**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(I)(i). Based on record review and interview; the facility failed to identify causal factors and to revise and/or develop additional interventions for the prevention of ongoing falls for Resident 29 and falls with injury for Resident 135. The sample size was 5 and the facility census was 34. Findings are: A. Review of the facility Falls-Clinical Protocol with a revision date of 3/2018 revealed the facility was to review each resident's risk factors for falling and document in the resident's medical record. If the resident had a fall, staff were to identify possible causes within 24 hours of the fall. The facility would then identify pertinent interventions to try to prevent subsequent falls and then monitor and document the resident's response to the interventions. If the interventions were successful in fall prevention the approaches would be continued. Staff were to assess the need for changes on the approaches of the plan of care and develop additional approaches to prevent ongoing falls as needed. B. Review of Resident 135's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/19/24 revealed diagnoses of fractures, arthritis, osteoporosis, previous stroke, non-Alzheimer's dementia, anxiety, and depression. The MDS further indicated Resident 135 had: -moderately impaired cognition, -was dependent on staff for assist with eating/drinking, personal hygiene, dressing, bed mobility and transfers, -incontinence of bowel and bladder, and -experienced 2 or more falls with no injury, 2 or more falls with injury (except major) and 1 fall with major injury. Review of Resident 135's Progress Notes revealed the following: -1/29/24 at 8:10 AM the resident had a witnessed fall in the resident's room. Resident 135 had fallen backwards when transferred by a staff member and was then lowered to the floor. Staff placed the resident in the lobby area for increased supervision and therapy was to assess the resident. -1/31/24 at 1:38 PM received orders for Occupation Therapy (OT) and Physical Therapy (PT) services. -1/31/24 at 9:10 PM the resident was found on the floor in front of the recliner in the lobby area. A new intervention was developed for a drug review due to increased confusion in the evenings. The Primary Care Provider (PCP) changed the resident's antidepressant medication to be given in the morning instead of the evening to minimize side effects. -2/27/24 at 1:00 PM the resident was found on the floor next to a chair in the resident's room. An immediate intervention to check the resident every 30 minutes for 8 hours was identified. Further review revealed no ongoing interventions and/or causal factors were identified related to the resident's fall. -2/27/24 at 2:55 PM revealed the resident was to be discharged from PT and OT due to goals met and resident had reached a plateau. -2/29/24 at 7:45 AM the resident was found on the floor in the resident's room. No causal factors were identified regarding the fall. The resident's medications were reviewed but no changes were made. -3/12/24 at 10:45 AM the resident was found on the floor of the resident's room. The resident had been lying in bed and stated a desire to get into the chair. A new intervention was developed to place non-skid strips next to the resident's bed. -4/11/24 at 4:00 PM the resident was found on knees on the floor. No causal factors were identified, and staff failed to revise current interventions or to develop new interventions to prevent further falls. -4/18/24 at 12:44 PM the facility visited with the family about the resident's behaviors and requested to move the resident to the Memory Unit. The family felt this would increase the resident's confusion and declined having the resident moved. -4/19/24 at 11:07 AM the resident was heard calling for help and was found on the floor in the resident's room. The resident had attempted to remove slacks and urinary incontinence brief. The resident, despite ongoing confusing was educated to use the call light to seek staff assistance. No further interventions were identified. -5/20/24 at 7:45 PM the staff heard a noise in the resident's room and found the resident sitting on the floor. The resident had been talking on the phone to family prior to the fall and fell when trying to hang up the phone. The resident was encouraged to call for assist as needed. The resident was screened by PT and orders were received for therapy to treat on 5/23/24. -6/18/24 at 3:23 PM the resident was discharged from PT as on 6/14/24 the resident was admitted to Hospice. -6/24/24 at 8:15 PM the resident was found on the floor of the resident's room and was lying on right hip. Hospice was to bring a scoop mattress for the resident's bed. -7/14/24 at 9:00 PM the staff heard the resident screaming in their room and calling for help. The resident was found on the floor next to the bed and was assisted to the bathroom. No causal factors were identified, and the facility failed to revise current interventions or to develop new interventions to prevent further falls. The staff sent a note to the PCP regarding assessment for a possible fracture but did not receive a response. -7/15/24 at 9:20 AM the resident had been positioned in a wheelchair at a table in the lobby area. The wheelchair brakes had been locked. The resident attempted to move the wheelchair