**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to comprehensively assess a resident, reevaluate interventions, or make changes to a care plan after a fall for one of three residents (R1) reviewed for falls when R1 had a previous fall with a history of letting go of the EZ stand lift grab bars. R1's recent fall resulted in fractures of her neck and back. Findings include: R1's admission record printed 2/5/24 stated R1 was initially admitted to the facility on [DATE] to the transitional care unit (TCU) and was transferred to long-term care (LTC) on 3/16/23 with a diagnosis of weakness and anemia. Additional diagnoses included multiple sclerosis, morbid obesity, tremors, gastric ulcers, and mild cognitive impairment. R1's care plan revised on 8/1/23 indicated R1 required assistance with activities of daily living (ADLs) due to her diagnosis of multiple sclerosis. One intervention is R1 required extensive assistance by one staff with a front wheel walker and gait belt for transfers during the day and for the evening/bedtime transfer R1 will use an EZ stand lift (An EZ stand lift is a transfer assist device and is designed primarily to transfer residents from chair, wheelchair, toilet, or bed. An EZ stand lift is used when a person can be actively involved in the standing process. There are two straps that should be used during the transferring process: the shin strap and the back harness. The shin strap is applied to the resident's legs to keep the resident's feet on the foot plate or their shins on the shin pad. The back hardness should be placed around the upper body of the resident, so the sides of the harness are between the patient's torso and arm, resting two to three inches below the underarm. This harness is to ensure resident safety) The care plan stated R1 should wear her bilateral lower extremity ankle foot orthotics (AFOs) (AFO braces are external devices utilized on lower limbs to stabilize the joints to improve gait and physical functioning of the affected lower limb) braces to be in place when transferred or up in her chair. R1's Lift Mobility Status assessment dated [DATE] indicated R1 can walk with no physical assistance, can stand, can pivot, can bear weight on at least one leg, and can grip the EZ stand lift with at least one hand with enough strength to actively participate in the EZ stand lift. The assessment indicated R1 was cooperative and non-combative. R1's Fall Risk assessment dated [DATE] indicated R1 has not had any falls in the past three months and was chair bound and to assist with elimination. The assessment does not indicate how many staff R1 was dependent upon for assistance with elimination. The assessment did not indicate any gait problems but did indicate R1 required the use of assistive devices such as a cane, wheelchair, walker, or furniture. The assessment indicated R1 scored a 12 on the assessment which indicated high risk for falls. R1's quarterly MDS dated [DATE] indicated on J1800 that R1 had no falls since her prior MDS assessment on 9/15/23. R1's brief interview for mental status (BIMS) had a score of 11 indicating her cognition was moderately impaired. R1's progress note dated 1/14/24 indicated R1 purposefully let go of the EZ stand lift and slid herself out of the back harness and landed on the toilet. The progress note did not indicate if the shin strap was used. The note indicated the intervention attempted was to re-educate R1 in order to use the EZ stand lift it required R1 to follow instructions and participate accordingly, otherwise the clinical manager will have to use the mechanical lift (a mechanical lift is a designed assist with transferring residents who can't safely walk or put weight on either leg. When transferring a resident via mechanical lift, a caregiver will use a sling that attaches to the lift. The sling wraps around the resident's high and crosses between the legs and then attaches to the lift). The note indicated the intervention was effective and that R1 stated her transfer mode of preference was with the walker. The note did not identify changes to R1's plan of care. R1's medical record did not identify an incident report for the fall on 1/14/24. R1's social services care conference dated 1/16/24 indicated R1 had a decline in cognition and memory. The care conference notes indicated R1 purposefully slid out of the back harness of the EZ stand lift on 1/14/23 during transfer to the toilet and indicated this was not the first time R1 has done this. The notes indicated staff educated R1 and family that if it happens again, they will have to downgrade to a mechanical lift. The notes indicated staff explained the risk of serious injury if R1 does not participate and follow instructions to use the EZ stand lift when transferring. R1's progress note dated 1/19/23 indicated R1 refused to use the EZ stand lift and the clinical manager offered to help R1 transfer using her walker instead of the EZ stand lift. The clinical manager and the NA attempted to assist R1 into a standing position from her wheelchair but R1 was unable to do so regardless of the amount of support provided. The note indicated the clinical manager informed R1 she will need to be transferred using the EZ stand lift and she agreed. R1's incident report dated 1/29/24 indicated R1 let go of the EZ stand lift handles while being transferred from the toilet to her wheelchair and fell on the floor. The incident report indicated R1 refused to let nursing assistant (NA)-D put on the shin strap per protocol and demanded to be transferred via EZ stand lift without the shin strap. The incident report indicated R1 hit her head and complained of serious pain from her mid back to head. The report indicated R1 was transferred off the floor to her bed via mechanical lift and three persons assist. The nurse practitioner (NP) and family was notified, and R1 was sent to the emergency department (ED) for evaluation. The report indicated no injuries observed. The report indicated predisposing physiological factors included impaired memory and incontinence. R1's incident investigation report from 1/29/24 fall indicated R1 had a fall from the EZ stand lift when transferring. The report indicated NA-D was transferring R1 from the toilet back to her bed, NA-D attempted to place the shin strap and the back harness, but R1 demanded the shin strap and the back hardness not be used when in the EZ stand lift. The report indicated while moving the EZ stand lift towards the wheelchair the stand lift wheel got caught with the wheelchair and NA-D decided