**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively reassess and, if needed, develop interventions with unsupervised eating to reduce the risk of accidental choking or asphyxiation for 1 of 1 resident (R67) who ate unsupervised in their room and had two documented episodes of choking. This constituted an immediate jeopardy (IJ) situation for R67. The IJ began on 9/14/24 when R67 choked for a second time on oral food, and the facility failed to comprehensively reassess R67's risk of choking, implement any interventions for increased supervision while eating or safe swallowing (i.e., speech therapy), or reeducate R67 and her responsible party on the risks of choking if R67 remained eating unsupervised as she had been despite choking. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 10/17/24 at 4:09 p.m. The IJ was removed on 10/18/24, but noncompliance remained at an isolated scope with potential for more than minimal harm that is not immediate jeopardy (Level D). In addition, based on observation, interview and document review, the facility failed to comprehensively assess for fall risk upon admission and with subsequent, repeated falls to determine what, if any, interventions were needed to ensure safety and reduce the risk of injury for 1 of 3 residents (R107) reviewed for accidents. R107 sustained actual harm when they fell multiple times after admission obtaining a head laceration and fracture hip. However, the facility had implemented corrective measures prior to the onsite survey, so these findings (falls) are being issued as past noncompliance. Findings include: CHOKING: R67's quarterly Minimum Data Set, dated [DATE], indicated R67 was admitted to the care facility on 12/9/22, had severe cognitive impairment, no swallowing problems and required partial to moderate assistance with eating and oral care. The MDS further indicated R67 was receiving hospice care. R67's facesheet, printed 10/17/24, indicated R67 had several medical diagnoses including dementia with behavioral disturbances, hemiplegia and hemiparesis following cerebral infarction (stroke), and dysphagia (difficulty swallowing) following cerebral infarction. R67's Orders, printed 10/17/24, indicated R67's diet order was mechanical soft, dated 3/23/24. R67's Progress notes, dated 3/4/24 through 10/17/24, indicated R67 had two choking episodes requiring staff intervention on 3/12/24 and 9/14/24. On 3/12/24 it was documented R67 was found in her room in a semi-Fowlers position, mouth wide open, not talking, trying to cough but couldn't. R67 required the Heimlich maneuver when finally a[n] object jumped out which was a piece of toast. The documented response was diet changed to mechanical soft with choking precautions for residents safety. On 3/12/24 it was documented the licensed dietician (LD) met with R67 who did not want to stop eating toast, however it was discussed cutting toast and other foods into small pieces, and alternating food and fluids. Also discussed cutting the crust off the bread. On 9/14/24 it was documented R67 was out in the small dining area when she was noted to be holding her neck and struggling to breathe when staff managed to get the food out that was stuck in resident throat. Approximately 20-30 minutes later, R67 became unresponsive for 5-10 minutes. On 9/16/24 it was documented R67 was visited by speech therapy, however a bedside ST [speech therapy] eval[evaluation] not completed d/t [due to] resident's active hospice status. OK for nursing staff to downgrade solids and liquids as needed for safety. R67's Associated Clinic of Psychology note, dated 3/13/24, indicated it was discussed with R67 that she could continue to eat preferred foods such as toast with a staff member present in her room, however lacked any discussion of the risks of choking or asphyxiation with R67 and her responsible party if R67 continued to eat unsupervised. R67's Care Plan, dated 3/13/24, indicated R67 was at risk for choking resident has no upper teeth, root tips on lower and had Dx [diagnosis)] = dementia, psychosis Res [resident] declines to get up for meals - eat in bed, declines staff sitting in room during meals ok'd [okayed] supervision. Risks and benefits discussed. A dcoument labeled, Approaches, also dated 3/13/24, indicated for staff to check R67's vital signs and lung sounds for 48 hours after a choking episode, to notify family, hospice and R67's nurse practitioner with significant changes, to check on R67 frequently throughout mealtime to ensure R67 is safe and free from choking, and to position R67 in a 90 degree position for each meal. The Care Plan lacked any clarity on what frequently meant or how often it would be expected for staff to check on R67. The Care Plan further lacked any updates after R67 second choking episode on 9/14/24. R67's electronic medical record (EMR) lacked documented evidence a discussion of the risks and benefits of R67 continuing to eat toast and a mechanical soft diet, unsupervised, after a second choking episode was discussed with R67 and her responsible party. R67's EMR further lacked a comprehensive reassessment and if warranted care plan updates were completed