back away from the table and tipped over backwards in the chair. The resident was unable to bear weight with continued complaints of hip pain. At 10:30 AM the resident was transferred to the emergency room (ER) for assessment. -7/15/24 at 2:49 PM anti-tip bars were placed on the resident's wheelchair after returned from the ER with diagnosis of 2 pelvic fractures. -7/17/24 at 4:22 PM the resident was found on the floor beside the resident's bed. The resident's incontinence brief was partially removed and there was urine on the floor. Staff identified interventions to toilet the resident every 2 hours and to position the resident to the middle of the mattress. -7/18/24 at 2: 25 PM the resident was found on the floor next to the resident's bed. The resident had a scoop mattress and body pillow in the bed when staff had checked the resident 2 minutes prior to the fall. An intervention was identified for a fall mat to the floor next to the resident's bed. -7/19/24 at 10:00 PM the resident had passed away. An interview with Licensed Practical Nurse (LPN)-B on 9/12/24 at 9:57 AM confirmed the following: -2/27/24 at 1:00 PM after the resident's fall, the staff were to do 30-minute checks for 8 hours. No further interventions were developed to prevent further falls and no casual factors were identified. -2/29/24 at 7:45 AM the resident was found on the floor in the resident's room. No causal factors were indicated. Medications were reviewed but no changes were made to prevent further falls. -4/11/24 at 4:00 PM when the resident was found on their knees, no casual factors were identified, and no additional interventions were developed. -4/19/24 at 11:07 AM the resident was found on the floor of the resident's room with brief and slacks lowered. Education was provided to the resident regarding calling for assistance despite the resident's confusion and safety impairment. -6/14/24 the resident was admitted to Hospice. -7/14/24 at 9:00 PM the resident was found on the floor of the resident's room. The resident had been restless earlier in the shift and had been positioned at the Nurse's Station for constant monitoring. The resident had complained of right hip pain and a facsimile was sent to the PCP regarding assessment for fracture of the resident's right hip. The facility again asked the family about moving the resident to the Memory Unit, but the family refused. -7/15/24 at 9:20 AM the resident had another fall when the resident tipped the wheelchair over backwards. The resident continued to complain of hip pain and was unable to bear weight. At 10:30 AM the resident was sent to the ER for evaluation. The resident was found to have 2 fractures of the resident's right pelvis. Anti-tip bars were placed on the resident's wheelchair upon return from the hospital and staff were instructed not to lock the wheelchair brakes when the resident was at the table. -7/17/24 at 3:25 PM the resident had another fall out of bed. The staff were educated to position the resident in the middle of the bed and to toilet the resident every 2 hours. -7/18/24 at 2:25 PM staff had checked on the resident who had been lying in bed with the scoop mattress and a body pillow. Two minutes later the resident was found on the floor. A fall mat was placed on the floor next to the resident's bed. -7/19/24 at 10:00 PM the resident passed away. C. Review of Resident 29's MDS dated [DATE] revealed diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, depression, anxiety, and dementia. The MDS further indicated Resident 29 had: -severely impaired cognition, -behaviors which included resistance with cares, wandering and verbal behaviors directed toward others, -was dependent on staff for assist with personal hygiene, dressing, bed mobility and transfers, -incontinence of bowel and bladder, and -experienced 2 or more falls with no injury. Review of Resident 29's Nursing Progress Notes revealed the following: -1/13/24 at 4:10 AM the resident was on the bathroom floor and was incontinent of urine. Staff felt the resident had been awakened on safety rounds. New interventions were identified to have staff do rounds more quietly and to toilet the resident at least 2 times throughout the night. -1/14/24 at 10:11 PM the resident was found on the floor in the corridor. No causal factors were identified, and staff indicated an intervention for therapy to re-screen the resident even though the resident was currently on therapy caseload. -1/15/24 at 8:00 PM the resident was found sitting on the floor of the resident's room. Family was concerned about a possible urinary tract infection (UTI) and new orders for a urinalysis. 