**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to comprehensively assess and provide the provision of supervision of self transfer to prevent and/or mitigate the risk of falls for 1 of 3 residents (R2) who had a history of falls. This resulted in actual harm for R2 who fell and sustained back and rib fractures. Findings include: R2's Minimum Data Set (MDS) dated [DATE], indicated R2 was a [AGE] year-old admitted on [DATE] with diagnoses including dementia, diabetes, history of transient ischemic attack (temporary disruption of blood flow to the brain), muscle weakness, difficulty in walking, unsteadiness on feet, other abnormalities of gait and mobility, weakness, and repeated falls. R2's Brief Interview for Mental Status score was 11, indicating moderate cognitive impairment. R2 utilized a wheelchair, required substantial assistance with toileting hygiene, and moderate assistance with bed mobility and transfers. Walking was not attempted due to medical condition or safety concerns. R2 was frequently incontinent of bowel and bladder. R2's care plan dated 1/4/24, identified a focus on falls and noted resident is at risk for falls related to impaired cognition secondary to dementia, impaired balance during transitions, impaired gait, and history of repeated falls, activity intolerance secondary to chronic lung disease and hypertension, potential medication side effects. Other contributing factors noted were lower back pain, sleeplessness, frequently waking up to use the bathroom, and frequent independent transfers. Current fall interventions included: -alert/orient resident to changes in environment routine and caregivers, -keep call light within reach and encourage use as needed, -complete fall risk assessment/evaluation quarterly and as needed, -check post-void residual as needed (amount of urine still in bladder after urinating), -encourage participation in activities that promote exercise and physical activity for strengthening and improved mobility such a physical and occupational therapies, ensure proper footwear is worn, -evaluate effectiveness of interventions on an ongoing basis, follow facility fall protocol, -give pain medication as ordered, -put motion sensor light in bathroom, -monitor for acute illness, -no repositioning sheet in bed, -pharmacy consultant review of medications at least monthly, -put night light near bed, -answer call light promptly, -place wheelchair with wheels locked next to bed when resident in bed, -physical therapy evaluation and treatment as needed, -remove clutter from room and keep a clear path to the bathroom, and noted to also see R2's care plan for activities of daily living (ADLs), mobility, and toileting. -Related ADL interventions included assist of one with dressing grooming and hygiene, and encourage/remind resident to use call light. -Related mobility interventions included active range of motion exercises of both lower extremities daily, resident preference to get up and do morning ADLs between 6:00 a.m. and 7:00 a.m., use of regular draw sheets on bed to prevent sliding off bed, and assistance of one with a gait belt for all transfers. -Related toileting interventions included assistance with toileting and repositioning every two to three hours during waking hours and on all overnight rounds, last revised on 11/9/23. R2's electronic health record (EHR) included documentation of repeated falls since admission. R2's EHR included Falls Follow Up Forms from 6/3/23, 6/6/23, 6/22/23, 7/16/23, 7/17/23, 8/3/23, 9/16/23, 9/27/23, 10/1/23, 10/9/23, 10/28/23, 11/9/23, 11/28/23, 12/11/23, 12/14/23, 1/9/24, and 1/13/24. A progress note dated 12/31/23 at 12:04 p.m. indicated an additional fall on that date. In review of R2's fall records at least 7 of the falls involved toileting; 6/3/23, 7/16/23, 8/3/23, 9/27/23, 10/9/23, 11/9/23, and 1/9/24. R2's Resident Occurrence Report completed by registered nurse (RN)-A and licensed practical nurse (LPN)-A dated 12/14/23, indicated R2 was found on the floor in her room at 1:10 p.m. on 12/14/23. R2 was last observed at 1:00 p.m. when transferred from bed to chair by RN-A. The last time R2 was toileted was unknown. The resident statement indicated R2 was trying to reach the remote control. The analysis of the cause of the occurrence was R2 was unable to demonstrate call light use. The action to minimize reoccurrence was checking on R2 every 15 minutes. Suggestions to prevent this from occurring again noted the resident may benefit from having one-to-one assistance. R2's Falls Follow Up Form completed by registered nurse (RN)-A and licensed practical nurse (LPN)-A dated 12/14/23, indicated R2 fell on [DATE]. The analysis and summary of causal factors noted R2 continued to self-transfer. RN-A's short-term intervention was to check on R2 every 15 minutes. The long-term intervention noted by the director of nursing (DON) on 1/8/24 after inter-disciplinary team (IDT) review was rearrangement of R2's room to create a clear path to the bathroom. A progress note by RN-A dated 12/14/23 at 2:11 p.m., indicated the intervention based on root cause analysis of the fall was the resident is unable to follow directions for call light use. Frequent checks (was not defined) continued with resident to be brought to the bathroom. A fall follow up progress note for R2's fall on 12/14/23 dated 12/17/23 at 7:28 a.m., indicated R2 continued to self-transfer and attempted to self-transfer three times during the night. R2 was rounded on frequently (was not defined) to monitor for safety and needs. A