**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of a facility fall investigation, hospital record review, review of the facility Fall policy and interviews, the facility failed to provide Resident #78 adequate assistance for transferring/ambulation with toileting to prevent a fall with major injury. This resulted in Immediate Jeopardy and Actual Harm on [DATE] when Resident #78, who was admitted to the facility for rehabilitation status post hospitalization for a left total knee replacement (on [DATE]) and who was assessed to be at moderate risk for falls sustained a fall while being assisted by one State Tested Nursing Assistant, (STNA) #176 to walk from her bed to the bathroom. The resident was subsequently assessed to have dislocation to her knee (replacement) and a popliteal artery injury (an injury mainly associated with high energy injury, including knee dislocation with causes including falls and crush injuries) requiring a left above the knee amputation. The resident did not return to the facility following the incident. This affected one resident (#78) of three residents reviewed for falls. The facility census was 77. On [DATE] at 11:16 A.M. the Administrator, Regional [NAME] President of Operations #402, Director of Clinical Services #404 and Regional Clinical Support #406 were notified Immediate Jeopardy began on [DATE] when staff failed to provide adequate assistance for toileting to Resident #78 resulting in a fall with major injury. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 7:20 P.M., Licensed Practical Nurse (LPN) #100 responded to the State Tested Nurse Aide (STNA) #176 yelling for help. The resident had sustained a fall and was subsequently transported to the hospital on [DATE] at 7:45 P.M. • On [DATE] at 11:46 A.M., all 33 facility STNA staff, 18 Licensed Practical Nurses (LPNs), and four Registered Nurses (RN) were educated by Onshift (e-mail or text) by the Director of Clinical Services #404 on the following topics: 1. All new admissions should use a gait belt and staff assistance of two with transfer/ambulation until evaluated or screened by therapy or a nurse. 2. Residents care plans would be updated after evaluation/screen with the level of assistance needed. 3. Any staff who does not answer/not working on [DATE] would be educated prior to their next shift by Director of Clinical Services #404. • On [DATE] by 2:15 P.M., an audit was completed for all in house residents by therapy staff to ensure the correct transfer status. • On [DATE] at 2:15 P.M., the Director of Clinical Services #404 and Regional Clinical Support #406 updated all resident care plans related to transfer status. • The facility developed a plan for the Director of Nursing/Designee to audit five times a week for four weeks on new admissions that their interview and/or observations notes support two-person assist and gait belt use were provided until the resident was evaluated by a therapist/nurse. • On [DATE] a Quality Assurance (QA) meeting was held with the following staff members in attendance: Medical Director #414, the Administrator, Regional [NAME] President of Operations #402, the Director of Nursing (DON), Director of Clinical Services #404, and Regional Clinical Support #406. • The facility developed a plan for the QA committee to review audit results weekly for four weeks. • On [DATE] from 9:01 A.M. to 10:05 A.M., interviews with Activity Director #104, Activity Aide #110, and STNA #170, revealed they had received education to use a gait belt and the assistance of two staff members for any new admission until the resident was evaluated by therapy. • On [DATE] from 9:01 A.M. to 10:05 A.M., interviews with LPN #200 and LPN #121 revealed they received education to ensure staff used a gait belt and the assistance of two staff members for all new admissions until the resident was evaluated by therapy and new interventions were to be added to the plan of care by the nurses when implemented. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #78's closed medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including left total knee replacement, diabetes with diabetic polyneuropathy, severe obesity, chronic venous insufficiency, chronic diastolic heart failure, and chronic venous hypertension with inflammation of bilateral lower extremities. The resident was admitted to the facility from the hospital for rehabilitation status post total left knee replacement (on [DATE]). The resident's height was noted to be four feet 11 inches with a weight of 207 pounds per medical record information from [NAME] Hospital. Review of the hospital physician assistant note dated [DATE] at 8:15 A.M. revealed Resident #78 had not yet been seen by physical therapy. Nursing reports Resident #78 wanted to get up to use the restroom and Resident #78 took a couple steps then requested a bedside commode due to pain. Resident #78 then required staff assistance and use of a [NAME] steady (a manual sit-to-stand transfer aid that enables one caregiver to transfer safely) to get back into bed. Review of a hospital rehabilitation therapy progress notes, written by the physical therapist dated [DATE] at 12:54 P.M., revealed the resident's transfer level of assistance required was moderate assistance: two-person assist. Resident #78 could stand with minimum of two-person assist. Resident #78 did not put weight on the left lower extremity and was unable to pick up the right lower extremity to take steps due to putting all her weight on that side. The note indicated the physical therapist was unable to assess ambulation. Review of a hospital therapy note dated [DATE] revealed Resident #78 was weight bearing as tolerated, had decreased lower extremity range of