**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documentation, facility investigation and staff interviews, it was determined that the facility failed to provide adequate supervision for one of three residents (Resident R1), which resulted in actual harm when an unsupervised fall occurred, and Resident R1 sustained multiple rib fractures, punctured lung and hospitalization which resulted in death. This failure created an Immediate Jeopardy situation for one of three residents (Resident R1). Findings include: Review of facility policy Fall Prevention Program dated 4/21/23, indicated the purpose of this protocol is to provide guidance to the department of Military and Veterans Affairs (DMVA), Bureau of Veterans Homes (BVH), State Veterans Homes (SVHs) to assist in fall management and prevention reducing the risk of serious injury from falls. Review of Resident R1's admission record indicated he/she was admitted on [DATE]. Review of Resident R1's MDS (minimum data set - a brief periodical assessment of resident needs) dated 11/16/23, indicated diagnosis of psychotic disorder with delusions (presence of one or more delusions- psychosis lost touch with reality), repeated falls, and unspecified dementia with behavioral disturbances (dementia affects your thinking, memory, reasoning, personality, mood and behavior with behavioral disturbances). Review of the MDS Section J 1700 dated 9/14/23, indicated: the resident has had a history of falls with injury. Review of progress notes dated 11/5/23, indicated writer at nurses station, charting heard a loud thump. Looked down the hallway and observed resident lying on the floor between wall and housekeepers cart with head of resident facing the nurses station. Resident C/O pain in head, left arm, left shoulder and generalized pain. Resident states he hurts everywhere and yelled out in pain anytime he was touched to assess. Resident R1 was sent out to the hospital and returned with arm in sling with fracture of shoulder. Review of Resident R1's care plan initiated 11/6/23, revealed Resident R1 is at risk for falls with the goal to remain injury free. Approach initiated 11/5/23 staff supervision 1:1 when a staffing allows (person sits with a resident to maintain their safety) due to high fall risk and frequent falls. Approach initiated 11/6/23, when unable to provide 1:1 supervision, resident is to be q15 minute safety checks due to high fall risk and frequent falls. Approach initiated 11/7/23, indicated 1 person assist, to utilize w/c for mobility when out of bed. Approach initiated 11/1/23, indicated to increase intensity of visual observation when resident is in room. No documentation could be provided for 15 minute safety checks due to high fall risk and frequent falls. Review of the clinical record failed to include further documentation of 1:1 supervision. Review of additional facility documentation daily staffing sheet failed to identify a 1:1 for Resident R1. Review of the clinical record showed inconsistent documentation of any type of supervision for Resident R1 to prevent fall or injury. Review of the MDS Section J 1700 dated 11/16/23, indicated: the resident has had falls that are more recent with injury and major injury. Review of progress notes dated 11/18/23, 6:00 p.m. (for incident at 5:15 per clinical note) indicated: As we got too Resident R1 room we heard the bed alarm then a loud thump, Both the writer of this note and the Nurse Aide rushed into the room. Resident found face down with head facing the window and feet facing the bed. Resident moaning in pain and repeatedly saying my back hurts, please don't leave me. Resident R1 initial assessment in the facility was completed on 11/18/23, at 5:15 p.m. ambulance was called for an emergency transfer (5:22 p.m.) and left facility at 5:50 p.m. MD was notified of fall at 5:15 p.m. Review of facility documentation signature page event report incident report indicated: Resident R1 fall 11/18/23, 5:30 p.m. Fall risk assessment: Description: unwitnessed fall with injury, Observation details: actual fall Mental status/level of consciousness - disoriented x3 diminished safety awareness Balance and Gait: Balance problem while standing, while walking change in gait pattern when walking through doorway, decreased muscular coordination, jerking or unstable when making turns, requires use of assistive devices, Ambulation/Elimination status: impaired mobility/incontinent Does resident have a history of falls in last 3 months: three or more falls Evaluation Fall risk score - Score of 10 or higher represents a high risk for falls - total fall risk score = 21.0000 Level: At Risk Possible contributing factors: indicated resident has poor safety recall, and that the resident tis impulsive and that Resident R1 is unsafe on their own. Review of hospital record history of present illness dated 11/18/23, 11:13 p.m. indicated: Resident R1 presented to level 2 trauma following a unwitnessed ground level fall. Of note, Resident R1 is on warfarin (blood thinner). Resident R1 previously fell last week and fractured his left clavicle (break in the collarbone). Impression and Plan: CT (x-ray) trauma pan scans obtained which demonstrate multiple rib fractures, and a small hemothorax (blood collects between chest wall and lungs). Plan for trauma surgery service admission. Diagnosis: Fall, multiple rib fractures, small pneumothorax (collapsed lung). Review of hospital record dated 11/24/23, indicated: Imaging (x-rays) revealed multiple right posterior medial rib fractures. Resident R1 was admitted to the hospital in the ICU (Intensive Care Unit) for pain control and pulmonary care (care for diseases affecting lungs). Repeat CT (x-ray) chest revealed moderate to large right hemothorax (with complete collapse of the right lower lobe), and near complete collapse of the right