**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facility document review, and facility policy review, the facility failed to consistently formulate and/or implement appropriate fall interventions for 1 (Resident #31) of 3 residents sampled for falls. Specifically, the facility repeatedly provided Resident #31, a resident with severe cognitive impairment, instructions to request assistance in response to multiple falls. In addition, the facility failed to consistently provide a sitter as directed in Resident #31's care plan due to lack of staff availability. This failure resulted in Resident #31 sustaining a right hip fracture on 01/26/2023. Findings included: A review of a facility policy titled, Falls and Fall Risk, Managing, last revised March 2018, revealed, Based on previous evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. A review of Resident #31's Facesheet revealed Resident #31 was admitted to the with diagnoses including dementia, senile degeneration of the brain, cerebral infarction, unspecified injury of the head, and essential hypertension. A review of Resident #31's comprehensive care plans revealed a care plan addressing Falls, dated 03/08/2021. This care plan indicated Resident #31 was at risk for falls related to cognitive deficits, impaired mobility, lack of safety awareness, incontinence, and dependence on staff for all activities of daily living (ADLs). This care plan indicated Resident #31 had a history of self-transferring from the bed to the wheelchair and the commode without calling for assistance or supervision. A review of Resident #31's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. According to the MDS, Resident #31 required limited assistance (staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person for transfers and toileting and was independent with locomotion, both on and off their unit. The MDS also indicated the resident was occasionally incontinent of urine and always continent of bowel. A review of a Resident Incident Report prepared by Registered Nurse (RN) #9 and dated 12/04/2022 with a timestamp of 7:51 PM, revealed Resident #31 sustained a fall. According to the report, the resident was exiting the bathroom and fell to the floor as witnessed by a certified nursing assistant (CNA) who was in the room feeding Resident #31's roommate. Immediate actions taken consisted of safety and education provided to the resident. A review of Resident #31's Falls care plan revealed an entry after the fall, dated 12/04/2022. The entry reflected that a fall with no injury occurred, with an intervention added that directed staff to ensure the resident wore proper footwear. A review of a Resident Incident Report, prepared by Licensed Practical Nurse (LPN) #7 and dated 12/05/2022, revealed Resident #31 fell again. According to the report, the resident was found on the floor in their bathroom doorway, sustained an abrasion to the left scapula area, and complained of pain all over. Immediate action taken consisted of educating the resident to ask for assistance with transfers. A review of Resident #31's Falls care plan revealed an entry after the fall, dated 12/05/2022. The entry reflected that a fall with injury occurred, which resulted in Resident #31 being sent to the emergency room (ER) for evaluation. According to the care plan, Resident #31 was diagnosed with a nasal fracture. An intervention was added to Resident #31's care plan on 12/05/2022 directing staff to evaluate the resident's blood pressure. On 12/06/2022, the facility initiated another care plan addressing falls related to Resident #31's poor safety awareness. The care plan indicated Resident #31 continuously got up without assistance and sustained a fall on 12/05/2022. According to the care plan, the ER report indicated the fall resulted in a minimally displaced right nasal bone fracture and a nondisplaced left nasal bone fracture. This care plan included interventions, dated 12/06/2022, directing staff to provide a sitter at the bedside, when available, and a referral to physical therapy for evaluation. A review of a PT [physical therapy] Evaluation & Plan of Care, dated 12/06/2022, revealed Resident #31 was educated regarding the need to always have assistance when standing up, but refused physical therapy services. A review of a Resident Incident Report, prepared by LPN #6 and dated 12/31/2022 with a timestamp of 1:31 PM, revealed Resident #31 was found on the floor near their bathroom with no apparent injuries. Per the report, an immediate action taken consisted of assessing the resident for injuries. A review of a Daily Sitter Schedule, dated 12/31/2022, revealed Resident #31 had no designated sitter assigned to their care at the time of the 12/31/2022 fall. The Daily Sitter Schedule included the following note to staff: If you are a CNA sitting and the floor is short, you are expected to take the floor. You are also responsible for all care and charting for the resident you are sitting with. A review of Resident #31's Falls care plan revealed an entry after the fall, dated 12/31/2022. The entry reflected that a fall with no injury occurred and indicated Resident #31 was referred to therapy for an evaluation of ambulation and unsteady gait. A review of a Resident Incident Report, prepared by LPN #7 and dated 01/13/2023 with a timestamp of 9:35 AM, revealed Resident #31 was found on the floor of their bathroom. Per the report, the resident was transferring from the toilet without assistance. The incident report indicated Resident #31 had their shoes on the wrong feet. Immediate actions taken consisted of providing education to Resident #31 regarding placing shoes on the correct feet and to call for assistance before transferring. A review of a Daily Sitter Schedule, dated 01/13/2023, revealed Resident #31 did not have a designated sitter assigned to their care at the time of the 01/13/2023 fall. A review of Resident #31's Falls care plan revealed an entry after the fall, dated 01/13/2023. The entry reflected a fall with a head injury occurred and indicated a bowel regimen was implemented on 01/13/2023. A review of a Resident Incident Report, prepared by LPN #7 and dated 01/26/2023 and timestamped 10:10 AM, revealed Resident #31 was holding onto the bed rail while