**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to evaluate and implement individualized and affective fall prevention care plan interventions, after a resident's fall with a major injury which resulted in blindness in one eye, and the resident to continued to fall, and had three more injuries, for 1 (#11); failed to assess, revise, and implement fall interventions, to prevent falls, for 2 (#s 14 and 25); and failed to ensure staff were trained in fall prevention and reporting, resulting in a major injury, for 1 (#39) of 8 sampled residents. Findings include: On 3/15/23 at 3:04 p.m., the St. [NAME] Community Nursing Home Director of Nursing, Assistant Director of Nursing, and Administrative Assistant, were notified of an Immediate Jeopardy situation for F689 - Accidents and Hazards, which included 1 (#1) resident. The Severity and Scope was identified to be at the level of J, and upon removal of immediacy, was lowered to G. The facility removed the immediate threat of harm on 3/16/23 at 11:00 a.m. 1. During an observation and interview on 3/13/23 at 12:49 p.m., resident #11 appeared lethargic, was falling asleep, and confused. Resident #11 was unable to complete the remainder of the interview. Resident #11 was observed to be on documented hourly checks, per the observation of a clipboard on the resident's door jamb. The hourly checks were incomplete. During an interview on 3/13/23 at 1:05 p.m., staff L stated, She (resident #11) waxes and wanes a lot throughout the day, some days she is clear but more often than not she is very lethargic and confused. Staff member L stated, [Resident #11] was scheduled to start physical therapy in a couple of weeks because she is having injections to control the pain in her back first. During an observation and interview on 3/13/23 at 1:15 p.m., staff member M stated, I help her (resident #11) get up and started for the day, dressing, brushing teeth and getting her to breakfast. Then I bring her back from breakfast, and she likes to stay in her room. I check and change her (brief) about three times a day, and that's about it. Resident #11 was in bed sleeping, with her bed in a high position, there was no fall pad by the bed on the floor, and there was a bed alarm under her. During an observation and interview on 3/14/23 at 11:05 a.m., resident #11 stated, I fall a lot, so they have me strapped up (referring to her bed alarm) because I seem to need to learn the hard way. Resident #11 was able to carry on the conversation with complete sentences, with some confusion noted. During an interview on 3/14/23 at 2:45 p.m., staff member C stated, (Resident #11's) Fall Investigation packets provided are all of the information we have, if the root cause and interventions are not there, then there were no new interventions added. Staff member B stated, We have applied for CMP monies to work on falls. Staff member C stated, We didn't have any more interventions than what is attached (to resident #11's fall investigations) . if there is nothing attached, then we didn't do anything else. During an interview on 3/15/23 at 7:30 a.m., staff member B stated, I've seen an uptick in falls in building since I started trying to work on fall issues. Staff member B stated she had requested [University name] to come in and do some fall education, but did not have a date for this training yet. Staff member B stated, It really doesn't look like the documentation is there (for the resident's falls), but I know we've really tried with her . You should call the [family member], she will tell you. Staff B stated the lack of fall care plan interventions, attached to the care plan, has been a problem. During an observation and interview on 3/15/23 at 9:30 a.m., resident #11's hourly checks, documented on the clipboard on the door jamb of her room, showed blank time slots during 3/13/23 - 3/15/23. Resident #11 stated she felt the facility could help her prevent falls by, Helping me with my balance, that's one thing, I'm sure there's more, but that's what I can think of now . I think a lot also has to do with this darn eye, my eye is on the floor or something, since I fell. During an interview on 3/15/23 at 10:00 a.m., staff member E stated resident #11's fall interventions did not consistently align with the causes of the falls. Staff member E stated, A lot of things just don't get charted as it really takes away from patient care . I'm sure we did things though. Staff E stated, She (resident #11) has permanent loss of sight in her right eye. During an interview on 3/15/23 at 2:00 p.m., NF2 stated resident #11, Is still distraught about the look and feel of the eye, and wants to hear from a doctor if any more can be done . [Resident #11] is very angry as more and more independence is taken from her. First it was the move here, then the electric wheel chair was taken away, then the loss of walking. Then her two-person transfer was lost, and now they stick a bedpan under her, how dignified is that? During an observation on 3/15/23 at 2:30 p.m., resident #11's hourly checks, documented on the clipboard, continued to have multiple gaps in documentation. During an interview on 3/16/23 at 11:27 a.m., staff member E stated, Well we just came from meetings and were discussing the fact that we do not have a formal fall assessment form (for resident #11), or process, so I wouldn't have any others except