progress note dated 12/18/23 at 5:10 a.m., indicated R2 attempted to self-transfer four times during the writer's shift and was rounded on frequently to monitor for safety and needs. A provider note by nurse practitioner (NP)-A dated 12/19/23, indicated R2 has a history of multiple falls, likely multifactorial and usually when R2 is attempting to self-transfer. The plan directed staff to continue to assist with ambulation to and from the dining room and bathroom and transfers, to continue frequent check-ins, and to monitor for falls. R1's care plan was not revised to include frequent check-in's per NP note on 12/19/24. R2's record did not indicate an assessment or evaluation to determine interventions to reduce R2's self-transfers thereby reducing R2's risk for falls. Additionally, the record did not include completed evaluation of the effectiveness of the 15-minute checks and/or the frequent monitoring that was not individualized or determined to identify how often R2 required increased supervision. A progress note dated 12/20/23 at 1:35 p.m., indicated the resident is unable to demonstrate call light use. A progress note dated 12/22/23 at 6:22 a.m., indicated R2 attempted to self-transfer to the bathroom three times during the writer's shift, was assisted to the bathroom, and was rounded on frequently (was not defined) to monitor for needs and safety. A progress note dated 12/26/23 at 12:29 p.m., indicated R2 was unable to demonstrate call light use. A progress note dated 12/26/23 at 10:13 p.m., indicated R2 self-transferred twice during the writer's shift and does not use the call light. A progress note dated 12/27/23 at 11:50 p.m., indicated R2 self-transferred three times during the shift and did not use the call light. A progress note dated 12/28/23 at 11:18 p.m., indicated R2 was found self-transferring four times and does NOT understand the call light. A progress note dated 12/31/23 at 12:04 p.m., indicated R2 attempted to use the restroom independently and fell in the morning. She did not use the call light for help and was found on the floor between her bed and armoire with her pants around her ankles. A Fall Follow Up Form for R2's 12/31/23 fall was not located in R2's EHR and no causal analsysis of the fall was evident. A progress note dated 1/2/24 at 2:05 p.m., noted the resident has a diagnosis of dementia with a poor ability to recall new learning or follow call light use directions. New interventions related to mobility and/or fall risk included frequent checks and offering toileting every two to three hours, checking on R2 on all rounds overnight and offering toileting when awake, putting wheelchair with brakes on next to bed, rearranging bedroom, and placing bed closer to the bathroom. A progress note dated 1/3/24 at 12:17 p.m., indicated R2 remained impulsive and did not demonstrate the ability to identify the need for call light use. An IDT follow up progress note dated 1/3/24 at 3:25 p.m., indicated a root cause analysis of resident fall in the bathroom with intervention of occupational therapy evaluating for bars from a commode base to be placed on R2's toilet to use for balance and to push up on when R2 self-transfers to the toilet. The date of the fall was not indicated and not evident R1's toileting schedule was re-evaluated for appropriateness. A progress note dated 1/8/24 at 3:59 p.m., indicated R2 self-transferred once during the writer's shift and interventions were minimally effective as the resident was not dissuaded from self-transferring. A progress note dated 1/8/24 at 9:50 p.m., indicated R2 self-transferred multiple times during the writer's shift and does not use call light despite continuing education and reminders. A fall progress note dated 1/9/24 at 7:23 a.m., indicated R2 was found on the floor returning from the bathroom without a wheelchair after self-transfer to the bathroom with a wheelchair. The intervention based on root cause analysis was 1:1 STAFFING WOULD BE MOST USEFUL - NOT AVAILABLE AT THIS TIME. An alternative intervention was not identified. R2's Resident Occurrence Report completed by RN-A dated 1/9/24, indicated R2 was found on the floor in her room on 1/9/24 at 6:45 a.m. The last observation of R2 prior to the fall was by nursing assistant (NA)-A at 6:30 a.m. when R2 was sleeping in bed with a wheelchair next to the bed. The last time R2 was toileted was not noted. The resident statement indicated R2 was trying to go to the bathroom and back to bed. The analysis of the cause of the occurrence was self-transfer to the toilet. The action to minimize reoccurrence noted new strategies were unable to be identified outside of one-to-one staff supervision. Suggestions to prevent this from occurring again were one-to-one staffing and noted frequent checks were inadequate and R2 was unable to follow directions. R2's Falls Follow Up Form completed by RN-A dated 1/9/24, indicated R2 fell on 1/9/24. The analysis and summary of causal factors noted R2 self-transferred for purpose of toileting without alerting staff, using a wheelchair to get to the bathroom and ambulating out of the bathroom without a wheelchair. RN-A's short-term intervention recommended one-to-one staff supervision. The long-term intervention noted by the director of nursing (DON) on 1/22/24 after IDT review was to continue to offer morning cares between 6:00 a.m. and 7:00 a.m. per resident preference. R1's record did not indicate an assessment or evaluation to determine interventions to reduce R1's self-transfers including re-assessment