**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility licensed nursing staff failed to thoroughly assess one resident to ensure appropriate transfer services and necessary medical assessments were completed and thoroughly documented after a resident's fall, and the resident sustained fractures, a broken tooth, and a head injury during the fall for 1 (#9). Nursing staff then directed CNA staff to transfer the resident from the floor using a mechanical lift, to her bed. This increased the risk for injury. Upon transfer to the ER, it was found the resident had significant injuries, to include fractures of her C-1 and C-2, a broken tooth, and a head laceration and was admitted to the Intensive Care Unit. The resident expired six days later at the faclity, and her care plan was not updated for fall prevention after returning; and, the facility failed to ensure a resident with multiple falls, to include with unjuries, was assessed for fall patterns and risks, and then update the resident's care plan as necessary with beneficial individualized interventions for fall prevention, for 1 (#4) of 5 sampled residents. Findings include: IMMEDIATE JEOPARDY On 12/6/23 at 4:18 p.m., the facility's administrator was notified an Immediate Jeopardy existed in the area of 689-prevention of accidents and hazards related to fall management for resident #9. The severity and scope identified for the Immediate Jeopardy was identified to be at the level of a J, and upon removal of the immediacy, was lowered to a G. 1. Record Review of resident #9's electronic medical record showed she was admitted to the facility on [DATE]. Upon admission, resident #9 had diagnoses of abnormal weight loss and age related physical debility. Record review of resident #9's Fall Risk Evaluation form, showed the resident was assessed and determined to be considered a high fall risk, effective 1/30/23. a. Resident Fall: Review of resident #9's electronic medical record incident description, dated 2/11/23, showed: - Resident was being pushed down Bitterroot hall in W/C by [NF1] and 2 nurses in med room able to observe fall. Resident placed feet down in front of W/C. At that time resident fell out of chair with face forward, she had a laceration to her forehead, laceration to bridge of nose, broken front tooth. Resident was alert and responsive time of fall when assessed by [staff member D]. (sic) - .[staff member D] instructed C.N.A.'s to use Hoyer lift to get resident back to room and lay resident on bed . Review of resident #9's progress note, dated 2/11/23 showed, .Resident was being pushed down Bitterroot hall in W/C by CNA and RN/LPN in med room able to observe fall. Resident placed feet down in front of W/C. At that time resident fell out of chair with face forward, she had a laceration to her forehead, laceration to bridge of her nose, broken front tooth. Resident was alert and responsive at time of fall when assessed by LPN .Resident was sent to [hospital emergency room] immediately after phone call with . NF4. b. Facility Fall Investigation and Reportable Event: Record review of facility State Reportable Incident Investigation Form, dated 2/11/23, showed a statement provided by NF1. The document showed, Resident [#9] was ready for bed pushed resident down the hall about a foot resident planted feet on ground and fell out of chair hitting knees then forehead/face .Resident fell in front of med room both nurses were in med room .We put towels on forehead wound both nurses stared at us. We told them that you could see (resident's) skull and she needs to go to the hospital .Both nurses told us to put resident in bed after me and two other cnas strongly disagreed. Nurse told us again, so we did get resident in lift resident was in a lot of pain as we did this .Resident was in so much pain she vomited. Nurses were not in room helping us or had called any sort of ambulance at this point. Nurses did not do an evaluation on resident either while she was on floor after fall. Record review of a facility State Reportable Incident Investigation Form, dated 2/11/23, showed a statement provided by staff member F. The document showed, .I exited the room to find [Resident #9] laying on the ground on her left side, staff [NF1] standing by [Resident #9]. She said [Resident #9] had put her feet down and was ejected from her wheelchair. I got down on the ground to assess [Resident #9] and noticed a puddle of blood forming under the left side of her head. [Resident #9] was in a lot of pain so we rolled her gently to her back while keeping her as stabilized as possible. As we are rolling her, she is screaming out in pain about her neck. Nurse [staff member D] was in med room looking @ [Resident #9] laying on the floor, nurse [staff member B] was behind the nurses desk messing around with paperwork. Neither nurse seemed to be concerned over [Resident #9]. Myself .told the nurses they needed to call for an ambulance and that it was not a good idea to move [Resident #9] with a potential neck injury and with the severity of her head injury. [Staff member D] asked if we should Hoyer her up we all suggested no and to call 911. After about 7 minutes [staff member D] finally decided to look at [resident #9's] head wound .