maybe the admission on e from 2020 We do not appear to have a fall assessment from admission on her (resident #11). Review of resident #11's falls, from 1/26/22-2/3/23, showed 23 falls in 2022, and four falls in 2023. Review of a sample of resident #11's fall investigation reports, including four falls with injury (6/15/22, 8/12/22, 9/1/22, and 9/26/22), and three falls without injury (8/16/22, 9/17/22, and 10/27/22), showed the fall investigation reports were incomplete, with missing Unit Manager reports for 4 of 7 fall investigation reports received. The fall reports included the following information: - 6/15/22: rolled out of bed causing fall with major injury (permanent loss of sight in right eye). Cognition noted as clear. Interventions: tab alarm and hourly checks x 1 week. - 8/12/22: reaching for something on bookcase and fell out of electric wheelchair. Dementia checked yes. Intervention: reminder to call for help. - 9/1/22: resident lost balance while toileting. Cognition noted as clear. Intervention: none listed. - 9/17/22: spilled water and stood up to clean up herself, slippery footwear worn and fell. Cognition checked yes, as potentially having been a factor in this fall. Intervention: electric wheelchair taken away. - 9/26/22: fell asleep and fell out of recliner. Sustained head injury requiring ER visit. Nurse stated root cause was, Resident has increased weakness/cognitive changes past months. Interventions: no new interventions noted. - 10/23/22: resident standing to reach outlet across bed and legs became weak. Cognition checked yes, as potentially having been a factor in this fall. Nurse statement showed, Resident is declining, more confusion and increased weakness chronic backpain. Intervention: reminder to call for help and slippers provided. - 10/27/22: attempted to self-transfer from wheelchair to recliner, stating wheels were not working on wheelchair. Cognition checked yes, as potentially having been a factor in this fall, with the nurse documentation showing, resident not thinking clearly. Intervention: signs to remind to call for help. Review of resident #11's Care Plan, dated 2/21/22, for falls, did not contain any interventions for reachers, a floor mat, or placement of an anti-slide mat in the resident's chairs. The safety reminders were shown to be ineffective due to the ongoing falls, and the resident's waxing and waning impaired cognition. Review of resident #11's EMR and hard copy documentation showed no Fall Risk Assessment was completed since the resident's admission. 2. During an observation and interview on 3/15/23 at 1:20 p.m., resident #14 was in her room with the door closed. Upon entrance, resident #14 was sitting in her wheelchair. Resident #14 stated she was not aware of a plan for her to keep her door open. Resident #14 appeared to be alert and oriented. During an observation on 3/15/23 at 2:19 p.m., resident #14's door remained closed. During an observation and interview on 3/15/23 at 2:20 p.m., in front of resident #14's closed door, staff member O described the intervention she used during her shifts to prevent falls for resident #14 was, Always keeping the door open so we can watch her. Staff member O stated, She (resident #14) closes the door sometimes. Staff member O then returned to working with other residents on the hall, and the door remained closed. Review of resident #14's current fall care plan intervention showed, Remind [Resident #14] to keep her door opened (okay with [family]). During an observation on 3/15/23 at 5:21 p.m., resident #14's door remained closed. During an observation on 3/16/23 at 10:35 a.m., resident #14's door remained closed. 3. During an interview on 3/14/23 at 10:18 a.m., staff member L stated resident #25 had a history of falls while trying to transfer herself. Staff member L stated resident #25 got confused, and thought she saw puppies in her room, and needed to take care of them, so she would fall. Staff member L stated the staff tried to ensure the call light was close by, toilet the resident every few hours, and kept the bed in a low position, to prevent falls. During an interview on 3/15/23 at 12:05 p.m., with staff member B and C, staff member B stated there had been no fall prevention training over the past year, due to COVID. Staff member C stated resident #25 did not have injuries with her falls over the past year, and falls were discussed in IDT care conferences. Staff member C stated the facility did not complete any fall investigations, root cause analysis, or implement new fall interventions for the resident's falls, because the resident did not have injuries with her falls. Staff member C stated staff member E oversaw the updating of the care plans, after the care conferences, and resident #25 should have had a fall risk assessment done upon admission to the facility. During an interview on 3/16/23 at 10:40 a.m., staff member P stated she was not sure when a fall risk assessment was done at the facility. During an interview on 3/16/23 at 10:43 a.m., staff member R stated she believed the fall risk assessments were completed for all residents, and she was, Pretty sure, the nurses had to complete one for the residents upon admission to the facility. During an interview on 3/16/23 at 12:08 p.m., staff member B and C stated when falls occurred, fall reporting sheets were to be filled out by the charge nurses. Staff