**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an environment as free of accident hazards as possible and to provide supervision and assistance to prevent falls for five of seven sampled residents (Residents #1, #3, #4, #5 and #6) by not implementing care planned fall interventions. On 12/31/24 Certified Nurse Aide (CNA) A failed to place Resident #1's bed in a low position. Resident #1 was found screaming and hanging off the bed holding onto the grab rail. A nurse assisted the resident to the floor. The resident sustained bilateral (both sides) fractured femurs (thighbones). The facility failed to complete post fall neurological (neuro) assessments (a series of questions and tests to check brain, spinal cord, and nerve function) as ordered by the physician and in accordance with the facility's policy for seven out of seven sampled residents (Residents #1, #3, #4, #5 #6 and #7), and failed to complete post fall follow-up documentation each shift for 72 hours after falls for six out of seven sampled residents (Residents #3, #4, #5, #6, #7, and #8). Additionally, the facility failed to update two of seven sampled residents' resident care plans (Residents #3 and #6) with interventions after falling. The census was 170. The Administrator was notified on 2/4/25 at 3:06 P.M., of an Immediate Jeopardy (IJ) which began on 12/31/24. The IJ was removed on 2/7/25, as confirmed by surveyor onsite verification. Review of the facility's Fall Risk/Fall Prevention Program, revised 7/24, showed: -Purpose: To identify residents at risk for falls and implement fall prevention interventions. To ensure appropriate and prompt follow up of resident falls; -Procedure: -1. The Morse Fall Scale Observation form will be completed electronically by the charge nurse on admission, re-admission, quarterly or when risk has changed from resident's previous risk score. When completing item #1 identify if the resident has had a fall in the last 3 months, regardless of when admitted ; -2. After completion, if the fall risk assessment is scored 25 or higher, the charge nurse may initiate the at risk fall care plan template in MatrixCare (electronic medical record). The CNA profile and/or assignment sheet will be updated; -3. If the resident scores 51 or higher, the resident will be identified as a High Fall Risk. The Fall Prevention Approaches order set in MatrixCare can be initiated if appropriate and resident specific fall interventions can be implemented based on the reason why the resident is at high risk on the care plan. Add this identification to the CNA Profile. The FALL RISK banner will populate on the resident's face sheet; -4. If the resident scores greater than 50, a Red bag tag may be placed on the resident's wheelchair and/or assistive devices to remind everyone of the high risk. Review of the facility's Post-Fall Assessment, revised 7/24, showed: -Purpose: All falls are investigated to determine the reasons for the fall and to develop interventions to minimize or eliminate future falls. Residents at risk for falls are identified on the Resident Banner in MatrixCare; -Procedure: -1. The nurse on duty will complete a Post-Fall Assessment Event for every fall; -2. Physician (PCP, primary care physician), and resident representative (RR) must be notified of all falls; -3. Neurological (neuro) Assessment should be initiated with all falls: Initiate Neurological Assessment Form for falls with head injuries. Initiate Neurological Assessment Form for unwitnessed falls without head involvement; -4. The charge nurse will implement any immediate interventions necessary to minimize risk of future fall. Be sure to note the date of the fall any injuries and any new/revised interventions; -5. Therapy will complete the Rehab Multidisciplinary Screening Form Observation within 24 to 72 hours, communicate any interventions to nursing staff, and document those interventions in the resident's care plan; -6. Nurses must assess the resident's condition following the fall and document every shift for 72 hours after a fall; -7. The Interdisciplinary (IDT) Fall Review Team will meet at least weekly and formally address every resident that has fallen during the previous week. Discussion will focus on interventions that have been implemented and other interventions that may be required to reduce falls and meet the resident's needs. Interventions are to be updated on the resident care plan. The Interdisciplinary Fall Review Checklist will be completed during fall rounds for Quality Assessment & Assurance (QAA) purposes; -Falls Definition Guidelines: -Current CMS policy regarding falls include: -a. An episode where a resident lost his/her balance and would have fallen, were it not for staff intervention, is a fall. In other words, an intercepted fall is still a fall; -b. The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without injury is still a fall; -c. When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred; -d. The distance to the next lower surface (in this case, the floor) is not a factor in determining whether or not a fall occurred. If a resident rolled off a bed or mattress that was close to the floor, this is a fall. