**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facilities stand up lift usage policy and procedure, dated 7/27/08, showed to use the stand up lift the resident must be able to partially bear weight and follow simple directions and must be able to hold on to the hand bars of the lifts. The stand up lift may be used by one person. Staff are directed to: -Inform the resident what they will be doing; -Have the resident's chair in positron and locked; -Place the resident on the edge of the bed; -Place the lift in front of the resident and place the resident's feet on the foot board; -Place waist strap around the resident and buckle into place. Pull strap until it is snug; -Make sure the resident's legs are against the leg rest and place the Velcro strap around the resident's calves; -Ask the resdient to place their hands on the hand bar; -Once the resident is positioned over the chair staff may press the down arrow on the hand control mechanism and lower the resident to the chair. 4. Review of Resident #44's quarterly MDS, dated [DATE], showed staff assessed the resident as the following: -Severe cognitive impairment for daily decision making; -Dependent on two or more staff for transfers; -Dependent on one staff for bed mobility, dressing, eating, toileting, personal hygiene, and bathing; -Incontinent of bowel and bladder; -Received as needed pain medication. Review of the resident's comprehensive care plan, last updated 3/1/19, showed staff assessed the resident as at risk for falling related to compromised mobility and need for assistance with transfers, the use of antibiotics, and cognitive impairment. The resdient fell on 9/29/18. Facility staff were directed to: -Use hoyer lifts for transfers; -Assess for adverse reactions to psychotropic medication; -Explain transfer procedure use hoyer lift during transfers to ensure the resident feels safe and secure; -Provide toileting assistance; -Staff will use wedge cushion for positioning when in bed. Review of the resident's nursing care plan, last updated 3/7/19, showed staff assessed the resident as oriented to self only and was a fall risk. Staff were directed to: -Assist with two staff using the hoyer lift for transfers; -Use a wedge cushion in bed for positioning; -Provide toileting every two hours; -Provide a puree no concentrated sweets diet with honey thickened liquids; -Use aspiration precautions; -Turn from right to left to back. Review of the resident's nurse's notes, dated 9/28/18, showed facility staff documented the nurse entered the shower room and observed the resident on the floor with the hoyer lift under him/her. The two CNAs stated the resident slid out of the toileting sling that they had on the lift. The resident complained of his/her head hurting. The resident had a 5 centimeter (cm) by 4 cm lump to the left side of his/her head, abrasions to his/her left thigh, middle of the back, and abrasions with bruising to several areas on his/her head. The physician was notified and the resident was sent to the emergency room for evaluation and treatment. Observation on 4/3/19 at 01:41 P.M., showed CNA H and L tucked and positioned the hoyer pad under the resident, turning the resident side to side. CNA H lifted the resident with the remote and pulled the resident with the machine away from the bed. CNA L guided the resident with his/her feet to his/her wheelchair. The CNA did not provide support behind or under the resident while transferring the resident to the wheelchair. CNA H lowered the resident into his/her wheelchair and CNA L propelled the resident out of the room. 5. Review of Resident #54's annual MDS, dated [DATE], showed staff assessed the resident as the following: -Severe cognitive impairment; -Requires extensive assistance of one staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Has limited range of motion (ROM) to one side of the upper extremity; -Always incontinent of bowel and bladder. Review of the resident's comprehensive care plan, last updated 3/17/19, showed the resident requires extensive assistance with activities of daily living (ADLs) and requires the use of a stand up lift for transfers. The resident has a history of an ileus (a painful obstruction of the ileum or other part of the intestine) and may have two bowel movements in a 24 hour period. Staff were directed to: -Ensure the resident is positioned properly in the stand up lift and explain proper procedure as they are lifting him/her; -Staff will use proper transfer techniques to reduces the risk of skin tears; -Ensure resident is allowed extra time in the restroom when needing to have a bowel movement; -Staff will provide toileting assistance every two hours and as needed. Review of the resident's nursing care plan, review date 3/7/19, showed staff were directed to: -Limit sitting on toilet to 15 minutes; -Stand up lift with one assist; -Broda chair; -Must have two bowel movements per 24 hours, monitor and report to nurse; -Toilet every two hours. Observation on 04/02/19 at 01:49 P.M., showed CNA M positioned the resdient over the toilet removed his/her wet brief and lowered the resident onto the toilet. Observation showed the CNA left the resident unattended attached to the stand up lift in the restroom, while stating, It'll take around 15 minutes for him/her to go to the bathroom. The resident continued to repeat help me. Observation showed CNA M entered the restroom at 1:55 P.M. The CNA lifted the resident off the toilet with the sit to stand and transferred the resdient to his/her Broda chair. 