**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to appropriately assess and implement appropriate interventions to prevent repeated falls for 2 of 2 residents (R1 and R3), who were at high risk for falls. This failure resulted in actual harm for R1 who sustained a mildly displaced right femoral neck fracture, right hip fracture, which required surgical repair and sustained a right periprosthetic femur fracture. Findings include: R1's face sheet undated, identified R1 had the following diagnoses: Alzheimer's disease, dementia, adult failure to thrive, ataxic gait, muscle weakness, syncope with collapse, repeated falls and unsteadiness on feet. R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had significantly impaired cognition, required one person assist with transfers, toileting, dressing and locomotion on the unit. R1 was not steady and only able to stabilize with human assistance for balance during transitions and walking. MDS identified R1 used a wheelchair for mobility. R1 was occasionally incontinent of bowel and bladder with no bowel or bladder toileting program. R1's bladder assessment, dated 7/12/23, identified R1 was frequently incontinent with risk factors of impaired mobility and dependent transfer. R1 has urine leakage on the way to bathroom and has wet close or wet incontinent pads. Environment limitations included impaired mobility and decreased manual dexterity with contributing diagnosis of Alzheimer's, diabetes, falls and pain with movements. Medications may be contributing to bladder dysfunction includes antidepressants, diuretics, and narcotics. Stress incontinence includes incontinence without sensation of loss of urine as well as urge urinary incontinence with strong uncontrolled urgency prior to incontinence and urine loss on the way to toilet. Scheduled toileting/habit training schedule includes every two hours with no further information. Fall care plan dated 3/28/23 identified R1 to be at risk for falls and interventions in place included soft touch call light, assist of one using EZ-Stand (mechanical lift) for transfers, wheelchair for mobility, nonskid footwear, nursing staff to encourage out of room activities, room close to nursing station and nursing staff to toilet ever two hours and as need to reduce risk of falls. Mobility care plan dated 5/25/23 identified R1 to have impaired mobility and history of repeated falls and unsteadiness on feet, R1 required assist of one person using front wheeled walker for transfers, ambulation, and toileting. R1 used wheelchair for mobility and can propel independently or with assist of one person as needed. R1 requires gripper socks at all times. The following Fall Risk Assessments were completed with a score of over ten indicating a high risk of falls. 12/21/23 with a score of 17, 3/22/23 with a score of 17, 3/28/23 with a score of 20, 5/1/23 with a score of 21, 7/12/23 with a score of 23, and 7/25/23 with a score of 19. Fall Risk Observations Reviewed: Dated 3/28/23 - Fall risk assessment summary: recent falls in the past three months and a score of 20 indicating high risk. Dated 5/1/23 - Fall risk assessment summery: Resident had unwitnessed fall on 3/23 resulting in a femur fracture. Requires the EZ-stand lift to assist with transfers with a diagnosis of Alzheimer's disease, dementia, ataxic gait, generalized muscle weakness and a history of falls. Dated 7/12/23- Fall risk assessment summary: At risk of falls with a score of 23 (high fall risk), Resident was alert but had confusion. Pivot transfers- do not walk with history of falls. Had multiple medications and diagnoses with potential to contribute to a fall. The following Fall Events and internal investigations were reviewed: Fall event 2/5/23 at 8:05 p.m., unwitnessed fall in room with walker and R1 sustained scratch and bump on head and small abrasion on left knee. Fall event 2/9/23 at 7:15 p.m., unwitnessed fall in bathroom attempting to self-transfer onto toilet without injuries. Fall event 3/23/23 at 4:45 a.m., unwitnessed fall in resident room self-transferring, wheelchair found outside the bathroom. Resident reported to the charge nurse he was attempting to get to the bathroom. Fall required hospitalization and found to sustain a right femur fracture requiring surgical repair. Internal investigation requested, however not received. Fall event 3/30/23 at 11:15 a.m., , unwitnessed fall in bathroom attempting to self-transfer from wheelchair onto toilet without injuries. Fall event 4/15/23 at 7:45 p.m., unwitnessed fall in bathroom attempting to self-transfer from wheelchair onto toilet. Fall event 5/6/23 at 7:50 p.m., unwitnessed fall in bathroom attempting to self-transfer from wheelchair onto toilet without injuries. Fall event 5/25/23 at 12:30 p.m, unwitnessed fall in