**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, interview, review of a facility Self-Reported Incident (SRI) and associated investigation, review of a corrective discipline record and policy review, the facility failed to ensure Resident #68 received timely comprehensive assessment and intervention following a fall with injury. Actual Harm occurred on [DATE] when Resident #68, who was assessed as severely cognitive impaired and at high risk of falls, sustained a fall and was not properly assessed after the fall. Following the fall, the resident experienced pain rated a 10 on a pain scale of 1 to 10 with 10 being the most severe pain and was assessed to have non-verbal indicator of pain including screaming, crying, agitation, combativeness and groaning. On [DATE] (five days after the fall) an x-ray revealed a right hip fracture which the facility correlated to the fall on [DATE]. This affected one resident (#68) of three residents reviewed for falls. The census was 66. Findings include: Review of the closed medical record for Resident #68 revealed an admission date of [DATE] with diagnoses of vascular dementia with other behavioral disturbances, Alzheimer's disease, paroxysmal atrial fibrillation, restlessness and agitation, anxiety disorder, severe dementia with agitation, and repeated falls. Resident #68 expired at the facility on [DATE]. Review of the Minimum Data Set (MDS) 3.0 significant change assessment dated [DATE] revealed Resident #68 was severely cognitive impaired, had other behavioral symptoms recorded on one to three days during the assessment, utilized a walker and wheelchair, and required partial/moderate assistance with bed mobility and transfers. Resident #68 was ordered hospice services. Review of the fall care plan dated [DATE] revealed Resident #68 was high risk for falls related to confusion, deconditioning, gait and balance problems, incontinence, and lack of awareness of safety needs. Interventions included educating the resident, family, and caregivers about safety reminders and what to do if a fall occurred and to follow the facility fall protocol. Review of the Fall Risk assessment dated [DATE] revealed Resident #68 was disoriented at all times, had a history of falls, attempted to stand from chair and used a wheelchair. Review of a late-entry health status note created on [DATE] at 8:23 P.M. for an effective date of [DATE] at 11:00 P.M. authored by Licensed Practical Nurse (LPN) #74 revealed an alarm was sounding in Resident #68's room. Upon observation, the nurse noted the resident sitting on the floor beside the bed on the mat. Resident #68's bed was in the low position with the bed pad still under her, and it looked as if she slid out of bed. The note included Resident #68 had no injuries and no complaints of pain at the time of incident. Resident #68 was put back to bed and she rested without distress. The note further stated the resident had been changed and repositioned throughout the night and had no complaints of discomfort. There was no evidence that Resident #68's vital signs or neurological checks were obtained, range of motion was assessed, or the physician, hospice, or resident's family was notified of the fall. Review of the health status note dated [DATE] timed 12:44 P.M. authored by the Director of Nursing (DON) revealed Resident #68 was seen by Physician #84. The note stated there were no new orders. Review of the orders-administration note dated [DATE] timed 7:20 P.M. revealed Resident #68 was administered a dose of Hydromorphone (a narcotic pain medication) one (1) mg by mouth as needed for pain/dyspnea. The note referenced Resident #68 complained of bilateral knee pain. Review of the [DATE] Medication Administration Review (MAR) for Resident #68 revealed the resident reported a pain level of eight out of 10 on the pain scale when administered as needed Hydromorphone 1 mg on [DATE] at 7:20 P.M. Review of the health status note dated [DATE] timed 7:24 P.M. revealed Resident #68 complained of bilateral knee pain. However, there was no visible sign of edema, redness, or discoloration. Scheduled pain medications given and as needed dose given. Review of the orders-administration note dated [DATE] timed 12:14 A.M. revealed Resident #68 was administered Ativan oral 0.5 mg tablet by mouth for anxiety/agitation. Resident #68 was lying in bed yelling for momma. The note indicated one-to-one, television, snacks had been provided. Resident #68 was checked and changed for incontinent care, and the resident refused to go to the restroom. With interventions, resident began becoming tearful. The note additionally referenced music was also