**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An IJ was identified from 12/11/24 through 12/12/24. The deficient practice remained at isolated level of a potential for harm. On 12/11/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement fall interventions for a resident with severe cognitive impairment and high fall risk. On 12/10/24, Resident #13 had a fall with injury in their room. Resident #13 fell during an independent transfer and was found by staff on the floor with their left foot rotated outward with no range of motion to left hip. Resident #13 was taken to the ER by staff. This fall resulted in Resident #13 acquiring a closed displaced intertrochanteric fracture of the left femur and laceration of scalp. On 12/11/24 at 3:04 p.m., the Oklahoma State Department of Health was notified and verified the existence of a IJ situation. On 12/11/24 at 3:56 p.m., the administrator and DON were notified of the IJ situation and the IJ template was provided. On 12/12/24 at 12:34 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal documented the total number of residents at risk for the same deficient practice was 35. It documented the actions to remove the immediacy of the alleged deficient practice were the following: a. on 12/11/24, Resident #13's care plan completed via phone with the family and the family agreed to move Resident #13 to the east side of the facility to be more closely monitored due to high fall risk; b. on 12/11/24, Resident #13's care plan was individualized with specific fall interventions; c. on 12/11/24, all staff were educated in person and by phone on the policy put into place, where to find the master list for fall risk, the falling leaf program, location of the fall manual, and where to find care plans for each resident; and d. all residents deemed a high fall risk care plan interventions were updated and falling leaf program updated. It documented action taken to prevent recurrence of the alleged deficient practice were the following: a. on 12/11/24, the facility fall policy and procedure manual will be located at the nurse's station for all staff to review at any time. The master list of all high fall risk residents will be located in the front of the binder. A falling leaf program policy will be implemented. Note cards will be available at the nursing station for all residents sorted by hall for quick reference of each residents care needs including fall risk category. The fall intervention list from the care plan for each resident will be available in the fall manual; b. a master fall risk list and note cards will be updated weekly by the DON to ensure accuracy; c. the DON or administrator will randomly interview three to five staff members once a week to ensure each one is aware of the new policies and where to find all the fall risk information. Staff will be reeducated as needed; d. new hires will be educated on fall program and policies and procedures upon hire; e. when a fall happens in the facility, the charge nurse will do a huddle with nursing staff immediately to look for interventions, update care plan if needed, and notify the PCP and family; f. as new interventions are put into place a huddle will be completed with all staff on duty for education; g. the IDT team will meet weekly on all falls. The care plan will be updated with new interventions; and h. the QAPI team will meet monthly and review all falls, monitor tracking and trending, and address any concerns noted. The IJ was lifted, effective 12/12/24 at 2:37 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained isolated with the potential for more than minimal harm. Based on record review, and interview, the facility failed to update and implement individualized fall interventions in the care plan after a fall for residents assessed as a high fall risk for two (#13 and #15) of two sampled residents reviewed for individualized fall interventions. The administrator identified 35 residents were high fall risk. Findings: An undated facility Accidents policy, read in part, The intent of this policy is to ensure this facility provides an environment that is free from accidents hazards over which the facility has control and provides supervision and assistive devices are provided for each resident to prevent avoidable accidents. This includes: a. Identifying hazards and risk, b. Evaluating and analyzing hazards and risk, c. Implementing interventions to reduce hazard, and d. Monitoring for effectiveness and modifying interventions when necessary. The policy also read, Individualized, person centered interventions will be implemented, including adequate supervision assistive devices, to reduce risk related to hazards in the environment. The facility's Falls and Fall Risk, Managing policy, read in part, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 1. Resident #13 had diagnoses which included anxiety, depression, cataract, and dizziness. Resident #13's Care plan, date initiated 03/02/22 and revised 10/23/24, documented interventions for fall focus, read in part, Fall interventions: purposeful staff rounding, proper seating in chair for W/C, ensure proper foot wear/nonskid socks, exercise program to improve