of R1's toileting time. A fall progress note by LPN-B dated 1/13/24 at 5:21 p.m., indicated R2 was found on the floor in her room between her bed and the bathroom on her left side with her left arm and leg underneath her body. Upon assessment R2 complained of pain, had unequal grip strength, could not move her left leg off the ground, and could not move her toes. R2 was sent to the hospital for further evaluation and treatment. R2's Resident Occurrence Report completed by LPN-B dated 1/13/24, indicated R2 was found on the ground between her bed and the bathroom at 4:40 p.m. on 1/13/24. Prior to the fall, R2 was last observed at 4:00 p.m. sleeping in bed when NA-B checked on R2 after R2 refused toileting offered at 3:30 p.m. The resident statement indicated R2 was going to the bathroom when she fell. The action to minimize reoccurrence and suggestions to prevent this from occurring again sections were not completed. R2's Falls Follow Up Form by LPN-B dated 1/13/24, indicated R2 fell at 4:40 p.m. on 1/13/24. The analysis and summary of causal factors noted R2 self-transferred, had no grippy socks, and did not use the call light. The short-term intervention was sending R2 to the hospital. A note dated 2/5/24 on the form from the DON after IDT review indicated R2 returned from the hospital with orders for physical and occupational therapies. The IDT would continue to evaluate R2's progress with therapy and update the plan of care as appropriate. A provider note dated 1/18/24, indicated R2 was admitted to hospital on [DATE] for evaluation after an unwitnessed fall at the facility. Imaging revealed a lumbar vertebral fracture and two rib fractures. R2 transferred back to the facility on 1/17/24 and was discharged from the hospital with a thoracic lumbar sacral orthosis (TLSO) (a mid to lower back brace) to wear for three months. R2's NA care sheet for 2/7/24, indicated that R2 was a fall risk and instructed NAs to perform safety checks at the beginning and end of their shifts, take R2 to the bathroom every two to three hours while awake and on all overnight rounds, and to leave wheelchair with wheels locked next to R2's bed when in bed for self-transfers/falls. In an interview on 2/5/24 at 12:40 p.m., trained medication aide (TMA)-A stated R2 self-transfers and is a fall risk, so staff put her call light right next to her in bed and put her wheelchair next to her bed with the brakes locked. TMA-A stated R2's care plan was to offer toileting every two hours and he tried to monitor R2 more frequently because R2 is a fall risk. TMA-A did not articulate how frequent was frequent. In an interview on 2/5/24 at 1:05 p.m., NA-C stated R2 fell a lot and did not say when she needed to be changed or toileted. R2 did not know how to use the call light at all and tried to self-transfer when in her room. NA-C stated R2's wheelchair was placed at bedside with the bed in low position in case R2 tried to get up. In an interview on 2/5/24 at 2:01 p.m., family member (FM)-A stated R2 had fallen in the past while trying to go to the bathroom. Sometimes R2 had to wait to go to the bathroom and tried to go by herself. R2 did not like to wait, she goes when she wanted to go. When R2 was asked if she needed to go to the bathroom she might say yes and might say no, sometimes she said no and then had to go a few minutes later. In an interview on 2/7/24 at 9:21 a.m., RN-A stated R2 has an inability to retain new learning and education and reminders about using the call light have not been effective. RN-A stated she did not believe it was appropriate to have call light use as a fall intervention because it was not effective, and education was not an appropriate intervention if R2 was unable to learn. R2 could not use it and did not use it. R2 did not refuse cares when offered but was impulsive and had toileting every two hours in her care plan. RN-A stated she wrote R2 needs one-to-one staff supervision on a recent fall report. RN-A reported that she had not seen any changes in how R2 was monitored or supervised since completing the report and believed R2's fall with injury on 1/13/24 could have been prevented with more supervision. In an interview on 2/7/24 at 9:40 a.m., NA-D stated R2 ambulated with extensive assistance and transferred with an assist of one with a gait belt. R2 was a fall risk and interventions were on her care plan such as putting R2's wheelchair at bedside and the call light right next to her. NA-D stated toileting was offered to R2 every two to three hours and NA-D tried to check on R2 every hour. NA-D noted frequent checks would be considered checking on R2 hourly. In an interview on 2/7/24 at 9:50 a.m., TMA-A stated the frequency of checks on a resident depends on the resident's care plan. For R2, the toileting care plan said to check every two hours. In an interview on 2/7/24 at 9:57 a.m., NA-C stated frequent checks meant checking on a resident every half hour or so, at least every hour, but more if possible. Checking on a resident was looking at them to be sure they were okay and safe. In an interview on 2/7/24 at 10:28 a.m., NA-A stated R2 was a big fall risk and tends to self-transfer from her bed to the bathroom all the time. Staff tried to toilet her as much as possible so she did not self-transfer, R2 needed to be toileted every three to four hours. Staff kept R2's call light close by, wheelchair at bedside with brakes locked, and placed a motion sensor light in R2's bathroom. NA-A stated she had never seen R2 hold or push her call light, R2 did not