attempted, and all interventions were without positive effect. Review of the health status note dated [DATE] timed 6:09 A.M. revealed vital signs of blood pressure 108/58, pulse 60, and respirations 16, temperature 98.4 degrees Fahrenheit (F) and 95% pulse oxygen saturation on room air. Resident #68 was alert and oriented to person only. She was confused to time, place and situation. Resident #68 refused to leave her clothes or brief on. When staff verbalized step-by-step what they were going to do, the resident became combative and kicked at staff with both legs. Resident #68 was provided reassurance with positive effect. Resident #68 left in safe position with all safety devices in place and reapproached. Resident #68 continued to take off clothes, blankets, and brief all shift. No further complaints of pain or discomfort this shift. Review of the orders-administration note dated [DATE] timed 9:49 A.M. revealed Resident #68 was administered Ativan 0.5 mg by mouth for anxiety/agitation. During morning care, the resident was fighting and screaming out due to pain in her right leg. Review of the orders-administration note dated [DATE] timed 9:52 A.M. revealed Resident #68 was administered a dose of Hydromorphone one (1) mg as needed for pain/dyspnea. The note stated while rolling Resident #68 in bed to change her, she was screaming out because of pain in her right leg. Review of the [DATE] MAR for Resident #68 revealed the resident reported a pain level of 10 out of 10 on the pain scale when administered as needed Hydromorphone 1mg on [DATE] at 9:52 A.M. However, record review revealed no evidence the resident's source of pain was assessed or the physician was notified on [DATE]. Review of the orders-administration note dated [DATE] timed 10:54 A.M. revealed the resident refused application of tubi-grips (elastic stockings commonly used to treat swelling) to her bilateral lower legs. The note referenced the tubi-grips were held due to complaint of pain with legs today and Resident #68 did not want them on. Review of the health status note dated [DATE] timed 4:14 P.M. revealed Resident #68 had been crying out and stripping clothes off her in bed off and on this shift, even with as needed medication. When turned, resident holds her right thigh and cried, it hurts help me. Staff tried to comfort but it was not working. As needed medication not helping as much as it should. The note referenced Hospice was called and a nurse visit was requested. However, there was no evidence the facility notified the physician or comprehensively assessed the source of the resident's pain at this time. Review of the orders-administration note dated [DATE] timed 4:32 P.M. revealed Resident #68 was administered Ativan 0.5 mg tablet by mouth for anxiety/agitation. Resident kept removing clothes and was very restless and anxious lying in bed but did not want to get up. Review of the health status note dated [DATE] timed 6:09 P.M. revealed the Hospice nurse arrived around 4:30 P.M. Hospice provided new orders to start Hydromorphone two (2) mg every four hours orally, Hydromorphone two (2) mg every two hours orally as needed for pain/shortness of breath, and Lorazepam (Ativan) 0.5 mg every eight hours orally. The Hospice doctor would send scripts to pharmacy. Review of the hospice skilled narrative note dated [DATE] revealed as needed visit due to unrelieved pain and agitation. Resident #68 had been screaming in pain since the night before. Facility Nurse (FN) reported Resident #68's pain seemed more severe with repositioning on right side. He believed her right lower extremity may be the focal point of pain. Per FN, resident was agitated as well. The resident was taking off her nightgown and screaming for most of the night and large part of today. Review of the health status note dated [DATE] timed 10:47 A.M. revealed Resident #68 was yelling out and complained of pain in the right leg/hip. The note stated the resident was a two assist with care and staff were unable to turn the resident on her right side during brief change due to complaints of pain and crying out. When hands-on care was completed, the resident stopped complaining. Review of the health status note dated [DATE] timed 12:37 P.M. revealed order for x-ray of right hip due was ordered by Physician #84 due to the resident's complaints of pain. The note included x-ray company was called and would be out to the facility that day to obtain the x-rays. Review of the July MAR for Resident #68 revealed the resident reported a pain level of eight out of 10 on the pain scale when administered as needed Hydromorphone 2 mg on [DATE] at 12:46 P.M. Review of