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/25, showed: -Moderate cognitive impairment; -Upper extremity: Impairment on one side; -Lower extremity: Impairment on both sides; -Dependent with eating, toileting, bathing, personal hygiene, dressing, rolling left and right, and transfers; -Fall in the last month prior to admission; -Fracture related to fall in the six months prior to admission; -Diagnoses included high blood pressure, heart failure, diabetes, hemiplegia and hemiparesis left sided, and fracture. Review of the resident's most recent Morse Fall Scale, dated 11/14/24, showed a score of 35, low risk for falls. Review of the resident's current care plan, showed: -Problem: Falls, resident is at risk of falls due to left side hemiplegia and hemiparesis, legally blind, problem start date, 6/27/23, edited 1/10/25; -Goal: Minimize the risk of falls and related injury through next review, edited 11/13/24; -Approach: -Resident had a fall on 12/31/24, low bed, fall mat and bed against wall, created 1/10/25; -On 7/29/23, resident slid from edge of bed after attempting to get out of bed without assistance, education received on use of call light, created 8/8/23; -Ensure call light is in reach and educate on use of call light if indicated, created 6/27/23; -Ensure environment is free of clutter, created 6/27/23; -Keep bed in lowest position when resident is in bed, created 6/27/23; -Keep personal items within reach of resident, created 6/27/23; -Physical Therapy (PT) and Occupational Therapy (OT) to screen and evaluation as indicated, created 6/27/23; -Problem: Activity of Daily Living (ADL) functional status/rehabilitation potential, resident requires total assist with ADL care, edited 1/9/25; -Approach: Transfer with Hoyer lift (mechanical lift) and assist of two; -Bed not against wall and one fall mat on the right side of the resident's bed. Review of the resident's event history, dated 11/1/24 through 2/3/25, showed: -Date/Time: 12/31/24 at 6:15 A.M., Short Description: Post fall. Review of the resident's post fall assessment, dated 12/31/24: -Event date: 12/31/24 at 6:15 A.M.; -Location of fall: Resident room; -What was resident doing just prior to fall: Sleeping in bed; -Was the fall witnessed: Yes; -Describe exactly what happened: Resident was hanging off the bed holding onto the grab rail; -Check all that apply: Other: rolled off the bed; -List immediate interventions taken to promote resident's safety: Pain management assessment, other: encouraged to call for help; -Was there an injury: No injury; -Did the resident hit their head: No; -Obtain resident statement of activity prior to fall if able: blank; -Behavioral characteristics that may have contributed to the fall: Afraid of falling, forgetful; -Describe the environment at the time of the fall: Call light in reach, lights on in room, assist rails/siderails up; -Pupils: Within normal limits; -Hand grips: Within normal limits; -Were any new medications started within the last month: No; -Notifications: -PCP: 12/31/24 at 7:45 A.M.; -RR: 12/31/24 at 7:26 A.M.; -Care Plan reviewed: Yes: Note: low bed, fall mat and bed against the wall; -Orders: Treatment: Fall: With suspected head trauma - Neuro checks per policy on paper neuro assessment form and compete nurses note every shift for 72 hours, order dated 12/31/24; -Notes: -12/31/24 at 7:57 A.M.: This morning at 6:15 A.M., Registered Nurse (RN) B was heading to the resident's room to give early morning medications and pain medication and heard the resident yelling for help. Resident was seen hanging off the bed and holding on to the grab rails with his/her legs on the floor wrapped with a blanket. The resident's bed was very high up. RN B called out to Certified Nurse Aide (CNA) A, but CNA A was in another resident room with the door closed and did not hear RN B calling out. The resident said he/she couldn't hold on anymore to the rail and that he/she needed to sit down. RN B had to lower the resident to the floor gently holding on to his/her hip and then went and got assistance. The resident was assisted back into bed by four staff on the hall using a blanket with the bed lowered all the way to the floor. The resident was assessed, no physical injuries noted. Resident complained of pain to right thigh. RN B massaged the resident's