**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and family, staff, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to provide care in a safe manner for 1 of 5 residents (Resident #1) reviewed for supervision to prevent accidents. Resident #1 was diagnosed with cerebellar ataxia (a condition that causes poor muscle control that causes clumsy movements), and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord) and was dependent on staff for assistance with care. On 1/18/24 Nursing Assistant (NA) #1 was providing Resident #1 with care when the resident experienced spastic/uncontrolled movements and the resident fell off the side of the bed striking his head on a bedside table causing a laceration on his forehead above his left eye before he fell onto the fall mat on the floor. Resident #1 was transferred to the Emergency Department and was treated for a left frontal scalp hematoma (a pool of mostly clotted blood) with a significant laceration with active bleeding that required 7 sutures for closure. Immediate jeopardy began on 1/18/24 when NA #1 failed to provide care safely to Resident #1. The immediate jeopardy was removed on 3/15/24 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower level and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place were effective. Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis that included stroke with right side hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body), functional quadriplegia, cerebellar ataxia, muscle weakness, lack of coordination and intellectual disability. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #1's cognition was severely impaired, and he was dependent on staff for activities of daily living (ADL) assistance, dressing, and bed mobility. He was coded to have received antiplatelets and had 1 fall with no injury since prior assessment on 8/7/23. He did not have behaviors. Review of the care plan for Resident #1 dated 10/20/23 included the following: - At risk for falls related to muscle weakness, cerebral vascular accident (stroke) with right sided hemiplegia, functional quadriplegia, intellectual disability, and cerebellum ataxia with a goal that Resident #1 would not have negative outcomes related to falls without appropriate nursing intervention through the next review (start date 2/28/23) with interventions that included to use a wider bed, floor mats beside bed, assist with toileting and transfers, keep the environment safe, and call light within reach. - Impaired physical mobility and required 1-2 person assist with ADLs related to right side hemiplegia with interventions that included to provide 1-2 person assist with ADLs as needed. In an interview with Nurse #2 on 3/12/24 at 12:08 pm it was revealed that Resident #1 had a diagnosis of cerebellar ataxia, had a recent deterioration in his condition and had become more spastic (uncontrolled movement) with increased muscle spasms and became more agitated at times. She stated he was at risk of falls because of his diagnosis. She indicated that some of the staff interventions used were: they approached him calmly as not to startle him, they kept his bed in a low position, padded the side rails with pillows, checked for incontinence and changed him as needed, and had floor mats on both sides of the bed to help prevent self-injury. The interview further revealed that Resident #1 had a wider bed to help prevent falls and that staff got him up in a chair and took him to activities to help keep him occupied and so they could keep a closer eye on him. Nurse #2 stated that a family member familiar to him visited daily and that helped. The interview further revealed that many different fall interventions had been exhausted for Resident #1 and he was reviewed in fall meetings regularly and medication reviews were done, and medications were adjusted as necessary. Nurse #2 stated he was prescribed lorazepam 0.5 milligrams at bedtime for anxiety and baclofen to help control his muscle spasms. Review of an Event Witness Statement dated 1/18/24 at 10:50 am written by NA #1 read went into the room and took his [Resident #1's] shirt off, he started moving around and fell off the bed. The statement was signed as witnessed by Nurse #3. Review of a Facility Event Investigation Form dated 1/18/24 at 10:50 am completed by Nurse #3 and signed by the Director of Nursing (DON) revealed that Nurse #3 responded to an NA's call for assistance because a resident had fallen out of bed. The review further revealed that Resident #1 was being assisted with dressing and changing when he started jumping and fell off of bed. The record had a hand drawn diagram that indicated that Resident #1 laid on the floor between both beds with a night stand near his head, it was noted that he was on his left side with his arms up by his chest, legs outstretched, and with blood on the floor coming from under him from an area on the upper left forehead. The record review further indicated that the care plan was updated to include 2 or more persons when ADL care was provided or for bed mobility. The form was dated and signed by the DON as investigation completed on 1/23/24. Review of a nurse's progress noted dated 1/18/24 at 3:12 pm written by Nurse #3 revealed that she was called to Resident #1's room by the NA and Resident #1 was on the floor between the beds in his room. The review further revealed he had fallen off his bed when the NA attempted to change and dress him. He was noted to have bled from an area on the left side of his forehead. 