[staff member D] ordered us to hoyer [resident #9] off the floor and to put her into bed again we all said that we shouldn't be moving her and what was going on with the ambulance .so we did as we were asked .[Resident #9] screamed in pain the entire time. The only assessment done on [Resident #9] was [staff member D] asking her if she could move her left leg and left arm. After we got [Resident #9] into bed she started to vomit .When the EMT's were asking nurse [staff member B] about her injuries she was unable to answer because they (nurses) didn't do an assessment .The EMT informed (them) that we shouldn't have moved her. (sic) Record review of facility document, State Reportable Incident Investigation Form, dated 2/11/23 showed a statement provided by staff member G. The document showed, At aprox 1830 (6:30 p.m.) resident [#9] put her feet down while being wheeled in hallway, this caused her to be ejected from the wheelchair face first into the floor. The nurse [staff member B] was one of the first to her and she didn't really assess. So she had the other nurse [staff member D] do it .nurse [staff member D] kept saying we should get her up off the floor .told her we should leave her. After about 10 mins later when nurse [staff member D] came back she told us to get her to bed. When we were moving res, she was yelling of neck pain (more than usual) .We used the Hoyer and walked her to her room (with mechanical lift) while she was yelling of pain. Later threw up. (sic) c. Staff Interviews During an interview on 11/21/23 at 4:47 p.m., staff member C stated a CNA was taking resident #9 back to her room in her wheelchair. Resident #9 slammed her feet down causing her to fall on the floor. Staff member B and D were in the medication room which was next to where resident #9 fell. Staff member C was thinking resident #9 didn't complain of neck pain until she was in her room. Staff member C stated she discussed the incident with staff member B, and staff member D but did not have documentation of those interviews. During an interview on 11/21/23 at 6:48 p.m., staff member B stated she and staff member D were in the medication room and observed NF1 pushing resident #9 in her wheelchair. When they went around the corner, resident #9 was observed putting her foot down on the floor and fell (from the chair). Staff member B told staff member D to complete an assessment. Staff member B stated she immediately went to call the on call physician to obtain transfer orders via EMS to the hospital. Staff member B stated, I have no reason to believe she wouldn't do what I told her. Staff member B stated since she was the nurse on the floor and staff member D was going off shift, staff member B would have documented the assessment was done. Staff member B stated the EMT's did not attempt to put a cervical collar on the resident. Interviews and statements from the nursing staff on shift during the time of the incident when #9 had her fall were requested, but not provided to the surveyor during the survey. d. Post Fall - Findings: Review of resident #9's Emergency Department to Hospital admission summary, dated [DATE], showed, Resident #9] is a 99 y.o. female who presents with forehead laceration, head face neck pain .she did complain of nausea and started vomiting after Zofran and fentanyl were administered by EMS. She complains of pain mostly in her neck . he then tested positive for COVID 19 and is now on precautions . Review of resident #9's Palliative care consult, dated 2/13/23 showed, [Resident #9] is a 99 y.o. who has a past medical history of hypertension, weight loss and frailty.[NF2 and NF3] noted that [Resident #9] has had a significant decline over the past year . She had a period of time last year where she voluntarily stopped eating and drinking, and lost a significant amount of weight . Nausea. Per family this has been an ongoing issues even prior to her admission . Review of resident #9'S Trauma Team Discharge summary, dated [DATE] showed: - Hospital Discharge Diagnosis - Principal Problem: Closed fracture of first cervical vertebra - Active problems: Fall from wheelchair, forehead laceration .Pt was admitted to ICU for close observation .Patient refusing collar, advised nursing that collar can be removed as patient is on comfort care . Son and Daughter-in-law report that about 1 year ago she stopped eating and taking medications because she was ready to die . They are supportive of end of life care based on her wishes . Keeping her comfortable this admission has been difficult due to nausea/vomiting with pain medications as well as C collar. She has so far shown no interest in food . Review of resident #9's care plan, most recent revision date of 2/9/23, showed a lack of updated interventions for the resident's care after return from the hospital. Review of the facility document, Mortician Receipt/Record of Death, dated 2/17/23, showed resident #9 passed away on 2/17/23 at 7:32 a.m. Review of facility document, Falls-Clinical Protocol, revised April 2013, showed, . in every instance of a fall the nurses will . b. If a fall is confirmed or suspected, an immediate assessment of the resident will be performed by the licensed nurse to assess for injury. Do not move the resident form the floor or other surface until after the assessment is performed. [sic] . c. Perform assessment and document in nursing notes . 