after R67's second choking episode. During observation on 10/14/24 at 5:34 p.m., R67 was sitting up in bed, unsupervised, with an over the bed table across her lap with her dinner set up. On her plate was two slider sized buns with sliced meat and multiple tator tots, not cut into small pieces. R67 was alone in her room with staff present in the main dining room area assisting other residents with dinner. During observation and interview on 10/16/24 at 10:16 a.m., nursing assistant (NA)-C brought R67 peanut butter and jelly toast, stating because it was R67's favorite. R67 was sat up in bed and NA-C left the room. During an interview on 10/16/24 at 11:41 a.m., NA-C stated he was aware of R67's choking episode but had been off that day, stating she had choked on a piece of toast. NA-C stated that despite R67 choking on toast, it didn't happen very often so R67 was still given toast to eat unsupervised in her room. During an interview on 10/16/24 at 12:05 p.m., speech therapist (ST)-A confirmed she was aware of R67's choking episodes but did not do an evaluation of R67's swallowing on 9/16/24 because she was on hospice, stating if she was not on hospice her choking episode would have warranted a full evaluation. ST-A stated R67 remained on a mechanical soft diet after her choking episode, and it was recommended for the nursing staff to downgrade [R67's] diet [to puree] as needed. During an interview on 10/17/24 at 7:55 a.m., social worker (SW)-A stated she recalled R67's choking episodes back in March but did not remember anything about R67 choking last month. SW-A stated she remembered having a conversation with nurse manager and registered nurse (RN)-A after R67's choking episode back in March and being told they should be offering R67 whatever brings her joy. SW-A confirmed R67 was not evaluated by speech therapy back in March after her first choking episode or last month after her second choking episode, nor by the dietician after her most recent choking episode and was unable to find any documented evidence of a risk versus benefit being competed with R67 for her responsible party regarding offering food choices to R67 that would bring her joy versus safety or what those safer food options would be. During an interview on 10/17/24 at 8:04 a.m., registered nurse (RN)-I stated it was a standing order for all residents that nursing staff could downgrade their diet if needed, meaning if a resident was coughing a lot while eating or drinking, they could downgrade their diet to mechanical soft or puree. RN-I stated they would change the diet and follow up with the doctor. During an interview on 10/17/24 at 2:06 p.m., RN-I stated when R67 was eating in her room, staff would try to check on her every 15-20 minutes. During an interview on 10/17/24 at 2:30 p.m., NA-E stated R67 was independent with eating after she was set up and stated staff would check back every 20-30 minutes to see how well she was eating. NA-E stated R67 loved eating toast for breakfast and was unaware of any choking episodes or problems R67 had with chewing or swallowing, again stating she was independent with eating. NA-E stated each resident had a care sheet hanging in their closet to explain what type of diet they were on and how they transfer and other cares however R67's was missing. During an interview on 10/17/24 at 8:44 a.m., RN-A stated there was a standing order for all residents that nursing staff can downgrade a diet if a resident was coughing, having difficult chewing, or choking on their food, stating nursing staff could change the diet and they would have speech therapy follow up and evaluate. RN-A stated R67 had coughing episodes, stating, I would not really call them choking episodes however agreed that requiring the Heimlich Maneuver and struggling to breathe would be considered a choking incident. RN-A stated after R67 required the Heimlich Maneuver back in March they attempted to change R67's diet to puree but she refused to eat stating they settled on a mechanical soft diet. RN-A stated her goal would be to have R67 out of bed for every meal, but she often refuses to get up and will often refuse to eat if a staff member is in the room with her, stating R67 will eat when she is ready. RN-A stated staff had been educated to ensure R67's head of bed was elevated when she was eating, as much as she [R67] will let us. RN-A stated she had talked with R67's responsible party at her last care conference on 9/11/24 (three days before her second choking episode). RN-A confirmed there was no documented risk versus benefits, no comprehensive reassessment of R67 after her second choking episode, and no changes to her care plan despite current interventions not preventing a second choking episode. During an interview on 10/17/24 at 8:11 a.m., R67's hospice nurse (HN) stated she was on call when R67 choked last month stating she received a call that R67 choked on a piece of bread and stated R67 didn't require the Heimlich Maneuver but at one point couldn't breathe and went into a state of unresponsiveness. HN stated the day after the choking incident R67 did not eat or take any of her medications, stating I