6. Review of Resident #57's significant change MDS, dated [DATE], showed facility staff assessed the resident as the following: -Severe cognitive impairment for daily decision making; -Dependent on one staff for bed mobility, dressing, toileting, eating, personal hygiene, and bathing; -Dependent on two or more staff for transfers; -Always incontinent of bowel and bladder. Review of the resident's comprehensive care plan, dated 3/20/19, showed the resident required total assistance to complete all ADL's related to the diagnosis of dementia, general weakness and compromised mobility. The resident required the use of a hoyer lift for transfers. Staff are directed to use a hoyer lift when transferring the resident, ensure he/she is properly positioned in the lift prior to the transfer, and explain the procedure as they are transferring the resident. Observation on 4/3/19 at 2:00 P.M., showed the resident sat up in his/her Broda chair. CNA M attached the hoyer pad loops to the hoyer lift and CNA N began to lift the resident. CNA N guided the machine over to the bed, while CNA M held onto the resident's feet. CNA M did not provide support to the resident by holding unto the resident's sling or under the resident. 7. Review of Resident #48's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Minimal cognitive impairment; -Requires extensive assistance of one staff for bed mobility, transferring, dressing, toileting, and bathing; -Requires limited assistance of one staff for personal hygiene; -Frequently incontinent of bowel and bladder; -Limited range of motion to one side of the upper and lower extremities; -Had one non-injury fall. Review of the resident's comprehensive care plan, dated 3/8/19, showed the resident has left sided hemiplegia (total or partial paralysis on one side to the body). The resident fell on [DATE]. The resident requires limited to extensive assist of one to complete ADL's such as transfers, toileting, transfers, and dressing. The resident will continue to use a stand up lift for transfers. Staff are directed to: -Remind the resdient not to transfer without staff assistance; -Offer toileting every two hours and as needed; -Instruct the resident in proper transfer techniques using the stand up lift. Observation on 04/02/19 at 09:27 A.M., showed CNA M assisted the resident into a sitting position. The CNA assisted the resident in dressing his/her upper body and placed the stand up lift sling around the resident's torso, connecting the sling to the machine. The resident was only able to hold on with his/her right hand. Observation showed the resident only had his/her right foot on the stand up lift base. The resident's left foot was dragging on the ground as the CNA transferred the resdient to his/her wheelchair from the bed. The CNA continued to transfer the resident to his/her wheelchair lowering the resident into the wheelchair and unattached the sling from the lift. The resident was unable to hold onto the lift with his/her left hand and the CNA did not ensure the resident's left foot was positioned onto the lift. 8. During an interview on 04/05/19 at 11:20 A.M., CNA A said during a hoyer lift transfer staff are to use two people, the right size sling, and ensure the battery is charged. The CNA said one staff controls the lift and one staff guides the resident. Staff are to make sure the resident's feet do not hit. Staff are not supposed to guide the resident by their feet, but with their hands on the resident's back. 9. During an interview on 04/05/19 at 11:25 A.M., CNA M said when transferring a resident using a hoyer lift staff are expected to use two people. Both staff are supposed to help guide the resident to ensure they do not hit anything. Staff should be holding onto the resident, one holding onto the sling on the back of the resident to help guide them. CNA A said staff should not guide the resident using their feet. When transferring a resident using a stand up lift, one staff can transfer the resident. Staff are to cue the resident and ensure the resident has a hold of the lift with both hands and both feet are on the lift base before transferring. 10. During an interview on 04/05/19 at 11:59 A.M., LPN C said staff are to ensure safety with lift transfers. Staff are to lock the wheelchair, move foot pedals, move to closest position, secure hoyer - two staff for hoyer lift and one to two staff for the stand up lift, depending on the resident. Apply the belt/sling for the stand up lift, ensuring that it is tight enough, have the resident hold onto the hand rail, and stand up with the lift. For the hoyer lift, have the resident cross their arms, open the lifts legs, approach wheelchair during transport with the hoyer. One staff is responsible to ensure the feet are going the right direction, one controls the lift movement. Staff should guide the resident at the feet - so they don't bump into anything. 