it was not safe to transfer to the wheelchair and started moving R1 towards the bed. The report indicated R1 stated let me fall and let go of the EZ stand lift handles and fell backwards through the harness. The report indicated R1 was rubbing her head and stating it hurt. R1 was transferred off the ground using a mechanical lift and the assistance of three staff members to her bed. The report indicated that during that transfer, R1 complained of moderate pain to her mid to upper back. The clinical manager alerted the NP and family that R1 had fallen and received orders to send R1 to the hospital for evaluation. The investigation indicated that other residents who used EZ stand lifts were interviewed and have had no issues with staff and transferring, and the use of EZ stand lifts were observed while transferring and no issues were noted. The investigation for R1 indicated the care plan was reviewed, resident and staff interviews were reviewed, and no changes were made to the policy and procedure after this incident occurred. The investigation indicated that R1 recently started letting of the EZ stand lift within the last six months with instances occurring on 1/14/24 and 9/10/23. The investigation indicated the care plan was updated and education was provided to staff about EZ stand lift training. R1's medication administration record (MAR) from January 2024, R1 had an order stated to evaluate and treat for difficult transfer and fall every shift for difficult transfer and fall. The start date of the order was 5/5/23 and the end date of the order was 2/1/24. The MAR stated that the only times this was indicated was starting the evening of 1/29/24 through 1/31/24 and that was due to R1 being hospitalized . All other dates and shifts indicated staff was completing this task. During an interview with FM-A 2/5/24 at 1:51 p.m., FM-A stated R1 had a fall on 1/29/24 and the clinical manager called her while R1 was on the floor telling me that she had a fall and while she was on the phone with the clinical manager, R1 was yelling in the background about her back. FM-A stated the clinical manager asked if she approved of the facility sending R1 to the emergency department and FM-A approved. FM-A stated she could not recall how many times R1 had fallen but though that the incident on 1/29/24 was about the fourth or fifth fall in the last six months. FM-A stated she asked the clinical manager several times to switch R1 from a EZ stand lift for transfers to a mechanical lift. FM-A stated once R1 was evaluated at the hospital it was determined that R1 had a broken neck and a broken back from the fall on 1/29/24. During an interview with NA-B on 2/5/24 at 2:19 p.m., NA-B stated he was trained on how to use the EZ stand lift when he first came to the facility. NA-B stated he had to demonstrate how to use the EZ stand lift to the leaders. NA-B stated he knows how each resident needs to be transferred by looking at the resident's care plans. NA-B stated that if a resident is refusing to transfer safely that he would leave the resident is a safe place and call for the nurse on duty. During an interview with NA-A on 2/5/24 at 2:30 p.m., NA-A stated that on his first day at the facility the leaders gave him paper documents about how to use the EZ stand lift and then he had to demonstrate to the leaders that he knew how to use the EZ stand lift. NA-A stated he looks at the resident's care plans to see how each resident is cared for. NA-A stated if a resident refuses to be transferred safely, he would report to the nurse before transferring the resident. NA-A stated when a resident falls, he would leave the resident on the ground in a safe spot then he would report to the nurse. During an interview with trained medical assistant (TMA)-A on 2/6/24 at 11:17 a.m., TMA-A stated that he knows how each resident is transferred by looking at each resident's care plan. TMA-A stated if a resident is refusing to be transferred safely, he would leave the resident where they are and will call for back up from his manager. TMA-A stated he was trained on the EZ stand lift by the education director when he first came here, and the facility has in-service trainings. TMA-A stated that he looks at each resident's care plan each shift to look for any changes made. During an interview with licensed practical nurse (LPN)-A on 2/6/24 at 11:24 a.m., LPN-A stated he knows how to transfer each resident by looking in the resident's care plan. LPN-A stated if a resident is refusing to be transferred safely, he would leave the resident and then he will ask why the resident wants to be transferred a different way than the care plan stated. LPN-A stated he will then update the clinical manager and then the clinical manager would give him direction on how to transfer the resident. LPN-A stated he was trained on using the EZ stand lift when he first came to the facility about a year ago. During an interview with NA-C on 2/6/24 at 11:32 a.m., NA-C stated that she been here about six weeks. NA-C stated that she knows how a resident need to be transferred when she looks at the care plan. NA-C stated if a resident is refusing to be transferred safely, she would leave the resident is a safe position, look at the care plan to ensure I was transferring her according to the plan, and then tell the nurse that the resident is not wanting to be transferred safely. NA-C stated she was trained on using the EZ stand lift during orientation in class by the director of staff development. NA-C stated that she was working the same floor and unit when R1 fell on 1/29/24. NA-C stated she was called to assist to help R1 off the floor. NA-C stated that R1 was wearing her AFO leg braces, and she was fully dressed including her shoes. During an interview with the director of staff development (DSD) on 2/6/24 at 12:16 p.m., the DSD stated that she does the training on the EZ stand lifts. The DSD stated she demonstrates how to use the EZ stand lift and then she requires the staff member to demonstrate how to use the EZ stand lift back to her. During an interview with the clinical manager on 2/6/24 at 1:08 p.m., the clinical manager stated it is all the leader's responsibilities to train and educate staff on using the EZ stand lift. The clinical manager stated her expectations if a resident is refusing to be transferred safely, that the staff member does not transfer the resident, keeps, or puts the resident in a safe spot, and consults with a leader. The clinical manager stated the guidelines for a resident to be able to use a EZ stand lift is that the resident needs to bare weight on at least one leg, hold on to the EZ stand lift grab bars with at least one arm, and follow instructions. The clinical manager stated a resident must be able to tolerate standing. The clinical manager stated when R1 fell on 1/29/24, R1 was demanding NA-D to transfer her from the toilet to her wheelchair without using the shin strap or back harness. The clinical manager stated the wheel of the EZ stand lift and the wheel of the wheelchair got stuck in between each other and the resident was demanding NA-D to let her fall and then let go of the EZ stand lift grab bars. The clinical manager stated R1 was wearing a pair of jean shorts, a short sleeve shirt, her AFO leg braces, and a pair of socks at the time of the fall. The clinical manager cannot recall if R1 was wearing shoes. The clinical manager stated after R1 fell, NA-D left the room and came to get her around the corner and the clinical manager came into R1's room. R1 was holding her head, saying her head hurt, and she was moving around a lot. The clinical manager stated she attempted to get assess R1's vital signs but could not obtain a blood pressure due to R1 moving around. The clinical manager called R1's daughter while she was still on the floor to see if it would help calm R1 down enough to get a blood pressure from her which was unsuccessful. The clinical manager stated herself and two NA's transferred R1 from the floor to her bed using a mechanical lift. The clinical manager stated during the transfer, R1 started to complain of back pain, and she assessed her back and noticed there was some discomfort to her mid-back up to her neck. The clinical manager stated after R1 was transferred back to her bed she attempted to get a blood pressure reading which was unsuccessful. The clinical manager stated she called the NP to get orders on sending R1 to the emergency department for further evaluation and updated R1's daughter. The clinical manager stated R1 was not seeing physical therapy (PT) at the time. The clinical manager stated R1 had a fall on 1/14/24 due to her letting go of the EZ stand lift grab bars. The clinical manager stated during that fall, R1 had her shin strap and back harness on. The clinical manager stated R1 continued stating she had to use the toilet, R1 let go of the grab bars on the EZ stand lift, held her arms in as she fell, slid through the back harness, and fell to the ground. The clinical manager stated R1 had a cognitive decline in the last few months. The clinical manager stated she told R1 she needed to be able to pivot transfer if she was not going to use the EZ stand lift so the next time R1 needed to use the toilet, R1 used the pivot transfer and completed the transfer successfully. The clinical manager stated R1 would then use the toilet the next time and would be too weak to do the pivot transfer and then R1 would need to use the EZ stand lift again. The clinical manager stated if R1 continued falling while using the EZ stand lift she would have to use the mechanical lift. The clinical manager stated the reason she did not change her care to use the mechanical lift after the falls on 9/10/23 and 1/14/24 is because she was trying to preserve R1's independence and her right to choose her care while still maintaining safety. The clinical manager stated her expectation if a resident is not wanting to be transferred safely, then the staff members stop the transfer or does not start the transfer. The clinical manager stated it is in her scope of practice to switch the mode of transfer if one mode of transfer is deemed unsafe for the resident. The clinical manager stated when a resident falls, the fall would be put on a building charge report and then IDT will meet to discuss the fall. The clinical manager stated it is the responsibility of the clinical managers to put in interventions into a resident's care plan after a fall. During an interview with the DON on 2/6/24 at 2:00 p.m., the DON stated the facility has a representative come in twice a year to train staff on the EZ stand lift and the last time the representative came to the facility was in fall 2023. The DON stated if a resident is refusing to be transferred safely, her expectation is the staff should stop and get a nurse. The DON stated the guidelines for determining if a resident is a good candidate for an EZ stand lift is if the resident can bare weight on one leg, hold on to the grab bar on the EZ stand lift with one arm, and follow simple instructions. The DON stated if a resident is unable to follow simple instructions the staff would cue the resident. The DON stated she knows R1 had a lot of falls but there were several instances of education with R1 that she needed to hold on to the grab bars on the EZ stand lifts during transfers. The DON stated educating R1 is the only intervention that she was aware of after R1's falls on 9/10/23 and 1/14/24. The DON stated she remembers R1's fall from 1/29/24. The DON stated she was informed R1 had a fall while R1 was still on the floor. The DON stated she went to R1's room and while the clinical manager and two additional NA's were transferring R1 from the floor to her bed, the DON educated NA-D stating he needed to use all the safety features on the EZ stand lift and if R1 didn't want to use the safety features of the lift that he needed to stop and not transfer her. The DON stated NA-D has been suspended after the fall on 1/29/24. The DON stated since R1's fall on 1/29/24, she done staff education about falls and EZ lift stands. During an interview with NA-D on 2/7/24 at 10:28 a.m., NA-D stated that he has worked in the facility for about a year. NA-D stated 1/29/24 was his second time working with R1. NA-D stated he was working between two residents, with R1 being one of those residents, during the last part of his shift. NA-D stated he had transferred R1 to the toilet and left her there to go help the other resident with their cares. R1 then used her call light and NA-D went back to R1's room and he attempted to attach the shin strap and the back harness, and she was very demanding stating she did not want the shin strap or back harness. NA-D stated he was going to try transfer her to her wheelchair using the EZ stand lift without the straps and sling. NA-D stated the wheels of the EZ stand lift and the wheels of the wheelchair were caught between each other. NA-D stated R1 stated just let me fall and he told her to hang on for a few more moments and she let go of the EZ stand lift grab bars falling to the