right thigh and bilateral legs and foot with diclofenac gel (used to relieve pain from arthritis). As needed (PRN) oxycodone (narcotic, used to treat moderate to severe pain) given for pain management. PCP aware order given to x-ray resident's right thigh and right hip, x-ray scheduled. RR made aware and stated would come and see resident this evening instead of tomorrow, as planned. Neuro checks initiated; -12/31/24 at 12:57 P.M.: Continues on observation related to being lowered to floor, awaiting x-ray. Resident resting in bed at this time remains alert and able to make needs known. Small emesis noted earlier, clear. Resident complained of upset stomach as needed (PRN) Mylanta (used to treat upset stomach, heartburn, and acid indigestion) given and effective. Vital signs stable, neuro checks within normal limits (WNL). No complains of pain or discomfort noted at this time. Review of the resident's Neurological Assessment for falls without head involvement, dated 12/31/24, showed: -Unusual verbalization, statements, or behaviors, YES/NO, document specific verbalization in nurse's notes: -12/31/24, 7:00 P.M. - 7:00 A.M., the entry was blank. Review of the nurses notes, showed: -1/1/25 at 2:59 A.M.: Incident follow up (IFU) fall, received x-ray results at 1:53 A.M. via fax. Right hip showing normal examination. Right femur shows acute fracture at distal (body part that is farther away from the center of the body than another part) femur. Call placed to PCP received new order to send to emergency room (ER) to evaluate and treat. Resident denied pain until transferred to gurney; -Evaluation: -Evaluation notes: Resident hanging off the bed holding onto side rail. Care plan: low bed fall mat and bed against wall: -Falls prevention program initiated: Yes; -Injury is resolved/healing without complications: Yes; -Care plan updated: Yes. Review of hospital medical records, dated 1/1/25, showed: -Resident presented from facility with complaint of distal right femur fracture, Facility staff reported resident was tangled in sheets and they tried to assist him/her back into bed. Family concerned resident may have fallen out of bed. X-ray obtained on 12/31/24 at facility showed periprosthetic (a fracture that occurs around or near a previously implanted femoral (thigh bone) prosthesis, such as a total hip or knee replacement) right distal femur fracture. Resident reports pain in bilateral lower extremities and neck pain; -Resident presents with bilateral lower extremity pain of possible ground level fall from bed. X-rays demonstrate bilateral distal femur fractures; -X-rays demonstrate obvious deformities of bilateral distal femurs. -Physical exam: Tender bilaterally in distal femurs, no pelvic tenderness to palpation (touch). Holds right leg in external rotation (movement of a body part away from the body's center). No tenderness in calves or ankles bilaterally. Review of the resident's electronic medical record, showed the facility readmitted the resident on 1/9/25. Review of a written statement and facility interview, dated 1/2/25, showed CNA A said he/she provided the resident's care on the morning of 12/31/24 around 6:00 A.M. CNA A stated he/she changed the resident, gave the resident his/her call light and raised the head of the bed slightly. The height of the bed was at waist height. CNA A stated he/she did not hear RN B yelling for help. During an interview on 2/6/25 at 7:24 A.M., CNA A said he/she worked with the resident on the morning of 12/31/24. CNA A said he/she was not aware the resident was a fall risk because the resident did not have any signs up, or a yellow wrist band that would indicate the resident was a fall risk. CNA A said after changing the resident, the resident fell about 10 - 15 minutes after receiving care. CNA A said he/she left the resident's bed a little bit over waist high. CNA A stood up and held his/her hand at waist level that measured approximately 44 inches high. CNA A said he/she was not aware the resident's bed was supposed to be at the lowest level when the resident was in bed and leaving the room. CNA A said RN B came and asked for assistance with transferring the resident back into bed. CNA A said one person got the resident's legs and one person got the top of the resident, and they lifted the resident into the bed. CNA A said to transfer the resident they are to use the Hoyer. CNA A said there was no reason they didn't use the Hoyer, they were just trying to hurry up and get the resident off the floor because it was cold. CNA A said the resident did not complain of pain when they transferred him/her off the floor and into the bed. CNA A said he/she did not stay in the room when RN B did the assessment on the resident after the resident was