**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record review of Resident 94's census sheet printed on 4-02-2024 revealed Resident 94 was admitted to the facility on [DATE] and was discharged on 9/3/2023. Record review of Resident 94 Medical Diagnosis sheet printed on 4-02-2024 revealed the following diagnosis: Attention and concentration deficit following cerebral infarction, cognitive social or emotional deficit following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction, and vascular dementia. Record review of Resident 94's annual Minimum Data Set (MDS, federally mandated assessment tool used for care planning), dated 6/29/2023 revealed Resident 94 had a Brief Interview for Mental Status (BIMs) score of 3. According to the MDS [NAME] a score of 0 to 7 indicates a person has severe cognitive impairment. Further review of Resident 94's MDS revealed Resident 94 had rejection of care issues 4-6 times during the look-back period. According to Resident 94's MDS dated [DATE] Resident 94's functional status revealed Resident 94 required extensive assist with bed mobility, limited assistance with transfers, supervision with eating, and limited assistance with toileting. Mobility devices used by Resident 94 were a walker and a wheelchair. Bowel and bladder status of Resident 94 revealed occasionally incontinent of urine and frequently incontinent of bowel. Record Review of Resident 94's Comprehensive Care Plan (CCP) revealed the following information: -Fall Problem: Falls-at risk due to history of falls, need for assist with Activities of Daily Living (ADLs) mobility due to balance issues, incontinence of bowel and bladder, does not recognize limitations due to dementia, non-compliant with calling for assist or waiting for assistance with transfers related to cognition and dementia, at risk per fall risk assessment. -Goals: Resident 94 will have no falls with injury thru next review. -Interventions: -Fall risk assessment completed. Fall score is 18. A score of 18 revealed Resident 94 is a high risk for falls. (No date). -Falling prevention program as indicated. Date identified as Status active and current. -Encourage to use the call light. (No date). -5/18/23-Physical therapy to evaluate and treat. -6/13/23-Request for Miralax (Laxative to treat constipation) to be changed to as needed (PRN). -6/26/23-X-ray done; sent to hospital due to inconclusive X-ray results. -3/8/23- Call don't fall sign in resident's bathroom. -7/27/23-Encourage resident to use the bathroom. 5/18/23-red tape to call light for visual acuity. -Transfer to stronger side-left side- (no date). -Keep assistive device within reach. -9/15/22-Call don't fall sign. -11/6/22-red tape to call light for visual acuity. -4/16/23-Physical therapy to evaluate and treat due to recent falls. -5/15/23-soft touch call light. Record review of a Huddle Report sheet dated 6/13/2023 revealed Resident 94 fell in the bathroom. In the section titled immediate interventions to be taken the following interventions were: Do not leave alone (Resident 94) with wheelchair in room, please rise slowly to prevent dizziness, non-slip socks, and staff to assist to bathroom on a schedule. Record review of a Huddle Report sheet dated 6/26/2023 revealed Resident 94 fell in the dinning area. Further review of the Huddle Report sheet dated 6/26/2023 revealed Resident 94 had complaints of left hip pain after being assisted back to Resident 94's room. According to the information in the Huddle Report sheet dated 6/26/2023 Resident 94 was sent to the emergency room (ER). Record review of a Fall with Injury sheet dated 6/28/2023 revealed Resident 94 had fallen while ambulating in the dinning room. Resident 94 complained of pain and was assisted back to Resident 94's room in a wheelchair. Resident 94 was sent to ER for an evaluation with the results being Resident 94 sustained a fracture of the left femur. Interview with MDS coordinator on 4/3/23 at 7:55 AM confirmed the intervention added to the care plan for fall dated 6/26/23 was X-ray done; sent to the hospital due to inconclusive X-ray results. MDS coordinator confirmed no further interventions are found nor implemented on the care plan. Interview on 4/4/24 at 4:31 PM with MDS Coordinator revealed the following interventions were never added to the care plan or implemented: Do not leave alone (Resident 94) with wheelchair in room, please rise slowly to prevent dizziness, non-slip socks, and staff to assist to bathroom on a schedule. Record review of Hillcrest Health Services, Fall Risk Management Program, with effective date 4/18/22, revealed: Determining Appropriate Interventions: 1. Nurse/Therapist reviews medical and personal history and completes additional screens/assessments as needed to assist in determining additional risk factors for falls. 