middle lobe (collapse of the right lung). Chest tube (tube inserted through chest into lung to reinflate or drain fluid) was placed on 11/20/23. Review of Certificate of Death, dated 12/4/23, Time of Death approximate 18:17 p.m. (6:17 pm.) p.m. revealed Resident R1 had ceased to breath on 12/3/23, with the immediate cause listed as Complications of Blunt Force Trauma of the Trunk and subsequent conditions as Fall. Review of facility video of nursing care unit hallway revealed a facility nurse walked by the room and looked in roughly 4 1/2 minutes prior to the fall. She walked by the rooms and looked in the doors. She did not stop to check to see if Resident R1 needed anything, was positioned correctly, had call bell accessible, etc. During interviews on 12/20/23, between 3:14 p.m. and 5:00 p.m., the following was indicated by employees: Employee E1: Resident R1 was declining and had been on 1:1 after a previous fall where he/she broke their collar bone. Administration determines who has 1:1 - staff was told that we would not be doing a 1:1 that day of Resident R1 fall. Resident R1 needed a 1:1 he/she was a fall risk. Employee E2: Resident R1 care plan does say 1:1 when staffing allows, and administration decides who gets the 1:1. Not aware of any criteria for 1:1. Employee E3: Resident R1 was on a 1:1 had behaviors. Staff was told he/she would not be a 1:1 and another resident was provided a 1:1. Staff working thought Resident R1 was still a fall risk. Employee E4: Administration makes decisions on 1:1, decided in the morning and gets told to staff working on nursing units who will need a 1:1. Employee E5: has never done a 1:1 at the facility but has worked on the nursing unit prior (the nursing unit in question had three 1:1). Employee was unaware of 1:1 for any residents on the unit. Employee E6: Resident R1 use to have a sitter but didn't have one that day, was a fall risk. Doesn't know why 1:1 not provided. On 1/4/23, at 12:34 p.m. the Nursing Home Administrator (NHA) was made aware that an Immediate Jeopardy situation existed, and the Immediate Jeopardy template was provided to the NHA. On 1/4/23, at 4:45 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -All residents will be assessed utilizing the fall risk acuity observation by 1/5/24, resident fall care plans will be updated accordingly. -The process Evaluating Increased Observations for Residents with Behaviors or High Risk for Falls was developed, and education was initiated to nursing staff 1/2/24, which included providing care and services to meet resident needs and interventions related to falls including 1:1. -All clinical staff will be educated on the Bureau of Veterans Homes policy for Freedom of Abuse, Neglect, Exploitation, and Misappropriation of Resident property, Fall prevention program policy the process, of evaluating increased observations, for residents with behaviors for high risk falls, the fall risk assessment, fall risk care plans and fall interventions used for fall precautions. -Facility will conduct audits on residents who are requiring any fall interventions weekly for 4 weeks and then monthly for 2 months to ensure that interventions are in place to meet resident needs and interventions related to falls, including 1:1 observation. Bureau of Veterans Homes policy for Fall Prevention Program was reviewed on 1/4/24. Results of these audit will be reviewed at monthly Quality Assurance meetings to maintain ongoing compliance. The facility did the following for the plan of correction: -All residents were assessed for fall risk acuity assessments by 1/5/24. -1:1 residents were identified as needing updated fall prevention care plans and received fall prevention care plans by 1/5/24. -Facility implemented process Evaluating Increased Observations for Residents with Behaviors or High Risk for Falls was developed and education was initiated to nursing staff 1/2/24, which included providing care and services to meet resident needs and interventions related to falls including 1:1. -Substantial number of staff were trained on new process by 1/6/24. -Tools were implemented for QA process of identifying residents with fall risk and staff have been trained on using new forms. -Staff received training on fall prevention program, policy, process of evaluating increased observations, for residents with behaviors for high-risk falls, the fall risk assessment, fall risk care plan and fall interventions used for fall precautions. -Staff received training on Abuse, Neglect, Exploitation, and Misappropriation of Resident property. -Staff have been trained via email or in-person training. During interviews of staff working on-site on 1/6/24, between 10:00 a.m. and 11:00 a.m. all clinical staff (31 of 31) confirmed they were trained on fall risk acuity assessment/fall prevention and Neglect. The Immediate Jeopardy was lifted on 1/6/24, at 2:00 p.m. During interviews on 12/21/23, at 11:30 a.m. Director of Nursing (DON) confirmed that Resident R1 was a fall risk, had a care plan for 1:1 as staffing permitted. There was a 1:1 on the nursing unit the day of the fall but, it was not for Resident R1. That the cause of death for Resident R1 is listed as Complications of Blunt Force Trauma of the Trunk and subsequent conditions as Fall. During an interview on 1/6/24, at 2:05 p.m. the NHA and DON confirmed that the facility failed to provide adequate supervision and interventions for Resident R1 to prevent an unwitnessed fall, which resulted in actual harm when an fall occurred, and Resident R1 sustained multiple rib fractures, punctured lung and hospitalization which resulted in death. This failure created an Immediate Jeopardy situation for one of three residents (Resident R1). 28 Pa. Code201.18e(1) Management. 28 Pa. Code201.20(a)(b) Staff development. 28 Pa. Code201.29(a)c(d) Resident rights.