transferred into bed. CNA A said he/she did not work with the resident again before the resident went to the hospital. Review of a written statement, dated 1/3/25, showed RN B wrote, on 12/31/24 morning at 6:15 A.M., he/she was doing his/her medication pass. Getting to the hall RN B was about to get medications on that side of the hall when RN B heard the resident shouting for help. CNA A said he/she had already changed the resident and that he/she did not know why the resident was screaming for help. RN B told CNA A he/she should have gone to see why the resident was screaming. While RN B was saying that to CNA A, RN B started making his/her way down to the resident's room. RN B went straight into the resident's room and found the resident hanging off the bed holding onto the grab rail. The resident's back was towards the door and the resident was facing the wall beside the heater. RN B began shouting for CNA A to come help, but CNA A never came to the room. Meanwhile RN B held the resident on his/her hip with both hands so he/she wouldn't fall to the floor because the bed was up high in the air. The resident's legs were on the floor wrapped around his/her blanket. RN B did not see the resident's legs and how they were positioned, but the resident's legs were on the floor while he/she was holding on to the grab rail. The resident then stated he/she could not hold on anymore and RN B told the resident to hold onto the rails firmly so that RN B could lower him/her to the floor. RN B tried to grab the small chair by the heater but was unable to without help. RN B lowered the resident to the floor while holding onto the resident's hips and around his/her waist and gently lowered the resident onto the floor. RN B left the room to get help and found CNA A. RN B told CNA A to go to the resident's room and RN B went to get more help. RN B called two additional staff to come and assist with getting the resident up. On assessment when the resident's blanket was moved, he/she was in a sitting position with both legs to the left side close to the heater. RN B and staff used a big blanket and put it underneath the resident and lowered the bed to the floor and transferred the resident back to the bed. The resident has never been able to do range of motion (ROM) on his/her lower extremities. Resident has a history of bilateral knee replacement of which he/she has arthritis really bad on both legs. The resident complained of right thigh pain, so the nurse massaged it with diclofenac gel, including both legs and feet. RN B also gave PRN (as needed) oxycodone for pain management. RN B notified the PCP immediately and got an order to x-ray the right thigh and right hip. RN B entered the order and called and scheduled the x-ray before leaving for the day. When RN B returned to work, he/she was told the resident had an acute distal femur fracture. RN B thinks the way the resident fractured his/her femur was when he/she rolled off and his/her leg hit the floor. Meanwhile no one witnessed this, it could have been worse if RN B did not hold the resident and gently lower him/her to the floor. With the height of the bed the resident would have broken his/her hip as well. The way the resident was positioned and the bed it would be have been difficult to get the resident up with the Hoyer, so they used four persons with a big blanket to transfer. During an interview on 2/4/25 at 9:40 A.M., RN B said on 12/31/24 at approximately 6:15 A.M., he/she was passing morning medication and heard the resident screaming. RN B asked CNA A who was screaming and he/she said it was the resident. When RN B went into the resident's room, he/she saw the resident's lower body hanging off the left side of the bed with the resident's legs wrapped in the resident's blanket. The resident was hanging onto the grab rail with both arms and the resident's bed was positioned as high as it could go. The resident's legs were wrapped in blankets and he/she was yelling for help. RN B said he/she placed his/her arms around the resident's waist trying to support the resident and yelled out for help. Nobody arrived to assist RN B when he/she was yelling out for help. The resident then said he/she needed to sit down yelling, I can't take it, help me so RN B tried to grab a chair and could not reach the chair, so RN B gently lowered the resident to the floor while holding the resident in a bear hug. RN B left the room to get assistance from other staff. RN B said when the blankets were removed, the resident's legs were bent at the knees and turned to the resident's left side. RN B got assistance from other CNAs and they lifted the resident into bed with a blanket that was placed underneath him/her. RN B said the resident normally