motion, decreased lower extremity strength, decreased functional mobility, impaired gait, increased fall risk, and balance deficits with pain limiting mobility. Review of a Hospital Discharge Examination, printed on [DATE] at 9:27 A.M. revealed Resident #78 was alert and in no apparent distress while sitting up in bed eating breakfast. The resident was doing fair postop day #2 from a left total knee arthroplasty. The resident's pain was controlled with the current pain regimen. She has been up with physical therapy but has not been moving very well. Review of the hospital Orthopedic Discharge Instructions dated [DATE] revealed Resident #78 had a total left knee arthroplasty on [DATE] (left) and activity was weight bearing as tolerated on operative leg and use of cane/walker during ambulation. The resident was noted to have a follow-up appointment with the surgeon in two weeks (no specific date provided). Review of the hospital Ambulance Transfer form (form provided from the hospital to ambulance company for continuity of care during transport) dated [DATE] at 12:02 P.M. revealed mobility level of assistance: Activity: in chair and the level of assistance required was four assists; at a moderate fall risk. Review of a handwritten admission report form dated [DATE] and completed by LPN #116 (report from the hospital staff to the nursing home staff) revealed Resident #78 had a left total knee replacement, left lower extremity weakness, was alert and oriented to person, place, time, and event, required 1-2 assist, and knee brace to be worn when up. Review of the facility admission assessment dated [DATE] and completed by LPN #116 revealed Resident #78 was admitted with left lower extremity weakness following a left total knee replacement. Resident #78 required limited assistance for transfers, toileting, and walking in room. Resident #78 was assessed as having unsteady gait. Review of baseline care plan dated [DATE] at 5:19 P.M. revealed Resident #78 was admitted on [DATE] for aftercare following joint replacement surgery with an anticipated short term stay at the facility. The baseline plan of care addressed activities of daily living (ADL's) indicating the resident was at risk for decline related to recent need for nursing home placement. The goal was to assist the resident to achieve desired level of ADL assist or independence. The intervention noted was therapy screen. The baseline plan of care revealed the resident was a Fall Risk/Safety Risk with a goal to minimize risk for falls. The intervention revealed to encourage call light use. The baseline plan of care also noted the resident was having current pain with an intervention to administer medication as ordered and note effectiveness. Lastly, the baseline plan of care included Therapy with a goal to identify therapy needs to maintain/improve functional status. A section for weight-bearing status was blank. Interventions under this section were also blank. Review of a nursing progress note, dated [DATE] at 4:41 P.M. and authored by LPN #116 included the resident arrived via cot at 3:30 P.M. Family was not at bedside but on the phone (did not specify which family was on the phone). Resident arrived alert and oriented (x4). The note revealed the resident denied pain. Foley catheter in place, but resident verbalizes continence of bladder before placement. Resident verbalizes continence of bowel. Resident is oriented to call light, bed alarm. No complaints or problems verbalized at this time. The note failed to contain any evidence the resident was assisted to stand/ambulate at the time of this note or that her ambulation/transfer ability was assessed. Review of a #716 Fall electronic note dated [DATE] at 7:20 P.M. and completed by LPN #100 revealed this nurse was administering medication to another resident when she heard STNA #176 yelling for help. When the nurse entered Resident #78's room, the resident was lying face down in front of the bathroom with her legs stretched out. Blood was coming from the incision to the left knee. Resident #78 stated STNA #176 was assisting her to the bathroom with her walker when her left leg gave out. The ambulance was called at 7:24 P.M. and arrived at the facility at 7:30 P.M. Resident #78 left the facility at 7:45 P.M. A corresponding nursing progress note, dated [DATE] at 11:04 P.M. and authored by LPN #100 included the same information as the #716 Fall electronic document. Review of a facility fall investigation dated [DATE] at 7:30 P.M., completed by LPN #100 and signed by the DON revealed the resident stated she was walking to the bathroom when her left leg gave out on her. The fall investigation noted the cause of the fall was the resident was ambulating to the bathroom with one assist with walker when her left leg gave out on her. A witness statement written by STNA #176 dated [DATE] at 7:20 P.M. revealed the STNA answered Resident #78's call light and Resident #78 asked for help to the bathroom. STNA #176 started to assist Resident #78 and when Resident #78 got to the bathroom door she stated honey, I can't it hurts and then Resident #78 began to fall. STNA #176 stated she had a hold of one of Resident #78's arms and helped guide her to the floor. Review of fall risk assessment dated [DATE] at 11:06 P.M. revealed Resident #78 was at moderate risk for falls. Review of the resident's medical record revealed prior to the fall that occurred on [DATE] at 7:20 P.M. she had not been assessed or physically seen by a facility physician or by staff from the facility therapy department. Review of a local hospital report (Genesis Hospital) dated [DATE] revealed Resident #78 had a knee arthroplasty completed on [DATE]. The resident had a bit of difficult recovery