911 was called and Resident #1 was transported to the hospital for evaluation and treatment. Review of a nurse's progress noted dated 1/18/24 at 3:28 pm written by Nurse #3 revealed that pressure was applied to Resident #1's head for bleeding, and he grimaced when pressure was applied. In a phone interview with NA #1 on 3/12/24 at 4:22 pm she stated that she was assigned to Resident #1 on 1/18/24 when he fell out of bed. She stated that she went into his room to give him a bath. She indicated he let her take his shirt off and at that point in time he started making his movements like he did. She explained that was when she remembered that he had a history of flailing around with agitated movements when he received care so she was going to go get someone to assist her. She indicated she left the side of the bed without lowering the bed. She stated that he then went off the other side of the bed so she ran out of the room to go get the nurse. NA #1 stated that Nurse #3 came into the room. She stated that when he started to move around in bed after she removed his shirt that she talked to him so he would not move as much. She indicated that she had his bed up to a working height that permitted her to provide care on the same plane (level) as Resident #1 when he fell. She further stated that Resident #1 typically moved around a lot but would let her do his care but this day he moved so fast that he fell off the other side of the bed (opposite from where she was standing) and hit his head on the bedside table before he fell onto the floor mats that were beside his bed. She stated that she then ran over to where he laid on the floor and asked him if he was ok and he said he was. NA #1 indicated that there was blood everywhere, on the privacy curtain, on the floor, and on his head and upper body. The interview further indicated that NA #1 recalled that Resident #1 had moved around a lot since she started working at the facility in July of 2023 and because of that 2 people usually worked with Resident #1. She further stated that she knew she should use 2 people when she provided care to Resident #1 because when she became employed at the facility other staff (no specific staff names provided) told her that. She indicated that there were no staffing issues on the morning of 1/18/24 when she provided care to Resident #1. She explained that she was not thinking that day and was just moving to get her patient care completed and as soon as she removed his shirt that she thought she needed to go get someone else to assist her when he started with his agitated movements. In a phone interview with the Administrator on 3/14/24 at 3:11 pm she stated that NA #1 wanted the surveyor to call her back so that she could clarify some information that she had given in a previous interview on 3/12/24 at 4:22 pm. The Administrator stated that NA #1 had never left the bedside on 1/18/24 when the resident fell out of the bed. In a follow up phone interview with NA #1 on 3/14/24 at 3:31 pm she indicated that her statement in a phone interview on 3/12/24 at 4:22 PM was correct but clarified that she never left his bedside prior to the fall. She explained that she stood beside the bed the entire time. She stated that she took his shirt off and thought in my head that she needed to go get someone to help when he got agitated. NA #1 stated that she stood beside his bed but did not grab him or hold him when he thrashed around because she did not want to restrain him but didn't want him to fall off the bed so she hovered her hand over his body without touching him. She stated she was on the side of the bed closest to the door and kept her hand hovered over him and that he thrashed toward her side of the bed. She felt that if she stood there and hovered her hand over him that she was not restraining him and if he moved to her side of the bed that he would not fall and hit the floor. She indicated that he then suddenly sat up and threw himself toward the opposite side of the bed and fell off the bed (from where NA #1 was standing) before she could stop him. She rationalized that when he sat up, she thought he was going to lay back down but he didn't and he instead flung himself off the opposite side of the bed. During an interview with Nurse #3 on 3/12/24 at 3:09 pm she stated that Resident #1 would get anxious when he was left alone or if staff tried to change him. She stated that his behavior was childlike and when he became anxious or agitated that he would swing his body, arms, and legs and that he could fall out of the bed. She described his movements as flailing and that he would flail and move around a lot when staff tried to provide care. She stated that interventions were in place for him that included lower bed position and fall mats on the floor. The interview further revealed that he had a fall in January 2024, but she could not recall the date, when NA #1, who was unfamiliar with him and did not know how anxious he would get, assisted him with morning care and he flipped himself off the bed. She stated