bathroom attempting to self-transfer with skin tear an inch long on wrist. Internal investigation identified gripper socks on but was not able to safely transfer without the use of an EZ stand lift and nursing staff to assist. R1 was last toileted at 10:30 and fall happened at 12:30. Fall event 7/6/23 6:27 p.m., unwitnessed fall in R1's room, resident on floor, w/c tipped over and walker next to wheelchair. Fall required hospitalization and identification of periprosthetic femur fracture. Review of facility's internal investigation notes indicated a patterned statement of root cause was due to resident's impaired level of mobility, cognitive status and generalized weakness. The internal investigation lacked evidence of a general assessment for pattern of falls, reason for falling (time, toileting needs, supervision) and lacked fall interventions to prevent future falls. R1's group assignment sheet information noted to be on two separate group sheets as indicated below. -R1's float group assignment sheet undated, identified R1 to require assist of one person with the use of EZ-Stand and toilet every two hours. Safety considerations include history of self-transfers, poor safety awareness/impulsive. Comments include bed in low position, lotion to feet/legs at night. -R1's west group assignment sheet dated 7/25/23 consistently notes assist of one person with use of EZ-Stand and toilet every two hours. Safety consideration includes history of self-transfers with bathroom, and comments include bed in low position, lotion to feet/legs every two hours, hip precautions, no bending past 90 degrees, no crossing legs. Incontinent of bowel and bladder, alert to self, forgetful needs cues. After visit hospital summery printed 3/27/23, indicated that R1 was hospitalized on [DATE] and admitted for evaluation and management of mildly displaced right femoral neck fracture due to R1 falling under unclear circumstances at skilled nursing home facility. Note further identifies that resident required surgical repair on 3/24/23 for a right hip fracture due to an unwitnessed fall. After visit hospital summery signed on 7/11/23, indicates R1 was hospitalized on [DATE] and discharged on 7/11/23 for a right periprosthetic femur fracture. It was determined to be treated non operatively. Group assignment sheets directing nursing aids provided inconsistent information, lacked information from the care plan and safety consideration for R1, including resident FALL RISK and care following femur fracture. During interview on 7/25/23 at 3:29 p.m., R1 indicated the staff are too busy so he uses the bathroom independently. R1 indicated to know how to use the call light, but he likes to take himself to the bathroom. During interview on 7/25/23 at 3:40 p.m., nurse aid (NA)-E indicated they used the the group sheets to know what care the residents need and if residents were a high fall risk, by the group sheet indicating *High Fall Risk.* During interview on 7/25/23 at 4:16 p.m., license practical nurse (LPN)-A indicated care group sheets should never have discrepancies from either the care plan or if a resident were to be on different groups. During interview on 7/25/23 at 4:59 p.m., LPN-B indicated R1 was a high fall risk only when in bed and interventions include floor mat, bed to the lowest position, and call light within reach to prevent falls. LPN-B declined R1 to be a fall risk from wheelchair and had never been notified R1 tries to self-transfer onto the toilet, just from the bed. During interview on 7/27/23 at 2:11 p.m., NA-C indicated R1 had a walker in his room however shouldn't be in his room because he doesn't use it and either should the nursing staff. NA-C indicated R1 did not use call light and would attempt to transfer from the wheelchair to the toilet on his own. NA-C indicated to be aware of R1's behaviors as R1 tends to wheel his wheelchair close to the bathroom door when he needs to go to the bathroom and R1 was not always incontinent and will request to use the toilet when needed. During interview on 7/27/23 at 9:00 a.m., physical therapist (PT)-A indicated R1 was a high fall risk and it was therapy's recommendation for nursing staff to use EZ-Stand for transfers for safety. PT-A indicated R1 was unsafe to transfer independently and unable to correctly position wheelchair or lock brakes to transfer to the toilet and does not follow the steps required to complete a safe and independent transfer, further R1 was impulsive with cognitive deficits. PT-A confirmed fall mat, high low bed and soft touch bedroom call light would not prevent or address a safety concern from R1 attempting to transfer to toilet. During interview on 7/27/23 at 9:04 a.m., RN-B indicated R1 had a room closer to the nurses station, high low bed, soft touch call light