11. During an interview on 04/05/19 at 01:54 P.M., the DON said, the stand up lift only requires one staff per the facility policy and the hoyer lift requires two staff for transfers. During a hoyer lift transfer one staff should be at the resident's side or back to guide the resident and the other staff should be guiding the machine. Staff should protect the feet from getting hit, but staff should be normally be on the back side of the resident to help guide and align them. 12. Observation on 4/01/19 at 2:31 P.M., on 4/2/19 at 3:43 P.M., on 4/3/19 at 9:12 P.M., and on 4/4/19 at 10:06 A.M., showed the medication cart on the 200 hall had a plastic container that contained lancets and insulin (a medication used to treat high blood glucose) pen needles. Observation showed the plastic container did not have a lock and was unattended. 13. Observation on 4/1/19 at 1:30 P.M., on 4/2/19 at 10:00 A.M., on 4/3/19 at 1:46 P.M., and on 4/4/19 at 10:27 A.M. showed the medication cart on the Medicare hall had a plastic box that contained lancets and insulin pen needles. Observation showed the box did not have a lock, was easily opened, and was unattended. 14. During an interview on 4/5/19 at 11:59 A.M., LPN C said sharps should be kept locked in the medication cart or medication room at all times. LPN C said the insulin supplies are in a plastic box kept on top of the medication cart unlocked. 15. During an interview on 4/5/19 at 1:54 P.M., the DON said the insulin supplies are kept on top of the medication cart in a closed container. The DON said the insulin supplies have lancets that could cause injury in them. Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #9) who had a history of falls received adequate care and supervision to prevent an accident in which the resident fell and sustained a broken hip, and failed to ensure one resident's (Resident #25) environment remained as free of accident hazards as possible due to the resident's history of falls and risk for choking. Facility staff failed to ensure staff transferred four residents (Residents #44, #48, #54, and #57) during mechanical lift transfers, safely and effectively. Facility staff also failed to ensure the resident environment remained free of accident hazards by failing to ensure sharps were not accessible to residents. The facility census was 100 with 45 residents in certified beds. 1. Review of Resident #9's Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/20/18, showed the following staff assessment: -Severely impaired cognitive impairment; -Able to make him/herself understood; -Able to understand others; -Extensive assistance by one staff for bed mobility, transfers, dressing, toilet use, and hygiene; -Limited assistance by one staff for walking in his/her room; -Used a walker. Review of the resident's plan of care, showed a plan addressing the resident's fall risk, last reviewed/revised 2/19/19, where staff noted the resident was at risk for falls related to dementia, compromised mobility with the need for assistance with transfers related to unsteady gait and use of psychotropic medications that may have adverse effects such as increased confusion, dizziness, and lethargy. Staff documented the resident fell on 2/11/19 and 2/13/19. The approaches for care to address the resident's fall risk directed staff to: -Assess for adverse reactions to psychotropic medication use such as increased confusion, dizziness and lethargy and report to the physician for followup (dated 12/21/18); -Assure the resident is wearing eyeglasses; Assure eyeglasses are clean and in good repair; -Assure the floor is free of glare, liquids, foreign objects (dated 12/21/18); -Encourage the resident to use environmental devices such as hand grips, hand rails, etc. (dated 12/21/18); -Give the resident verbal reminders not to ambulate/transfer without assistance (dated 12/21/18); -Keep call light in reach at all times (dated 12/21/18); -Keep personal items and frequently used items within reach (dated 12/21/18); -Obtain physical therapy consult for strength training, toning, positioning, transfer training, gait training, mobility devices, etc per physician's orders (dated 12/21/18); -Occupy the resident with meaningful distraction such as activities, one on one conversation, music, etc (dated 12/21/18); -Provide the resident an environment free of clutter (dated 12/21/18); -Provide proper, well-maintained footwear (dated 12/21/18); -Provide toileting assistance every two hours and as needed (dated 12/21/18). Review of the plan showed staff did not update the plan after the resident's falls on 2/11/19 and 2/13/19, except to add the date of the falls. Review showed staff did not update the care plan to specifically address any determined causal factors related to the falls and any revised interventions after the two falls. During an interview on 4/18/19 at 10:00 A.M., MDS Coordinator K said the resident's most recent care plan is his/her admission care plan, dated 12/27/18 (care plan conference date). Review of a progress note dated 2/11/19 at 9:01 P.M. showed staff observed the resident on the floor. The resident was alert and oriented times two (knows who he/she is and where he/she is but unable to determine time). The resident was assessed, physician notified, and message left for his/her spouse. Staff did not note any change to the resident's care plan to prevent further falls. Review of a progress note dated 2/13/19 at 7:33 P.M. showed the resident was noted on the floor in his/her room next to the bed. The resident's wheelchair was noted behind the resident, the resident was lying on his/her back, was alert and oriented times two. The resident was unable to state what happened. Staff noted they assessed the resident who denied complaints of pain or discomfort, and assisted the resident to bed. Staff noted a faint