**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to follow a care planned intervention to prevent or reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell and sustained a right fibular fracture which required an emergency room (ER) visit. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severely impaired cognition and diagnoses of dementia, fracture of upper and lower end of right fibula, anxiety disorder and depression. Further identified R1 required 2-person extensive assist with bed mobility, transfers, and toileting. R1 had one fall with injury and two falls with major injury. R1's fall Care Area Assessment (CAA) dated 5/28/24, identified R1's was at risk for falls due to R1 received physician ordered anti-depressant medications. R1 has had one fall during this assessment period. Nursing staff assisted R1 with activities of daily living (ADL)'s as needed according to facility policy. R1 was at risk for fall related injury. No referrals at this time, will proceed to care plan with goal to have no fall related injuries. R1's care plan dated 7/1/24, identified R1 was at risk for falls due to generalized muscle weakness, use of high-risk psychotropic medications, and cognitive impairment. An intervention directed staff will wake and assist R1 to bathroom every day at 11:00 p.m., and 4:00 a.m. Additional intervention dated 8/9/24 identified night light to be used at all times due to R1 keeping the lights off and shades shut most of the time. R1's progress note dated 8/9/24, identified R1 had a fall at 7:15 a.m., R1 was calling out for help and found sitting on the floor in front of her bed. R1's room was dark at the time of the fall with the lights off and the shades pulled down. R1 stated she was on her way back from the bathroom and had attempted to get back into bed when she fell. No injury noted. R1's Fall Event Report, dated 8/9/24 identified R1 had an unwitnessed fall and was coming back from the bathroom and getting into bed. On 8/9/24 at 10:40 p.m., R1 had no complaints of pain, did have a night light placed in her room in the am and R1 commented she liked it. R1's progress note dated 8/12/24, identified R1 was heard yelling for help on the night shift around 1:10 a.m., R1 was discovered in her room lying on the floor on her right side. R1 had complaints of severe lower extremity pain, primarily on her right lower extremity (RLE) but upon focused assessment had more difficulty moving her left lower extremity (LLE). R1 was alert and oriented and stated that she hit her head, and a lump was noted to the back of her head. Family member (FM)-A was contacted due to R1 reports of severe pain and was agreeable to emergency transport to hospital for further assessment. R1 was transported from the facility to the hospital around 2:50 a.m. for further assessment. R1's Event report dated 8/12/24, included the aforementioned information pertaining to R1's fall. Additionally noted R1 was unsure what she was doing prior to fall but verbalized needing to use the restroom. R1's progress note dated 8/12/24 at 7:04 a.m., identified a call was received from the hospital indicating R1 will be sent back via ambulance with a right fibular fracture, proximal to R1's ankle. A Facility Investigation, completed 8/15/24, IDT team reviewed fall on 8/12/24 that occurred at 1:10 a.m. Fall was not witnessed, and staff were alerted to fall by resident calling out in pain. R1 was located lying on the floor next to her bed and could not state what she was doing but did verbalize needing to use the restroom. R1 had not been offered toileting at 11:00 p.m. by NA-A as the care plan stated and R1 was not checked on at midnight by NA-A during rounding. Interventions were to remove pillow top mattress, switch rooms so R1 could be closer to center of unit and not at end of hall so staff could see her more frequently. Toileting changed to every 2-3 hours. [NAME] light was added as R1 stated she was confused by the red button call light. Care plan updated to have transfers with assist of two and ceiling track. Physical therapy (PT) and occupational therapy (OT) was ordered by provider. Family approved of interventions. Care plan, group sheets, and communication book updated. R1 had an appointment with certified nurse practitioner (CNP)-A to review falls in one week and review pain management on 8/13/24. Education was provided to NA-A regarding care plan stating resident was to be toileted at 11:00 p.m., as this did not occur and of the importance of visualizing resident during rounds. NA-A last day of employment was 8/16/24 