ground. NA-D stated right after the fall he notified the clinical manager. NA-D stated at the time of the fall R1 was wearing shorts, her disposable brief, her AFO leg braces, and her shoes. NA-D stated he did not know R1 had several falls in the past, that R1 lets go of the EZ stand lift grab bars, or if R1 had safety interventions in place from her previous falls. NA-D stated he was trained on the EZ stand lift when he first came to the facility. NA-D stated he was trained on how to use the EZ stand lift and then had to demonstrate it back to the leaders. NA-D stated because this was his second time working on the third floor, he would consult with the nurses on how to care for each resident. NA-D stated he did not review the resident's care plans before consulting with the nurses. NA-D stated if a resident is refusing to be transferred safely, he would refuse to transfer the resident and report it back to the nurse. During an interview with the clinical manager on 2/7/24 at 11:51 a.m., the clinical manager stated if the resident is seeing PT, then PT will determine a resident's mode of transfer and if the resident is not seeing PT, then the clinical managers can determine the mode of transfer. The clinical manager stated the reasoning behind her decision on why she kept R1's mode of transfer an EZ stand lift was R1 had demonstrated to her multiple times she was able to use the EZ stand lift and pivot transfers safely. The clinical manager stated she was trying to preserve R1's independence by keeping R1 with the EZ stand lift. The clinical manager stated R1's fall from 1/29/24 was unavoidable because R1 purposefully let go of the grab bars on the EZ stand lift. The clinical manager stated she determined R1 purposefully let go of the EZ stand lift grab bars because she had talked to several staff and the staff had reported back to her that R1 would say just let me fall and then let go of the EZ stand lift grab bars. The clinical manager stated she does not believe this is a physical decline because R1 was not complaining of her legs, her hands were not shaking, or her legs were not shaking. The clinical manager stated she thought R1 purposefully let us go of the grab bar on the EZ stand lift because R1 is stubborn, she does not like the EZ stand lift machine, and she just wanted to sit down. The clinical manager stated R1 has never told her she is weak. The clinical manager stated after R1's fall on 1/14/24 she observed R1 with her walker, walk about five feet, pivot transfer, and then sit in her wheelchair successfully. The clinical manager stated she did not do any assessments on the EZ stand lift transfers after the fall on 1/14/24. The clinical manager stated no interventions were put into R1's care plan because R1 did not fall on the ground but she fell on the toilet and IDT determined that it was not a fall. The clinical manager stated the behavioral charting that she wrote on 1/14/24 stated the fall intervention was to re-educate the resident to use the stand lift and she monitored the effectiveness by observing R1's successful use of the walker, pivot transfer, and not letting go of the grab bar on the EZ stand lift on that day. The clinical manager stated the intervention was monitored for just one day. The clinical manager stated she thought R1's fall on 1/14/24 was unavoidable because she let go of the grab bar on the EZ stand lift, brought her arms in, and slid through the sling and fell on to the toilet. The clinical manager states she did not do any assessments on R1 after her fall on 1/14/24. The clinical manager stated the care conference after R1's fall on 1/14/24 concluded the fall was an isolated event, and the facility would continue to monitor R1. The clinical manager stated the family was included in the care planning process and R1 refused the mechanical lift. A Falls and Fall Risk, Managing policy/procedure reviewed on 10/4/21 indicates staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The policy indicates if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The policy states in conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess fall risk and implement appropriate fall interventions to decrease the risk for 2 of 3 residents (R1, R2) with falls. This resulted in harm for R1 who sustained two serious head injuries, was transferred to the hospital, and later died as a result of his injuries. Findings include: Vulnerable adult maltreatment report submitted to the State Agency dated 1/8/24, identified R1 was discharged from hospital on [DATE] and admitted to transitional care unit (TCU). R1 was readmitted to hospital on [DATE] . R1 was diagnosed with subdural hematoma, subarachnoid hemorrhage, parietal skull fracture, deep tissue injury to left heel, pressure injury to the coccyx. None of these conditions were present at the time of discharge from the hospital on [DATE]. R1's Face Sheet undated, identified R1 had diagnoses that included anoxic brain damage (lack of oxygen to the brain), nuclear cataract (excessive yellowing center of eye), unspecified hearing loss in the left ear, repeated falls, syncope (dizziness) and collapse (fall or give away). R1's fall risk assessment dated [DATE] identified R1 was a high fall risk with a score of 11, and had one to two falls in the last three months. R1 was chair bound and required assistance with elimination. Evaluation of R1's gait was not performed, and R1 was on medications that caused lethargy or confusion. R1 had predisposing diseases that impacted his fall risk. R1's admission assessment 12/19/23, identified R1 had a fall in the last month prior to admission to the facility. R1 was transferred from home to the hospital on [DATE] for an evaluation following a fall with syncope. Further identified, R1 was a Cantonese speaker and required the use of an interpreter. R1 had moderate difficulty with ability to hear, and no hearing aids or appliances were normally used. R1's family member (FM)-A was available and helped with admission assessment and anytime they needed to interpret tasks for R1. FM-A informed facility staff resident was hard of hearing and an IPad interpretation may not help. R1's bowel and bladder program screener dated 12/19/23, indicated R1 required assistance of one person to get to the bathroom, was alert and oriented, and sometimes mentally aware of the need to toilet. The screener identified R1 was a candidate for a bowel and bladder training program. There was no indication a bowel and bladder program had been initiated. R1's care plan dated 12/21/23 