think she was afraid to choke again. The HN stated because it was an isolated event and R67 was on hospice, a speech evaluation was not done and further stated at a care conference back in March they had discussed R67's diet and the risks associated with it but had not discussed it since her most recent choking episode. During an interview on 10/17/24 at 11:53 a.m., the director of nursing (DON) stated he could not recall R67's choking incident which happened last month and stated he would have expected the dietician to be involved, hospice to be notified and a speech therapy evaluation to be completed, even with R67 on hospice, confirming the dietician did not evaluation R67 nor was a speech therapy evaluation done after the choking episode in September. The DON further stated he would have expected a comprehensive assessment of what R67 would be willing to do/eat and what she wouldn't, along with the risk associated, and stated this should all have been documented in the EMR. The DON further stated he would have expected for a new plan to be developed since the current interventions in place did not prevent a second choking episode. During an interview on 10/17/24 at 12:08 p.m., R67's responsible party and family member (FM)-A stated she was not aware that R67 was still eating toast for breakfast and thought R67 was on a pureed diet. FM-A stated, I guess she can't have toast anymore and they would have to determine what else R67 would be willing to eat for breakfast. FM-A stated she did not believe that R67 would logically be able to make the decision on her own regarding the risks versus benefits of continuing to eat toast and other non-pureed foods. FM-A further confirmed the risks of potentially choking to death were not discussed with her and while she acknowledged R67 was on hospice she did not want her to die in a horrific manner from choking. During a follow-up interview on 10/17/24 at 2:35 p.m., nurse manager and RN-A stated they had tried cutting up R67's toast and cutting the crust off per the dietician's March note but R67 would not eat it that way. RN-A stated there was not a time frame for how often to check on R67 when she was eating, and stated she tires easily when she eats so staff were not sure when she would be eating or sleeping. RN-A further stated they had not documented the attempts to cut R67's crust off her toast and she had not discussed the choking episodes with R67's provider but believed the floor nurses had updated the provider. During an interview on 10/18/24 at 10:55 a.m., the medical director (MD) stated he was not made aware of R67's choking episodes until today. The medical director stated he would have advised to change her diet to puree and recommended that she eat in a supervised environment, even with a pureed diet, stating it was an issue with personal preference but also safety. The MD Further stated there was no reason R67 could not have a speech therapy evaluation. The immediate jeopardy that began on 9/14/24, was removed on 10/18/24, when the facility comprehensively reassessed R67, changed her diet to puree, documented discussing the risks of eating unsupervised with R67's responsible party, and educated staff on the care plan changes for R67, but the noncompliance remained at the lower scope and severity because of the continued risk for potential harm with R67 continuing to eat unsupervised. FALLS (past noncompliance): R107's admission Minimum Data Set (MDS), dated [DATE], identified R107 admitted to the care center from the acute hospital. The MDS outlined R107 had severe cognitive impairment, demonstrated no physical or verbal behaviors, and had no rejection of care episodes. The MDS continued and listed a section labeled, Section J - Health Conditions, which identified R107 did not have a terminal prognosis along with several questions related to R107's fall history (i.e., falls in the month(s) prior to admission), however, these were all answered with, 9. Unable to determine. However, after admission to the care center, the MDS recorded R107 had sustained one fall without injury. The MDS corresponding CAA (Care Area Assessment) Summary Report, completed 8/1/24, identified the various triggered CAAs for R107 which included one labeled, CAA 11. Falls. This identified R107 was at risk for falls related to impaired cognition, pain, and impaired mobility. The CAA recorded, One fall during look back without injuries with a matt [sic] placed on the floor next to his bed when he is in bed for safety/injuries. Receives supervision assist with bed mobility, toileting, and transfers currently in therapy, plan is for short term care per wife . Staff to place call light within his reach at all times when in his room and encourage him to use. Fall risk assessments per facility protocol. The CAA directed care planning would be completed adding, Proceed to care planning for fall and injury prevention. On 10/14/24 at 1:50 p.m., R107 was observed seated in a standard wheelchair in the commons area of the locked unit (i.e., memory care) with good posture and no leaning or slouching. R107 had a tan-colored bandage on his right hand and stated he had