that NA #1 had the bed raised while she gave him care and worked without assistance with him the day he fell. After he fell his care plan was changed so that 2 or more staff assisted Resident #1 when care was provided. She recalled that blood was everywhere, and she called a code green (to indicate a fall) and after she saw the amount of blood that she called 911 (EMS-Emergency Medical Services) and stayed with him until EMS arrived. Nurse #3 further indicated that she attempted to get a brief on him after he fell when he was on the floor while she waited for EMS to arrive, but he twisted all around and she could not. She stated that he had a laceration to his left forehead that bled a lot. In an interview with a family member on 3/12/24 at 3:00 pm it was revealed that Resident #1 fell out of his bed on 1/18/24 and was taken to the hospital where he received sutures to his forehead. She stated that she arrived at the facility on 1/18/24, the day he fell off the bed, just before he was transported to the hospital and that his face was covered with blood. Review of hospital emergency department (ED) records dated 1/18/24 revealed Resident #1 was received in the ED on 1/18/24 at 1:11 pm from EMS (Emergency Medical Services) with a chief complaint of a fall out of bed with a laceration above the left eye. Resident #5 was assessed to have the worst possible pain as rated on a numeric/faces pain scale (a pain scale that assigns a number to a face to assess pain in an individual that is unable to report pain. A 0 point 'happy face' represents the absence or lack of pain. A 10 point 'crying face' represents the worst possible or most excruciating pain). The physician was called to the bedside immediately due to the nature of Resident #1's laceration. He was assessed by the physician to have a large hematoma above his left eye with a significant laceration that actively bled and the bleeding was not well controlled with applied pressure. Resident #1 was placed in a C (cervical) collar (to prevent movement of the head and neck) and lidocaine (a medication to numb) and epinephrine (a medication to constrict blood vessels) were ordered to get as rapid a closure [of the laceration] as possible. 7 sutures were placed to close the laceration. Resident #1 received fentanyl (pain medication) 25 micrograms/0.5 milliliters via intravenous push (medication given all at one time). A CT (computerized tomography) brain scan (a diagnostic imaging exam that uses X-ray technology to produce images of the inside of the body) was done with the findings of a left frontal scalp hematoma (a pool of mostly clotted blood) with no intercranial (in the brain) bleeding. Resident #1 was discharged back to the facility from the hospital on 1/18/24 at 6:03 pm. In an interview with the DON on 3/13/24 at 10:17 am it was revealed that the facility provided fall prevention training for staff when every fall occurred. She stated that it was discussed in the training how the fall happened, how the fall could be prevented, if the care plan needed to be updated, and how many staff should have been used. She indicated that Resident #1 received care using the number of staff that he was care planned for at the time of the fall which was 1-2 staff members. During an interview with NA #2 on 3/13/24 at 1:31 pm she stated that Resident #1 moved around a lot during his care and that she noticed that his movement increased around the time he had a fall but did not recall if the increased movement started prior to his fall in January 2024. She described his movement as jerk-like and stated that when he was rolled over in bed that he would jerk his body and swing his arms and legs. She stated that he had always had these types of movements since he was admitted about a year ago but it had gotten worse. She stated that he had always required 2 staff to assist with all his care since he was admitted to the facility about a year ago because he moved a lot. NA #2 stated that she believed it was not safe to work with Resident #1 without assistance from another staff for the safety of Resident #1 and the staff since he kicked and moved around so much during ADL care and when he was handled in any way. She indicated that that staff had received training specific to his care periodically since he was admitted prior to his fall in January of 2024. She was unable to provide specific dates that training occurred prior to the 1/18/24 fall. She further indicated that the trainings were informal and usually in a group and delivered verbally by nurse supervisors, usually after he had a fall or any change in care needs. The training typically included things like to keeping the bed in a low position, using floor fall mats beside his bed, and to always use 2 staff when care was provided. In an interview with NA #3 on 3/13/24 at 1:56 pm she stated that she had worked at the facility for about 9 months and that she had often worked with Resident #1. She stated that she and other staff had always used 2 people when they transferred or did ADL care with Resident #1 because he got agitated and had muscle spasms in his legs and that his limbs started to move around and he flopped like a fish out of water and she could not contain him alone. She further stated that his condition had worsened