member B and C stated falls were to be tracked and trended on fall logs, but there were a lot of informal meetings about patterns in falls with the IDT. These meetings were not documented. Staff member B stated the facility would be better at coming up with interventions moving forward, as what the facility was doing was, Not working. Staff member B stated she had not had training on how to complete PIPs, which was why the PIP she provided surveyors, regarding falls, was incomplete. Review of resident #25's EHR Nurse Note Narratives, dated 10/19/22 to 3/3/23, showed the resident had ten falls, with the following documented injuries: - 12/30/22: Resident hit back of head on the floor, small raised area on the right back side . - 2/1/23: . tailbone hurt and said it was from a fall before. The fall noted in the Nurse Note Narratives, on 2/20/23, did not include a progress note or any information explaining the details of the incident. Review of resident #25's Social Services Notes, dated 11/8/22 - 2/9/23, including the IDT care conference notes, showed there were no new fall interventions discussed. Review of resident #25's Quarterly MDS, with an ARD of 11/8/22, showed the resident had a BIMS of six; severely impaired cognition. The MDS showed the resident was frequently incontinent and needed a one-person physical assist with toileting and transferring. The MDS showed the resident had two or more falls since the prior annual assessment, on 8/8/22. Review of resident #25's Quarterly MDS, with an ARD of 2/8/23, showed the resident had a lower BIMS score of five; severely impaired cognition. The MDS showed the resident, again, had two or more falls since the prior assessment, on 11/8/22, and with one of the falls, there was a resident injury. The MDS also showed the resident still required a one-person physical assist with transfers and toileting. Review of resident #25's Care Plan, reviewed 2/9/23, reflected a lack of new or revised fall interventions after 8/11/22. The Care Plan included an intervention to, Keep call light within reach and encourage to use when needing assist. This intervention was not beneficial due to the resident's severely impaired cognition. The care plan did not include the bed being kept in a low position, or toileting the resident every few hours. On 3/16/23 at 11:18 a.m., surveyors requested resident #25's Fall Risk Assessment. The documentation was not provided by the end of the survey. 4. Review of a facility reported incident, dated 5/23/22, showed Resident #39 sustained right side facial bruising, eye swelling, and an abrasion to her right shoulder. The incident showed, [Staff member Q] .stated when he went to change her at 2am he rolled her towards him, and her skin was sweaty and slipped out of his grip. She started to fall forward, and he used his knees to catch her causing the mattress to shift towards the wall. This exposed the metal bed frame which resident bumped head and shoulder on. He caught resident with arms and knees and turned her, rolled her back over, and didn't see any injury at that time. He thought she was ok, so he never reported anything. [sic] During an interview on 3/16/23 at 11:57 a.m., staff member Q stated he recalled the incident with resident #39 in May 2022. Staff member Q stated resident #39 was sweaty when he went to change and move her, towards the end of his shift. Staff member Q stated she slipped, and he braced her with his knees. Staff member Q stated he received training after the incident on reporting, falls, and transferring. Staff member Q stated prior to the incident, he had training when he was in school, but it had been three years after he finished school before he started his job. Review of resident #39's Care Planning Worksheet, showed the resident was a, Fall Risk. Review of resident #39's Annual MDS, with an ARD of 6/12/22, showed the resident required a one-person physical assist with bed mobility. Review of the Root Cause Analysis, dated 5/28/22, showed the Root Cause of the fall was, Staff member (Q) in a hurry to get cares done. There was no further causation that showed why staff member Q was in a hurry, or if the transfer was safe, per the resident's identified transfer/turning positioning requirements. Review of staff member Q's personnel file, and educational records, showed a lack of fall prevention training for the past year, and the post incident education given to staff member Q. Review of the facility's annual training attendance and agenda, dated 11/22/22, reflected a lack of fall prevention training for all staff. Review of a facility document, Performance Improvement Project (PIP) Guide, dated 2/1/22, showed: Key Area for Improvement: Reduce # of falls per month + falls with injuries. The sections Goal, Root Cause, and Barriers, was incomplete. A review of the facility's policy, Falls, dated 5/20/20, showed, E. If a resident falls, the fall is documented in their chart . A report is completed to include circumstances of fall, vital signs at time of fall, any injury that may have occurred, etc. Fall reports are reviewed to identify any potential cause of fall and to help prevent further falls. Incidence of falls reports are logged and kept on file. The facility's fall policy reflected a lack of QAPI involvement, fall prevention education for staff, care plan updating and completion, and root cause analysis.