transfers with a Hoyer lift, but the way the resident was positioned they could not use the Hoyer lift and used the blanket instead. The resident complained of right thigh pain and rated the pain as a 9 out of 10 (0-3 mild pain, 4-6 moderate pain, 7-10 severe pain). RN B did not check ROM on the resident's legs due to the pain reported. RN B contacted the PCP and obtained an order for a stat (immediate) x-ray to right thigh and hip. RN B said he/she massaged the resident's right legs with diclofenac gel and gave the resident oxycodone for pain. RN B said he/she thought there was a fall mat on the right side of the resident's bed but there was no fall mat on the left side of the resident's bed at the time of the fall. RN B said when the resident's legs went over the edge of the bed and hit the floor from the high position, he/she believes that is when the resident fractured his/her legs. RN B said the resident's call light was not on when the resident was screaming for help, RN B said the resident normally uses his/her call light when he/she needs assistance, but sometimes the resident gets confused. RN B said the resident fell because he/she was trying to get out of bed to look for his/her family members. RN B said it is not the first time the resident had attempted to get out of bed to look for family. RN B said the resident attempted to get out of bed last year to look for his/her family, but staff redirected him/her before the resident fell. Observations on 2/3/25 at 8:50 A.M., 2/3/25 at 1:57 P.M., and 2/4/25 at 6:55 A.M., showed the resident lay in his/her bed in low position on a low air loss mattress. A fall mat was on the right side of the resident's bed, no fall mat was on the left side of the resident's bed. The resident's bed was not against the wall. During an interview on 2/4/25 at 11:54 A.M., agency RN C said nobody told him/her why the resident only had one mat. The physician order should be specific to one or two fall mats, and which side the fall mat goes on. There should be an order for a low bed. The resident is a high fall risk when he/she is in bed. The nurses on the floor can get the order from the doctor or therapy depending on what the interventions are. The nurse on the floor does not put interventions into the care plan. The nurse on the floor gets the order and puts the order in the computer. During an interview on 2/4/25 at 12:20 P.M., CNA D said fall interventions for the resident include to make sure his/her bed is as low as possible, fall mat in place, and rounds every two hours. Sometimes, the resident thinks he/she can walk. CNA D said the mat is on the left side. The right side is the side the resident turns to. That is the side when he/she feels that he/she can walk that he/she tries to get out of. CNA D said there should be one on each side. The bed has never been against the wall. Observation on 2/4/25 at 12:23 P.M., showed the resident lay in his/her bed in low position on a low air loss mattress. A fall mat was on the right side of the resident's bed. No fall mat was on the left side of the resident's bed. The resident's bed was not against the wall. During an interview on 2/4/25 at 12:52 P.M., the DON said she did not recall any specific fall interventions for the resident. The DON said she feels the resident is a high fall risk since the resident had his/her fall in December. Observation and interview on 2/4/25 at 1:29 P.M., showed the resident lay in bed. The bed was in a low position. There was a fall mat on the right side of the resident's bed and no fall mat on the left side of the bed. When the Assistant Administrator (AA) looked at the resident's room, she said there was only a fall mat on the right side of the resident's bed not a fall mat on the left side. The AA said there should be a fall mat on both sides of the bed. The AA was unsure why there was only one fall mat next to the resident's bed. If there is one fall mat, the resident's bed should be up against the wall. The AA said the resident fell off the left side of the bed where there was no fall mat. The AA verified the resident's bed was not against the wall as listed on his/her care plan. The AA expected interventions listed in the resident's care plan to be in place. The AA did not recall the resident's bed ever being against the wall. Without the fall interventions listed on the care plan in place, it puts the resident at risk for the same thing happening again; falling again and the possibility of the resident getting injured again. The concern she had was the fall mat not on being on the left side of the bed with the bed not being against the wall and the bed not being against the wall as care planned. The AA expected a fall intervention to be put in place after every fall. The CNAs find out what fall interventions are in place through the nurse. CNAs have a computer system, but the Internet connection is bad, so the CNAs need to get report from the nurses. 