2. Review of resident #4's nursing progress notes, dated August 2023 - December 2023, showed the resident had five falls in a five-month period. All five falls were falls out of bed within the same two-hour window between 11:00 p.m. and 1:00 a.m. Three falls occurred while the resident had a UTI. Two falls resulted in minor injuries. As a result of the two other falls, the resident sustained major injuries including rib and facial fractures. A. Review of resident #4's nursing progress notes, dated August 8, 2023, showed: - Resident #4 was found lying on the floor, next to her bed, in the fetal position. She was found around midnight. - She had a hematoma to her forehead and bruising to her thumb and elbow. - Resident stated she just pushed myself off. Review of resident #4's fall care plan, with a review date of 10/23/23, showed the following interventions for falls: - At each encounter, ensure that I have my call light and I am aware of how to use it to call for any assistance that I may require. - Ensure that I have appropriate and well-fitting footwear or non-slip socks when I am ambulating or transferring. - Keep my bed in its lowest position to remind me that I should not try to get out of bed without assistance. - Keep my room and the hallways free from clutter and spills. - Place those items that I might want or need in easy reach. All Interventions had an initiation date of 7/10/23, the resident's admission date. B. Review of resident #4's nursing progress notes, dated 9/30/23, showed: - Resident #4 was found in front of bed on left side of body. The note showed she was found within an hour of midnight. - She had a skin tear to her left arm. - Resident stated she wiggled myself all the way to the floor. - Resident #4 was started on antibiotics for a UTI on 9/30/23. C. Review of resident #4's nursing progress notes, dated 10/12/23, showed: - Resident #4 was found lying face down next to her bed at 1:45 a.m. - She had a hematoma on her forehead and her nose appeared to be shifted to left side. Her right wrist was swollen. She was later diagnosed with facial fractures and a wrist sprain. - Resident #4 was started on antibiotics for a UTI upon returning from the hospital. There were no care plan updates related to the resident's increased fall risk and UTI symptoms. During an interview on 12/7/23 at 1:30 p.m., staff member A stated the resident had a problem with sundowning and an intervention they had done was to increase her melatonin. Review of resident #4's physician orders, dated 11/8/23, show an increase in Melatonin from 1 mg to 3 mg, was initiated a month after her fall, caused by being restless at night. D. Review of resident #4's nursing progress notes, dated 10/31/23, showed: - Resident #4 was found partially on the floor holding the side of her bed. - Time of fall was documented as Approximately 11:00 p.m. - Resident #4 was restless throughout the night and attempting to get up and find her shoes. There were no fall committee notes or care plan updates for review E. Review of resident #4's nursing progress notes, dated 11/28/23, showed: - Resident #4 slid from her wheelchair to the floor. This was witnessed at 12:50 a.m. - Several hours later resident #4 complained of lower back pain, but no other concerns. - Resident #4 was taking antibiotics at the time of the fall for a UTI. Review of a facility reported incident, dated 11/29/23, showed, resident did slide out of her wheelchair during the night on 11/28/2023 with no signs of injury or c/o pain at the time. Injuries noted at this time do not fit the type fall she had. Upon further investigation by nursing staff resident stated that she had rolled off her bed and hit legs on her bedside table last night but put herself back in bed . Review of an SBAR note, not dated, showed, Noted bruising to L side from under arm down ribs to L hip . when questioned she was able to let us know in detail how she had a fall out of bed onto the bar on her bedside table the bruising lines up perfectly with the bar . Review of resident #4's fall committee note, dated 11/29/23, showed, The resident experienced an isolated incident that was witnessed. Staff will continue to attempt to anticipate the resident's needs and check on resident frequently. There were inconsistencies in the investigation to the root cause of this fall with fractures. Review of resident #4's care plan, with a review date of 10/23/23, showed the same five interventions that had been implemented in July 2023 upon admission. There were no new documented fall prevention interventions related to the various root causes for the recent falls after her admission for floor staff to utilize and understand the risks and interventions necessary to prevent falls. During an interview on 12/7/23 at 1:30 p.m., staff member A stated they didn't have a standard set of interventions. The fall committee would review the nurses' report and go from there in the investigation to determine the root cause of a fall and interventions to prevent the next one. During an interview on 12/7/23 at 2:15 p.m, staff member C stated staff does more frequent rounding for residents at night. She stated they would add the rounding to the care plan interventions.