2. After completion of additional assessments, admitting nurse or therapist determines what factors could contribute to fall risk. a. Based on these factors, the admitting nurse and/or therapist determines appropriate interventions to implement within the baseline care plan/nurse tech care plan. 3. Selected interventions will be updated to the Care plan and/or Nurse Tech Care plan by the clinical care coordinator, therapist and/or designees. Therapy selected interventions will be communicated to the nurse on shift and initially implemented by therapist of designee. 4. Fall Risk interventions should be reviewed by the interdisciplinary team as needed and can be included in the Quality assurance, Huddle, Risk, and All Team Meetings. 5. Care plan interventions are reviewed during interdisciplinary team meetings assuring interventions continue to be appropriate for the resident/patient. a. Care Plan Interventions should be monitored and/or audited for consistent application in the care of the patient. Care plan interventions should be monitored and/or audited for consistent application in the care of the patient. Care plan interventions can be listed on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) and/or nurse tech care plan according to the Plan of Care policy. 6. Nursing/Therapy leadership will educate the nursing/IDT (Interdisciplinary Team) on a regular basis regarding care plan interventions for all risk reduction efforts, changes in care, etcetera. Licensure Reference Number 175 NAC 12-006.09D7a Based on interview and record review, the facility failed to ensure 1 (Resident 48) of 8 sampled resident's safety belt remain secured during the bathing process and implement interventions to prevent a fall with fracture for 1 (Resident 94) of 8 sampled residents. The facility census was 92. Findings are: A. Record review of the facility's Bathing Procedure dated 05/23/2024 revealed the spa tub procedure was to assist residents out of their clothing and onto the tub chair utilizing appropriate transfer device and ensure the safety belt was on the resident. NEVER leave guest unattended during bath. A record review of Resident 48's Medical Diagnosis dated 04/04/2024 revealed the resident had diagnoses of Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (confusion), Other Sequelae of Cerebral Infarction (altered sensation following a stroke), Memory Deficit Following Cerebral Infarction (poor memory following a stroke), Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus (uncontrolled seizure disorder), Long Term (Current) Use of Opiate Analgesic (long term use of a pain patch), and Essential (Primary) Hypertension, (high blood pressure). A record review of Resident 48's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 02/14/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) that was blank. The resident was dependent for all activities of daily living (ADL), transfers, and rolling left to right. The MDS revealed Resident 48 was on Hospice (end of life care). A record review of Resident 48's Care Plan with an admission date of 01/17/2020 revealed the resident was admitted to the facility on [DATE]. The resident had a Focus area of at risk for falls due to a history of falls, balance issues, at risk for falls per fall risk assessment, incontinence, use of PRN opioid meds (medications), impulsive and does not recognize her limitations due to dementia and multiple interventions for falls. The Care Plan revealed the residents would require 2-person assist with ADLs for safety and was a mechanical lift for transfer with 2 staff assistance. A record review of Resident 48's Progress Note dated 03/22/2024 at 1:32 PM revealed the Hillcrest Hospice Bath Aide (HHBA)-X finished giving Resident 48 a bath and was about to start dressing the resident when HHBA-X saw the resident leaning forward. HHBA-X went to stop the resident from falling and ended up falling on the spa floor and Resident 48 fell on top of HHBA-X. The resident hit the resident's head, needed stitches, and was sent to the Emergency Department (ED). A record review of the Abuse, Neglect or Misappropriation (stealing) reportable sheet dated 03/26/2024 revealed on 03/22/2024 at about 12:20 PM, the HHBA-X was getting Resident 48 out of bath and drying resident off. HHBA-X lowered the shower chair and removed bath strap and reached for resident's shirt and the resident fell out of the chair onto staff member that slipped trying to stop the fall. The resident fell on HHBA-X and hit the resident's head on floor that required sutures. The resident was a Hoyer lift (mechanical lift for transfers) for all transfers. The resident was alert and oriented to the resident's name only. The resident was assessed and sent to ED. Permanent measures to prevent reoccurrence were that Hospice was to increase their presence with the resident, continue comfort meds, and the resident would require 2 staff assist when bathing, transferring, and dressing. A record review of the Hillcrest Hospice Patient Fall dated 3/22/2024 revealed Resident 48 was