with therapy and moving after her surgery. She was transferred to the (skilled nursing) facility this afternoon and apparently while trying to be transferred to the bathroom she sustained a fall and the inability to ambulate. She landed directly on this knee. She was evaluated in the emergency department and identified to have dislocated total knee arthroplasty. Commuted tomography (CT) angiogram (procedure to visualize blood vessels) was obtained which revealed a popliteal injury. Physician #254 was of course called as this was my patient and again patient was two days post-op. She presents with close dislocation of the total knee arthroplasty. The CT scan reveals disarticulation of the knee with anterior translation of the tibia on the femur. There is also a popliteal artery injury and suspected also neurologic injury. After the knee was reduced a light wrap was placed on the knee as this did cause some bleeding of the incision, however there was no recovery of the pulses when assessed with the doppler. There is no recovery of the neurologic function of the foot. The resident was transferred to Ohio State University ([NAME]) Hospital as the neurovascular injury was concerning and felt to be more than what could be handled here by our vascular team. From the total knee standpoint this was something that could be dealt with in the future and revision may be necessary as obviously there was ligamentous integrity issue with this knee at this point. The neurovascular status of the lower extremity however takes precedence at this time. Post-reduction films were obtained. The knee was located and joint concentric. No obvious fractures were noted. Review of the CT ANGIO of the left lower extremity dated [DATE] revealed Clinical Indications: Popliteal entrapment syndrome suspected. (a rare condition that affects the main artery behind the knee, called the popliteal artery. In this condition, the calf muscle is in the wrong position or it's larger than usual. The muscle presses on the artery, making it harder for blood to flow to the lower leg). The left lower extremity was reduced prior to transfer to [NAME]. Post reduction x-rays were obtained showing a successfully reduced concentric knee. On presentation to the trauma bay she presented with cold left lower extremity without left popliteal, posterior tibial and dorsalis pulse signals. Compartments feel tight and there was loss of motor and sensation to the extremity. Resident #78 consented for possible fasciotomy, possible bypass, possible left lower extremity amputation, we will proceed to the operating room. A left above knee amputation was deemed necessary. Review of an [NAME] social worker progress note dated [DATE] revealed Resident #78 stated that the accident (fall) occurred because she had slipped on the floor while an aide was helping her to ambulate at the skilled nursing facility. She reported that she told the aide that she would need two people to help her, but the aide insisted that she would be able to help lift her. Review of [NAME] Discharge summary dated [DATE] revealed Resident #78 was status post above left knee amputation on [DATE] and was being discharged to an in-patient rehabilitation facility. On [DATE] at 11:01 A.M., during an interview with the DON, the DON revealed STNA #176 had not been using a gait belt when assisting Resident #78 on [DATE] prior to the fall and that the facility doesn't have a policy for use of a gait belt. However, the DON indicated gait belts were available for use. When asked if a gait belt should have been used, the DON again indicated they were available for use. The DON reported Resident #78 did have a knee brace in place at the time of the incident. On [DATE] at 11:08 A.M., telephone interview with STNA #176 revealed on [DATE] she had answered Resident #78's call light and then assisted the resident to get up (to go to the bathroom). The STNA revealed the resident had her knee brace on and her walker. The STNA stated they got to the bathroom door, and the resident said her leg was hurting so she put on the resident's call light and then the resident said I can't and started going down. The STNA stated she was standing on the resident's weak side, so she assisted her to the floor and then ran out and yelled for help. The STNA verified she was not using a date belt at the time of the transfer/ambulation with the resident. There were no other staff in the room assisting with the resident's care at the time of the incident. Interviews conducted on [DATE] and [DATE] at various times during the onsite investigation with STNA #134, #148, #157, #170 and #181 all indicated gait belts should be used with all residents when transferring unless directed otherwise. On [DATE] at 3:15 P.M., a telephone interview with Physical Therapy Assistant (PTA) #212 (from Genesis Hospital therapy department) revealed following the total knee replacement on [DATE], Resident #78 required a two person assist to get from the bed to the chair and stated that was all Resident #78 really did while she was in the hospital. On [DATE] at 4:48 P.M., a telephone interview with Resident #78 revealed she had been admitted to the facility for therapy to gain additional strength to be able to go home. The resident revealed on the d. The resident stated the STNA told her, I got you, but my leg was still numb. The resident indicated the STNA didn't have a gait belt; she grabbed the back of my gown. I told her I wasn't going to make it and tried to sit back down on the bed and the walker went one way and I went the other. I fell face down and onto my knee, the STNA did not lower me to the floor. I was told to stay the way I was until the ambulance arrived and they got me onto the cot. On [DATE] at 8:25 A.M., interview with Resident #18, (Resident #78's roommate at the time of the fall on [DATE]) revealed STNA #176 had stood Resident #78 up to go to the bathroom. Resident #78 was bent over and leaning forward, and her knee brace looked loose and then dropped down. When STNA #176 bent to pull it up, Resident #78 fell forward. On [DATE] at 9:06 A.M., a telephone interview with Physician #258, the vascular surgeon from [NAME] revealed Resident #78 had a blocked artery from the fall and dislocation of the knee which probably precipitated this event (the amputation). Physician #258 revealed his intention was to try and save the extremity, however the duration of time from the injury, and it was in such bad condition and the muscle had already died, he could not. On [DATE] at 1:21 P.M., a telephone interview with Physician #254, the orthopedic surgeon who completed Resident #78's left total knee replacement (on [DATE]) revealed the injury she sustained would not have happened if she had not had the fall. When she fell it dislocated the knee causing the injury. He also revealed she was having a hard time with even ambulating before she left the hospital, that was why she was sent to the facility. The physician stated most patients go home the next day. During the interview, the physician indicated the resident required at least two persons for transfer/ambulation. On [DATE] at 2:15 P.M., during a telephone interview with LPN #116, the LPN who completed the admission assessment for Resident #78, the LPN was asked how she determined Resident #78 required limited assistance for toilet use and transfers. The LPN stated she completed an interview with the family and resident, and also conducted an observation. She stated she had Resident #78 stand, and she used a walker and a gait belt, and she took a couple steps. She revealed she also had two STNAs present in the room with her at the time. The LPN stated she felt the resident required one to two staff to assist, but at the time she evaluated her, she only needed one. There was no indication during the interview as to how it would be determined or who would determine what level of assistance the resident would need to transfer/ambulate (one or two staff) until the time she was evaluated/assessed by therapy staff. On [DATE] at 10:05 A.M. a telephone interview with One [NAME] RN/Clinical Coordinator #214 from Genesis Hospital revealed at the time of discharge from the hospital on [DATE], Resident #78 required a forward wheeled walker and the assistance of two staff for transfers/ambulation. On [DATE] the facility provided a written statement from LPN #116, dated [DATE]. The statement indicated I received report from Genesis hospital, during that report I was told by the nurse overseeing [Resident #78's] care that she was a x1 assist. I was also told by the same nurse that the nursing staff at Genesis had had her up and ambulating and she performed well. This statement did not address why the same nurse documented on the handwritten hospital admission report the resident was a one to two assist. There was no statement from LPN #116 on [DATE] at the time of the incident. On [DATE] from 4:51 P.M. to 5:11 P.M. telephone interview with Resident #78's daughter revealed she was not present with the resident at the time she arrived to the facility on [DATE] from the hospital, however she did get to the facility at approximately 4:30-4:45 P.M. The daughter indicated she stayed at the facility for approximately an hour to an hour and 45 minutes and during that time period, three staff members had come into the resident's room to weigh the resident. The daughter indicated the resident was weighed in bed and did not get out of bed during the weighing process. Resident #78, was also present during this call and was asked if she had been out of bed or if she had stood/taken steps/walked with staff following her admission prior to the incident when she fell. The resident denied being out of bed prior to when she fell. The resident again reported she fell while being helped to the bathroom by one STNA and the STNA didn't have a gait belt. When asked what the resident's ambulation status had been in the hospital prior to admission, the resident's daughter indicated she was not aware the resident had been walking in the hospital prior to the nursing home admission and stated that was part of the reason why she was being transferred to the nursing home (for therapy). The daughter revealed staff had reported to her during her visit that no one from therapy was in the facility at that time, stating he had already left for the day so the resident would not been seen on this date. The daughter indicated she was unaware when therapy would start for the resident. The resident's daughter indicated she had left the facility to go home and hadn't been gone very long when she got a call that there had been an incident (the daughter indicated she was still driving at the time the call came to her). The daughter stated the call had come on [DATE] at 7:36 P.M. She stated she turned around and went straight to the hospital, arriving there between 7:40 P.M. and 7:45 P.M. and indicated the resident was in x-ray when she arrived to the hospital. Review of the Fall Policy dated 02/2018 and revised 04/2021 revealed it was the policy of the facility to assure proper fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related falls. Facility staff worked with the resident/resident representative to determine risk factors for falls and appropriate interventions that promote independence while reducing the risk of falls/injuries from falls. This deficiency represents non-compliance investigated under Compliant Number OH00149311.