the hospice skilled narrative note dated [DATE] revealed Resident #68 was grimacing at times and grabbing her right leg. The note referenced the hospice nurse spoke with the FN who informed this nurse that the facility physician ordered an x-ray examination of the resident's right hip due to pain. The hospice nurse called the hospice physician who ordered to discontinue x-ray due to possible transitioning and no recent falls. The note further referenced a call was received from a family member of Resident #68 who wanted the x-ray examination completed to know if it was arthritis or a fracture causing the resident's increased pain. Review of the health status note dated [DATE] timed 2:27 P.M. revealed the x-ray was cancelled by the hospice doctor and Resident #68's family was notified. Review of the hospice skilled narrative note dated [DATE] revealed upon arrival, called the resident by name and the resident partially opened her eye. Tremors began and the resident started removing nightgown and blanket. FN stopped by, explained her assessment of terminal agitation with right hip guarded pain and denied the resident had any falls or injury. The note revealed symptoms started this past Wednesday ([DATE]). The hospice nurse called the resident's daughter and provided an update, and the family decided to continue with the x-ray examination. Review of the health status note dated [DATE] timed 1:39 A.M. revealed the x-ray examination was reordered due to the resident's complaints of continued pain. Resident #68 had signs of pain by moaning and guarding her right hip. The x-ray company was called, and the facility was awaiting a return call. Pain medication was given as ordered per hospice. Review of the health status note dated [DATE] timed 10:16 A.M. revealed x-ray was at the facility to perform the ordered x-ray examination. Review of the radiology results report dated [DATE] timed 11:09 A.M. of Resident #68's x-ray to the right hip revealed a unilateral examination with pelvis imaging was performed. The report revealed findings of a displaced intertrochanteric fracture. Review of the health status note dated [DATE] timed 12:28 P.M. revealed the x-ray showed intertrochanteric fracture of the right hip. Hospice was notified and would return call with any new orders. Resident #68's POA aware and will be updated again when hospice called back. Review of a facility Self-Reported Incident dated [DATE] revealed on [DATE] staff noted that Resident #68 was complaining of pain when they were providing care. An x-ray examination was performed, and the x-ray revealed a displaced intertrochanteric fracture. Upon notification of x-ray results and injury, the facility began an investigation to determine the cause of injury. Staff who worked with the resident from [DATE] to [DATE] were interviewed and statements were obtained regarding the status of the resident, care provided and if anything unusual occurred. During the investigation it was discovered that on [DATE] at 11:00 P.M. during walking rounds, Resident #68 was observed by staff on the floor mat at the side of her bed. The resident was assisted back to bed by three staff after the nurse assessed. Witness statements received from those staff members present regarding details from that instance. No other staff interviews revealed any situation out of the ordinary that would contribute to an injury. Resident #68 had a diagnosis of dementia and was unable to state how the injury may have occurred. Resident #68's husband also resided in the same room and had dementia with a Brief Interview for Mental Status (BIMS) of 4 (severely cognitively impaired) and was unable to provide any meaningful information. Based on the facility's investigation, the facility was able to conclude that the resident's fall on [DATE] was the probable cause of her fracture. Review of a witness statement within the SRI investigation authored by CNA #88 dated [DATE] revealed, On Monday, [DATE], [Resident #68] did not express any complaints of pain throughout the shift and appeared comfortable. On Tuesday, [DATE], after the resident was laid down for bed. She began groaning. When asked if she was in pain, she stated that her knees were hurting. I immediately notified the nurse on duty, and the nurse conducted an assessment of the resident. Review of the witness statement within the SRI investigation authored by CNA #86 dated [DATE] revealed, [DATE] at 11:00 P.M., Resident #68 complained about pain. It was hard to change her, so we did it in the bed! She didn't get up at all that night. It took two people to change her, and I reported to the nurse about her crying about