sitting in the bath chair and was finished with bathing. HHBA-X was present and stared to dress the resident. HHBA-X turned to grab the resident's shirt and the resident was leaning forward when HHBA-X reached to catch the resident. HHBA-X slipped on water and fell and the resident fell over HHBA-X. Resident 48 hit the resident's head on the bath chair leg. There was a large laceration on top of the resident's head and a moderate amount of bleeding. The wound measured 6.5 centimeter (cm) long, 0.7 cm wide, and 0.4 cm deep but it was an approximate measurement because the resident's hair and bleeding interrupted the view. A record review of the Hospice Nursing Clinical Note dated 03/22/2024 revealed the same information as the Hillcrest Hospice Patient Fall dated 3/22/2024 and also revealed Resident 48 was moaning occasionally, the wound was on the crown of the head, and the wound appeared deeper in some areas than what was measured. The Hospice Nurse, Case Manager (HNCM)-Y, notified the Emergency Medical Services (EMS) that the resident was a Hospice patient, and they only wanted the head laceration addressed, no other tests, procedures, or treatments. The HNCM-Y then spoke with the ED and notified the ED that the HNCM-Y only wanted the resident's head assessed with no other treatments, assessments, or procedures and then send the resident back to the facility. A record review of Resident 48's Progress Note dated 03/22/2024 at 06:00 PM revealed the resident returned from the ED with the head laceration (cut) was repaired with dissolving sutures (stitches) and that the resident had no signs of pain at that time. A record review of Resident 48's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated March 2024 revealed the resident had an order for Morphine Sulfate (concentrate)(a liquid pain medication) Oral Solution 100 milligrams (mg)/5 Milliliters (ml). Give .025 ml every 6 hours for pain and every 1 hour for pain as needed. The order for as needed has only administered (given) on 03/01/2024 and 03/04/2024 prior to the resident's fall and the last dose of that order was administered 03/22/2024 at 12:00 PM. After the fall the Morphine Sulfate (concentrate) Oral Solution 100 mg/5 ml was changed to: • Give .5 ml every 4 hours for pain and every 1 hour for pain as needed which was last administered 03/23/2024 at 12:00 PM • Give .5 ml every 4 hours for pain and every 30 minutes for pain as needed which was last administered 03/23/2024 at 12:17 PM • Give .5 ml every 2 hours for pain and every 1 hour for pain as needed which was last administered 03/24/2024 at 04:00 AM • Give .75 ml every 4 hours for pain and every 1 hour for pain as needed which was last administered 03/25/2024 at 08:00 AM • Give 1.25 ml every 2 hours for pain and every 1 hour for pain as needed which was last administered 03/25/2024 at 10:00 PM • Give 1.75 ml every 2 hours for pain and every 1 hour for pain as needed which was last administered 03/29/2024 at 10:00 AM • AT 2:00 PM at 2:00 PM Oxycodone HCL (a pain medication) Oral Tablet 10 mg, Give 2 tablets under the tongue every 2 hours and every 1 hour as needed for pain or shortness of breath, crush tabs and dissolve in a small amount of liquid was last administered 03/31/2024 at 6:00 AM. In a telephone interview on 04/04/2024 at 3:26 PM, HHBA-X confirmed HHBA-X got Resident 48 out of the bath and resident was still in shower chair. HHBA-X took the safety strap off and went to reach for the resident's clothing and it was out of reach, so HHBA-X had to take a step away from the resident. HHBA-X noticed the resident start to fall so HHBA-X stepped to put a hand in front of the resident, the HHBA-X slipped, and the resident fell on top of HHBA-X and smacked the resident's head on shower chair leg. My biggest mistake was I took the strap off too soon. In a telephone interview on 04/04/2024 at 1:43 PM, HNCM-Y confirmed Resident 48 fell, hit the resident's head, was bleeding, and sent to the ED. HNCM-Y confirmed HHBA-X told HNCM-Y that HHBA-X got the resident out of the whirlpool and the resident was in the chair, the chair was in the normal sitting position. HHBA-X started drying the resident, took the safety belt off and threw it in the corner, went to reach for Resident 48's clothing but it was out of reach, so HHBA-X had to take a couple of steps away and the resident started leaning forward so HHBA-X lunged back toward the resident and slipped in water, and resident 48 fell over HHBA-X and hit the resident's head. HNCM-Y confirmed the safety belt should have been left on the resident anytime the resident was in the bath chair unless another staff member was there to assist. HNCM-B confirmed the resident did have increased pain following the fall. In an interview on 04/04/2024 at 11:26 AM with Regional Nurse Consultant (RNC)-A confirmed HHBA-X should not have taken the safety belt off the resident prior to getting the resident dressed and transferred.