**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible by failing to ensure safety in the outdoor courtyard for one resident (Resident #235) with a history of falls when the ground next to the pathway to the courtyard had washed away, leaving an approximate 5 inch drop to the ground from the pathway. The resident self-propelled in a wheelchair to the courtyard and the wheelchair tipped off the side of the pathway. This failure resulted a serious injury of three fractured ribs and required the resident to be sent to the hospital. In addition, the facility failed to follow their transfer policy for one resident that was transferred in a Hoyer lift (mechanical lift) without the required two person assistance (Resident #26). The census was 137 with 99 residents in certified beds. 1. Review of the facility's fall management and reduction program policy, revised 3/2019, showed: -Purpose: To provide guidelines to manage and attempt to reduce the incidence of resident falls; -Responsibility: It is the responsibility of all staff to know and follow this policy; -Policy: All residents admitted will be assessed upon admission, quarterly and as needed for fall risk using the MORSE fall risk scale (method of assessing a resident's risk of falling). Appropriate safety interventions, including potentially being placed in a fall reduction program, will be implemented. A fall interdisciplinary team (IDT) will consist of nursing, therapy and other disciplines as appropriate. This team will meet at least weekly to review and make appropriate recommendations for residents who have fallen; -Practice: Upon admission to the facility, all residents will be assessed using the MORSE fall risk scale; -At a score above 45, the resident is identified at a high risk of falls. A fall reduction program will be initiated; -If at any time the MORSE fall risk assessment receives a total score above 45 and the resident is not already in the fall prevention/reduction program, the nurse will place the resident in the program and update the care plan; -The fall management/reduction program (a score above 45) requires the following: -To alert staff to the increased fall risk by communicating in shift reports and in the care plan. It is also identified in the resident's electronic record denoting high fall risk status. Other safety interventions specific to the individual resident will be implemented as deemed appropriate by the nurse or supervisor and added to the care plan. Review of Resident #235's medical record, showed: -admitted on [DATE]; -Diagnoses included: End stage kidney disease, history of syncope (fainting) and collapse. Review of the resident's admission nursing flowsheet, showed: -On 9/21/19 at 4:48 P.M.: The resident is a new admission and medications were verified; -Transfer assistance: Partial/moderate assistance; -Used a manual wheelchair; -Ability to wheel 50 to 150 feet with two turns: substantial/maximal assistance; -Barriers to learning: cognitive deficits, memory problems; -General symptoms: confusion, disorientation, edema (swelling), faintness and weakness; -Neurological symptoms: faintness, memory problems; -Makes self-understood and understands others; -Tremors (shaking): yes; -General safety measures: frequent checks on rounds; -Fall in the last three months: yes, presence of a secondary diagnosis; -Gait weak or impaired fall risk: impaired; -Mental status MORSE: forgets limitations; -MORSE fall risk score: 75; -Participative in fall prevention: yes; -Behaviors exhibited: calm and impulsive; -Orientation assessment: Orientated times four; -Assistive device: wheelchair; -Locomotion on unit and support provided: total dependence of one person physical assist; -Elopement or wandering: no; -Short term memory: impaired; -Precautions observed: bleeding, fall risk, transfer and mobility. Review of the resident's admission physician order sheet, showed: -An order dated 9/21/19 at 5:37 P.M., for fall risk precautions, constant order. The resident is a high fall risk, keep the bed in the lowest position when in bed and the bed against the wall per resident's spouse. Review of the resident's completed nursing Morse Fall Scale assessments, showed: -On 9/21/19 at 6:54 P.M., the resident scored a 75 (high fall risk), had a history of falls in the last three months, had a secondary diagnosis, no use of ambulatory aid and used bed rest, had an impaired weak gait or impaired fall risk and mental status or forgetting limitations. Further review of the resident's nursing flow sheet assessments, dated 9/21/19 at 9:00 P.M. into 9/22/19, showed: -Behaviors exhibited: agitated, impulsive, irritable, refused care and uncooperative; -Verbally aggressive description: cursing; -Interventions used after behavior: comfort and compassion, constant monitoring, toileting; -Impact on behavior on the resident: significantly interferes with the resident's care; -Resident used wheelchair: yes; -Wheel 50-150 feet: independent; -Gait weak or impaired fall risk MORSE: impaired; -Mental status fall risk MORSE: forget limitations; -MORSE fall risk score: 75; -Date, time of fall: 9/22/19 at 3:15 P.M; -Fall witness: unwitnessed; -Interventions in place to prevent falls: adequate lighting, attendance while in bathroom, frequent observations; -Injury: bruise and no treatment needed; -Location of fall: resident's bathroom; -Description of fall: unknown, found on the floor. Physician notified and no new orders. Family notified; -Neurological symptoms: memory problems; -Gait: unsteady. Review of the resident's completed nursing Morse Fall scale assessments, showed: -On 9/22/19 at 3:15 P.M., the resident scored a 75 (high fall risk), had a history of falls in the last three months, had a secondary diagnosis, no use of ambulatory aid and used bed rest, had an impaired weak gait or impaired fall risk and mental status or forgetting limitations. Review of the admission baseline care plan, updated on 9/22/19, showed: -Activities of Daily Living (ADL, are routine daily care tasks or activities): The resident is on fall precautions. He/she is at the facility for physical and occupational therapy. He/she requires assistance with ADLs. Staff to encourage the resident to do as much as possible for himself/herself and encourage him/her to call for assistance as needed; -Goal: To return to pre-hospital level of independence of ADL capacity. The resident can self-propel in his/her wheel chair throughout the facility; -General information: The resident has diagnoses of end stage renal disease and syncope. He/she is alert and oriented times four and able to make needs known. He/she is on fall precautions. He/she has behaviors of impulsiveness and noncompliance, staff to remind him/her to ask for assistance for transfers as needed. Further review of the resident's completed nursing Morse Fall scale assessments, showed: -On 9/23/19 at 2:00 A.M., the resident scored a 75 (high fall risk), had a history of falls in the last three months, had a secondary diagnosis, no use of ambulatory aid and used bed rest, had an impaired weak gait or impaired fall risk and mental status or forgetting limitations. Further review of the resident's nursing admission flow sheet, dated 9/23/19 at 2:00 A.M., through 4:52 P.M., showed: -Neurological symptoms: memory problems; -General safety measures: frequent checks on rounds; -History of fall in the last three months: yes; -Use of ambulatory aid MORSE: none, bed rest, wheelchair or nurse; -Gait weak or impaired: impaired; -Mental status fall risk MORSE: impaired and forgets limitations; -MORSE fall risk score: 75; -Locomotion on the unit: independent. Further review of the resident's nursing admission flow sheet, dated 9/24/19 at 1:56 A.M., through 12:28 P.M., showed: -Neurological symptoms: none; -Orientation assessment: orientated x four; -Gait: unsteady. Observation on 9/24/19 at 10:50 A.M., showed the resident lay on the ground in the landscaping outside the rehab unit leading into the courtyard. Multiple staff present and provided assessment of the resident. The resident told staff he/she had propelled himself/herself out of the rehabilitation unit doorway into the courtyard. The front wheels of his/her wheelchair caught the edge of the concrete pad and he/she tipped forward out of the wheelchair, fell and hit the pipe that protruded out of the ground. He/she did not hit his/her head. He/she heard a loud pop when he/she fell onto the pipe and his/her left lower rib area hurt. Staff called emergency services. During an observation and interview at 10:52 A.M., the facility onsite physician responded to assess the resident. The physician stated the resident had marks, bruising and pain from hitting the pipe. The resident did not hit his/her head and the facility had called emergency services. During an interview on 9/24/19 at 10:55 A.M., Certified Occupational Therapy Assistant (COTA) C said he/she had been sitting at a table outside in the courtyard working with another resident and heard someone yell out. He/she looked up and saw the resident lying down on his/her side on the ground and the wheelchair lying on top of the resident. He/she ran over to the resident and pulled the wheelchair off of him/her. The physical therapist walked outside and COTA C told him/her to go get help, while he/she remained with the resident until nurses arrived. During an observation and interview on 9/24/19 at 11:00 A.M., emergency services arrived on scene and provided care to the resident. The resident noted to voice pain to the area of his/her left lower ribs. Maintenance supervisor D said the depth of the concrete pad from the top of the pad to the ground was five inches, the area where the resident fell had a sprinkler head and the dirt had been washed out. During an interview at 11:45 A.M., the maintenance supervisor said he had called the groundskeeper and dirt would be added to the area to back fill in the low spot. He did not know how long the low spot had been like that, the area could have been like that for six months or a year. The sprinkler maybe causing the dirt to wash out. At 12:02 P.M., the maintenance supervisor added the vent pipe the resident fell onto measured 7 3/4 inches from the top of the pipe to the ground. During an interview on 9/24/19 at 1:40 P.M., the Director of Nursing (DON) said the emergency room had called and notified the facility the resident had fractured some of his/her ribs. The facility would be starting an investigation. During an interview on 9/24/19 at 1:49 P.M., the hospital emergency room (ER) registered nurse (RN) called and informed the surveyor the resident had fractured his/her left 6th, 7th and 8th ribs. The