identified R1 was at a high risk for falls due to a history of recent falls. The care plan directed staff to anticipate and meet needs, ensure the call light was in reach, and encourage resident to use call light as needed. R1 required prompt response to all requests for assistance. Physical therapy was to evaluate and treat as ordered or as needed, and R1 required assist of one with a front wheeled walker for transfers. The care plan did not identify a toileting schedule and/or a positioning schedule. R1's initial Minimum Data Set (MDS) dated [DATE], identified R1's preferred language of Chinese, and R1 needed or wanted an interpreter to communicate with a doctor or health care staff. Brief interview for mental status (BIMS, to assess cognition) was not completed. R1's assessment for lying to sitting on the side of the bed and ability to sit to stand were not applicable and not attempted. R1's chair to bed transfer required dependent assist and toilet transfer required substantial to maximum assist. R1 required substantial to maximum assist for toileting. R1 had not had a trial of a toileting program and R1 was frequently incontinent of bladder and always incontinent of bowel. A toileting program was not being implemented to manage continence. R1's fall Care Area Assessment (CAA) with an assessment reference date of 12/25/23, indicated R1 had an actual fall in the last month prior to admission. However, R1's history of falling and physical performance limitations were not complete. Medications included diuretics and internal risk factors of circulatory/heart (cardiac dysrhythmias) neuromuscular/functional (incontinence and traumatic brain injury) perceptual (hearing impairment) orthopedic (arthritis) psychiatric (cognitive impairment). The care plan was not completed or identified any goals or overall objectives as a result of the CAA. R1's fall risk dated 1/5/24 identified R1 was a high fall risk with a score of 13. R1 had no falls in the past three months, was ambulatory and incontinent. R1 had balance problems with standing and walking, decreased muscular coordination, and required use of an assistive device. R1's incident report dated 1/6/24, indicated R1 had an unwitnessed fall and was found lying on the floor at 5:30 a.m. He was on his right side at the back of his room door. R1 hit the back of his head and had a laceration approximately size of a dime. R1 was shivering with a blanket partially covering his body and was unable to explain what occurred due to not speaking English. Nursing assistant reported the last time she checked on resident, he was sleeping soundly in bed. Immediate action taken was physical assessment, and vitals signs (blood pressure 115/45, pulse 88, tempature 97.3 and respirations 18).Was unable to complete pain assessment and R1 was assisted back to bed with the use of a Hoyer lift (full body mechanical lift) by two nursing staff. Level of pain rated at a score of three with facial expressions being sad, frightened, frowned body language tensed, distressed pacing, conceivability distracted or reassured by voice or touch. There were no predisposing environmental factors, physiological factors. Predisposing situation factors included using walker, call light within reach, ambulating without assist. Corresponding note dated 1/8/24, indicated interdisciplinary team (IDT) review of fall; patient last observed less then 60 minutes prior to fall or roll out of bed. Care plan followed. Patient did have a history of laying very close to the side of bed. Will look at and change care plan when R1 returns from emergency room and can get input from FM-A. R1's medical record from 1/5/24 to 1/6/24 between 11:00 p.m. and 5:30 a.m., had no documentation R1 was provided with any cares and/or was toileted. During interview on 1/10/24 at 10:55 a.m., (FM)-A indicated R1 resided with him prior to being admitted to the TCU. R1 had three falls while at home and the first fall happened due to R1 trying to get out of bed on his own and reported needing to go to the bathroom. The second fall happened while going down stairs, and the third fall happened attempting to get to the bathroom on his own. FM-A indicated R1 had the desire to go to the bathroom frequently and would attempt to go on his own. FM-A was notified of the fall on 1/6/24 and asked why R1 was on the floor. When FM-A arrived at the hospital R1 informed him he was trying to go to the bathroom. During interview on 1/10/24 at 1:33 p.m., licensed practical nurse (LPN)-A identified she was R1's nurse the night of the fall. The last time she was in R1's room was to give intravenous therapy (IV) medications (fluids) at around 12:30 a.m. LPN-A reported R1 was COVID positive and R1's bedroom door had been closed. Around 5:30 a.m. LPN-A went to check on R1 and attempted to open the door a few times but noted resistance. LPN-A was able to gain visual entrance to the room and saw R1's head against the backside of the door causing the resistance. R1 was laying on the floor and had a blood smear and a laceration (cut) on the back of his head. R1 was breathing fast and shaking. LPN-A noted blood smears and drops of blood around the bathroom and entrance to the room. LPN-A indicated it was as if R1 was coming out of the bathroom had fallen. He was positioned between the room entrance and bathroom entrance. LPN-A left R1 unattended to go get assistance from nursing assistant (NA)-A and asked when NA-A last provided cares and timing however, timing reports were inconsistent. LPN-A explained NA-A reported to her she did not toilet R1 on the last check because he was sleeping and R1 was supposed to use his call light. Then NA-A went back to assist R1 and LPN-A called nurse practitioner (NP), 911, and the nurse manager. LPN-A reported it was an unwitnessed fall with a head strike and R1 was on anticoagulation. LPN-A went back into the room to complete vitals and assessment. During interview on 1/11/24 at 2:30 p.m., LPN-B indicated she helped LPN-A with R1 the night of the fall with the IV around 12:30 a.m. R1 was awake at 12:30 p.m. and was in bed the whole time during the interaction. The second time LPN-B was in the room was after R1 had fallen and was already transferred back into bed. LPN-B indicated LPN-A had not called 9-1-1 at that time so instructed for LPN-A to call 9-1-1, NP and family. During interview on 1/10/24 at 3:52 p.m., nursing assistant (NA)-A indicated LPN-A had left R1 to find her to notify her of the fall. NA-A entered the room alone and visualized R1's head against the door to enter