balance, gait, strength, assist, staffing, environment, friendly to reduce clutter, assess medications - side effects and interactions - PCP and pharmacy review, educate resident regarding risk for falls, increased observation, increased activities, restorative care, staff education on falls and interventions, keep items within reach, bed, and low position when occupied with format. Answer, call promptly, re-orientate to call if needed, use of pictures to provide cues and reminders to call for staff assist, evaluate hearing, vision as needed, root cause analysis for falls, assess for illness, open, parentheses delirium, UTI, respiratory, infection, etc in parentheses, educate resident when applying intervention, create something that makes high-risk followers, identifiable, open, parentheses falling, leaf, pictures, etc. In parentheses involve all staff to prevent falls, maintain daily routine, assist WF/toileting before and after each meal, at bedtime as needed. Evaluate B/P for hypotension, rooms/bathrooms with adequate light, call light in reach of resident at all times and remind them to call for staff assist, PT evaluation, evaluate height of bed/toilet seat/chairs, etc. Offer nutritional stacks and meals, offer fluids, everyone- two hours during waking hours promote hydration, proper ambulation, assistive devices (walker, cane W/C space ETC.) and educate on proper use of devices. A Un-Witnessed Fall report, dated 08/01/24, read in part, resident observed laying on her stomach on the floor with no bottoms on. Urine and BM on the floor by the bathroom. Neighbor unsure of how she fell, just that she fell. Resident had abrasions noted to both knees and good range of motion. There was no documentation the care plan was updated with new specific interventions after the fall. Resident #13's Morse Fall Scale, dated 09/19/24, documented high fall risk with a score of 75. A Significant Change assessment, dated 09/23/24, documented Resident 13's cognition was severly impaired. It also documented Resident #13 was independent with walking with walker and going to bathroom independently. A Incident note, dated 11/29/24, read in part, resident reported fall in room- unknown how resident fell. Nurse called to dining room by hospice aid. 2 cuts noted near left eye brow, inner nose swollen and bruised, nurse took resident over to ER- resident refused to stay at ER. Nurse did treatment on eye brow with steri strips and family, PCP notified of her refusal of care in ER. There was no documentation the care plan was updated with new specific interventions after the fall. A Incident note, dated 12/10/24 at 10:41 a.m., read in part, Resident noted yelling out from room. [They]were sitting on floor at foot of bed next to side table. Left foot was rotated outward and [they] did not have ROM in this hip without having pain. [They] also had blood noted running down [their] cheek. Resident stated 'I fell, help me up and leave me alone' Cleaned face up to assess head wound, laceration appears to be superficial. Assisted [them] up into wheelchair without applying weight to left hip. Notified PCP and brought [them] to ER. Also notified DON, ADM, and [family member]. admitted to hospital. There was no documentation the care plan was updated with new specific interventions after the fall. An initial State Reportable Incident, dated 12/10/24, documented Resident #13 was found sitting on their floor in room. It documented Resident #13's left foot was rotated outward and did not have range of motion in the left hip without having pain. It documented Resident #13 arrived at the ER on [DATE] at 11:57 a.m. Resident #13's ER report, dated 12/10/24, documented they were treated and then transferred to another hospital for a closed displaced intertrochanteric fracture of the left femur and laceration of scalp. There was no documentation the care plan was updated with new specific interventions after the fall on 08/01/24- no injury, the fall on 11/29/24- laceration above left eye and inner nose, and the fall on 12/10/24- injury obtained. On 12/10/24 at 2:56 p.m., the DON was asked the reason Resident #13 was transferred to bigger hospital. The DON stated for a fractured left hip. On 12/12/24 at 11:02 a.m., MDS coordinator #1 was asked the policy for updating and revising interventions on the care plan. They stated they were updated as needed. MDS Coordinator #1 was asked to review Resident #13's care plan for falls and was then asked if new fall interventions were added, updated or revised after the fall on 08/01/24. They stated no new interventions were put into place. They were then asked about the fall on 11/29/24. They were asked if there were new fall interventions put into place, updated or revised. MDS Coordinator #1 stated, No. MDS Coordinator #1 was then asked if all fall interventions were from a generic list or were they individualized for the specific resident. They stated if staff started a new intervention then they updated or revised the care plan as needed. 