scratched it but was unsure how. R107 was unable to recall how long he had been at the care center and abruptly replied, I don't live here. R107 stated he was unsure what, if any, lunch meal they had that day, either. R107's current care plan, dated 8/26/24, identified R107's assessed problems, respective goals, and subsequent interventions to meet those goals. A total of three sections were labeled, Category: FALLS, and each outlined R107's various rationale for fall risk including but not limited to a history of falling, gait/balance problems, self-transfer attempts. All these sections were recorded as still in effect (i.e., not resolved) and these problem statements and interventions in chronological order outlined: Problem Start Date: 07/20/2024, outlined R107 as being at risk for falls and was last edited on 10/1/24, and a goal was listed which read, Will remain free from falls and fall-related injuries, with a goal date recorded, 11/21/2025. The section included multiple interventions to help R107 meet the goal including staff to do hourly well-checks to ensure safety, offer toileting or food if persistently self-transferring, and a low bed for safety. However, all the interventions listed within this section listed a start date of 8/21/24 or later. The problem statement and interventions were all initiated by registered nurse unit manager (RN)-A. Problem Start Date: 07/22/2024, outlined R107 as being at risk for falls and was last edited on 7/22/24, and a goal was listed which read, Will remain free from falls and fall-related injuries, with a goal date recorded, 10/22/2025. The section included multiple interventions to help R107 meet the goal including pharmacy consults per protocol, promoting scheduled rest periods, reinforcement to request assistance, not leaving unattended while in the bathroom, safety checks on shoes, monitoring for foot pain, ensuring proper lighting, providing non-skid material in the wheelchair and, When falls occur investigate root cause through IDT [interdisciplinary team] meeting protocol, and, When falls occur nursing to monitor using CEOM [Catholic Eldercare on Main] fall protocol. All the interventions listed had a start date recorded, 07/22/2024. R107's progress note, dated 7/19/24, identified R107 admitted to the care center locked unit on 7/19/24 for long term care placement. R107 was recorded as having a history of alcohol-induced dementia, chronic obstructive pulmonary disease (COPD), and prior stroke. The note outlined, Resident alert, memory is impaired with poor insight and judgement . has Foley Catheter . He is totally dependent on staff for ADL including dressing, grooming, bathing, and transferring. A subsequent note, dated 7/21/24, identified R107 was alert with impaired memory and poor insight. The note added, He attempt to self transfer with out adequate or calling for help [sic]. He is easy to redirect . is totally dependent on staff for ADL . Later, on 7/21/24, another note identified a bed rail was added to his bed to promote increased independence with mobility adding, Bed rail necessary for use as mobility device, and Nurse manager updated. On 7/22/24, the notes outlined R107's Foley catheter was removed, and routine bladder scans were started. On 7/23/24, R107 was found with bloody urine adding, When this writer arrived patient was standing in the middle of his room, urinating and his urine and mixed [sic] with large amount of blood. VS WNL [vital signs stable] . Further, another progress note, dated 7/24/24, was recorded with R107 now being COVID-19 positive with symptoms of nasal drainage and emesis. R107's 'SBAR [situation, background, assessment, response]' progress note, dated 7/26/24 at 5:36 p.m., identified R107 sustained a fall without injury. The note outlined, [nursing assistant] approached this staff at [3:00 p.m.] to say pt [patient] was on the floor in his room. This staff found pt laying on the floor near his bed. Pt denied pain. This staff noted that pt didn't have one of his gripper socks on . stated that he was self-transferring. Neuro's intact X1, ROM [range of motion] X4 . R [response]: This staff informed the Evening Supervisor, the Nurse Triage line, the POA [power of attorney]. This staff placed a floor mat in pt's room next to pt's bed. This staff updated pt's care plan to the fall. R107's corresponding Event Report, dated 7/26/24 but closed 8/21/24, identified R107 had sustained a fall without injury in his room adding, Pt found on the floor near his bed by the NAR. R107 was recorded as lying in bed just prior to the fall and the fall itself was unwitnessed. R107 demonstrated no pain from the fall and the section provided to record what, if any, injury was obtained answered, N/A. A section labeled, Possible Contributing Factors, identified R107's impaired cognition and infection (COVID-19) with a checkmark placed next to each, respectively. R107 was recorded as being on an antibiotic and a subsequent section was labeled, Interventions - Immediate measures taken, which had a checkmark placed next to, Rest, and Other - Floor mat to floor next to bed. The report included multiple follow-up progress notes