1/18/24 a new antibiotic was ordered to treat the infection. -3/13/24 at 1:07 PM the resident was found on the floor next to the resident's bed. No causal factors were identified. The facility completed urinalysis which was negative, and therapy re-screened the resident but did not pick up for therapy. -5/14/24 at 11:28 PM the resident was observed seated on the floor in front of the recliner. Staff assisted the resident out to the commons area for closer supervision. Staff were to do frequent checks and encourage the resident to remain in the recliner in the commons area for supervision. In addition, a new order was received to increase the resident's Tylenol Arthritis to three times a day for pain control. -6/25/24 at 3:30 PM the resident was found sitting on the floor of the resident's room. The resident was assisted into the wheelchair and out to the common's area for closer supervision. Further review revealed no causal factors were determined and no additional interventions were identified. -6/26/24 at 2:22 AM the resident was found on the floor next to the resident's bed and in front of the wheelchair. The resident was incontinent of urine. A new intervention was developed for use of a pancake call light which was to be positioned on the right side of the bed. -6/30/24 at 3:10 PM the resident was lowered to the floor when became unsteady during assisted toileting transfer. Further review revealed no evidence current fall interventions were revised or new interventions developed. -8/6/24 at 2:29 PM the resident was found on the floor of the commons area next to the resident's wheelchair. The resident had attempted to stand and sat down on the floor. An intervention was put into place for one staff on the Memory Unit to always supervise the resident. -8/28/24 at 11:00 PM the staff entered the resident's room and witnessed the resident stand and then slide down to the floor. The resident was barefoot and had been incontinent of urine. An intervention was added to the resident's treatment sheet for the Charge Nurse to verify the resident was wearing gripper slippers when not wearing shoes. 9/8/24 at 5:47 AM the was found seated on the floor in the doorway of the resident's room. The resident was not wearing shoes or the gripper socks. Staff received written education regarding use of the gripper socks and the resident's bed was no longer to be placed in the lowered position but was to be placed at the height of the resident's wheelchair. During an interview pm 9/11/24 at 11:22 AM, LPN-B confirmed the following regarding fall prevention assessment and interventions for Resident 29: -1/14/24 fall at 10:11 PM there were no causal factors identified regarding the resident's fall. A screen went out to have therapy re-screen the resident despite already being on their case load. No further interventions were identified. -3/13/24 fall at 1:07 PM there were no causal factors identified. A urinalysis was completed and was negative. In addition, a therapy screen was completed but therapy did not pick the resident up for treatment. No new interventions were indicated to prevent further falls. -6/25/24 at 3:30 PM the resident was found on the floor of the resident' room. The resident was assisted into the wheelchair and then out to the common's area for increased supervision at the time of the fall. No causal factors and no further interventions were identified. -6/30/24 at 3:10 PM the resident fell when the staff were transferring the resident onto the toilet. There was no evidence current interventions were revised or additional interventions developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Review of Resident 29's MDS dated [DATE] revealed the following: -the resident was cognitively intact, - the resident was independent with transfers and dressing, needed supervision with eating, and limited assistance with toileting, - had diagnosis of cancer, heart failure, renal (kidney) disease, and pulmonary (lung) disease, -had shortness of breath with exertion and when lying flat, and -was on supplemental oxygen. Review of Resident 29's Care Plan with a last revision date of 8/19/23 revealed the following: -the resident was sent to the hospital on 8/12/23 and readmitted to the facility on [DATE] with a diagnosis of pneumonia, -the resident could be tested for Covid-19 as needed, and -the resident was to wear oxygen during the night and staff were to offer oxygen during the day. Review of Resident 29's Progress Notes dated 8/11/23 at 7:30 PM revealed the resident complained of not feeling good and stated that when the resident coughed, the residents whole body hurt. The resident's lung sounds were diminished (decreased air movement which makes lung sounds hard to hear) and had wheezes. The resident reported coughing up green phlegm. The resident's oxygen saturation was at 85% (normal is above 90) and oxygen was placed on the resident and a fax was sent to the provider. Review of the Resident 29's Progress Notes dated 8/12/23 at 10:44 AM revealed the resident stated the resident was not feeling good and didn't want to get out of bed. The resident reported every time the resident coughed, it hurt the residents back and abdomen. The resident asked the Registered Nurse to call (gender) son and that the resident wanted to be seen in the clinic that day. The RN assessed the resident and the resident continued to have diminished lung sounds and wheezing. Further review revealed at 11:40 AM the son updated the facility that the resident was admitted to the hospital with pneumonia. Interview with Resident 29 on 8/21/23 at 10:32 AM revealed the resident was recently in the hospital with pneumonia and was taking an antibiotic. Interview on 8/22/23 at 12:15 PM with RN-R revealed that if the nurse faxes the physician after clinic hours or on a weekend, they will follow up the next day or on Monday. Further interview at 2:30 PM revealed if the nurse faxes on the weekend, they were to follow up or refax on Monday, but they would monitor the resident's symptoms. If the condition persisted or worsened, they were to call the Provider. Interview on 8/22/23 at 2:44 PM interview with Licensed Practical Nurse (LPN-Q) revealed that if the resident's condition persisted the nurses were to send the resident to the ER if the provider or family wanted. Interview on 8/22/23 at 2:49 PM Interview with RN-R revealed the facility had no evidence the facility notified the provider regarding Resident 29's condition. Further interview confirmed no documentation that the fax was followed up on and that the resident requested to be seen by the provider the next day and was admitted to the hospital. Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify the physician of a significant change for Resident's 8 and 29. The sample size was 18 and the facility census was 33. Findings are: A. Review of the facility policy Change in a Resident's Condition or Status with a revision date of 2/2021 revealed the following; -the facility promptly notified the resident, the attending physician, and the resident representative of changes in resident's condition/status. -the nurse notified the resident's attending physician or physician on call when there had been a change in the resident's physical/emotional/mental condition, or a need to alter the resident's medical treatment significantly, -the facility defined a significant change of condition as a major decline or improvement in the resident's status that would not normally resolve itself without intervention, impacted more than one area of the resident's health status, and required interdisciplinary review and/or revision to the care plan, and -except for in emergencies, notifications of change would be made within 24 hours of a change occurring, B. Review of Resident 8's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated 7/21/23 revealed the following; -The resident received limited assistance with bed mobility, transfers, and toileting, -had a diagnosis of heart disease, high blood pressure, anxiety, depression, and -used oxygen. Review of Resident 8's Care Plan with a revision date of 8/15/23 revealed the following; -the resident returned to the facility following a hospitalization for sepsis from a broken tooth and pneumonia, -used oxygen as needed, and -needed limited assistance of 1 staff member for bed mobility, transfers, and hygiene. Review of Resident 8's Progress Notes revealed the following; -On 8/3/23 at 2:46 PM the resident complained of feeling tired and used a wheelchair to get to and from meals. -On 8/4/23 at 2:35 AM the resident had activity intolerance, tired quickly after minimum efforts, used a wheelchair to get to and from meals and used a Stand-up Lift -(mechanical lift on wheels used to aid the resident to a standing position and move the resident from a sitting to a standing position and then back to a sitting position) was activity intolerant, and tired easily. -On 8/4/23 at 7:03 PM the resident reported terrible when asked how they were, complained of a headache, right arm and shoulder pain, and used a wheelchair to and from meals. -On 8/5/23 at 3:28 AM the resident continued to be activity intolerant, used a wheelchair for meals, and required 2 staff to transfer. -On 8/5/23 at 4:04 PM the resident had been coughing up mucus, had rattling lung sounds, continued to feel weak, and staff had used the stand lift for transfers. The facility faxed the physician requesting nebulizer (inhaled breathing treatments often used to treat shortness of breath, chronic lung conditions, or acute lung/breathing conditions) and no evidence the physician responded to the request. -On 8/6/23 at 1:27 AM the resident had a body temperature of 99 degrees and had coarse lung sounds, and a productive cough with thick phlegm. -On 8/6/23 at 9:49 AM the resident had a body temperature of 100.3 degrees, oxygen saturations between 85-88% (90 -100 is normal), and unstable vital signs, a pain rating of 10 out of 10, and was sent to the emergency room (ER) by ambulance. (At the time of the transfer the physician had still not responded to the fax sent on the previous day). Review of a Fax Communication to Physician for Resident 8 dated 8/5/23 revealed no response other than a signature to a request for nebulizer treatment and an x-ray that was not noted (signed by a nurse acknowledging the physician directions) until 8/7/23 (1 day after the resident had been taken to the emergency room (ER) and admitted to the hospital). During an interview on 8/23/23 at 11:15 AM Registered Nurse (RN)-G confirmed the facility did not receive a signed physician response for Resident 8, in regard to the facilities request for a nebulizer treatment and/or an x-ray for Resident 8 on 8/5/23 until 2 days later on 8/7/23 at which time the resident had already been taken to the ER for evaluation. During an interview on 8/23/23 at 11:30 AM the Director of Nursing (DON) revealed the facility had no evidence the facility attempted to contact the physician for Resident 8 after not receiving a fax response to a request for nebulizer treatments and an x-ray on 8/5/23. Further interview confirmed the resident was taken to the ER on [DATE] for unstable vital signs and continued condition decline. In addition, the DON confirmed the facility should have contacted the physician again on 8/5/23 when a response was not received regarding the request for treatment of the resident's change in condition.