pain. Review of the health status note dated [DATE] timed 12:00 P.M. authored by the DON revealed Physician #84 in and was updated that this resident was observed on the floor by staff on [DATE] around 11:00 P.M. as walking [rounds] were completed. The nurse and two nurse aides assisted the resident back into bed. Review of the health status note dated [DATE] timed 12:24 P.M. authored by the DON revealed this nurse and the social worker updated Resident #68's daughter that the resident was observed by staff on [DATE] during walking around on the floor beside her bed. The resident was assisted back into bed by three staff. Review of the corrective discipline record dated [DATE] revealed LPN #74 received a verbal warning for an incident on [DATE] at 11:00 P.M. that any change in plane was considered a fall. The record included CNA reported Resident #68 on [DATE] was on the floor at the foot of the bed. No incident report, progress note, or notification was made to the primary care physician or the family. With any incident, report and document an incident report, progress note, and notify physician and resident representative. LPN #74 signed the form on [DATE]. Interview on [DATE] at 7:25 A.M. with LPN #74 revealed on [DATE] at 11:00 P.M., Resident #68 was observed sitting on the floor next to her bed. LPN #74 stated she did not consider that a fall because the resident had only fallen a couple of inches. LPN #74 and CNA #78 put Resident #68 back to bed. LPN #74 verified she did not obtain vital signs after the fall, did not assess range of motion after the fall, and did not notify the physician, hospice or the resident's family of the fall. LPN #74 was unsure if she notified the [DATE] oncoming nurse of Resident #68 falling and being found on the floor. Interviews were attempted via telephone with CNA #78 on [DATE] at 8:40 A.M. and on [DATE] at 9:35 A.M., however the interviews were unsuccessful. Interview on [DATE] at 10:10 A.M. with the Director of Nursing (DON) revealed Physician #84 did not actually assess Resident #68 on [DATE] because the resident was sleeping so Physician #84 only observed the resident. The DON verified Physician #84 was not notified on [DATE] of Resident #68's fall that occurred on [DATE] at 11:00 P.M. because at that time, the facility was unaware the resident had fallen. The DON also verified the SRI investigation concluded Resident #68's right hip fracture was a result of the fall on [DATE] at 11:00 P.M. Review of the facility's Accident and Incident policy dated 2008 revealed if the incident was a fall, check for limited range of motion, bruises, pain, lacerations, swelling and vital signs. If the fall involved a possible head injury, check the pupils and level of consciousness, obtain a statement of what occurred from anyone who witnessed the incident and/or resident if capable, notify the attending physician if the resident has sustained any serious injury, notify the family or responsible party, write an incident report, notify your supervisor, and notify the oncoming nurse. This deficiency represents non-compliance investigated under Complaint Number 2576943 and Self-Reported Incident Control Number 1281390.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, emergency department encounter report review, and facility policy and procedure review, the facility failed to ensure adequate supervision to prevent Resident #168, who was a high-risk for elopement, from exiting a fifteen second delayed and alarmed egress door resulting in a fall with injury. This affected one resident (Resident #168) of three residents reviewed for elopement. The facility census was 68. Actual harm occurred on 03/23/24 around 4:20 P.M. when Resident #168, who was severely cognitively impaired, exited the facility through a fifteen second delayed and alarmed egress door in a wheelchair. Resident #168 fell forward on a ramp leading to the parking lot and was found face down leaning to her left side with obvious facial injuries that were bleeding. Resident #168's wheelchair was behind her and her shoes had come off during the fall. Resident #168 sustained a six-centimeter laceration in the center of the scalp requiring sutures to close and acute bilateral nasal bone fractures. Findings include: Review of the closed medical record for Resident #168 revealed an admission date of 12/07/23 and a discharge date of 03/25/24. Diagnoses included but were not limited to intracerebral hemorrhage, hemiplegia and hemiparesis, type one diabetes mellitus, dysphagia, stage III chronic kidney disease, major depressive disorder, and depression. Review of Resident #168's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status