R1's room. R1 had dried blood matted in his hair, dried blood on both hands, dried blood spots of blood on the floor, and dried blood on the door of the bathroom. NA-A indicated it looked as though R1 was coming out of the bathroom himself and fell hitting his head on the bathroom door. R1 had gotten a blanket somehow because it was over him. R1 was only in a hospital gown and shivering, he said he was cold. NA-A transferred R1 from the floor to a standing position with the use of a transfer belt and walked him with a walker from the entrance of the room to his bed. R1 was sitting on the edge of the bed while NA-A cleaned all the blood off of him and changed his gown to get him ready to go to the hospital. NA-A was unaware of the last time R1 was toileted but thought R1 had gotten up to go use the bathroom alone and fell. NA-A stated the director of nursing,clinical manager or administrator had not asked any questions about the event since the date of the fall. NA-A indicated even though the blood that was in R1's hair, on the floor, and on the bathroom door was dried, she did not think R1 was not on the floor too long because she had just been in the room between 4:00 a.m. to 4:30 a.m. During an interview on 1/11/24 at 3:59 p.m., clinical manager (CM)-A indicated R1 was expected to use his call light, but only used it very very few times because R1 did not really understand. CM-A could not confidently say if R1 knew how to use the call light. Staff were suppose to check on R1 frequently and anticipate basic needs such as food and toileting due to communication barriers. It was expected staff are anticipating needs visually and should be checking during rounds no longer than an hour to confirm resident safety and avoid accidents such as falls . If residents are up in the middle of the night it was the expectation staff would offer toileting. Staff were to be visually checking residents on walking rounds if the door was closed. R1's door was kept open until testing positive for COVID on 1/4/24, then R1 was on isolation and his door was kept closed. During interview on 1/10/24 at 3:29 p.m., the director of nursing (DON) indicated the expectation with falls with head strikes include a head to toe physical assessment, neurological examination, and pain assessment to be completed. Moving a resident following a fall with a head strike would depend on the findings of the assessment. DON indicated it would be good nursing practice for the nurse to stay with the resident upon moving a resident following a fall with a head strike. DON was aware of a fall and was notified the next day on 1/7/24 at 11:27 a.m. by the day shift charge nurse. The investigation involved asking if the care plan was followed at the time of the fall, the last known well time, and if there was anything suspicious regarding the fall. DON indicated R1's last known well time was approximately 4:30 a.m., an hour before the fall and the nursing assistant who was involved was nursing assistant (NA)-B, however did not have time to confirm if that was accurate. DON was unaware of the last time R1 was toileted as it was not documented. DON did not identify anything suspicious regarding the event of the fall. DON indicated the facility handled the fall and everything was completed appropriately with no concerns following proper protocol and the care plan was followed. DON indicated R1 had a history of falling very close to his bed prior to admission and the causal analysis was R1 rolled out of bed and crawled to the door. DON did not complete any interviews with nurses or nursing assistants that were present at the time of the fall. During a subsequent interview on 1/11/24 at 11:14 a.m., DON and administrator both indicated they had not reviewed the facility's video footage as part of the fall investigation. DON stated she did not report the fall with major injury because the care plan was being followed. DON ascertained that information through the investigation that consisted of interviewing dayshift charge nurse (RN-A) and the incident report. According to her interview and the documentation of the event, the nursing assistant had reported checking on him an hour before the fall occurred. DON stated she checked the NA charting, however the time documented of that check, was completed after R1 left the facility. DON did not interview any other staff members including the staff that had worked when the fall occurred. During review of hallway camera video footage on 1/11/24 at 11:45 a.m. with DON and administrator identified inconsistencies with the incident report, facility investigation, and staff interviews. The DON indicated the time on the video was within 15 to 30 minutes of the actual time. The video identified the following: -12:37 a.m. LPN-A and LPN-B were in and out of the room [ROOM NUMBER]:42 a.m. LPN-B exited room and 12:45 a.m. LPN-A exited rooms. -12:45 a.m. to 4:40 a.m. staff were noted to be in hallway, however, R1's door remained closed with no visual checks completed. -4:41 a.m. LPN-A noted to be at R1's bedroom door pushing on door and had difficulty opening it. LPN-A was able to gain entrance and had her head through the opening in the door, however, did not enter room. LPN-A walked away from room with hands down at side in an unrushed manner. -4:42 a.m., NA-A entered room and at 4:45 a.m. A plastic bag was placed outside of the doorway -4:49 a.m., NA-B gowned with personal protective equipment (PPE) and brought a full body mechanical lift to the doorway of the room. Mechanical lift never entered the room. -4:53 a.m., LPN-A entered room with vital signs machine. NA-A exited room with linen in hand and returned to room with pillow and pillowcase. At 4:56 a.m. NA-A exited room and at 5:02 a.m. LPN-A exited room. -5:05 a.m. LPN-B entered the room and exited the room at 5:08 a.m. -5:22 a.m. NA-A returned to the room, exited a couple of seconds later, went back into the room at 5:27 a.m. -5:29 a.m. paramedics arrive, at 5:31 a.m. paramedics entered R1's room, at 5:34 a.m. R1 left with paramedics. During interview on 1/11/24 at 1:16 p.m., following the video review, the DON indicated the camera footage to actual time may vary by 15-30 minutes. Based on the camera footage R1's first and last visual check and last known well time before the fall was at 12:45 a.m. when nurse left the room. LPN-A did not immediately enter the room after observing R1 on the floor to complete a physical assessment and left R1 alone. The full body lift was never entered into the room to get R1 off the floor. During