resident had experienced a lot of pain and the ER. RN had administered morphine (narcotic pain medication) to control the resident's pain. The hospital will be conducting further scans. Observation of the courtyard on 9/24/19 at 2:50 P.M., showed the area where the fall had occurred, showed no changes or improvements. No safety precautions noted in place. Review of the resident's emergency room visit and assessment notes, dated 9/24/19 at 11:36 A.M., showed: -Subjective: The patient presents to the emergency room from a fall at 11:00 earlier today. The patient was in his/her wheelchair when a wheel fell off the sidewalk and the wheelchair fell over and he/she impaled himself/herself onto a PVC pipe. The patient complains of rib pain. He/she is in a wheelchair due to weakness in his/her legs after last hospital admission; -Review of skin: Abrasions to the left flank (side) and left medial (middle) ecchymosis (bruising); -Radiology impression: Fractures of the left sixth, seventh and eighth ribs with minimal displacement; -Summary statement: Discharge with oral Dilaudid (narcotic pain medication) and Lidocaine (pain medication) patches. Review of the resident's readmission nurse note, dated 9/24/19 at 10:29 P.M., showed the resident readmitted into the facility. Diagnosis of rib fracture related to fall in the yard out of his/her wheelchair. Instructed to splint his/her chest with a pillow in order to take deep breaths with the least amount of pain. Educated the resident and spouse regarding risk of pneumonia if unable to deep breathe. Physician onsite with the resident and discussed future care with the resident and spouse. New orders for Dilaudid and pain patch. The resident rates pain a 10 out of 10 (0 indicated no pain and 10 indicated the worse pain imaginable). Pain medications given. The resident unable to sit up and must keep the head of the bed low. He/she had to eat dinner with the head of the bed low and cannot tolerate the head of the bed being elevated. Review of the resident's readmission physician progress note, dated 9/24/19, showed: -History and physical: admitted for fall, near syncope and passing out. Recent fall and broke three ribs; -Past medical history: stroke, irregular heartbeat, diabetic neuropathy (loss of sensation in fingers and feet) and kidney failure; -Neuro: Alert and orientated times one; -Plan: Rib fractures pain management. Review of the resident's readmission nursing assessment pain flow sheet, showed: -On 9/24/19 at 8:28 P.M., a pain rated 10, or the worst pain possible in the chest. Pain medication given. At 3:00 A.M., no pain noted; -On 9/25/19 at 5:10 A.M., and 6:02 A.M., a pain rated 10. Medication administered and effective. Review of the resident's physician order sheet (POS), reviewed on 9/25/19 at 7:57 A.M., showed: -An order for Lidocaine 4 percent (%) patch- apply daily for chest pain; -Hydromorphone (Dilaudid) 2 milligram (mg) every four hours as needed for severe pain, administered on 9/24/19 at 8:28 P.M., with a pain 10/10, administered 9/25/19 at 5:10 A.M. with a 10/10 pain scale. Observations on 9/25/19, showed: -At 8:25 A.M., the resident sat in his/her wheelchair in the dining room for breakfast. He/she talked to other residents and noted to brace his/her left arm against his/her left side. He/she appeared pale and slow to move in his/her wheelchair; -At 8:28 A.M. and 9:32 A.M., no dirt, rock or material had been placed in the area of the courtyard where the resident fell. During an interview on 9/25/19 at 9:37 A.M., the therapy program director said the resident had been admitted to the facility the weekend before. He/she received the initial therapy evaluation on Sunday and had been noted to have impaired cognition by the occupational therapist. The physical therapy assistant saw the resident on 9/25/19 in the morning, however the resident did not perform much of the session related to his/her pain and the therapy session stopped. During an interview on 9/25/19 at 10:15 A.M., Certified Nurse Aide (CNA) F said he/she had taken care of the resident on the day of his/her fall, on 9/24/19 and had also cared for him/her the morning of 9/25/19. On the morning of 9/24/19 the resident did not want to get up and had slept in, and ate a late breakfast while in bed. CNA F felt the resident had been confused and after the resident ate, he/she assisted the resident out of the bed and into the bathroom. When the resident had finished in the bathroom, he/she assisted him/her to get dressed and into the wheelchair. The resident seemed slightly confused at times and unsteady during the transfers from the bed and in the bathroom. The resident appeared comfortable and wanted to remain in his/her room. A facility housekeeper began to clean the resident's room and was talking to the resident. CNA F reported to the resident's nurse he/she was going to lunch break and the resident was in his/her room. While he/she was on break, staff reported that a resident had fallen in the courtyard. Observation of the courtyard on 9/25/19 at 11:04 A.M., showed no dirt, rock or safety markers in place. During an interview on 9/25/19 at 12:40 P.M., Licensed Practical Nurse (LPN) G said the courtyard is used by the facility rehabilitation residents. The area is usually used by residents who are alert and orientated. Nursing staff usually