**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to maintain resident safety from harm for 1 of 1 resident. Specifically, while bathing Resident (R)1 on 09/01/23, Certified Nursing Assistant (CNA)1 grabbed the bed linen/sheet and attempted to move/reposition R1 resulting in R1 falling to the floor and suffering injuries. On 11/09/23 the facility presented a Time Line of events. The survey team's investigation revealed the facility implemented interventions to address the noncompliance, indicating past noncompliance as of 09/02/23. Findings include: Review of the undated facility policy titled Fall Management System revealed, Standard: This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. Policy: It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses to include but not limited to, dementia, convulsions, hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/25/23, revealed a Brief Interview for Mental Status (BIMS) was not conducted due to R1 being non-verbal. Further review of R1's MDS revealed R1 needs extensive assistance with two person physical assist with bed mobility and R1 is total dependence with two person physical assist with transfers. Review of R1's Care Plan (unspecified date) revealed, Falls: risk for injury/falls r/t impaired mobility/coordination, cognitive/judgement deficits, medications . Risk for injury/falls will be minimized . Interventions include, Anticipate and meet needs. Mechanical lift for transfers. Needs a safe environment: . the bed in low position at night; side rails as ordered . Further review of the Care Plan revealed, ADL Mobility: ADL Self Care Performance Deficit r/t Disease Process and Limited Mobility. ICH/CVA with Left Hemiparesis, dysphagia, aphasia, seizure disorder, hydrocephalus, MDD, GERD, HTN, gastrostomy. Interventions include, Transfer: Requires (2) staff participation: Mechanical Aid (Sling) for transfers. Bathing: Usually needs total assistance. Bed Mobility: Usually needs total assistance. Review of R1's Progress Note dated 09/01/23 at 5:08 AM, written by Advanced Practice Nurse (APN) revealed, [R1] is a pleasant [AGE] year-old female resident who presents this morning with a chief complaint of fall from bed during care with contusion of the head. A small laceration with active bleeding to the occipital area was found by nursing and they initiated emergent transfer to the ER due to head injury with active bleeding. Review of R1's Neurosurgery Consult Note dated 09/01/23 revealed, .presenting as transfer from living facility with trace right frontal traumatic subarachnoid hemorrhage. Patient was being bathed by the facility staff when she was dropped and struck her head. Unknown if loss of consciousness. Patient is not on any AC/AP meds. Per EMS and patient's facility, she is at her neurologic baseline. On my exam, patient's eyes are open spontaneously, pupils reactive, right gaze preference, moans, purposeful on the right, contracted on the left. Patient was a trauma transfer he [sic] also has some C-spine fractures per report. Review of R1's Discharge summary dated [DATE] revealed, .presenting as transfer from living facility with trace right frontal traumatic subarachnoid hemorrhage. Transfer for higher level of care needs and transferred to [local hospital] after sustaining a reported slip w/ care needs. Hospital Course . Consultants were obtained 2/ 2 complex injury patterns . Chronic ossific fragment vs osteophyte fracture at C6. Review of a witness statement written by CNA1 on 09/01/23 revealed, I was bathing the resident in room [ROOM NUMBER]-B while I was bathing her, she was pulling on her brief and her feeding tube. I held her hand gently to stop her from pulling on anything else and proceeded to bathe her. I then used the sheet to pull her towards me and the chuck pad and turned her in the opposite direction. I rolled the resident over and she fell off the bed onto the floor. I then checked on the resident and laid a towel under her head. I went to the hallway and called for the nurse. Review of a witness statement written by Licensed Practical Nurse (LPN)1 on 09/01/23 revealed, This nurse was passing Meds on Hall one [CNA1] assigned to [R1] came to me to report that the resident had fallen out of her bed and was bleeding from the head. This nurse went immediately to check on the resident. Upon entering the resident room, she was noted laying on the floor on the right side of the bed nearest the air conditioner lying on her back and her head at the base of the nightstand. Bright red blood noted. [CNA1] had placed a towel under her head for support and to stop the bleeding. Third eye on call Advance Practice Nurse (APN) notified with message. I will be there shortly resident was assisted off of the floor to be cleaned as she noted having a BM and the floor soiled water or urine. After assisting resident to bed, she was turned over so this nurse could check to see where she was bleeding. A laceration was noted to the back of her head. EMT notified for transport to ER [local hospital] for further eval. On call NP and R/P are made aware. During an interview with the Director of Nursing (DON) on 11/09/23 at 1:37 PM revealed, My expectation is to follow the training they received when hired and [CNA1] did not. The DON stated staff should never reposition/move a patient in that manner. On 11/09/23, the facility presented a timeline of events which included interventions that were implemented to address the noncompliance. 11/9/2023 - Self Reportable investigation regarding [R1] [R1] had a change of elevation on 9/1/2023 during a bed bath. The patient required emergency medical services and was transported to [local hospital], the Registered Nursc at [local hospital] notified staff on 9/1/2023 at 11:26 am that the patient had sustained a neck fracture. 9/1/2023 - Immediate education was started with staff on the following: Providing Care to residents with restlessness, total assist; Post Fall instruction for possible Major/Serious Injury and Turning and Repositioning a Client as well as education on LMS/Relias for Dementia Care: Performing ADLs. 9/1/2023 - Teachable moment provided with CNA stating: When assisting a total care patient, 2 staff members are required for all care. Patients must be turned toward you and not away from you. 1:1 Education. 9/1/2023: Witness statements began to be obtained per investigation process and Interventions added to patient plan of care. (Fall Mats, Bolstered Mattress to aide with centering re ident in the bed and 2 person assist with ADLs). 9/2/2023: Patient returned to the facility from the Hospital with set interventions in place per IDT Team. At the hospital per discharge summary the patient did not require Acute Neurosurgical interventions, Repeat CTH upon arrival from [local hosital] to [local hospital] was stable, no additional imaging necessary. [R1] was kept overnight for observation and discharged back with the documentation from [local hospital] stating that patient was at Baseline. Orthopedic Spine consulted at [local hospital] and deemed no C Collar needs at time of discharge.