaware of R1's urinary status and the frequency of which staff assisted her to the BR. NP-A denied she was involved in a comprehensive analysis of R1's falls to determine details that may have been used to decrease R1's fall risk or fall related injuries. NA-A confirmed she was unaware of the exact cause of R1's death; however, she explained the fall and fractures did not help. During interview on 2/14/23, at 11:13 a.m. R1's family (FM)-A stated R1 had a long history of falls in which she knew at some point a fall related break was going to be the death of [R1]. FM-A identified she was involved in care conferences with the facility in which they discussed R1's overall health; however, she denied they discussed R1's falls. She explained those meetings focused on the progress R1 made with therapy and the hope R1 would be able to return to her prior memory care facility. When interviewed on 2/14/23, at 1:09 p.m. nursing assistant (NA)-C confirmed she took care of R1 on 1/30/23 in which R1 was her usual self: super confused, hard to redirect, and had a short attention span. She denied that on 1/30/23 R1 displayed any signs or symptoms which would have identified declines in her medical or overall status. NA-C explained R1 often self-transferred and was hard to catch: one moment R1 was in her w/c and the next in bed or vice versa. NA-C stated R1 slept poorly at night and often napped much of the shift prior. R1 also frequently utilized the BR which NA-C thought R1 used to calm herself down. NA-C explained she often attempted to keep R1 distracted, entertained, and within her sight as much as able. NA-C denied management staff talked with her related to R1's fall risk factors and which interventions were effective and which ones were not. During interview on 2/14/23, at 1:24 p.m. licensed practical nurse (LPN)-A stated she was expected to initially investigate a resident's fall, initiate a Risk Management incident report, and implement an immediate fall risk intervention to mitigate further falls. After that, a care coordinator would review, adjust the intervention as needed, and care plan it. LPN-A confirmed the coordinator followed up with her after she managed a residents fall; however, she denied she was ever involved in any sort of comprehensive analysis of resident fall(s) to determine details that may have been used to decrease resident fall risks or fall related injuries with R1. LPN-A stated R1 was a roamer and she attempted to keep R1 as close to her as able. She explained R1 was quick, and staff could assist her to bed one moment and then the next she was by them needing some sort of assist. R1 always had to go to the BR and staff could tell her over and over she needed help, but she did not have the capability to remember that. LPN-A confirmed not all of the interventions they attempted with R1 were on her care plan and/or Kardex: We should all know the interventions, but probably could have been in the Kardex. LPN-A explained she was unsure of what interventions would have worked for R1 other than to provide R1 with 1:1 supervision at all times. LPN-A confirmed R1 was not provided 1:1 supervision at all times. LPN-A stated R1 was stable before her hospital stay: They were talking about sending her back to [prior memory care facility]. When interviewed on 2/14/23, at 1:40 p.m. registered nurse (RN)-C stated she expected staff to make sure an immediate intervention was implemented after a resident fall which was based on the nature of the fall and either documented in the progress notes or on the incident report: not just passed on during shift to shift report. Then, she explained, they reviewed the fall, the intervention, adjusted the intervention as needed, and initiated it within the care plan. RN-C stated fall risk assessments were completed with the MDS process and she denied they completed a comprehensive fall risk assessment and/or analysis of R1's falls outside of this process or met with the IDT (interdisciplinary team) to discuss and analyze R1's falls. She verbalized if a resident had multiple falls, a comprehensive fall and fall risk analysis was very important in order to determine the root cause of the fall, to prevent injury, and to keep residents safe; however, she was unaware of the facility policy and/or protocols on fall assessments if a resident were to have multiple falls. After RN-C reviewed a Fall Review Evaluation, she stated the evaluation did not have everything you would look at to analyze falls and fall risk. RN-C explained R1 was compulsive with her transfers in which she followed up with therapy about a walking program or exercising; however, therapy disagreed related to R1's dementia and not wanting R1 to be triggered into thinking she could walk on her own. RN-C described interventions attempted for R1 which were present on her care plan prior to her hospitalization. RN-C confirmed R1's fall interventions were not adjusted and/or new interventions implemented once R1 returned. RN-C stated R1 was stable prior to her hospitalization. R3: R3's Initial Intake provider visit progress note, dated 11/4/23, identified R3 was admitted to the facility on [DATE], after he required hospitalization as a result of frequent falls and a UTI. R3's admission MDS, dated [DATE], identified R3 was severely cognitively impaired and required limited to extensive physical assist for cares. R3 relied on a w/c for locomotion and showed minimal walking. R3 diagnosis was polyneuropathy, UTI, Alzheimer's Disease, dementia, muscle weakness, and repeated falls. R3's baseline care plan, initiated 11/3/22, identified R3's fall risk related to impaired mobility and cognition, and history of falls in which he would be safe and free from falls. The care plan directed staff to orient R3 to his room and call light system and to provide R3 with reminders as often as necessary, along with