**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls for two (#23 and #41) of 3 sampled residents reviewed for falls. The facility failed to: a) Assess the residents to determine needs of residents. b) Thoroughly investigate falls to determine underlying causes of falls for the residents. c) Implement preventative interventions to prevent falls for the residents. Resident #23 was on the dementia unit and had advanced dementia with behaviors. The resident sustained seven falls between March 2018 and May 2018. The resident sustained an eighth fall in September 2018. The resident was sent to the hospital. A hospital CT scan documented the resident had an upper arm impacted fracture of the humeral neck. Resident #41 was a new admission who was confused, agitated, and had behaviors toward others. The resident fell in his room and hit his head. The resident was transported to the hospital. The hospital discharge summary documented the resident had a intracranial hemorrhage. The risk management report documented 21 residents had experienced falls since August 1, 2018. Findings: The facility policy for fall prevention documented staff was to complete hourly rounding and check residents for positioning, check to ensure resident possessions were close, check residents for pain, and check residents for potty needs. The policy documented staff were to offer restless residents snacks, fluids, television, or company. The policy documented staff must huddle, complete a fall scene and incident investigation report, and complete an incident report after each fall. The policy documented staff were to evaluate information gathered till the cause of the fall was determined. The policy documented new interventions were to be implemented with each fall or indicate why the current approach was still relevant. 1. Resident #41 was admitted to the facility on [DATE] with diagnoses which included vascular dementia with behavioral disturbances. The fall risk assessment, dated 07/30/18, documented the resident was at moderate risk for falling. The physician orders, dated 07/30/18, did not document the resident was to receive psychoactive medication. A physician order, dated 07/31/18, documented an order for physical therapy (PT) to evaluate the resident for a walker. The care plan, dated 07/31/18, documented the resident needed assistance with activities of daily living (ADLs) and was at risk for falls. The care plan documented the interventions to prevent falls were for the staff to check on the resident frequently throughout the day and night. The care plan documented the staff were to encourage the resident to wait for staff assistance and keep the call light within his reach. The care plan documented the staff were to ask resident if he was thirsty, hungry, needed toileting, and provide assistance as needed when the resident was restless. The care plan documented the staff were to remind the resident to stand slowly and lock the brakes on his wheelchair. A discharge assessment, dated 08/02/18, documented the resident was discharged from the facility to the hospital. A progress note, dated 08/02/18, at 11:30 AM, documented the resident had extreme behaviors of hitting and yelling at other residents. The note documented the daughter was notified the resident was to transfer to the hospital for a psychiatric evaluation. An entry assessment, dated 08/15/18, documented the resident returned to the facility. The physician orders, dated 08/15/18, documented the resident was to receive Lorazepam (an antianxiety medication) every six hours for anxiety and agitation and Quetiapine Fumarated 50 mg (an antipsychotic) one time per day for behaviors. A progress note, dated 08/15/18 at 1:19 PM, documented the resident was combative toward staff and other residents. The note documented the resident was sent to the hospital for evaluation. A progress note, dated 08/15/18 at 5:08 PM, documented the resident arrived back to the facility at 2:42 PM accompanied by his daughter and was pleasantly confused. A progress note, dated 08/15/18 at 5:16 PM, documented the resident was agitated at dinner and displayed aggressive, violent, and verbal behaviors. The note documented Lorazepam was administered to the resident. An incident report, dated 08/15/18, documented the staff found the resident on the floor in front of his sink. The report documented the resident could not state what had occurred and complained of pain in his back. The report documented the resident had no apparent injuries and his vital signs were within normal limits. The report documented the resident stated he hit his head. The report documented the doctor was notified and received an order to send the resident to the emergency room. The report documented the family was notified. A fall investigation note, dated 08/16/18 at 01:28 AM, documented the events of the fall. The note did not document details of a fall investigation. A hospital Discharge summary, dated [DATE], documented the resident had a diagnosis of traumatic intracranial hemorrhage with a cerebral contusion and a petechial hemorrhage of the left frontal lobe. A progress note, dated 08/20/18 at 11:55 AM, documented a new order for Trazodone (an antidepressant) 50 mg 1 every 6 as needed for anxiety. A progress note, dated 08/20/18 at 6:21 PM, documented the resident returned to the facility at 2:15 PM accompanied by his son. The note documented the resident was alert and oriented to self. The physician orders, dated 08/20/18, documented the resident was to receive Keppra (an antiseizure medication) 500 mg for behaviors and Lorazepam topically every 6 hours for anxiety or agitation. A fall risk assessment, dated 08/20/18, documented the resident was a high risk for falls. The admission assessment, dated 08/30/18, documented the resident was moderately impaired for daily decision making. The assessment documented the resident had physical behaviors towards others and rejected care