and slipper socks as interventions implemented prior to February of 2023 frequent monitoring is encouraged, however no formal protocol or time frame of the expectation. RN-B indicated there should never be discrepancies on care cards or group guides and it was identified the care guides directed nursing assistance to use EZ-Stand, however the care plan reflected assist of one person with walker and it was identified on 7/25/23 as a discrepancy. Upon reviewing interventions for falls for R1, RN-B indicated the current interventions do not prevent or address R1 from self-transferring in the bathroom and an intervention should have been in place. RN-B furthermore reflected there was not enough causal analysis of stopping and preventing falls in the bathroom and if frequent checks are encouraged it should be care planned and on the group guides. Fall risk assessment scores reviewed and noted an upward trend from 12/21/23 to 7/25/23 with no preventative action. During interview on 7/27/23 at 2:27 p.m., (PT)-B indicated it was not therapies recommendation for nursing staff to use the walker with R1, however sees no issue with it being accessible in his room. PT-B indicated the first functional bathroom transfer assessment was completed on 7/25/23 and not addressed prior. PT-B declined occupational therapy to be involved or evaluate or provide recommendations for functional transfer training in bathroom or cognitive based interventions. During interview on 7/27/23 at 10:10 a.m., fall review completed with director of nursing (DON) and noted 3/23/23 root cause of fall to be R1's cognition and fall happened due to self-transferring and R1 not consistently use call light. Following the fall on 3/23/23, the wheelchair was implemented for mobility, mat and high low bed were also implemented (changes were not reflected on care plan dated 3/28/23). DON indicated for the 3/30/23, 4/15/23, 5/6/23 falls without interventions in place she would expect something more have been in place and frequent checks should have been put in both the care plans and group sheets. R1 was screened by physical therapy after 5/6/23 fall, however it was not indicated for therapy to see him on caseload and R1 was transferring with the EZ-Stand per therapy recommendation at that time with nursing. After the 5/25/23 fall also did not have interventions placed and the DON indicated the facility should have done something more including identified, trend tracking of self-transferring, placed interventions to protect R1 and recognition current toileting schedule was not preventing falls. DON added, the 7/6/23 fall was reviewed and the intervention that was placed was anti-lock brakes on to the wheelchair to prevent it from sliding as well as initiating therapy (changes were not reflected on care plan dated 3/28/23). Reviewed group sheets with DON which identified the Float and [NAME] group sheet were not consistent, DON indicated care plans and care guides should not have conflicting transfer status as it could pose a safety risk to the resident. DON indicated R1 should not have a walker in his room and could lead to additional falls and could encourage him to self-initiate ambulation or self-transfer. R3's face sheet undated, identified R3 had the following diagnoses: Osteoarthritis of right knee, pain in right knee, right patella fracture, diabetes, chronic congestive heart failure, history of diseases of the digestive system, GI bleed, chronic kidney disease, and constipation. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitive and required one person assist with toileting and transfers, also identified R3 to be occasionally incontinent, however did not require a toileting program. Fall care plan dated 5/11/21, identified R3 to be at risk for falls and interventions in place included having call light within reach, non-skid footwear with all transfers/ambulation and assist of 1 with transfers and ambulation using four-wheel walker. Additionally, intervention dated 3/16/23 directed staff to follow wheelchair behind when ambulating and remove the footrests for safety. Mobility care plan dated 5/11/21 identified R3 to require assist of one person and four wheeled walker to assist for both transfers and ambulation and assist of one person to propel wheelchair on and off unit. R3's group sheet indicated R3 required assist of one person with walker for transfers, ambulation and toileting/peri care. R3's group sheet lacks information regarding high fall risk, requiring wheelchair follow when ambulating nor need for slipper socks. R3's bladder assessments dated 6/17/23 indicate R3 was occasionally incontinent, impaired mobility and ambulation with contributing diagnosis and medications related to bladder dysfunction and both stress and urge incontinence. Based off assessment a scheduled toileting program was indicated, however lacks details on program type and frequency. The following Fall Events and internal investigation was reviewed: 5/15/23 witnessed fall in bathroom lowered to floor due to bucking knees and sustained a 4 cm scratch on back. Fall event identified R3's knees are buckling. 