**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, interviews, and observation, the facility failed to ensure 1 resident, (R)114 out of 1 reviewed for accidents related to falls did not sustain a major injury. Specifically, R114 had an unwitnessed fall in the shower room, was transferred, and admitted to a local hospital which resulted in laceration to the head and a fractured elbow. The lack of adequate supervision placed the resident at risk for physical and or psychosocial harm. Findings include: Review of the facility's undated policy titled, Identifying and Managing Dementia Resident Safety Risks, last revised on 10/19/21, revealed the Policy Statement: PruittHealth recognizes that we serve a significant number of residents with various stages of dementia, which may change or progress over time. Residents with dementia are at a greater risk for falls, bruising, skin tears, wandering, and elopement, accidental ingestion of harmful substances, burns, and infection. Each resident's risks must be assessed, and a care plan developed based on those risks .3. Preventing Falls: 1. Assess the resident's risk of falling using the approved Falls Risk Assessment Tool . Review of the facility's undated policy titled, Occurrences, last revised 05/04/2016, revealed, The healthcare center recognizes that due to frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. In an effort to prevent occurrences, each patient/resident will be observed and assessed for risks. ARicppropriate [sic], realistic interventions will be implemented in accordance to their plan of care .Definitions: Occurrence hazards are physical features in the healthcare center environment which may pose a risk to patient/resident's safety, included but not limited, any event, accident or incident, on or off healthcare which results in an injury or has potential for injury. Medication discrepancy and adverse drug reaction, Unexplained injury to a patient/resident where no specific or actual incident was observed; yet the patient/resident exhibits evidence of an injury, such as bruise or skin tear. Review of R114's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to, dementia with behavioral disturbance, adult failure to thrive, muscle weakness, unsteadiness on feet, scoliosis, osteoarthritis and cognitive communication deficit. Review of R114's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/24/22 revealed a Brief Interview of Mental Status (BIMS) score of 00 out of 15, indicating she is cognitively impaired. Further review of the MDS assessment revealed R114 required supervision to limited assistance with activities of daily living (ADLs). She also was coded for exhibiting behaviors of wandering daily. Review of the Comprehensive Care Plan with a start date of 08/24/22 revealed R114 was at risk for falls related weakness and impaired cognition. Under the section titled, Goal revealed resident will not sustain injury related to falling through next review. The goal target date was noted as 11/10/22. The following interventions were recorded: 1. Keep environment safe-start date 08/24/22 2. Cue for safety awareness-start date 08/24/22 3. Assist for toileting and transfers PRN-start date 08/24/22 4. Transfer to MUSC Fairfield ER for eval r/t [related to] fall head injury-start date 08/26/22 5. Ensure resident is wearing appropriately sized clothing-start date 08/26/22 6. Refer to ortho for fracture-start date 08/31/22 7. Move room closer to the nurses station-start date 09/02/22 Review of progress notes dated 08/26/22 revealed, Patient is a poor historian due to cognitive/psychiatric impairment. The chief complaint/reason for visit noted as fall. The history of present illness (HPI) relating to this visit revealed that R114 was seen to be examined after a fall. The staff reported to provider that R114 did complain of elbow pain, but no swelling was noted. Staff also reported no changes in R114's neurological status and vital signs stable. Will send R114 out to emergency room for further evaluation. The assessment and plan noted: 1. Falls: acute unwitnessed fall last night; no changes in neurological status; vital signs stable; maintain fall precautions 2. Laceration-injury: acute; top of head, deep laceration; will send out to emergency room for staples and further evaluation. Review of the two-hour initial incident report submitted to the state agency on 08/31/22 at 4:40 PM revealed the type of injury of unknown source as a humeral fracture (upper arm fracture). The date and time of the reportable incident was noted as 08/31/22 at 4:20 PM. The description given for reporting the incident was c/o [complaint of] pain to arm. X-ray complete. Fracture to the humeral bone. Previous fall on 08/25/22. Investigating cause of fracture. Possible second fall overnight. Review of the five day follow up report submitted to the state agency on 09/05/22 at 12:46 PM by Director of Nursing (DON) revealed the type of injury of unknown source as fracture of undetermined ae of greater trochanter proximal left femur, impacted fracture of the left humeral neck (upper arm fracture). The diagnosis/medications with potential for placing resident at risk for injury was noted as: unspecified dementia with behavioral disturbance, muscle weakness (generalized), unsteadiness on feet, scoliosis unspecified, clonazepam (medication to control seizures), methadone (medication to treat Opioid disorder), and fentanyl (Opioid medication for pain). The resident condition prior to reportable incident was noted as complaining of left arm pain, guarding (behavior aimed at preventing pain). Details of Reportable Incident: Guarding and pain noted to left