as separation of employment. During a phone interview on 11/4/24 at 2:48 p.m., NA-A stated she remembered the night R1 fell and stated she was very busy that night and did not make it into R1's room at 11:00 p.m., to toilet her, also stated she did not get to R1 on rounds at 12:00 a.m. NA-A stated she was on a different floor when R1 fell on 8/12/24. NA-A stated someone at that facility did educate her about the importance of following the residents care plan and the importance of rounding timely. During a phone interview on 11/4/24 at 2:56 p.m., licensed practical nurse (LPN)-A stated she was the nurse that worked the floor the night R1 fell. LPN-A stated it was her first time working at the facility and had been walking to another residents room to give some medications when she heard R1 calling for help. LPN-A stated she asked another nurse for help due to being unfamiliar with R1 and R1 ended up being sent to the ER and came back with a fractured lower right leg. LPN-A stated R1 was in a lot of pain, and she had not been in R1's room prior to the fall. During an interview on 11/4/24 at 2:13 p.m., registered nurse (RN)-A indicated R1 fell on 8/12/24 at 1:10 a.m., due to needing to use the bathroom which resulted in a trip to the ER and a fractured right fibula. RN-A indicated nursing assistant (NA)-A did not offer toileting at 11:00 p.m. per R1's plan of care and this could have prevented the fall. NA-A was educated on the importance of following the care plan. RN-A stated we review falls in interdisciplinary Team (IDT) meeting Monday through Friday, we will look at all of the information documented to ensure a root cause, appropriate interventions are in place and to ensure the care plan was being followed. RN-A stated on Wednesdays we review all falls for the week to ensure the interventions we put in place remain appropriate, if not we may remove intervention and add a new one. During an interview on 11/4/24 at 3:08 p.m., director of nursing (DON) and regional nurse consultant (RNC)-A reviewed R1's facility fall investigation and identified a comprehensive fall investigation was completed to include a summary of events, interviews, resident assessment, description of immediate resident protections, notifications, causal and/or contributing factors, and an overall detailed summary. DON and RNC-A indicated on 8/12/24, R1's care plan for toileting was not followed resulting in a fall with a fracture. DON and RNC-A indicated education was completed with NA-A on the importance of following the care plan and the importance of rounding timely along with expectations. DON and RNC-A indicated all falls are reviewed Monday through Friday to ensure interventions are in place and to ensure the care plan was followed. DON and RNC-A further indicated they meet every Wednesday to ensure all fall interventions are appropriate. The deficient practice was corrected on 8/15/24, after the facility implemented a plan that included the following actions: R1 was immediately assessed and fall protocols were followed. Upon R1's change in pain and mobility status, R1 was transferred to the ED. Facility investigation was coordinated with interviews of staff and R1, along with care plan review. NA-A was provided verbal coaching and education after it was determined she failed to follow R1's plan of care. The facility reviewed falls at IDT Monday through Friday to ensure the care plan was followed for each fall and reviewed all falls weekly on Wednesdays to ensure current prevention interventions that were in place were effective. The facility was free of additional falls after 8/15/24 related to failure to follow plan of care. The corrective actions were verified through documentation review and staff interviews. Facility policy, Comprehensive Assessments and Care Planning, revised 9/27/23, identified a purpose to provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental, and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the RAI specified by the State .11. All person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication . Facility policy, Integrated Fall Management, reviewed 9/2023, identified the Purpose: Fall risk assessment, identification, and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls. Residents with risk for falling will have interventions implemented through the resident centered care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to provide appropriate care in a timely manner to prevent a decline in condition for 1 of 1 residents (R32) when R32 continued to experience prolonged nausea