score of seven which indicated severe cognitive impairment. The assessment also indicated Resident #168 required supervision for wheeling wheelchair 50 feet, maximum assistance for toileting, bathing and transfers, and for wheeling wheelchair 150 feet. Review of Resident #168's elopement risk evaluation dated 02/05/24 revealed a score of one indicating the resident was not at risk of elopement. No additional elopement risk evaluations were completed. Review of the nursing progress note dated 02/25/24 timed at 1:33 P.M. revealed Resident #168 was exit-seeking and pushing on doors. Resident #168 was redirected; a wanderguard (a bracelet worn by the resident that sets of an alarm and locks armed doors), was placed on her ankle and the physician was notified. Review of nursing progress note dated 02/26/24 timed at 2:45 P.M. revealed Resident #168 was observed by a therapist at Exit door 12 holding it open. Resident #168 did not go outside and was redirected to the activities room. Review of nursing progress note dated 03/02/24 timed at 11:27 A.M. revealed Resident #168 continued exit seeking. Review of the nursing progress note dated 03/18/24 timed at 5:29 P.M. revealed Resident #168 was exit-seeking and appeared to be getting worse. Review of the nursing progress note dated 03/18/24 timed at 6:20 P.M. revealed Resident #168 was exit-seeking, one-on-one was unsuccessful and family came to sit with Resident #168. Review of the nursing progress note dated 03/19/24 timed at 5:00 P.M. revealed Resident #168 was pushing on Exit door 8 causing the alarm to sound. Resident #168 had a wanderguard attached to her ankle, but it did not trigger the door alarm. The wanderguard was replaced with a functioning wanderguard. Review of Resident #168's care plan with a revision date of 03/20/24 revealed Resident #168 was an elopement risk related to wandering, disoriented thinking, impaired safety awareness and confusion. Interventions dated 02/28/24 included assess for fall risk, wanderguard, distract the resident with activities, food, TV, and staff interaction. An intervention dated 03/20/24 indicated replacement of wanderguard. Resident #168 was noted to have an activities of daily living deficit related to right hemiplegia, limited mobility and stroke and required staff assistance for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. Review of the nursing progress note dated 03/21/24 timed at 5:14 P.M. revealed Resident #168 was exit-seeking, stating she wanted out of the facility and redirection after each attempt was completed. Review of the nursing progress note dated 03/23/24 timed at 5:00 P.M. revealed Registered Nurse (RN) #13 was approaching the [NAME] unit lounge when she heard a door alarm. RN #13 immediately responded to Exit door 12 and observed Resident #168 outside on the ramp; Resident #168 had fallen forward out of her wheelchair. RN #13 alerted staff to get immediate assistance and went out to assess Resident #168. Resident #168 was laying on her belly leaning to her left side with obvious facial injuries that were bleeding. Resident #168's wheelchair was behind her, and her shoes had come off her feet during the fall. Another nurse called emergency medical services (911) at 4:25 P.M. Resident #168 was alert and able to speak and stated she wanted to get up. Resident #168 was moving her head and denied any neck pain. No inward or outward rotation to the bilateral lower extremities were noted. Laundry staff brought out towels to put pressure on her head wound. Three nurses and one State Tested Nursing Assistant (STNA) assisted Resident #168 back into her wheelchair. Resident #168 was noted to have a head laceration about three centimeters long and one quarter inch wide at the center, and her nose was bleeding. Resident #168 was brought back into the building and pressure was applied to her forehead laceration and blood was cleaned off her face. Emergency medical services (EMS) arrived at 4:30 P.M. and Resident #168 was transported to the hospital. Review of the Emergency Department Encounter dated 03/23/24 timed at 5:10 P.M. revealed Resident #168 arrived at the hospital with a six-centimeter laceration in the center of the scalp down to the [NAME] with no skull visible and acute bilateral nasal bone fractures. The laceration required simple interrupted sutures at the level of the epidermis. Interview on 04/15/24 at 1:35 P.M. with RN #13 revealed she found Resident #168 when she was transporting another resident to the activity lounge around 4:20 P.M. on 03/23/24 and heard the door alarm. RN #13 ran to Exit door 12 and saw Resident #168 through the