which interfered with the provision of care. The assessment documented the resident required extensive assistance with transfers, mobility, and other activities of daily living (ADLs). The assessment documented the resident did not walk during the assessment period, was not steady with transfers, had no range of motion impairment, used the wheelchair, and was frequently incontinent of bowel and bladder. The assessment documented the resident had falls before admission. The assessment documented the resident received antipsychotic, antianxiety, antidepressant, and diuretic medications. The care plan, dated 09/17/18, did not document new interventions to prevent falls. On 10/02/18 at 2:12 PM, the resident was observed. The resident was resting in bed. The bed was in low position and the call light was in reach. The resident had a Broda chair and a gait belt in his room. On 10/03/18 at 9:30 AM, the resident was observed in the living area, sitting in a Broda chair, and was in front of the television. No foot support was in place and the resident's feet were dangling. The resident's eyes were closed but he was easily awakened. The resident was not interacting with other residents or staff. On 10/03/18 at 12:00 PM, a family member was interviewed. The family discussed concerns relating to staff supervision, the treatment for the resident's behaviors, and the use of antipsychotic and antiseizure medication. The family stated the resident fell and hit his head the day he returned from the hospital. The family stated the resident had a bleed in his head. On 10/08/18 at 9:30 AM, the fall investigations were requested. The director of nurses (DON) provided the facility's fall incident report and stated the facility had no other fall investigation information documented. The DON stated an investigation huddle was to be completed at the time of the fall and documented on a form. The DON stated after the information was input into the computer, the form was discarded. The DON reviewed the incident report and stated no huddle or fall investigation information was documented on the report. On 10/08/18 at 3:19 PM, CNA #5 was interviewed regarding fall prevention. The CNA stated the resident was advanced with his dementia. The CNA stated when the resident was first admitted the staff attempted to walk the resident with his walker and it was difficult. She stated the resident would usually sit in his wheelchair and move his feet all the time. The CNA stated the resident had behaviors directed to the staff but not to other residents. The CNA stated the resident resisted care. The CNA stated the family brought a recliner for the resident and he would sit in the recliner in his room reading the Bible by himself. The CNA stated once the resident was in bed, the staff would check on him hourly. On 10/08/18 at 3:30 PM, CNA #4 was interviewed regarding the resident and his fall on 08/15/18. The CNA stated the staff supervised the residents in the television area and checked the residents every 30 to 40 minutes. The CNA stated she did not know who placed the resident in his room that evening. The CNA stated a staff member found him on the floor. The CNA could not state details of the fall. On 10/08/18 at 3:46 PM, LPN #2 was interviewed regarding the events of the resident's fall. The LPN stated the fall was not witnessed. The LPN stated 30 minutes prior to the fall incontinent care had been provided and the resident was placed in his recliner. The LPN stated the resident had not been agitated. The LPN stated the staff performed rounds at least every two hours and sometimes would sit with a resident. On 10/08/18 at 3:57 PM, the director of nurses (DON) was interviewed regarding falls. The DON stated at the time of the fall, the staff on duty was to have a huddle and document the details of the fall on the Fall Scene and Incident Investigation Report (FSII). The FSII report was the initial part of the fall investigation. The DON stated the report would be given to the unit coordinator and the coordinator would input the fall information to the electronic incident report. The DON reviewed the resident's incident report. The DON stated the report required less information than what was on the FSII report and the initial fall investigation details were not documented on the incident report. The DON was not able to provide a thorough investigation report documenting the underlying or root cause of the resident's fall. The DON stated the fall was discussed in the morning meeting and it was determined the resident had to go to the bathroom and that was the cause of his fall. The DON reviewed the admission care plan and the current care plan. The DON stated the care plan was not updated with a new intervention to prevent the resident from falling. 2. Resident #23 was admitted to the facility on [DATE] with a diagnoses which included vascular dementia with behaviors, collapsed vertebra, cervical fracture, muscle weakness, and hypertension. The fall risk assessment, dated 02/19/18, documented the resident scored a 75 which was considered a high fall risk. The physician orders for February 2018 documented the resident was to receive Seroquel and Ativan. The comprehensive assessment, dated 03/04/18, documented the resident was severely impaired for daily decision making and required extensive assistance for activities of daily living. The assessment documented the resident required a wheelchair for mobility and was usually incontinent of bowel and bladder. The assessment documented the resident was taking antianxiety, antidepressant, and hypnotic medication. An incident report, dated 03/05/18 at 5:15 AM, documented the resident fell, was found on the floor next to her bed, and was yelling out. The report documented the nurse gave the resident Tramadol to help with yelling. The report did not document new interventions to prevent falls. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. An incident report, dated 03/05/18 at 6:00 AM, documented the resident was found lying on the floor, on the fall mat, and next to her bed. The resident was sent to the hospital for evaluation. The report did not document new interventions to prevent falls. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. The nurse notes, dated 03/05/18, documented the resident fell two times and was having behaviors. The note documented the resident was sent to the hospital for an evaluation. The care plan, dated 03/05/18, documented the resident required assistance with activities of daily living (ADL), had vascular dementia with behaviors, was incontinent, and was considered a high fall risk. An incident report, dated 03/17/18 at 10:00 PM, documented the resident fell and was found on the floor in her room. The report documented an X-ray of the right hip was obtained and the results were negative. The report documented hourly rounding was to continue and the staff was to sit with the resident until she fell back asleep that night. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. An incident report, dated 03/21/18 at 7:19 PM, documented the resident was found on her knees by her bed. The report documented hourly rounding was to continue. The report did not document a new intervention to prevent falls. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. An incident report, dated 04/03/18 at 10:00 PM, documented the resident stood up from her wheelchair without assistance and immediately sat on the floor in front of her wheelchair. The report documented the immediate action was for staff to offer activities, food, or fluid. The report documented the staff was to ask the resident the four P's (pain, potty, position, and possession). The facility was not able to provide a completed fall investigation. The offering of food, fluid, and the four P's were not documented on the care plan. An incident report, dated 04/05/18 at 5:45 PM, documented the resident was found on the floor by her wheelchair in her room. The report documented hourly rounding was to continue and provide constant monitoring while awake. The report documented the staff was to place a chair outside the resident's room and monitor while the resident slept. The facility was not able to provide a completed fall investigation. The care plan was not updated with a new fall intervention. The nurse notes, dated April 6, 2018 to April 30, 2018, were reviewed. The notes did not document the staff was monitoring the resident while she was sleeping. An incident report, dated 05/25/18 at 1:10 AM, documented the staff witnessed the resident slide out of the bed. The report documented the resident was wet and the floor was wet. The report documented the resident had been toileted at 11:30 PM. The report documented the resident did not sustain an injury from the fall. The facility was not able to provide a completed fall investigation. The care plan did not document a new intervention to prevent future falls. The quarterly assessment, dated 06/04/18, documented the resident was still dependent for daily decision making. The assessment did not document the resident had falls. The care plan, dated 08/22/18, documented the resident had one fall with injury. The care plan did not document new or updated interventions since 03/05/18. The incident report, dated 09/27/18 at 10:00 PM, documented the resident was found lying on the floor behind the door. The report documented the resident was complaining of left arm pain. The report documented the resident was assisted into wheelchair by the staff. The report documented the resident was sent to hospital for x-rays. The nurse notes, dated 9/28/18 at 6:33 AM, documented the resident returned to the facility. The X-ray report, dated 09/28/18, documented there was no acute fracture or a dislocation of the left arm. The nurse notes, dated 09/28/18 at 9:09 AM, documented the resident was complaining of severe pain of the left arm. The notes documented the physician was notified and the resident was sent back to the hospital for an outpatient CT scan. The CT report, dated 09/28/18 at 1:54 PM, documented the resident an impacted minimally displaced fracture of the left humeral neck. On 10/08/18 at 12:56 PM, the director of nurses (DON) stated the fall investigations should be with the incident reports. The incident reports did not include documentation regarding thorough fall investigations. On 10/08/18 at 3:10 PM, certified nurse aide (CNA) #5 was interviewed. The CNA stated resident #23 would try to get up in the dining area and the staff would assist her back to her chair. The CNA stated she did not sit by the resident's room while the resident slept. The CNA stated she would check on the resident every hour. On 10/08/18 at 4:00 PM, the DON was interviewed regarding how the facility investigated falls. The DON stated the staff on duty at the time of the fall was supposed to fill out a fall safety intervention investigation (FSII) report. The DON states the report was discussed in the morning meeting and the staff tried to figure out the cause of the falls. The DON stated the household LPN coordinator was to transfer the information from the FSII report to the facility incident report. On 10/08/18 at 4:18 PM, the LPN coordinator for Cobb Landing was interviewed. The LPN stated he entered the information on the FSII report regarding the fall and then discarded the FSII report. The LPN stated he did not document all the information on the new report because there was not a place for all the information. The LPN stated during stand up meetings every morning they would look for consistent factors related to the fall. The LPN stated the fall investigation was not documented. The LPN stated after a fall, the facility reviewed the resident's medication. The LPN stated the physician was aware of the resident's fall and had not reviewed her medicine at that time. The LPN stated he was notified when a fall occurred.