and decline lasting more than three weeks causing harm. As a result, R32 was sent to the emergency department (ED) and admitted to the intensive care unit (ICU) after the facility failed to ensure the provider was fully appraised of R32's signs and symptoms. Findings include: R32's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R32 was admitted to the facility on [DATE] after a right knee fracture, had moderate cognitive impairment and was dependent on staff for toileting, bathing, personal hygiene, transfers, and locomotion. During an interview on 12/11/23 at 3:59 p.m., R32 stated she had not seen a physician in person since she had started feeling sick, stating she was nauseated all the time and was not able to eat much due to her nausea. R32 stated she was able to tolerate the pain from her fracture but could not live with this nausea. During an interview and observation on 12/13/23 at 10:40 a.m., R32 stated she just wanted to get better but did not want to go to the hospital. Stating she continued to feel nauseated all the time. R32 was pale in color. R32's progress notes indicated the following: 11/21/23 R32 complained of being nauseated with little appetite, stating she felt like spitting up. 11/23/23 R32 tested positive for COVID. The nurse practitioner (NP) was updated and started R32 on Mirtazapine for appetite stimulant. 11/27/23 R32's nausea was continuing. R32 stated, I can't eat if I'm always nauseated. 11/28/23 R32 had a spell in the bathroom where her colored turned pale, her head lowered and she came back around after a few seconds. It was also documented R32 had 2 loose stools, black in color. R32 stated not right now when offered to be sent to the hospital. 11/29/23 the nursing assistant (NA) found R32 to be unresponsive while changing her brief. The nurse was called to the room and found R32 with brownish liquid coming from her mouth. R32 did not respond when the nurse called her name or shook her. When R32 came around she was asked if she wanted to be seen in the emergency department and refused. 11/29/23 R32 had a loose, blackish stool and was noted to have a spot of darkened blood on her gown. R32's daughter in law was updated on the small spell in the bathroom on 11/28/23. 11/30/23 a referral for hospice was made and R32 continued to have loose black stools. The note indicated the medical director (MD) would be updated on the hospice consult. 12/2/23 R32's appetite remained poor, R32 stated I'm so sick to my stomach, I can't eat, The note indicated R32 was having a difficult time taking medications. 12/3/23 R32 had complaints of nausea. R32 became tearful when she was too weak to transfer on her own. 12/4/23 R32 stated she was nauseated, had a difficult time taking medications and did not eat any breakfast. 12/4/23 R32's weight was declining due to R32 refusing most meals and was being followed by the registered dietician (RD). 12/5/23 R32 continued to state feeling sick to my stomach and did not eat any breakfast. 12/6/23 R32 continued to have multiple loose stools, stating I can't eat if I am nauseated all the time. The nurse practitioner (NP) was informed and gave an order for as needed (PRN) Zofran (an antiemetic that can prevent nausea and vomiting). 12/7/23 R32 received an order from the provider for occupational therapy for lymphatic treatment and massage due to new swelling of her lower extremities. 12/8/23 the MD was updated about R32 having bleeding gums. R32 continued to have slight nausea. 12/8/23 the MD ordered labs to be obtain to include BMP and CBC with differentials due to concerns with bleeding gums. 12/8/23 R32's platelets within normal limits (WNL) and do not indicate a bleeding concern. R32 continued to have nausea and loose stools. 12/9/23 R32 had a negative COVID test and was removed from COVID isolation. 12/11/23 R32 became upset she was feeling so rotten all the time and had no breakfast. R32 was documented as being pale in color. 12/11/23 R32 continued with nutritional decline and significant weight loss. The RD met with R32 who stated she can't keep anything down due to her ongoing nausea. 12/11/23 R32 had complaints of nausea and diarrhea. R32 had two stools that shift and had two spells of passing out while being transferred to the toilet. It was documented with both episodes she became flaccid and during the second episodes had difficulty holding her head up. 12/12/23 R32's daughter in law was updated regarding the evening shift toilet episodes and R32 continued to not eat and remain nauseated even after Zofran was given. R32 was noted to have four loose stools that shift. 