interview on 1/10/24 at 4:19 p.m., NP-A indicated she was notified immediately following R1 being found on the floor. She directed facility staff to send R1 to the hospital due to being on anticoagulation medication and reported bleeding from the head. NP-A indicated a fall with a head strike for a resident who was on blood thinners was a huge risk and would require immediate medical attention, especially an unwitnessed fall. NP-A would expect nursing staff to complete physical assessments right away and would not expect facility staff to attempt to transfer or walk a resident after a fall with a head strike without instruction and was under the impression R1 remained on the floor. During interview on 1/11/24 at 2:05 p.m., hospital medical doctor (MD)-B indicated R1 was pronounced dead at 1:30 p.m. on 1/11/24. The diagnosis of R1's demise was subdural hematoma and hemorrhage. The impact of the fall to R1's head was the cause of death. MD-B indicated there was no reason to believe R1 would have not died if a fall did not occur causing R1 to hit his head. R2's face sheet, undated identified R2 had diagnoses that included cerebral infarction, hemiplegia affecting left nondominant side and neurological neglect syndrome. R2's mobility care plan dated 11/21/23, identified R2 had self-care deficits and required the assist of one to two staff to transfer with the use of a stand pivot with initiated date of 12/18/23. R2 required minimum assist with bed mobility and heel boots on when in bed with an initiation date of 12/5/23. R2's fall care plan dated 12/11/23, identified R2 was high to moderate risk for falls due to right side CVA (Stroke) and staff are to anticipate and meet the residents needs. Place call light within reach and encourage the resident to use it for assistance as needed. The resident uses call don't fall sign to remind R2 to call for assistance. R2's fall risk assessment dated [DATE], 12/29/23 and 1/10/24, identified R2 had a history of falls of one to two falls in the past three months. Chair bound and requires assist for elimination and the gait evaluation was not completed. R2 takes one to two medication that may cause lethargy or confusion and had one to two predisposing diseases that could impact fall risk. R2's admission MDS dated [DATE], identified R2 did not have cognitive impairment and required substantial to maximal assistance to sit to laying on the edge of the bed, sit to stand and char to bed transfers. Dependent assist for toileting transfers. Substantial maximal assistance to put on take off footwear. MDS identified R1 had a fall in the last month prior to admission, unable to determine if the resident had a fall any time in the last two to six months, and no fracture related to a fall in six months prior to admission. R1 had one fall since admission or prior assessment. R2's incident report dated 1/2/24 identified R2 called for help and was found on the floor facing door. Resident description: She was trying to reach wheelchair from the beside and the wheelchair rolled and she fell. Immediate action taken: vitals done, head to toe assessment done, R2 transferred back to bed via full mechanical lift and three staff and provider updated. Injury type left shoulder (front). Level of pain 5. No injuries observed post incident. Predisposing environmental factors: other, physiological factors were confusion, gait imbalance, and other, predisposing situational factors included call light within reach. R2 tries to be independent. Notes dated 1/3/24, IDT review of fall: R2 interviewed post fall. Stated she was sitting on beside. Decided she needed to reach for something on the wheelchair or was reaching for the wheelchair. Wheelchair rolled on her and tray table skidded across the floor and she fell. Landing strip placed at bedside. Wheelchair moved away from bedside. Grabber made sure was within reach and call don't fall sign to be placed on wall under the TV. Patient denied injury, only concerned about when she can leave room to smoke. R2's care plan was not revised with the aforementioned interventions other than placing the sign. R2's progress noted dated 1/2/24, titled post incident note indicates R1 had a unwitnessed fall from previous shift and fell around 14:30 p.m. and writer got report from outgoing nurse that patient verbalized trying to reach wheelchair and fell. R2 was found on the floor on the left side body facing door. Had no injuries but notified nurse of pain on the shoulder. Skin intact, alert and oriented to situation. Encouraged R2 to always call for help and a call and do not fall sign were to be added to the door. R2's progress note dated 1/3/24, indicated R2 was sleeping most of the night. Woke up complaining pain 10/10 in left shoulder from yesterdays fall. Offered ice pack, requested Tylenol and gave 650 milligrams (mg). Additional note dated 1/3/24, identified current intervention in place appear effective for patient safety, however R2 complaining of pain in left arm with swelling. On-call provider agreed with concern and approved X-rays. R2's final report from dispatch health imaging dated 01/04/24 identified the reason for exam was due to pain and swelling due to a fall. Study completed 73060 (LT) Xray, humerus, minimum of 2 views. Findings included a fracture of the humeral head and neck. There was no displacement or dislocation or subluxation. Impression identified an acute fracture of the humeral head and neck. A subsequent X-ray was taken on 1/8/24, identified there was no evidence to suggest acute fracture or dislocation, but if there were persistent symptoms, follow-up X-ray or CT (type of imaging) may be obtained if clinically warranted. During an observation and interview on 1/12/24 at 8:41 a.m., R2's call light noted to be tangled on the lowest part of the bed rail near the floor intertwined with the cord of the bed controls and a heating pad. The button of the call light was sitting on the ground and the clip of the call light was clipped to bed linen. There were no call don't fall signs in the room. R2 recalled fall from 1/2/23. R2 indicated she was getting dressed while sitting at the edge of the bed with a nursing assistant (NA). R2 reported the NA informed her she would be right back because she had someone on the toilet. The NA was not coming back, R2 started looking for the call light, however it was tangled up at the bottom of the side rail. When attempting to reach for the call light her feet slid forward as she was wearing socks without shoes and fell to the floor. R2 recalled hitting the