light green/purple bruising to right buttock. The physician was notified. Staff did not note any change to the resident's care to prevent further falls. Observation on 4/1/19 at 3:03 P.M., showed the resident stood at the sink in his/her room alone, holding onto the sink. Observation showed Certified Nurse Aide (CNA) B entered the room and assisted the resident to walk to the restroom. Observation on 4/4/19 at 10:30 A.M. showed the resident sat in his/her wheelchair in his/her room, facing his/her television, which was off. The resident occasionally looked off to the right to his/her roommate's television, which was on. The resident's call light was not in reach at this time. Continued observation on 11:04 A.M. showed the resident continued to sit in his/her wheelchair looking ahead at his/her mirror or television that was off, and occasionally looked far to the right to his roommate's television that was on. The resident's call light continued to be out of reach. Observation on 4/4/19 at 3:35 P.M. showed the resident lay in bed. The resident said he/she hurt his/her leg, but couldn't describe what had happened. Review of a progress note dated 4/4/19 showed staff documented the resident was attempting to get up from his/her wheelchair and fell onto the floor on his/her bottom. The resident was assessed and stated he/she had pain of three out 10 in the left hip. The resident was able to move both lower extremities within normal limits with no added pain. The resident was assisted from the floor with assistance by two staff. The resident was alert and oriented times three. The physician was notified and an X-ray was ordered. Family was also notified. The resident was educated on the need to use the call light when assistance is needed to further prevent fall and possible injuries. Review of a progress note dated 4/4/19 at 3:27 P.M. showed staff documented they spoke with the resident's spouse, updated him/her on the resident's fall and complaints of left hip pain, informed her that X-ray had been ordered and staff would notify him/her of results. Staff noted they asked the resident's spouse for approval to use a personal safety alarm on a trial basis, as the resident could not recall what he/she was attempting to do before he/she fell. Staff noted the resident complained of left hip pain with passive range of motion. Review of an X-ray of the resident's left hip, unilateral with pelvis, dated 4/4/19, showed: -A fracture through the femoral neck is identified. Minimal displacement is identified. Inferior angulation is noted. The fracture does not involve the articular surface. The femoral head is well-seated within the acetabulum. Moderate degenerative changes are noted. The surrounding soft tissues are normal. -Impression: Femoral neck fracture, as detailed above. Clinical correlation and follow-up are recommended. Review of a physicians order, dated 4/4/19 showed an order directing staff to send the resident to the emergency room for evaluation and treatment. During an interview on 4/5/19 at 11:20 A.M., CNA A said the resident hasn't fallen a lot. The CNA said he/she makes sure his/her leg rests are on the wheelchair, and ensure the resident has his/her fall alarm in place. When asked to clarify if the resident had a fall alarm prior to his/her fall the day before, the CNA said he/she thought the resident had a fall alarm in use prior to the fall and should've had it on. The CNA did not see the fall occur the day before, but staff told him/her the resident tried to scoot him/herself to the sink and stand up. The CNA said he/she had assisted the resident to the toilet after lunch and before the resident's fall. During an interview on 4/5/19 at 11:59 A.M., Licensed Practical Nurse (LPN) C said the resident has Parkinson's so his/her gait is very unsteady. The resident used to walk with a walker before he/she developed the wounds, but uses a wheelchair now until the wounds heal. The resident does occasionally try to get up and walk on his/her own. After the fall yesterday, staff discussed with the resident's spouse, trialing a period with a personal body alarm for the resident's wheelchair. Staff were unable to figure out why the resident was trying to get up yesterday, but his/her guess was the resident tripped over his/her foot pedals. The resident said he/she didn't remember what he/she was trying to do. The resident had been toileted right before the fall and the call light was in reach. The LPN said the resident doesn't use the call light very often. He/she did not have a personal alarm prior to the fall yesterday. During an interview on 4/5/19 at 11:59 A.M., LPN C said any nurse can update the care plan, but the MDS coordinator, social service director, and the DON update the care plan when things change with the resident, quarterly. LPN C said staff should update the care plans with new interventions if needed after a fall. During an interview on 4/5/19 at 1:54 P.M., the Director of Nurses (DON) said any nurse can update a resident's care plan. The nurses and supervisors update the care plan on the resident's door and the MDS Coordinators update the care plan in the computer. Care plans should be updated at least quarterly, and with any status change, transfer change, or if the resident has a fall. After a resident falls, staff should document on the care plan that the resident had an actual fall and the date of the fall, whether or not the