**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring and ensure the safety and well-being of a cognitively impaired resident who displayed frequent wandering patterns, and the resident had an unwitnessed fall with major injury. This failure resulted in the resident being transferred to the ER, a hospitalization, a surgical procedure, and a total loss of independent ambulation for 1 (#4) of 6 residents sampled for falls; and the facility staff failed to follow the established policies and procedures. These failures were identified to be an Immediate Jeopardy situation.On 9/2/25 at 4:05 p.m., the Administrator and facility management team, including corporate staff, were notified that an Immediate Jeopardy existed in the area of F689 - Accidents and Hazards, related to the failure to provide sufficient supervision and adequate and timely response to an unwitnessed fall for resident #4. The severity and scope identified for the Immediate Jeopardy were identified to be the level of J, and upon the removal of immediacy, lowered to a G. The facility provided a plan to remove the immediacy, and this was accepted by the State Survey Agency. The facility carried out the plan, which was verified by the surveyors onsite, on 9/3/25 at 4:16 p.m.Findings include:1. Resident #4:During an observation on 8/27/25 at 4:08 p.m., resident #4 sat in a wheelchair in the hallway outside of a staff meeting room. Resident #4 attempted to push open the door to the room. Resident #4 smiled and rolled herself back in the hallway, away from the door when surveyor went to close the door to make a phone call.During an observation on 9/2/25 at 5:33 p.m., resident #4 was sitting in a wheelchair in the dining room. Resident #4 would roll back from the dining room table, then roll back up to the dining room table, without assistance. During an interview on 8/27/25 at 11:28 a.m., staff member H stated she worked the day shift the morning resident #4 was transferred out of the facility by EMS. Staff member H stated she had very little information given to her during the shift change report. Staff member H stated resident #4 had been active in the facility most days, up and walking around. Staff member H stated resident #4 seemed grumpy most of the time, and sometimes it was hard to tell how she was doing due to her mental status. Staff member H stated she entered resident #4's room and saw her in bed with her face pointing upward in a hard stare. Staff member H stated she asked resident #4 if she was hurt, when she noticed her face and saw her holding her left side. Staff member H stated she went to get assistance from staff member M to respond to resident #4. Staff member H stated staff member M called for EMS to respond to resident #4. Staff member H stated, The EMS people were here for a while before they left.During an interview on 8/28/25 at 8:02 a.m., staff member M stated she received a shift change report from staff member N the morning resident #4 was transferred from the facility by EMS. Staff member M stated staff member N told her resident #4 had a fall and was in a lot of pain. Staff member M stated she did not know what the staff did for her through the night. Staff member M stated she asked staff member N why resident #4 was not sent out to the hospital for an evaluation after the fall, and he stated staff member B told him not to send her. Staff member M stated she entered resident #4's room and saw resident #4 in bed, moving around, making facial grimaces. Staff member M stated she checked the resident in the bed and saw she was wet. Staff member M stated that with the help of other staff members, she rolled resident #4 to her side for support to change her. Staff member M stated she heard a loud sound from resident #4's left leg. Staff member M stated she could see the resident's condition and called EMS for assistance.During an interview on 8/28/25 at 12:24 p.m., staff member L stated she had been working the night shift when the event occurred with resident #4 and the fall. Staff member L stated she had been getting residents ready to put them to bed, when a kitchen worker arrived to seek nursing assistance. Staff member L stated that three staff members (including herself and staff member N), responded to the dining room to find resident #4 on the floor. Staff member L stated they moved resident #4 from the dining room floor and put her into a wheelchair. Staff member L stated they lifted the resident manually from the floor to the wheelchair, with a staff member supporting the resident under each shoulder and arm. Staff member L stated resident #4 fought the staff, pushing out at them, when they went to move her pants for the transfer. Staff member L stated the three staff members moved resident #4 to her bed using the wheelchair and manually transferring her. Staff member L stated she checked on resident #4 in bed throughout the night.During an interview on 9/2/25 at 9:14 a.m., NF3 stated he received a call from a male nurse the night of 4/10/25. NF3 stated the nurse told him resident #4 had fallen from her bed, that she might have rolled from bed. NF3 stated he asked the nurse if it was serious and if he should come over to check on her. NF3 stated the nurse told him no, that he wanted to let him know she had a fall and had to be lifted into bed. NF3 stated he thought about resident #4 being in pain that night. NF3 stated when he was notified resident #4 was sent out the next morning to the hospital, she must have been in pain.During an interview on 9/3/25 at 6:06 p.m., staff member N stated he was the nurse on duty the night resident #4 had the fall on 4/10/25. Staff member N stated he was at the nursing station when a kitchen staff member told him resident #4 had fallen in the dining room and was lying on the floor. Staff member N stated he walked down to the dining room and found resident #4 lying on the floor, on her side. Staff member N stated resident #4 was non-verbal and cognitively impaired. Staff member N stated he did a quick assessment of her head and found a large bump on the back of her head, and at that time, staff member N stated he did not feel resident #4 was expressing any problems. Staff member N stated, We picked her up and put her into a wheelchair, and she started to show signs of pain, so we put her to bed and started neuro checks. Staff member N stated resident #4 did not weigh much, so a lift was not used to put the resident into a wheelchair. Staff member N stated he completed a range of motion assessment on resident #4's upper extremities but did not complete an assessment on her lower extremities. Staff member N stated, Resident #4 could be combative at times, and I don't like to get hit, so I did not push it. Staff member N stated he notified the power of attorney and the physician of the fall. Staff member N stated he had written a nursing note about the incident, but had to strike it out because it was not written in the right place, but he did not go back into the medical record and write another progress note regarding resident #4's fall or status. Staff member N stated he could not remember if he completed a pain assessment after resident #4's fall. Staff member N stated, If I did, it would be documented in the chart.Review of resident #4's EMS notes, with the assessment date and time documented as, 4/11/25 at 6:26 a.m., showed: . Narrative . Upon arrival, facility staff states that (resident #4) fell last night and canceled A4D prior to EMS arrival due to non-injury. Staff states that at shift change she was informed that (resident #4) had fallen around 1900 (7:00 p.m.) Roughly 1 hour after the fall, staff states, (resident #4) was being changed in bed when staff noticed a deformity of (resident #4)'s hip. Staff is unsure why EMS care was not initiated at that time. Due to dementia, pt is unable to provide a narrative of the events before and after the fall, however, continues to complain of pain until therapeutic threshold of analgesics. Left lower extremity is laterally rotated and pt is unable to move left leg on command. Deformity of pelvic girdle on left side with no discoloration. Pt is tender at the femoral head and pain continues with palpation of left upper leg. [sic]Review of resident #4's hospital physician notes, dated 4/11/25 at 3:47 p.m., showed: . Patient is a [AGE] year-old female with severe dementia who resides at [Facility Name] in Columbus. She is ambulatory without ambulatory assistive devices and (NF3) tells me she basically wanders the halls all day. However, she is completely nonverbal and very demented. She sustained a left intertrochanteric fracture with some. displacement. and she is taken the operating room for operative treatment. [sic]Review of a document in resident #4's electronic medical record, titled, Durable Power of Attorney for Healthcare Form, dated 5/11/23, showed: . My Agent's health care decision shall be subject to any statement of desires, special provisions and/or limitations set forth below: . a) I want Pain releif [sic], Medications, Cardiac Resuscitation .Review of resident #4's care plan, with the initiation date of 12/6/24, showed the diagnoses including Alzheimer's disease, depression, and paranoid personality disorder. The care plan showed problems resident #4 had, which would increase the risk of safety concerns: - . requires the use of anti-depressant, anti-anxiety, anti-psychotic (medications). - . has a communication problem r/t Alzheimer's disease. The resident will be able to make basic needs known on a daily basis through the review date, Anticipate and meet needs.- . has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's. The resident will be able to communicate basic needs on a daily basis through the review date, Administer medications as ordered. Monitor/document for side effects and effectiveness.- . is at risk for falls r/t Wandering, goal of resident will be free of falls with injury through the review date and an intervention of Educate and encourage the resident to wear appropriate footwear, such as non-skid socks or shoes, when ambulating/mobilizing. [sic]Review of a facility document titled, Neurological Flow Sheet Form, showed a date beginning on 4/10 at 7:00 with initial vital signs of B/P: 114/61 Pulse: 60 Respirations: 17 Temp: 97.3 O2 sats: 93. and no nursing initials below the times when the checks were performed. One set of vital signs showed, 4/11 at 11:25 with, B/P: 119/82 Pulse: 81 Respirations: 18 Temp: 98 02 sats: 95. The document did not include any assessment of PERRLA (check of eye pupil reaction), even though the resident hit her head during the fall, per staff member N's interview, or an assessment of staff using a verbal or non-verbal scale of pain to show a baseline pain level for the resident until the time the resident was transferred from the facility by EMS.Review of resident #4's Quarterly MDS, with an ARD of 3/16/25, section GG, showed resident #4 was independent with ambulation and required supervision for toileting and transferring in and out of bed. Resident #4 showed she needed substantial assistance for dressing, bathing, and personal hygiene. Resident #4 was not coded as using a wheelchair. Section M of resident #4's MDS showed no surgical wounds, and Section J showed no fractures.A review of resident #4's Quarterly MDS, with an ARD of 6/19/25, section GG, showed resident #4 was coded for wheelchair use, and was no longer able to ambulate independently, and had