floor hard bruising her hip, breaking her arm, and ongoing pain from the event. When asking R2 where call light was R2 reported probably where I can't reach it, which is an ongoing issue. R2 stated she needed the call light for help because she could not move very well following her stroke. R2 reported recalling a call don't fall sign in her old room, however did not have one in her current room. During interview on 1/12/24 at 11:20 a.m., nursing assistant (NA)-C indicated she was familiar with R2 and was unaware if R2 had any falls. Any resident that were high risk of falls, their bed should always be lowered, a bed matt should be put in place, never leave residents on the edge of the bed, and always provide the call light by clipping it to resident's shirts and not to bedding as the bedding can fall to the floor. NA-C was unaware of any signs in R2's room for falling. During interview on 1/12/24 at 11:49 a.m., LPN-C stated she was in the hallway on 1/2/23, heard knocking and R2 yelling help me, help me coming from R2's closed door. She found R2 laying next to the door and no call light was activated. During interview on 1/12/23 at 11:39 a.m. RN-C indicated R2 fell at the change of shift was found by LPN-C on the floor. RN-C reported R2 was attempting to grab something while sitting at the edge of the bed, and slid off the bed. RN-C indicated R2 crawled to the door of the main entrance to the room the door was closed and the call light was on. RN-C reported doing range of motion as R2 reported pain in the shoulder. RN-C declined doing neurological checks due to R2 declined hitting head. RN-C reported RN-B took over for her following the remaining shift. The following day RN-C cared for R2 and ongoing reports of pain in the shoulder and R2 was unable to move arm or complete range of motion. RN-C indicated calling provider and received an order to complete an Xray. During interview on 1/12/24 at 1: 44 p.m., RN-B described R2 as impulsive, a high risk for falls, unaware of her own abilities and tried to do tasks in which she can't do on her own, such as reaching for things. RN-B indicated to be involved in two falls for R2 and the first unwitnessed fall on 11/22/23, was due to R2 trying to reach her call button and get something. The second fall on 1/2/24, RN-B was notified by RN-C at the start of RN-B's shift. Upon arrival into R2's room RN-B recalled R2 to be right next to the entrance door. The door was open as staff had been in the room, RN-B was unsure if the call light was on. RN-B completed risk management, notified clinical team and tried to contact family. The interventions in place included keeping R2's bedroom light on, bed in lowest position, and provide education to use call light. During interview with clinical manager (CM)-B on 1/12/24 at 11:55 a.m., CM-B reported his role was to review care plans, root cause analysis of falls and complete the facilities risk management. CM-B reported R2 had two unwitnessed falls in the facility 11/22/23 and 1/2/24. R2 fell on [DATE], the day after admission and the root cause of fall was R2 attempting to reposition self in bed and didn't ask for help. CM-B reported R2 had her call light at the time of the fall reporting everyone always has their call light in reach. The intervention put in place was updating the care plan to R2 required minimum assist with bed mobility. Prior to the update there was no assist level identified. CM-B did not reassess the fall risk as there was no initial fall risk completed. CM-B indicated R2 was a high fall risk at the time of admission due to physical limitations. CM-B reported the fall on 1/2/24, was due to R2 reaching for the wheelchair from sitting on the bed, the wheelchair rolled away, and she fell in an attempt to self transfer. The call light was on, the door was closed, and it was RN-B that located R2. R2 had no injuries, education provided to call for help and a call don't fall sign was put on the door. CM-B reported causal analysis of the fall included interviews with R2 and RN-B. R2 was complaining of pain and the determination for further assessment of injury was required . CM-B indicated R2 was not found by the bedroom door, R2 did not crawl anywhere following the fall. CM-B was unaware of what was on R2's feet at the time of the fall. Interventions in place included fall don't call sign and interventions in place appear affective for patient safety. A functional mobility assessment was completed following the fall, however the post fall risk assessment was not completed until 1/10/24. During interview on 1/12/24 at 12:41 p.m., DON indicated the intervention put in place for R2 following 11/22/23 fall was to continue with therapy to improve independence. The immediate intervention was notification to the on-call provider and for R2 to be monitored for pain. Following R2's second fall on 1/2/24, a fall don't call sign was placed on the door and patient education provided to use call light. DON was unsure if door was open or closed, unsure what was on R2's feet at the time of the fall, and if the call light was in reach. DON would expect the sign to still be in R2's room, but due to COVID and room changes it may not. DON reported that a repeat Xray of R2's shoulder revealed that R2 did not have a fracture, however that documentation was not scanned into R2's medical record. During interview with DON and Administrator on 1/12/24 at 5:07 p.m., indicated all residents who have high fall risk factors should have appropriate interventions to mitigate the risk of falling. The purpose of care planning was to direct the care of the patient and care plans need to be accurate and updated to ensure the appropriate interventions are provided to residents. Policy dated 10/4/21 titled Falls-Clinical protocol identified for facility staff to: Assessment and Recognition The physician will help identify individuals with a history of falls and risk factors for falling, Staff will ask the resident and the caregiver or family about a history of falling; The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause include: Precipitating factors, details on how fall occurred, current medications especially those associated with dizziness or lethargy; and all active diagnoses. Cause Identification: For an individual who has fallen staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. A new fall, pain assessment and care plan updated as needed. Review medications, and combinations of medications increase the risk of falling. Staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.