resident had any injury, and what happened, for example if the resident slipped in water. Staff should analyze the fall and then add interventions as needed, typically try to update the care plan within 24 hours. If staff review a resident's care plan after a fall and no new interventions are needed, it would be documented in the nurses notes. The DON said she was not sure of the resident's fall interventions, but staff should follow his/her plan of care. 2. Review of Resident #25's most recent MDS, dated [DATE], showed staff assessed the resident: -Had severe cognitive impairment; -Required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Did not walk; -Fell since the prior assessment; -Had one fall with no injury; -Had one fall with injury (not major). Review of the resident's plan of care addressing his/her risk for falls, last reviewed/revised 3/16/19, showed the following: -Staff noted the resident was at risk for falls related to impaired mobility secondary to poor safety awareness and dementia. -The resident is a retired social worker and likes to stay busy. Nursing can usually keep the resident busy with papers doing paper work. -The plan directed staff to place the resident's bed in the lowest position with a fall mat in place while the resident is in bed. -The plan showed the resident fell once on 3/14/19. Review of the resident's care plan showed no plan to direct staff of the resident's potential for choking, due to the resident putting non-edible items in his/her mouth. Review of the resident's physician's order sheet showed the following physician orders: -CHOKING HAZARD!!!! RESIDENT PUTS NON-EDIBLE ITEMS IN MOUTH; PLEASE KEEP OUT OF HIS/HER REACH (CRAYONS, PAPER, PUZZLES, ETC); -Low bed with mat for poor safety awareness; -PSA (Personal Safety Alarm) in wheelchair for safety. Review of the resident's record showed on 12/20/18, staff documented the resident was found in his/her room on the floor mat. The resident was found in urine, sitting up and trying to put on his/her gown; no injury noted. Review of the resident's record showed on 1/21/19, staff documented the resident was observed putting non-edible items in his/her mouth such as wooden puzzles, wedding ring, paper, crayons etc; Staff were made aware of the resident's choking risk. The resident's physician and responsible party were updated. The resident's wedding rings were removed and the spouse was asked to pick up the rings. Review of the resident's record showed on 2/2/19, staff documented the resident was observed standing from his/her wheelchair, lost his/her balance and fell to the floor onto his/her left side. Review of the resident's record showed on 3/14/19, an LPN documented he/she found the resident up from his/her wheelchair, walking and pushing an office chair. The resident's PSA was on his/her wheelchair, the string was detached and the alarm sounded. Before the LPN was able to reach the resident, he/she lost his/her balance and fell to the floor hitting his/her right hip and right side of his/her head against the wall. Observation on 4/3/19 on 9:18 P.M. showed the resident lay in his/her low bed. The bed was pushed against the wall on one side, and a fall mat lay beside the other side of the resident's bed on the floor. Observation on 4/3/19 at 10:28 P.M., showed Certified Medication Technician (CMT) G and CNA H checked the resident for incontinence while the resident lay in bed. After the CNAs provided incontinence care, they lowered the resident's bed and placed the fall mat next to the bed. CMT G then placed the resident's bedside table completely on top of the fall mat across from the resident's head and upper body, at a point that if the resident were to fall out of bed, he/she could fall directly onto the legs/wheels of the bedside table. Observation on 4/3/19 at 10:58 P.M. showed LPN I and the night shift charge nurse made rounds through the hallway and residents' rooms prior to LPN I leaving for the evening. The night shift nurse entered the resident's room to check on the resident; the charge nurse did not move the bedside table off of the fall mat and away from the resident's head and upper body in case of a fall to the mat. Observation on 4/4/2019 at 12:18 P.M., showed the resident sat at the dining room table. The resident tore his/her napkin apart and put a piece in his/her mouth, put the rest down and took a drink. Observation showed CNA A sat at the same table feeding another resident. During an interview on 4/5/19 at 11:20 A.M., CNA A said he/she was not aware the resident had any risk for choking hazards. The CNA said she was not aware that the resident puts things in his/her mouth that are not food. However, the CNA said once, the resident did put a Lego in his/her mouth, but this was not an every day thing. The CNA said he/she did not notice the resident took a bite of his/her napkin at lunch yesterday. The CNA said it would never be a good idea to put a bedside table up against a bed for residents with low bed and fall mat because they are at risk for falls and could fall off the bed and and hit the table. During an interview on 4/5/19 at 11:59 A.M., LPN C said for a resident with a low bed and fall mat, staff should not put a bedside table on top of a fall mat next to the resident while in bed. During an interview on 4/5/19 at 1:54 P.M., the DON said a resident should not have a bedside table on top of the fall mat next to their bed.