refuse cares, R2 would get up and used the bathroom when she needed to. In an interview on 2/7/24 at 11:42 a.m., director of nursing (DON) stated when a resident had a fall with an injury the first question was to see if the plan of care was followed. The IDT met to review falls and made sure the plan of care was followed. If it was followed the IDT looked at what else could prevent the fall. The team considers what the recommendations were from the nurse and as a team we come up with interventions. Then after two weeks we review the fall again at the IDT meeting, go over what interventions were put in place, see if they are effective, and decide how to proceed. The fall risk assessment was the comprehensive assessment completed when the the resident was admitted . We review that as we get to know the resident and develop the care plan. If someone was a fall risk, we add the risks and interventions to the care plan and do the assessment every three months. DON stated R2 had approximately 14 to 15 falls since admission and fell frequently. For R2, nursing recommended one-to-one supervision, but DON did not offer that as an intervention because knew R2's family did not have resources. DON noted that the last revision to R2's toileting care plan was on 11/9/23 with the addition of an intervention to toilet R2 every two to three hours and on overnight rounds. DON stated the falls form from R2's 7/16/23 had a short-term intervention to continue hourly safety checks which staff could do but was not added to R2's care plan. DON explained there was an assessment of safety which included meeting a resident's needs but there was no separate assessment that determined supervision. To determine R2's level of supervision DON thought a sleep log was completed, pain management assessment, and the nurses and aides did safety checks at the beginning of their shifts. DON explained there were repeated recommendations from nursing to increase R2's supervision. DON stated I don't think it is practical to say someone will go in every half hour or every hour to check on [R2], it is not realistic. Checking on a resident frequently is not on care plans because if you say frequently you have to say how often, I can't tell the aides to check on the residents frequently without giving a time frame. DON believed the toileting every two to three hours that was currently in place was appropriate. After R2's fall on 1/9/24, the intervention was continuing the plan of care, DON was not sure why. We can continue the plan of care but continue to also reapproach the resident when offering toileting if they say they do not need to toilet at the time. DON believed R2 has used the call light or but not aware of how frequently she used it. DON stated an awareness R2's cognition was continuing to decline. In an interview on 2/7/24 at 3:45 p.m., NP-A stated numerous interventions have been tried regarding R2's falls but it seems like every intervention tried helps for a short period of time and R2 continues to not use the call light. R2 often says she wants to go back to bed, and it is tough to keep her up. NP-A thought trying to keep R2 in the common area more, having eyes on her more so R2 can't just climb out of bed would help. NP-A stated she could talk to R2's care team about how to have more eyes on her and not have R2 in bed the majority of the day so when R2 feels the need to get up she can be watched more closely by staff. NP-A stated staff do check-ins on R2 every two hours and believed staff should lay eyes on R2 every hour at least and make sure her basic needs are being met, especially during the day when she is more up and active. NP-A was not sure of the facility's availability but thought the facility was able to do that and it would be a good idea to step up those checks on R2. The facility's Fall Prevention and Management Program Policy dated April 2021 included the following: Clinical Coordinator or designee is responsible for implementation and oversight of individualized residents fall prevention care as follows: a.) Assessing fall risk upon admission, quarterly, with significant change in condition. b.) Determining risk for fall and establishing appropriate interventions in the care plan related to fall risk in the plan of care. c.) Implementing the interventions specific to fall risk data collection. d.) Supervising personnel in delivering safe and personalized care. e.) Evaluating the effectiveness of interventions in relation to the resident specific plan of care. f.) Collaborating with the interdisciplinary team in the prevention of falls. g.) Appropriately managing residents who experience a fall by implementing interventions to prevent further falls. h.) Complete and update fall tracking. Prevention Interventions/Strategies: a.) Environmental Safety - Environmental rounds will be completed monthly. b.) Nursing staff will implement interventions according to resident specific risk factors. c.) Medications will be reviewed monthly by the consulting pharmacist and quarterly by nursing staff. d.) Care plans will indicate the resident specific interventions to prevent falls. Post Fall Management: The staff nurse will review the Occurrence Report and will: i.) Assess all factors contributing to the fall event including intrinsic and extrinsic factors and which interventions were in place at the time of the fall using Falls Follow Up Form as a guideline. ii.) Recommend interventions and changes to plan of care to prevent a repeat fall. iii.) Communicate and document results.