which outlined R107 was at baseline. However, R107's medical record lacked recorded evidence the IDT had reviewed this incident or what, if any, interventions aside from a mat on the floor were considered or implemented. Further, the record lacked any completed comprehensive fall evaluations or assessments upon admission to the care center (on 7/19/24), including with all potential risk factors and what, if any, immediate interventions were assessed as needed despite R107 being recorded in the progress notes as having cognitive impairment with poor insight, needing total assistance with ADLs, and being found standing up in the middle of the room after his Foley catheter was removed (i.e., self-transfer). R107's SBAR progress note, dated 8/19/24 at 6:54 p.m., identified R107 sustained an unwitnessed fall with injury. The note outlined, . was found in room on the floor with his wheel chair upside down. He had a cut over his left eye and blood on the floor. Resident was assessed and transferred to chair, pressure applied to site and bleeding stopped . ROM is intact, he was able to move all extremities, a neuro assessment and vitals started. Resident spouse was notified and along with [medical provider]. There was no corresponding Event Report for this incident identified in the medical record. A series of subsequent progress notes, dated 8/20/24 through 8/23/24, reiterated the fall had occurred along with nearly all of them having outlined R107 had returned to baseline, and with a dressing in place over his left eye now adding a purple discoloration was present, too. However, a note dated 8/21/24 at 4:44 p.m., had R107 recorded as having some delusional thinking. The note outlined, . pt wanted this staff to close the garage door and get his wife. However, again, R107's medical record lacked documented evidence the IDT had reviewed this incident for any root-cause analysis review nor what, if any, other interventions were considered or implemented by the IDT. Further, the medical record continued to lack any completed comprehensive fall evaluations or assessments despite R107 having sustained two falls and demonstrating delusional thinking during similar evening hours (i.e., 4:00 to 7:00 p.m.). There was no evidence documented to provide rationale for what, if any, comprehensive causative factors were considered or evaluated to ensure effective, proactive interventions to reduce his fall risk despite the care plan being updated on 8/21/24 with interventions (i.e., low bed) which were not documented as being a factor in the progress note about the fall with injury. R107's SBAR progress note, dated 8/26/24 at 5:30 a.m., identified R107 sustained a fall due to self-transferring. The note outlined, Resident was found on the floor when aide notified nurse around 0523 when he was being check on [sic]. Resident was found in the supine position at the foot of his bed . incontinent of bowel; and bladder when he was found . bed was in lowest position when he was found on the floor with w/c [wheelchair] in the middle of the room . showed no signs of having pain at the time . was resistive to care at the time he was being assisted . Will report to AM staff to notify [medical provider], family, and continue to monitor. However, a subsequent note dated 8/26/24 at 7:10 a.m. (little over 90 minutes later), identified R107 was found sitting up in bed at 0640 and complaining of right hip pain. The note outlined, . [R107] had grimacing on his face and notified staff his right hip/side is in excruciating pain . complained of pain to touch and with ROM on his right hip . cognition is impaired with primary DX [diagnosis] of dementia and history of fall. The note identified the medical provider was updated, and an order for pain medication and an x-ray obtained. A subsequent note, dated 8/26/24 at 2:38 p.m., identified R107 was being transferred to the hospital with . Right femoral intertrochanteric fracture possibly post fall. A subsequent note, also dated 8/26/24, identified R107 had dementia adding, Pt has a dx of Dementia and fell today this am, fracturing his right femur . Pt's [family] talked with MD at the hospital and plans on pt having surgery to fix his right femur. R107 was re-admitted to the care center from the hospital on 8/30/24. R107's corresponding North Memorial Health admission History and Physical, dated 8/26/24, identified R107 who presented to the hospital . after an unwitnessed fall with right hip pain, found to have a hip fracture. He has bruising scattered throughout his body but only c/o [complains] pain in his right leg. Denies other concerns, though he is not oriented. A series of imaging was obtained, including an x-ray of the femur, which identified, Acute fracture of the proximal femur. R107 was recorded as preparing for surgery intervention to preserve quality of life and needed to be hospitalized for surgical management. R107's John Hopkins Fall Risk Assessment Tool, dated 8/31/24, was completed after R107 returned from the hospital and included multiple questions answered to help determine a risk-based score for falls such as previous number of falls and changes in condition. This