reviewing fall prevention with R3's representative on admission and to follow physical therapy (PT) and occupational therapy (OT) instructions for mobility function. The care plan identified R3 required a Foley catheter in which staff were not to leave R3 unattended on the commode. On 11/10/22, the care plan was updated, after a bowel assessment was completed, which directed staff to offer and encourage R3 to toilet every two to three hours while awake. R3's medical record identified the following entries and identified information: -Progress notes, dated 11/5/22, 11/6/22, 11/7/22, 11/8/22, all identified R3 was alert and oriented to self only and often tried to self-transfer. -A progress note, dated 11/11/22, R3 ambulated with his walker to the manager's office while he held his catheter bag. He was assisted to his room and staff were to monitor for further episodes of self-transfers. A Fall Review Evaluation, locked 11/10/22, identified R3's prior to admission falls and identified the following factors which increased R3's fall risk: Alzheimer's Disease, dementia, polyneuropathy, osteoarthritis, weakness, altered mobility, indwelling urinary catheter, frequent bowel incontinence, and new admission. The evaluation summary identified the risk factors and directed staff to orient him to his new room, ensure the call light was within reach and to encourage him to wear proper footwear when out of bed. R3 also worked with PT and OT. The evaluation lacked identification of R3's numerous self-transfer/ambulation attempts. Fall CAA, dated 11/10/22, identified R3's fall review evaluation risk factors and the use of antidepressant medication. The CAA's Care Plan Considerations section indicated the care plan objective was to avoid complications and to maintain his current level of functioning. R3's subsequent medical record identified the following entries and identified information: -A Fall Investigation report, dated 11/15/22, R3 self-ambulated in the hallway and staff intercepted his fall by lowering him to the floor. R3 stated he tried to 'fix/ find missing cable.' R3's Foley catheter tubing was pulled from his bladder and he was incontinence of bowel. R3 was brought back to his room, incontinence hygiene provided, a new catheter inserted, and he was encouraged to use his call light. R3's progress notes did not identify R3's 11/15/22 fall. -Progress notes, dated 11/16/22 and 11/17/22, R3 tested positive for COVID-19 with required room isolation and experienced increased weakness and difficulty with transfers. -An incident report, dated 11/17/22, at 2:35 p.m. R3 was found on the floor next to his bed. A progress note, dated 11/17/22, lacked evidence of R3's fall; however, the note identified R3 was free of injury, his vitals were stable, and he was encouraged to use his call light (despite the intervention or reminder not effective due to dementia). -A progress note, dated 11/18/22, R3 was ordered antibiotics based on urinalysis results [R3 was diagnosed with a UTI]. -A progress note, dated 11/20/22, at 2:18 a.m. R3 often forgets and required redirection back to room in which staff found him back out of room/self transferring. -A progress note, dated 11/20/22, at 5:30 p.m. R3 was observed to be in his BR doorway when staff intercepted a fall and lowered him to the floor. Staff placed him in bed after. The progress note and incident report lacked an identified fall analysis or new intervention. -A progress note, dated 11/24/22, R3 was observed self-ambulating down the hallway. -A progress note, dated 11/25/22, R3 face planted and sustained an abrasion to his forehead, fixed pupils, and double vision. [R3 was sent to the ER and admitted ]. -A progress note, dated 11/29/22, at 1:34 a.m. R3 returned to the facility and required assist of two staff with a mechanical standing lift for transfers and that R3 was noted to self transfer x1. A provider visit progress note, dated 12/5/22, identified R3 fell in November during isolation with subdural hematoma and neuro changes, send to ER and hospitalized for [three] days. -A progress note, dated 12/2/22, at 3:21 p.m. R3 was found on the floor about a foot from his w/c. R3 stated he hit his head. Family denied ER transport. The incident report identified staff collaborated with therapy on R3's transfers and he had a UTI which required antibiotics. -A progress note, dated 12/5/22, R3 was found on the floor at 2:50 a.m. The incident report identified R3 was to have his w/c next to the bed when he was in bed. R3's care plan identified, on 1/10/23 (more than a month later), the intervention was initiated. A Fall Review Evaluation, dated 12/5/22, completed per facility MDS process(es), identified R3's fall history prior to and during his stay and identified the same evaluation summary and interventions as the 11/10/22 fall review evaluation, with the addition of the subdural hematoma diagnosis. The evaluation lacked identification of R3's numerous self-transfer/ambulation attempts and/or analysis related to the falls which occurred after admission and hospital return. R3's subsequent medical record identified the following entries and identified information: -A progress note, dated 12/9/22, at 2:48 a.m. R3 was lowered to the floor when he became weak after he was found attempting to walk with his w/c near the dining room (DR). The incident report identified Actogram watch would start on 12/12/22. R3's medical record lacked documented evidence the Actogram recording period was reviewed and/or followed up on. -Progress notes, dated 12/9/22, 12/10/22, and 12/12/22, R3 self-transferred multiple times each day. -A progress note, dated 12/12/22, R3 was found on the floor at 3:00 p.m. after he was in his bed. Identified intervention directed for gripper socks instead of regular socks. R3's care plan identified, on 12/15/22 (three days later), R3 was to be highly