since the beginning of 2024. She stated that NA's were taught how to go into the computer to see the care plan and she could see how many people were needed to assist a resident, but that they received in-services each time Resident #1 had a fall and were educated verbally by a nurse supervisor to get assistance when she worked Resident #1 so she did. In an interview with the Administrator on 3/13/24 at 4:15 pm she stated that at the time of the fall that Resident #1 was a 1-2 person assist. She stated that the care plan had been updated on 2/7/24 from a 1-2 person assist to a 2 or more person assist after his fall on 1/18/24. In an interview with the MD on 3/14/24 at 3:41 pm it was revealed that Resident #1's falls were directly related to his diagnosis of cerebellar ataxia and that his spasticity had increased recently so his medication baclofen had been increased in the past few months but she was unsure of the date. She stated that he was at risk for falls related to his diagnosis. In an interview with NP #2 on 3/15/24 at 1:35 pm revealed that Resident #1 had a diagnosis of spinal cerebellar ataxia which caused uncontrolled movements and that his condition had worsened in the past few months. The Administrator was notified of immediate jeopardy on 3/13/24 at 3:53 pm The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 01/18/2024 at 10:50AM, at the time of the fall, the bed was the proper height for providing activities of daily living (ADL) care for Resident #1 (proper bed height can vary from resident to resident and based upon the height of the care provider); NA # 1 was at bedside and in the process of changing the resident's shirt. The following safety precautions were in place at the time of the incident: siderail, fall mats on floor on both sides of bed, and safety wedges in place bilaterally for edge of bed awareness. During this provision of care, Resident # 1 began flailing, fell out of bed and hit the bedside table resulting in a laceration to left eyebrow. NA #1 called for assistance and three staff members responded (registered nurse (RN), licensed practical nurse (LPN), certified nursing assistant (CNA). 911 was called and Resident #1 was transported to the emergency room (ER) at 3:12PM. Resident # 1 returned to the facility at 1:27AM on 01/19/2024. Resident # 1 fell from his bed secondary to uncontrollable flailing due to exacerbation of his diagnosis of cerebral ataxia. On 01/18/2024, prior to resident's return to the facility, room furnishings were rearranged by an LPN to prevent further injury and assist in facilitating an optimally safe environment. On 01/19/2024, pharmacy recommended an adjustment to Resident # 1's dosage of medication used for muscle spasms; nurse practitioner (NP) approved recommendation; new order implemented. On 01/20/2024, Clinical Competency Coordinator (CCC) completed education with CNAs regarding safety awareness and precautions while providing ADL care. Education included the importance of understanding the resident's physical and cognitive condition/ limitations in providing safe care. CNAs have access to care needs and interventions through the tablets provided for CNA documentation. On 02/07/2024, an additional fall mat was placed on the left side of bed. On 02/07/2024, care plan was updated to reflect, provide 2 or more person assist with ADLs as needed. On 02/15/2024, mattress with bolsters in place for edge of bed reminder. On 02/20/2024, a pharmacy consultant conducted medication review for purposes to reduce falls. Vitamin D added. Per the National Institute of Medicine, Vitamin D has a direct influence on muscle strength and is regulated by specific vitamin D receptors in muscle tissue .Insufficient vitamin D is associated with lower physical performance and greater declines in physical functioning . On 03/02/2024 & 03/03/2024, Director of Health Services (DHS)/ Director of Nursing (DON) conducted a review of residents at high risk for falls (as identified by our Electronic Health Record (EHR) clinical risk insight report) related to diagnosis and/ or physical/ cognitive limitations. Safety interventions were reviewed to ensure individual needs for assistance with ADLs are being met and are identified on the care plan as well as the CNAs documentation tool. Individual resident needs for assistance with ADLs may be identified through any of the following, but are not limited to: care plan meetings, multiple nursing resident assessment tools, Minimum Data Set assessments, therapy evaluations, residents' history and physical, etc. Any outstanding interventions were entered as identified during the audit process by the respective auditing clinical manager; the CNA documentation tool is automatically updated when a care plan intervention is added or updated in the EHR. On 03/06/2024, medical director (MD)/ NP reviewed medications for purposes to reduce falls. Medication used to decrease anxiety was added to the resident's medication regimen. All residents have the potential to be affected if staff fail to follow safe resident care practices. Safe resident care practices include but are not limited to the following: bed in optimal position for resident safety, bed at appropriate height during the provision of ADL care, after providing ADL care staff are to ensure all ordered fall interventions are in place prior to leaving the room, staff are to utilize tablets to access resident specific safe care interventions, etc. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 03/13/2024, CCC provided education (additional to education provided on 01/20/2024) to RNs, LPNs, and CNAs which included checking room environment for safety prior to leaving the room (e.g., ensuring bed is in optimum position for individual resident safety, any fall interventions are in place prior to leaving room, etc.). Staff who did not receive education were removed from the schedule until education can be provided. Facility does not utilize agency staff. On 03/14/2024 & 03/15/2024, clinical staff (RNs, LPNs, & CNAs) educated by the CCC on the importance of optimizing resident safety during the provision of ADL care and post care. Education included the following but not limited to: understanding resident limitations/ capabilities, knowledge of where and how to locate resident specific safety interventions, gathering care products prior to initiating resident care, after care has been started resident is not to be left unattended, after care is provided checking the environment to ensure all safety interventions are in place (e.g., fall mats, bed in lowest position (if applicable to resident need), etc.). Staff who did not receive education were removed from the schedule until education can be provided. This education will be added to new clinical team member orientation; classroom orientation is completed prior to unit/ room assignments. On 03/13/2024, an ad hoc Quality Assurance and Process Improvement (QAPI) meeting was held. Attendees were Administrator, Admin-in-Training (AIT), Director of Health Services (DHS), Unit Coordinators, Infection Preventionist (IP), CCC, Skin Integrity Nurse, and Senior Nurse Consultant (via conference call). Items discussed included: creating a safety task force reviewing all ADL care plans to ensure interventions reflect current and individualized resident needs. The task force will focus on resident safety during ADL care utilizing visual observation rounds, the clinical event log, the resident care plan, and a quality assurance (QA) tracking tool. On 03/13/2024 & 03/14/2024, clinical managers completed 100% audit of ADL care plans to ensure any resident specific safety interventions are in place and appropriate. Audit outcome reflected a need to improve timely entry of new safety interventions (e.g., fall mats, wedges, etc.). Any outstanding interventions were entered as identified during the audit process by the respective auditing clinical manager. On 03/14/2024, CCC provided education to the Nursing Staff (Licensed Nurses and C.NAs) on providing ADL care in compliance with individual safety interventions per the residents' plan of care. Nurses and CNAs are to review the CNA Care profile in electronic health record (EHR) available on documentation devices for information on resident specific care needs. Staff who did not receive education were removed from the schedule until education can be provided. Facility does not utilize agency staff. CCC monitors education for completion. Effective 03/14/2024, CCC will provide education to new clinical team members orientation (RNs, LPNs, CNAs) regarding the importance of understanding your residents and meeting their individual needs. This education will include where and how to find information on interventions needed for the provision of safe care for each resident. Classroom orientation is completed prior to unit/ room assignments. Date of Immediate Jeopardy Removal: 3/15/24 The credible allegation of immediate jeopardy removal was verified on 3/15/24. Interviews were conducted with a sample of Nursing Assistants and Nurses to verify education was conducted for Nurses and NAs regarding safe delivery of care for residents. Documentation of in-service records was reviewed. A review of audits of ADL care plans dated 3/13/24 and 3/14/24 were verified to be completed. In an interview with the Clinical Competency Coordinator on 3/15/24 at 4:05 pm, he stated that all Nurses, Nursing Assistants, and therapists had been educated on providing care for all residents, how to access the electronic medical record and find the care plan and if in doubt to ask a nurse, supervisor or therapy. He stated that he was responsible for orienting new nurses and nursing assistants on providing safe care to residents for all residents. He further stated that orientation had been updated to include Resident Safety Awareness/training for nursing staff that included falls, what to do, interventions, and who to notify. An observation of the Resident #1's room and environment revealed that Resident #1 was in bed and fall mats were in place on both sides of the bed, the bed was in a low position, furniture had been arranged a safe distance away from the bed, side rails hand been padded, and mattress bolsters were in place at the edges of the bed. A family member of Resident #1 was in the room sitting at his bedside. During the survey, observations were made of care being provided to multiple residents and no concerns were identified with the safe provision of care. The facility's immediate jeopardy removal date of 3/15/24 was validated.