window and observed she had fallen out of her wheelchair onto the cement. Resident #168 was observed about four feet from the door lying on her stomach leaning to the left trying to get back up. RN #13 yelled for assistance. Two other nurses reported to the scene, and they began to assess Resident #168. Resident #168 was noted to have a laceration on her forehead and was bleeding from her nose. Licensed Practical Nurse (LPN) #9 called for EMS and then came back to assist. Three nurses and an aide assisted Resident #168 back into her wheelchair and used towels to apply pressure to her wounds. EMS arrived within five to ten minutes of being called and she left for the hospital. Phone interview on 04/15/24 at 3:57 P.M. with LPN #8 revealed when she got report at 3:00 P.M. on 03/23/24 she was told that Resident #168 was exit seeking and they had placed her at the nurse's station. LPN #8 had just seen Resident #168 and taken her blood sugar at the nurse's station and then walked to the end of the hall to start passing medications and before being able to start passing medications was paged to Exit door 12. When LPN #8 arrived, Resident #168 was sitting up on the ground at the top of the ramp. LPN #8 assisted the other nurses and aide to get Resident #168 back up into her wheelchair. Resident #168 stated she was trying to leave. They obtained vitals and then called the doctor and waited for EMS to arrive. EMS arrived in less than ten minutes, and she left for the hospital. Interview on 04/16/24 at 8:20 A.M. with LPN #9 revealed she was working on the [NAME] unit on 03/23/24. LPN #9 stated earlier on 03/23/24 she heard the alarm for Exit door 3 going off and found Resident #168 at the door and had the door open, but staff brought her back to the nurse's station before she got outside. Staff were watching her at the nurse's station. About 4:20 P.M. on 03/23/24, LPN #9 was passing medications down by Exit door 3 and was alerted by another staff Resident #168 had gotten outside and fallen out of her wheelchair. LPN #9 ran to Exit door 12 to assist and then ran back inside to call 911 and then proceeded to get her equipment to take vitals. LPN #9 did an assessment on Resident #168 and then she along with three other staff lifted Resident #168 back into her wheelchair and brought her inside until the ambulance arrived. Interview on 04/16/24 at 10:40 A.M. with the Director of Nursing (DON) revealed Resident #168 was cut from skilled services on 02/14/24 and moved to a semi-private room on 02/15/24. On 02/23/24 Resident #168 was noted to be picking at her skin and having mental changes and a urine sample revealed a urinary tract infection (UTI) which was treated with an antibiotic. On 02/25/24, Resident #168 was observed by staff at Exit door 12 with the door open. Staff redirected her. On 02/28/24, Resident #168 continued to be exit-seeking and a wanderguard was applied. On 03/18/24 Resident #168 was again exit-seeking and staff provided one-on- one supervision and then called family who came and sat with her. On 03/19/24 Resident #168 was pushing on exit doors and her wanderguard did not activate properly. Resident #168's wanderguard was replaced. A urine sample was obtained on 03/21/24 and was negative for a UTI. The DON confirmed the current elopement assessment was dated 02/05/24 and an elopement assessment was to be completed following each attempt to elope and had not been completed following attempts on 02/25/24, 02/28/24, 03/18/24, 03/19/24, and 03/21/24. Interview on 04/16/24 at 11:22 A.M. with Corporate Quality Assurance Nurse #16 confirmed Resident #168's care plan was not updated following exiting attempts on 03/18/24, 03/19/24, and 03/21/24. Interview on 04/16/24 at 11:45 A.M. with Maintenance Director #17 confirmed Exits 3, 4, 5 and 12 were not wanderguard armed; they were 15 second delayed alarmed egress doors. The doors alarmed and released when the bar at the center of the door was pushed and held for 15 seconds. Review of the facility policy Wandering/Elopement, dated December 2015 revealed the resident would be screened during preadmission, an assessment would be completed upon admission, quarterly and with a change in condition and with any attempt to leave the facility unplanned or unsupervised. When identified as a wanderer, the facility would identify the need for regular monitoring of the resident's whereabouts each shift and would include the frequency of monitoring. Additional interventions could include a wanderguard or placement on a secured unit if applicable. The care plan would be updated. This deficiency represents non-compliance under Control Number OH00152564.