encourage[d] to use non-slip footwear at all times. -A progress note, dated 12/17/22, R3 was found sitting on the floor with his back against the bed at 8:20 p.m. R3 was incontinent of bowel and a spilled water cup was on the floor by his bed. He was assisted into bed and bowel hygiene provided. The incident report identified staff were to ensure R3's bed was kept at a therapeutic height to set R3 up for successful self-transfers due to history of impulsivity and self-transferring. On 12/19/22, R3's care plan identified Low Bed and lacked identification of therapeutic height directives. -Progress notes, dated 12/19/22 and 12/29/21, R3 self-ambulated from his room down Northwoods hallway and self-transferred and ambulated in the DR, respectively. A Fall Review Evaluation, dated 12/30/22, completed per facility MDS process(es), identified R3's fall history prior to and during his stay and identified the same diagnoses as past evaluations; however, included R3 showed poor safety awareness and impulsivity which increased his fall risk. The fall summary identified the following interventions: Actigraphy PRN, therapeutic bed height, non-slip footwear at all times (highly encouraged), assistance with safety reminders PRN, and orientation to room and call light. The evaluation lacked identification of R3's numerous self-transfer/ambulation attempts and/or analysis related to the falls which occurred after admission and hospital return. R3's subsequent medical record identified the following entries and identified information: -A progress note, dated 1/1/23, at 3:24 p.m. R3 was found sitting on the floor in an adjacent unit Pod area. The incident report identified foot pedals to be stored in w/c bag when R3 was not assisted with locomotion. R3's care plan identified, on 1/19/23 (18 days later), initiation of the intervention. -A progress note, dated 1/5/23, R3 was found lying on the floor next to his w/c in the DR at 4:30 p.m. R3 sustained a right elbow scrape. The incident report identified staff collaborated with R3's provider in which orders were provided for an antipsychotic medication related to impulsivity, poor safety awareness, and behaviors. -A progress note, dated 1/6/23, at 2:16 p.m. R3 was found outside of his room on his hands and knees. R3 was brought to the DR and provided a snack. The incident report identified R3 was unsafe to be in his room alone while in his w/c. R3's care plan identified, on 1/10/23 (four days later), R3's unsafe room status. -A progress note, dated 1/8/23, at 11:09 p.m. R3 was found sitting on the DR floor. He was incontinent of bowel. R3 was provided bowel hygiene care and assisted to bed. The incident report identified to offer R3 toileting after meals. R3's care plan identified, on 1/10/23 (two days later), the intervention was initiated. -A progress note, dated 1/9/23, R3 was found on his BR floor leaning against his BR door around 1:50 p.m. R3 was previously in his recliner. At the time of the fall, the recliner footrest remained elevated. An intervention was implemented to unplug the recliner, leave in a stationary position, and to store the remote in a manager's office. R3's care plan lacked the intervention. -A progress note, dated 1/13/22, R3 started an antibiotic for a UTI. -A progress note, dated 1/16/23, R3 attempted to standup from his w/c throughout the shift despite a bath, snacks, and being kept as close to staff, as much as possible or with in eyesight. -A progress note, dated 1/17/23, at 8:03 p.m. R3 was found on the floor near the nurse's station. R3 stated he attempted to walk to another resident so he could help him. The incident report identified an intervention for a hospice evaluation and medication review with rounding provider. R3's care plan identified, on 1/17/23, an intervention to keep frequently used items within R2's reach with each interaction. -A progress note, dated 1/18/23, at 9:14 a.m. activity staff were to increase one on one (1:1) activities with R3. R3's care plan lacked the intervention. -A progress note, dated 1/19/23, at 6:49 p.m. R3 was found kneeling on the floor next to his w/c in the DR. R3 stated he attempted to get into another chair situated next to the DR table. R3 was assisted to the BR and had a BM. -A progress note, dated 1/21/23, R3 was found crawling on the DR floor at 6:00 p.m. The incident report identified hourly safety checks. R3's care plan identified, on 1/23/23 (two days later), the intervention was initiated. -A progress note, dated 1/22/23, at 1:29 a.m., R3 was found on his BR floor at 12:30 a.m. during midnight rounds and assessed to have a skin tear on his knee. He was taken to the BR and had a BM. The incident report identified to offer R3 toileting after all meals and prior to bedtime. R3's care plan identified, on 1/23/23 (one day later), R3's toileting plan was revised. -A progress note, dated 1/22/23, at 10:34 a.m. R3 was found kneeling on his bedroom floor by his recliner with his locked w/c next to the bed. R3 stated he 'needed to go over there.' The incident report identified a medication review and hospice nurse consult with another review on 1/26/23 to see if recommended increased PRN medication usage was effective. A Fall Review Evaluation, dated 1/25/23, completed per facility MDS process(es), identified the following fall risk summary for R3: R3 was alert but lethargic and only oriented to self. He required mechanical sit to stand lift for transfers and was non-ambulatory in which he continued to make multiple self-transfer attempts per day and attempted to walk. He was unsuccessful in this which led to numerous falls in the past quarter. Will continue to closely work with hospice team and [medical provider] to monitor and minimize falls. The summary listed the following fall interventions: those listed with the 12/30/22 fall evaluation, foot pedals storage, items [TRUNCATED]