assessment tool scored R107 as 23.0 which outlined, High Fall Risk. This evaluation was the first one completed as identified within the medical record. When interviewed on 10/16/24 at 1:21 p.m., NA-D stated they had worked with R107 multiple times at the care center and described him as needing total assist with cares. NA-D stated staff often have to use encouragement to get him to allow cares and verified R107 was no longer ambulatory since he fractured his femur adding, He used to [walk[ but not anymore. NA-D stated staff tried to just keep checking on him often since he returned from the hospital, and explained R107 used to try to self-transfer more often which caused his falls. NA-D stated R107 had used a low bed since he admitted to the care center and obtained the bedside mat after one of his falls adding, Not everybody get floor mat. NA-D stated if a fall happens, they report to the nurse who then must evaluate them before staff can get them up adding any new interventions or care following a fall would be communicated to the NA staff using shift-to-shift verbal report and the care card. NA-D stated these were kept both in the room and on the computer for the NA to reference on how to care for each resident adding it was our responsibility to view them each shift. NA-D stated R107 currently used a low bed, mat on floor and was being routinely checked on adding he was less mobile than prior. On 10/16/24 at 1:36 p.m., licensed practical nurse (LPN)-A was interviewed, and explained when a resident admits they are assessed for their fall risk using a John Hopkins tool which then helps develop the care plan. LPN-A verified the floor nurses are responsible to do the tool. LPN-A stated if a fall happens after admission, the nurses will check the resident' vital signs, assist them up, and initiate neurological checks if the fall was unwitnessed. LPN-A stated any immediate interventions to help prevent further falls would be dependent on what the situation is adding every fall is kind of different. LPN-A explained the nurse should be updating the medical provider along with doing three items post-fall which included starting a short-term fall care plan, stating an event, and completing the paper-based data collection tool. LPN-A explained the paper-based tool was used to record initial data adding it was kind of brief with not too many lines to do before it gets routed to the nurse manager who, from there, takes the data and meets with IDT where they talk about it. LPN-A explained the event and short-term care plan were like a template which could help guide the nurses on actions or possible interventions. LPN-A recalled R107 having sustained a fall and explained he now used a low bed along with a bedside mat to prevent injury adding they can't remember off hand when each intervention was added. LPN-A stated staff always try to keep an eye on him and ensure the call light was in reach, too, as R107 still, at times, could be a busy man and try to move around. LPN-A stated R107's mobility since the femur fracture had decreased a little bit and he was no longer ambulatory. Further, LPN-A stated any root-cause analysis of the falls, including potential proactive intervention development, would be the nurse managers to do with IDT as they do their analysis and determine the cause. On 10/17/24 at 10:06 a.m., registered nurse unit manager (RN)-A and the director of nursing (DON) were interviewed, and R107's medical record was reviewed. DON explained, upon admission, the nurse was responsible to complete the fall risk assessment on each resident which DON verified was the John Hopkins tool. The completed tool is then reviewed by the MDS nurse or unit manager, and the evaluation is then repeated quarterly thereafter with the fall risk care plan being developed from it. DON verified the care plan and fall risk assessment were the only two items used within the medical record to demonstrate the facility' comprehensive fall risk evaluation process. DON verified the fall risk assessment was not completed upon admission and should have been, however, attributed the development of a care plan (dated 7/20/24, 7/22/24) as belief someone had done an evaluation. RN-A stated they likely initiated the care plan for R107 on 7/20/24 but added, I don't remember. RN-A explained they initiated the 7/22/24 falls care plan for R107 but expressed they didn't recall if they reviewed any completed fall risk evaluations or not with it. RN-A stated the main reason they initiated it was R107 had a history of falls adding the interventions placed on both the initial care plans, dated 7/20/24 and 7/22/24, were placed while we [got] to know him as the team didn't know him right away. RN-A and DON both verified the first completed John Hopkins fall risk evaluation was completed upon R107's return from the hospital after he sustained a broken femur and DON added, I think there was a miss there. DON stated they felt a possible Internet global failure around the same time may have contributed to it being missed for so long but were unsure. RN-A explained R107 had used a low bed from day one as R107's family [TRUNCATED]