2. Resident #15 was admitted on [DATE] with diagnoses which included unspecified dementia without behaviors and anxiety. Resident #15's Care plan, date initiated 12/20/22 and revised on 10/23/24, documented interventions for fall focus, read in part, Fall interventions: purposeful staff rounding, proper seating in chair for W/C, ensure proper foot wear/nonskid socks, exercise program to improve balance, gait, strength, assist, staffing, environment, friendly to reduce clutter, assess medications - side effects and interactions - PCP and pharmacy review, educate resident regarding risk for falls, increased observation, increased activities, restorative care, staff education on falls and interventions, keep items within reach, bed, and low position when occupied with format. Answer, call promptly, re-orientate to call if needed, use of pictures to provide cues and reminders to call for staff assist, evaluate hearing, vision as needed, root cause analysis for falls, assess for illness, open, parentheses delirium, UTI, respiratory, infection, etc in parentheses, educate resident when applying intervention, create something that makes high-risk followers, identifiable, open, parentheses falling, leaf, pictures, etc. In parentheses involve all staff to prevent falls, maintain daily routine, assist WF/toileting before and after each meal, at bedtime as needed. Evaluate B/P for hypotension, rooms/bathrooms with adequate light, call light in reach of resident at all times and remind them to call for staff assist, PT evaluation, evaluate height of bed/toilet seat/chairs, etc. Offer nutritional stacks and meals, offer fluids, everyone- two hours during waking hours promote hydration, proper ambulation, assistive devices (walker, cane W/C space ETC.) and educate on proper use of devices. Resident #15's Morse Fall Scale assessment, dated 01/11/24, documented Resident #15 was at high risk for falling. The facility's Un-Witnessed Fall report, dated 02/08/24, read in part, Neighbor observed sitting on the floor at the foot of [their] bed. Wheelchair was flipped over as well. Neighbor stated [they] were getting up to go to the bathroom and grabbed at the wheelchair when [they] started to fall and it flipped over. Assessed for injuries, reports not hurt and did not hit [their] head. Has good ROM noted. Assisted to standing position and returned to bed. Resident #15's Morse Fall Scale assessment, dated 04/09/24, documented Resident #15 was at high risk for falling. The facility's Witnessed Fall report, dated 04/27/24, read in part, CNA informed nurse of neighbor laying on [their] floor. Neighbor observed to be laying on floor on [their] left side with top of head towards the restroom door,eyes facing towards hall.Neighbor bent at waist with feet and legs pointed towards the hall.ROM performed, neighbor c/o pain to BLE and to back rated at an 8. Asked [them] if [they] hit [their] head and suite mate stated that neighbor did hit [their] head.No skin impairments, hematoma, or injury noted to head. Eyes PERRLA.VS:165/93p-76, T-98.2, O2-92%RA, R-20.Neighbor assisted up slowly via x3 staff to sitting position and then slowly up to WC via x3 staff.Quartersized skin tear noted to left elbow.Call light was observed to be in reach but not on. Alarm to bed was noted to have light on but was not sounding. Neighbor began to vomit into emesis bag.Neighbor then taken to [name withheld] ER. Resident Description: When asked what happened neighbor stated that [they] was going to the restroom. When asked how come [they] didn't use the call light [they] stated 'I did. A Incident Report Form dated 04/27/24, read in part, resident observed lying on the bathroom floor by CNA. Resident stated [they] had gotten up to use the bathroom and fell. It also read, Resident was transferred to [name withheld]. Resident #15's hospital operative report , dated 04/29/24, read in part, L1 vertebral compression fracture. Resident #15's Care Plan fall focus, revised 08/05/24, read in part, [Resident #15] is a (high) risk for falls r/t weakness/gait/balance problems and impaired mobility. The care plan did not document interventions after the falls on 02/08/24 and 04/27/24. Resident #15's quarterly assessment, dated 11/04/24, documented their cognition was moderately impaired and they were dependent on staff for ADLs. On 12/11/24 at 11:43 a.m., MDS coordinator #1 was asked what was the facility fall protocol. They stated after a resident was assessed, they completed a report, and huddled with staff for documentation for additional ideas and interventions in the care plan. They were asked what interventions were added after the two falls on 02/08/24 and 04/27/24 to prevent future accidents and hazards. MDS Coordinator #1 stated there were no interventions added to the care plan after the two falls. They were asked about the fall interventions initiated on 12/20/22 and revised 10/23/24. They stated they had a list of interventions for falls and added them to all residents who fall. MDS Coordinator #1 stated those interventions were not specific to the resident, but all residents that fall. They stated that was part of their facility fall protocol. On 12/11/24 at 12:30 p.m., the administrator was asked to review the care plan for Resident #15. The administrator stated that there was no new interventions added after the falls on 02/08/24 and 04/27/24 and the care plan was not individualized and specific to the resident.