arm noted on 08/31/22, X-ray revealed fracture of undetermined age. Sent to ER on [DATE] and X-ray of left hip revealed a fracture of undetermined age. Interventions in place prior to reportable incident: removed large clothing from room. Immediate corrective action/assessment following reportable incident: X-ray ordered obtained, ortho referral made, sling provided. Physician notified: yes. Date/time: 08/31/22 at 3:00 PM. Interventions by facility to prevent future injury/alleged abuse: relocated resident room closer to the nurse's station. The summary report of the facility investigation noted an error in previous report; fall on 08/26/22 not 08/25/22. On 08/26/22 MSU resident had an unwitnessed fall. Initially complained of right elbow pain and PRN Tylenol was given. No further complaints at this time. However, resd [sic] did not allow nurse to assess her. The following morning assessment complete and open area was noted to head. Sent to ER where they placed staples and sent resd back to facility. Resd likely tripped over her clothing which has since been addressed. On 08/30/22 resd made complaints of pain to left arm but would not allow nurse to assess, is witnessed walking through out the shift as well. On 08/31/22 orders received to DC Fetanyl Patches and decrease Clonazepam to .05 mg every HS and taper methadone. Received n/o from NP to X ray left arm. Results show a humeral fracture of undetermined age. Orders given to refer to ortho, Ibuprofen 800 mg TID every 8 hours for 3 days and apt was made for 9/1/22 at 2:30 pm. Transportation not available for this apt. Therefore, MD gave orders to send to ER. At the hospital she began to complain of left hip pain as well. X-ray was done and a fracture of undetermined age and Osteopenia was noted. ER gave resd a sling for left arm and wt bearing as tolerated. Not a surgical candidate and to follow up with ortho. Returned to facility. Resd is observed continuing to walk on hip and use left arm daily since the fall on 8/26/22 through currently. Has been non-compliant with sling. Follow up ortho apt made for [DATE]th. Resd moved to a room closer to the nurse's station as she doesn't remember to use the call light. This is a frail 74 lb dementia patient with a BIMS of 10. States she recalls falling over a chair, and that she has only had 1 fall since she has been here. Fall on 8/26/22 was unwitnessed but in the shower room. Resd is very mobile and waunders [sic] through the unit. It is possible the resident had another fall and got herself up, not reporting to the nurse. Resd is identified as a high fall risk and has a history of falls prior to admission. She has been on several pain medications routinely, including DC' ed her fentanyl and methadone trapper down on 8/31/22. It is also possible that the pain medications were masking the pain from the initial fall on 8/26/22. However, the resident does not indicate that injuries was caused by a staff member or resident. I do not suspect abuse or neglect. During an interview with the Administrator on 11/17/22 at 11:48 AM, she revealed that she did not remember much about R114 and she did not know if she was still here. When surveyor stated she passed away, the Administrator stated that the staff working during the incident were Certified Nursing Assistant (CNA)1 and CNA2. During an interview with CNA2, she stated she does not work night shift; however, she knew about the fall but did not know or see how it happened. During an interview on 11/17/22 at 12:11 PM, CNA1 was asked about R114. Initially, CNA1 did not remember who it was. When asked if she remembered a resident falling, she stated oh yes, I remember now. When asked what happened, CNA1 stated she was at the nurses station her and another nurse and heard a thump. They went down the hall and she found R114 on the floor of the shower. She stated the shower should be locked but she thinks whoever was giving showers forgot and that is how R114 got into the shower. On 11/17/22 at approximately 1:33 PM, observation made with CNA2 of the shower unit where the fall occurred. CNA2 entered a code to open the shower door. She revealed that the door is to be always locked. When asked about the door being unlocked during the incident with R114, she didn't see how that could occur, unless someone forgot to close the door. She stated if you close the door, it automatically locks. During an interview on 11/17/22 at approximately 1:36 PM with CNA3, she states the shower is to be locked and always closed. During an interview with LPN2 at approximately 1:40 PM, she revealed that she remembers R114 as a very small woman. When asked if resident was a wanderer, she stated no. R114 did not go in and out of resident rooms but did walk up and down the hall. When asked about R114's fall, LPN2 stated that she was not at work at the time. When asked about the protocol for the shower doors, LPN2 stated it is to be locked at all times. During an interview on 11/17/22 at approximately 1:48 PM, with the DON, a request was made for the facility's policy on dementia and locked units. She revealed that they do not have one. When asked if the showers should be locked on the dementia unit, she stated yes because there could be chemicals in there. During an interview on 11/17/22 with DON at approximately 2:11 PM, she confirmed that they do not have a policy regarding locked showers on the dementia unit. During an interview on 11/17/22 with Corporate Clinical (CC) at approximately 2:58 PM, she also confirmed that there is no policy regarding locked showers on the dementia unit. She also stated that there are no chemicals in the shower, and they do not have to be locked.