become dependent on staff for transferring in and out of bed, toileting, bathing, dressing, and personal hygiene. Section J was marked as having no fractures. Resident #4 sustained a hip fracture due to a fall that occurred on 4/10/25.Review of a facility document titled Root Cause Analysis, dated 4/11/25, prepared by staff member B, showed: . On 4/10/2025,, a resident was found on the floor in the dining room following an unwitnessed fall. Upon assessment, the assigned nurse (staff member N), observed a large hematoma on the resident's head. When the resident was assisted to a sitting position, she complained of pain in her left hip. (Staff member N) proceeded to call 911, then contacted (staff member B) to report the situation. During the initial report, the nurse stated the resident had a hematoma but did not immediately communicate the complaint of hip pain. Based on the initial report, the DON questioned whether a transfer was necessary, given that neuro checks were reportedly within normal limits. When the nurse later clarified the resident also had hip pain, the DON confirmed that the resident should be sent to the hospital.However, it was later discovered that the resident was not transferred to the hospital until the day shift nurse arrived the following morning, resulting in the potential for a significant delay in care. A review was conducted of the residents pain management, during the night, and the resident did not report pain during the night after lying down and had no pain signs or symptoms. [sic]Review of a facility document titled, Verbal Education Statement - (staff member B) to (staff member N): . When a resident complains of hip pain after a fall, they should not be moved until a thorough assessment is completed, and appropriate precautions are taken to rule out fractures or other injuries. Moving a resident with suspected hip trauma can potentially worsen the injury. Please remember to follow fall protocol and notify the provider immediately if there's any sign of pain, bruising, or abnormal positioning after a fall. Initially, you mentioned the hematoma, but you did not mention the hip pain until later in our conversation. That delayed my understanding of the full clinical picture, which in turn delayed the decision to send the resident out. Always ensure that you're providing. all symptoms, assessments, and your nursing judgment. Once a decision is made to send a resident out, it's critical that the transfer be carried out in a timely manner. That delay could have serious implications for the resident's health. emphasize the importance of using your nursing judgment. If you believe a resident needs to be evaluated at the hospital - especially following a fall with pain or visible trauma - you have the authority and responsibility to act in the best interest of the resident. Early intervention can prevent complications and improve outcomes.The document was signed by staff member B, with a date of 4/11/25, and it did not include the signature of staff member N.Review of a facility policy, titled, Fall Prevention Program, dated 4/11/25, showed: . Policy Explanation and Compliance Guidelines .9. When any resident experiences a fall, the facility will:a. Assess the resident.b. Complete a post-fall assessment.c. Complete an incident report.d. Notify physician and family.e. Review the resident's care plan and update as indicated.f. Document all assessments and actions.g. Obtain witness statements in the case of injury.Review of a facility policy, titled, Elopements and Wandering Residents, revised date 4/30/25, showed: . This facility ensures that residents who exhibit wandering behavior. receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care.Review of a facility policy, titled, Notification of Changes, dated 4/11/25, showed: . Compliance Guidelines:The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include:1. Accidentsa. Resulting in injury.b. Potential to require physician intervention.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include:a. Life-threatening conditions, orb. Clinical complications. 2. Residents incapable of making decisions:a. The representative would make any decisions that have to be made.b. The resident should still be told what is happening to him or her.Review of a facility document, titled, Standing Orders for Nursing Home, with a review date of August 2024, showed: . After business hours and on weekends. contact the on-call staff with:1. Critical patient care issues that need to be addressed prior to the next provider visit.Falls For falls with injury, notify the provider immediately.Review of a facility in-service attendance document, titled .Nursing Professional Standards., not dated, showed seven staff nurses received written education beginning on 8/28/25 and ending on 9/1/25. The unwitnessed fall event to resident #4 occurred on 4/10/25. Pertinent information included showed: 1. Immediate Post-Fall Assessment and Precautions.When a resident complains of hip pain after a fall, do not move them until a thorough assessment is performed. Moving a resident with suspected hip trauma may worsen a fracture or other injuries.2. Effective and Complete Communication.Always communicate a full and accurate clinical picture to the nurse in charge, supervisor, or provider. Incomplete information can lead to delayed interventions and harm to the resident. 3. Timely Transfer to Hospital.If the transfer cannot occur during your shift:- Communicate clearly with the oncoming nurse.- Ensure it is documented in the chart and in the shift report.- Escalate to the supervisor if necessary.4. Use of Nursing Judgment.As a licensed nurse, you are empowered and obligated to advocate for the resident's safety.