12/13/23 it was documented R32 had a spell of unresponsiveness at 4:00 a.m. While being transferred R32 had explosive, loose, dark stool stating she felt sick, holding her mouth as if to vomit. R32 progressively became unresponsive, bowing her head. Progress note included, R32 had flaccid, arms barely supporting her weight on the sling. On coming shift was updated. 12/13/23 R32 refused breakfast and when R32 attempted to sit on the side of the bed she stated she needed to lay back down and was pale and nauseated. B/P was 67/45 while up and 92/60 when laying back down. R32 stated, why do I feel so sick? Medications were held and supervisor was updated. 12/13/23 the NP decided R32 should be sent to the hospital for evaluation. R32 was okay with going to the hospital if they could get her to feel better. 12/13/23 R32 was in the ICU with a potential GI bleed. R32's family refused diagnostic testing for confirmed GI bleed but okayed R32 receiving a blood transfusion for low hemoglobin. R32's electronic medical record (EMR) indicated R32 had a face-to-face provider visit twice since admission. On 10/26/23 the MD saw R32 for her admission visit and on 11/22/23 the NP saw R32 for a routine visit. R32's Active Orders list indicated the following medication orders: amlodipine 2.5 milligrams (mg) daily (a high blood pressure medication), adjusted on 12/12/23; lisinopril 5mg daily (a high blood pressure medication), adjusted on 12/12/23; ferrous sulfate 325 mg daily (iron supplement), dated 11/1/23; Eliquis 5mg twice a day (a blood thinner medication), dated 10/9/23; and Zofran 4 mg every eight hours PRN for nausea and vomiting. R32's care plan lacked interventions to address R32's frequent and continued nausea and diarrhea described as loose and black in color. During an interview on 12/13/23 at 2:58 p.m., the rehab social worker (SW) stated she reached out to the hospice social worker after the hospice meeting on 11/30/23, who stated family was waiting on an x-ray scheduled for 12/4/23 to decide if they wanted to continue with therapy or pursue hospice. The SW was unsure if staff had followed up with family after the x-ray on 12/4/23. R32's EMR lacked evidence the family had been re-approached about hospice care versus continuing with therapy after the x-ray on 12/4/23. R32's Physical Therapy Treatment Encounter Note, dated 11/28/23, indicated physical therapy (PT) entered R32's bathroom, R32's head was hanging down and she was not responding to verbal or tactile cues. R32 began saying a few words after several minutes but was not responding appropriately. Session ended due to patient medical condition. R32's Physical Therapy Treatment Encounter Note, dated 12/11/23, indicated R32 was complaining of an upset stomach after sitting on the edge of the bed. The note indicated R32 was receiving nausea meds but was unsure if they were helping. R32 stated she wanted to get better but was unable to continue with the therapy session due to an upset stomach. R32's Physical Therapy Treatment Encounter Note, dated 12/13/23, indicated R32 had complaints of feeling like she was going to pass out when sitting on the edge of the bed. The note indicated R32 was still not eating or drinking daily due to nausea and had been taking nausea medicine daily without a notable difference. Therapy session was stopped due to R32's medical condition. During an interview on 12/13/23 at approximately 9 a.m., occupational therapist (OT)-A stated she had an order to see R32 for lymphedema treatment due to increased swelling in her lower extremities. OT-A stated due to R32's low blood pressure and continued nausea she would not be medically stable enough for lymphedema treatments. During an interview on 12/13/23 at 9:15 a.m., NA-A stated R32 was often nauseated and weak, stating they just want us to use the bed pan and push fluids. During an interview on 12/13/23 at 10:15 a.m., licensed practical nurse (LPN)-D stated she would not update the provider if there was a concern with a resident or a change in condition, as she would let the charge nurse know, even on the weekends. LPN-D stated R32 hadn't been good lately and has been sick on and off for a few weeks. LPN-D confirmed utilizing R32's PRN Zofran the past couple of days, stating it was not working. During an interview on 12/13/23 at 11:30 a.m., the assisted director of nursing (ADON) stated R32 came to the facility for rehab due to a knee fracture and did not have a good appetite since admission and would make statements she was ready to go to heaven. During