2. Review of Resident #3's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -Dependent with toileting, bathing, and lower body dressing; -Maximal assistance with bathing transfers; -Fall since admission or prior assessment, no; -Uses wheelchair for mobility; -Diagnoses included Parkinson's Disease (a progressive neurological disorder that affects movement, balance, and coordination), arthritis, dementia, unspecified fall and rhabdomyolysis (a rare muscle injury when the muscle tissue breaks down and releases damaging substances into the blood). Review of the resident's most recent Morse Fall Scale, dated 12/2/24, showed a score of 50, high risk for falls. Review of the resident's current care plan, showed: -Problem: Falls, the resident is at risk for falling due to decreased mobility, unsteady gait, unassisted attempts to stand/transfer/ambulate and poor safety awareness, edited 2/3/25; -Goal: Prevent manage possibility of falling, edited 12/4/25; -Approach: -Resident had a fall on 1/8/25, staff to ensure resident is up in a chair for all meals, created 1/10/25; -Resident had a fall on 12/12/24, staff to offer to sit in TV area or close to nurses station, edited 2/3/25; -Resident had a fall on 11/26/24, staff will encourage use of assistive device while walking in his/her room, edited 11/27/24; -Resident had a fall on 9/7/24, staff will provide frequent rounds, created 9/10/24; -Resident had a fall on 9/3/24, encourage to use call light to get things that are out of reach, created 9/4/24; -Follow facility protocol after any fall, created 6/1/24; -Keep call light in reach, encourage resident to use it and wait for staff when in need of assistance, created 6/1/24; -Keep resident in a supervised area as much as possible, created 6/1/24; -Monitor for decreased/loss of functional status, created 6/1/24; -PT/OT evaluate and treat as ordered and PRN, created 6/1/24; -Resident may utilize a low bed with fall mat and bed against the wall, created 6/1/24; -Resident may utilize a perimeter mattress (bolster mattress, mattress cover with built-in foam bolsters that create a raised rail around the bed's edges) to bed, created 6/1/24; -No intervention listed for fall on 1/31/25. Review of the resident's event history, dated 11/1/24 through 2/3/25, showed: -Date/Time: 11/26/24 at 4:07 A.M., Short Description: Post Fall assessment; -Date/Time: 12/12/24 at 12:47 P.M., Short Description: Fall no injuries; -Date/Time: 1/8/25 at 8:58 A.M., Short Description: Fall on floor in room rolled out of bed; -Date/Time: 1/31/25 at 2:30 A.M., Short Description: Fall. Review of the resident's post fall assessment, dated 11/26/24, showed: -Event date: 11/26/24 at 4:07 A.M.; -Description: Post fall assessment; -Location of fall: Resident room; -What was resident doing just prior to fall: Lying in bed; -Was the fall witnessed: No; -Describe exactly what happened: Resident stated he/she was walking around in room and his/her legs became weak; -Check all that apply: Walking; -List immediate interventions taken to promote resident's safety: Encourage assistive device use; -Was there an injury: Yes, describe below; -Describe injury and first aide, if provided: (this was not completed by facility staff); -Did the resident hit their head: Yes; -Obtain resident statement of activity prior to fall if able: Bilateral lower extremity weakness; -Behavioral characteristics that may have contributed to the fall: Does not use call light, poor safety awareness; -Describe the environment at the time of the fall: Call light in reach; -Pupils: Within normal limits; -Hand grips: Within normal limits; -Foot pushes: Within normal limits; -Were any new medications started within the last month: (this was not completed by facility staff); -Notifications: -PCP: 11/27/24 at 1:01 P.M.; -RR: 11/27/24 at 9:42 A.M.; -Care Plan reviewed: Yes, encouraged use of assistive devices even when walking in room; -Orders: -Chart every shift for 72 hours related to fall, order date 11/26/24 - 11/29/24; -Fall without head involvement: Complete paper neuro assessment form per policy per policy every shift and complete nurses note for 72 hours, order date 11/26/24 - 11/29/24; -Fall: With suspected head trauma - Neuro checks per policy on paper neuro assessment form, and complete nurses note every shift for 72 hours, order date 11/26/24 - 11/29/24; -Notes: 11/26/24 at 4:15 A.M., resident was observed on the right side of the bed facing the wall at 4:00 A.M. Resident stated that he/she was attempting to walk in his/her room when his/her legs gave ou