5/28/23 unwitnessed fall in bathroom- attempting to self-transfer and legs gave out and was wearing non-skid footwear. 6/21/23 unwitnessed fall in bathroom- attempting to self-transfer and legs gave out. Was wearing non-skid footwear. Root cause of falls were due to residents increased weakness and impaired level of mobility, balance with transfers and ambulation. During interview on 7/27/23 at 2:20 p.m., NA-E indicated working with R3 and she had intervened and needed to stop R3 from self-transferring and it was common behavior. R3 tends to self-transfer after meals and mainly in the afternoon. During interview on 7/25/23 at 1:44 p.m., trained medication aid (TMA)-A identified to have worked with R3 and observes her as cognitively intact, pleasant and not impulsive. TMA-A indicated to be aware of R3's falls as R3 attempts to self transfer onto the toilet. TMA-A was unaware of any interventions in place to prevent falls as R3 uses the call light appropriately, R3 was just impatient. During interview on 7/27/23 at 1:53 p.m., NA-C was aware of R3's falls and indicated its due to R3 self-transferring. NA-C reported R3's knees are bouncy and give out during transferring, R3 will use the call light in the mornings, but doesn't typically use to call for help in the afternoons and would self-transfer from the wheelchair to the toilet. NA-C had not observed her self-transfer elsewhere. NA-C indicated R3 was at high risk of falls after lunch or following mealtimes as it was when she was in the wheelchair and her wheelchair was a surface she could physically self-transfer from. During interview on 7/27/23 at 2:28 p.m., PT-B indicated therapy had been involved to assessed R3 on both 5/25/23 and 6/26/23 and was aware of R3's bouncy knees, however when therapy assessed R3 did not exhibit bouncy knees and there was no clinical diagnosis. Additionally, no recommendations were made to the floor staff from therapy as they did not identify any concerns. PT-B indicated R3 did well with therapy involvement and makes progress and R3 knee concerns started when she was taken off caseload from therapy. PT-B declined therapy involvement with causal analysis when it comes to falls and typically done within the management meetings with nurse managers and DON. During interview on 7/27/23 at 3:30 p.m., DON indicated she was unaware R3 was known to be self-transferring from wheelchair to toilet. DON indicated the bowel and bladder assessments should identify individual needs and identifies risk factors related to self-transferring in relation to toileting. Reviewed bowel and bladder assessments completed on 3/30/23 and 6/17/23, however there was not a bladder assessment on or near 5/28/23 despite R3 falling next to the toilet. R3's bladder assessment on 6/17/23 lacked any individualized recommendation. Facility policy titled Accident Prevention- Fall Risk Observation dated 2/2023 indicates the purpose of the policy was for residents to be assessed for his/her risk for falls and or accidents. Residents identified to be at risk for falls have interventions implemented through the care plan and the licensed nurse was responsible. -It was to be used as a consistent method to determine residents at risk for falls in addition to the MDS, Corresponding Care Area assessment (CAA) for falls, cognitive loss/dementia, physical restraints, and psychotropic drug use are completed to identify additional risk factors and interventions. -Residents at risk for falls/accidents have an individualized care plan developed. Care plan interventions are based on the findings of fall risk observation. -Additional professionals may be contracted to provide assessment regarding fall risk and prevention including but not limited to attending physician, pharmacist, physical therapist and occupational therapist. Facility policy titled transfer/lifting policy and Procedure dated 3/2023 indicates the purpose of the policy was to provide safe transfer techniques to reduce incidents or injuries to all residents and staff, as well as to establish and communicate transfer and lifting policies for facility. The expected transfer plan for each resident was to be found on the care plan and the nursing assistant group sheet and it's the responsibility of all employees to follow the care plan and designated lifting policy for each resident for their personal safety as well as responsibility to report problems that would make compliance difficult.