use the courtyard as a walk through as it connects different areas of the rehab hallways. At times, physical therapy staff will work with a resident out in the courtyard. Nursing staff do not monitor which residents use the courtyard. Staff know if a resident is out in the courtyard by seeing them through the windows or hearing the doors close. There are no alarms on the doors to the courtyard. The courtyard is in disrepair. During an interview on 9/25/19 at 1:32 P.M., RN H said that he/she had not been told or in-serviced on additional safety precautions regarding the courtyard since the resident had fallen on 9/24/19. During an interview on 9/25/19 at 1:42 P.M., Housekeeper I said he/she entered the resident's room on 9/24/19 and started to clean the room. The resident had told him/her that he/she wanted to go outside and he/she liked to be outside. Housekeeper I told the resident he/she needed to let someone know he/she wanted to go outside. The resident told housekeeper I that he/she did not need to tell anyone, and the resident propelled himself/herself out of the room. Housekeeper I did not tell nursing staff of the resident's desire to go outside. Housekeeper I continued to clean the resident's room, and looked out the resident's window that faced the courtyard and noted the resident coming out of the facility door into the courtyard. He/she assumed a staff member had let the resident out of the door. A few minutes later, he/she looked out the window again and observed the resident on the ground next to the concrete sidewalk and several staff around the resident. During an observation and interview on 9/25/19 at 2:05 P.M., the courtyard was noted to not have any new safety precautions in place, no dirt to back fill in the area of the fall. The administrator said that the company grounds management is aware and a plan is in place to address the issue. There was no immediate plans to repair the area. He/she did have bags of dirt at the facility but the sprinkler needed to be repaired first or the dirt would wash away. He/she could not place a hand rail at that location and he/she was waiting to speak to the vice president. During an interview on 9/25/19 at 2:18 P.M., the maintenance director said he had contacted the company grounds director and he came and observed the area of the courtyard where the resident had fallen. There had been no decision made if rock or dirt would be added to the site. It had been discussed the sprinkler head needed to be repaired first or it would wash away any dirt. During an interview on 9/25/19 at 3:48 P.M., the administrator said she had placed a large planter in the courtyard in the area of the fall incident. She will be working with corporate to repair the area of the courtyard. 2. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/3/19, showed: -A Brief Interview of Mental Status (BIMS) score of 10 out of 15, showed the resident cognitively moderately impaired; -Diagnoses included high blood pressure, diabetes, hyperlipidemia (high level of lipids), stroke, hemiplegia (paralysis on one side of the body) and depression; -Total dependence and required two person assist for transfers; -Impairment on one side of the upper and lower extremities; -Uses a wheelchair. Review of the resident's care plan, dated 7/12/19, showed resident needed extensive assist of two with bed mobility, dressing and toileting. He/she used a Hoyer (mechanical) lift for transfers. Observation on 9/23/19 at 1:56 P.M., showed the surveyor knocked on the resident's door. There was no answer; surveyor opened the door to the resident's door and said hello. The resident was observed in a sling that was hooked to a Hoyer lift. He/she was suspended approximately two feet above his/her wheelchair. CNA F was observed with the electronic remote in his/her hand. There was no other staff in the room except the resident and CNA F. CNA F continued to transfer the resident while he/she was suspended in the air. CNA F managed the hand control to transfer the resident from his/her wheelchair to the bed. The resident's body received no guidance during the transfer. The resident was transferred and lowered onto the bed. CNA F unhooked the sling and moved the Hoyer lift to the middle of the resident's room. CNA F said another staff will come in and assist him/her with turning the resident. CNA F exited the room. During an interview on 9/23/19 at 2:00 P.M., the resident said he/she is often transferred by one staff using the Hoyer lift. It depended on which staff was operating the Hoyer lift that determined if he/she felt safe during the transfer. Review of the facility's Use of Mechanical Lift policy and procedure, revised November 2017, showed facility policy requires two persons when using any mechanical lift. Resident's transfer needs should be assessed upon admission, quarterly, and as needed. This is to be documented in the resident's care plan. During an interview on 9/23/19 at 2:10 P.M., the administrator and DON said they would expect staff to follow the facility's policy in regards to Hoyer transfers. They would expect the residents to be transferred by two staff. There should be one staff to operate the lift and the other staff to guide the resident's body. The administrator confirmed that the CNA F had received training and education on transfers.