review of the EMR, the ADON confirmed R32 had not seen a provider since 11/22/23 but on 11/1/23 labs were drawn and an iron supplement was started, 11/23/23 Mirtazapine was started as an appetite stimulant, 12/6/23 Zofran was started (14 days after first unset of nausea), 12/7/23 orders were received for occupational therapy, 12/8/23 labs were completed and on 12/11/23 blood pressure medications were adjusted. The ADON was unaware R32's unresponsive episodes started on 11/28/23 and was under the impression the first episode was early that morning. The ADON stated she would like to be updated on R32's unresponsive episodes but it was unrealistic to know about them all and she expected the nurses to update the providers on any change in condition. The ADON was also not aware the Zofran was ineffective for R32 stating, apparently it is not working if she is still nauseated. The ADON stated they had recommended hospice, but the family was still undecided on hospice versus continuing to treat with therapy. During an interview on 12/13/23 at approximately 2:00 p.m., the NP stated she sent R32 to the hospital due to her low blood pressure. The NP stated she aware of R32's unresponsive episode early that morning but was unaware they started back at the end of November, stating she would like to be made aware of every episode but not necessarily the same day they happened. Further, the NP was unaware of the uncontrolled nausea, stating she had initiated the Zofran but was not aware it was not working. The NP did confirm she was aware of the black tarry stool, stating since R32 was on iron it was hard to tell if it was related to her low blood pressure readings. (Black stool is often a sign of gastrointestinal bleeding, but not always. Certain medications and supplements, such as iron, may turn stool black.) During an interview on 12/14/23 at 10:19 a.m., the medical director (MD) stated she met R32 for her initial visit on 10/26 and that was the only time she met with R32. The MD stated R32 came to the facility with a knee fracture and history of dementia. She was doing therapy but not participating well. The MD stated she was aware of R32's poor appetite and had started mirtazapine for an appetite stimulant. She was aware R32 was started on Zofran for nausea and had started cutting back on some medications on 12/12/23. The MD further stated R32 would be a good candidate for hospice. The MD stated she was not personally aware of R32's multiple unresponsive episodes, the episodes of loose, black stools, the brown liquid found coming from R32's mouth or that her nausea remained uncontrolled. The MD stated she was notified of possible bleeding gums, which was why she had ordered labs on 12/8 but not of the brown liquid coming from R32's mouth while unresponsive or the loose black stool. The MD further stated she would want to be made aware of these episodes but not necessarily the day they occurred, stating she did not believe she had a full picture of R32's condition, stating multiple providers were made aware of different situations making it difficult to see the full picture, as many of these signs and symptoms indicate a potential GI bleed. The MD stated she would have approached R32's care different had she been aware, starting a proton pump inhibitor (a class of medications that cause a profound and prolonged reduction of stomach acid production), more routine hemoglobin checks, more intensive interventions for her nausea and a more forward conversation about goals of care with R32 and her family to appropriately address R32 with either treatment focused interventions or comfort care. The MD stated R32's hemoglobin went from 11.3 to 9.6 this morning, stating she would suspect a GI bleed until it was ruled out, stating the only way to conclusively tell would through an endoscopy (a flexible instrument inserted through the mouth or rectum to view the inside of the GI tract). During an interview on 12/14/23 the director of nursing (DON) stated R32 had been addressed at their interdisciplinary team (IDT) meetings and she would have expected the nurses to take care of it. The DON stated she did not want R32 back to the facility without a clear plan of either treatment or comfort focused care. A facility policy titled Change in Condition, reviewed 10/2/23, indicated when a significant change in the resident's physical, mental or psychosocial status is identified by the license nurse, or when there is a need to alter treatment significantly. The licensed nurse consults with attending provider or the medical director.