facing the bed and stepped back to sit in their roommate's chair and fell. After the fall, Resident #31 complained of right hip/leg pain and their right foot was turned outward. New orders were obtained to send Resident #31 to the hospital. A review of a Daily Sitter Schedule, dated 01/26/2023, revealed Resident #31 had no designated sitter assigned to their care at the time of the 01/26/2023 fall. The schedule listed Nursing as Resident #31's sitter name, instead of a designated staff member. A review of Resident #31's Falls care plan revealed an entry after the fall, dated 01/26/2023. The entry reflected a fall with right hip fracture occurred and directed staff to provide a sitter for the resident to assist with all transfers. On 04/05/2023 at 2:59 PM, the Director of Nursing (DON) confirmed Resident #31 had no sitter assigned to their care on 01/26/2023. A review of Resident #31's hospital Discharge Summary, dated 01/31/2023, revealed the resident sustained a fall at the facility and subsequently complained of right leg pain. Resident #31's discharge diagnoses included a closed right hip fracture. A review of a Resident Incident Report, prepared by LPN #6 and dated 02/26/2023 with a timestamp of 12:28 PM, revealed Resident #31 sustained a fall. Per the report, staff observed the resident lying on their back on the floor. The incident report indicated Resident #31 was trying to transfer to another resident's bed. A review of a Daily Sitter Schedule, dated 02/26/2022, revealed CNA #10 was the designated sitter for both Resident #31 and their roommate at the time the 02/26/2023 fall occurred. A review of Resident #31's care plan addressing poor safety awareness and falls, dated 12/06/2022, revealed an entry dated 02/26/2023 that reflected a fall with injury occurred, with an intervention dated 02/26/2023, denoting fall with injury- sitter at bedside. A review of a Resident Incident Report, prepared by LPN #7 and dated 03/28/2023 with a timestamp of 4:55 PM, revealed Resident #31 was found sitting on the floor beside their bed with their wheelchair behind them. The incident report indicated Resident #31 was transferring from the chair without assistance. A review of a Daily Sitter Schedule, dated 03/28/2023, revealed Sitter #11 was the designated sitter for both Resident #31 and their roommate at the time the fall occurred. A review of Resident #31's Falls care plan revealed an entry that reflected a fall with no injury occurred and an intervention for sitter at bedside as indicated, dated 03/28/2023. On 04/05/2022 at 12:22 PM, LPN #6, the nurse who completed the incident reports after Resident #31's 12/31/2022 and 02/26/2023 falls, was interviewed. LPN #6 said after a resident experienced a fall, the nurse was expected to review the resident's care plan, along with any prior falls, to identify causal factors and new interventions. LPN #6 stated that all falls were also reviewed during morning meetings. LPN #6 stated Resident #31 had no short-term memory retention. She stated staff could ask the resident a question and the resident would not remember what was asked a minute later. LPN #6 stated she was unsure what fall interventions were currently in place for Resident #31, but noted she knew the resident had a sitter. LPN #6 noted she was unsure on what date sitter services were initiated but stated it had been in place for a while. LPN #6 stated she could not recall any specific details about Resident #31's falls. On 04/05/2023 at 1:03 PM, LPN #7, the nurse who completed the incident reports after Resident #31's 12/05/2022, 01/13/2023, 01/26/2023, and 03/28/2023 falls, was interviewed. LPN #7 said after a resident had a fall, the nurse was responsible for completing the incident reports and implementing immediate interventions, noting further interventions would then be discussed in morning meetings. LPN #7 stated she did not remember any specific details about Resident #31's falls on 12/05/2022, 01/13/2023, 01/26/2023 or 03/28/2023. She noted she was unable to remember if she put any immediate interventions in place after the falls, but stated there should have been a new intervention identified after each fall. LPN #7 acknowledged that providing education or reminding Resident #31 would not have been an effective intervention to keep the resident safe and prevent additional falls because Resident #31 had no short-term memory retention. LPN #7 also stated Resident #31 had a sitter, but she was not sure what the expectations for the sitters were, such as whether they should always remain with the resident or if someone else should take over supervision of the resident when the sitter went on break. During an interview with CNA #8 on 04/05/2023 at 4:51 PM, CNA #8 said Resident #31 had a sitter, but there was not a sitter assigned to the resident during every shift on every day. CNA #8 expressed uncertainty regarding why the resident had a sitter sometimes and not others. CNA #8 said Resident #31 was unable to retain any new information and could become combative and resist care at times. On 04/06/2023 at 5:17 AM, RN #9, the nurse who completed the incident report after Resident #31's fall on 12/04/2023, was interviewed via telephone. RN #9 stated after a resident had a fall, staff tried to determine what caused the fall and tried to identify appropriate interventions to prevent additional falls. RN #9 stated Resident #31 seemed very alert but could not retain information. RN #9 also stated that when staff tried to redirect Resident #31, the resident became combative and resisted care. RN #9 stated that staff constantly educated and encouraged Resident #31 to ask for assistance but agreed that educating Resident #31 to call for assistance was not an appropriate or reliable way to reduce the potential for additional falls. RN #9 stated sitters had been the most effective intervention for Resident #31. However, RN #9 said Resident #31 only had a sitter sometimes. RN #9 lacked knowledge regarding why Resident #31 had a sitter on an intermittent basis, noting the Administrator and DON made the sitter schedule. During an interview on 04/06/2023 at 8:15 AM, CNA #10 explained she was a CNA and was also assigned as a resident sitter on some shifts. CNA #10 stated that when she was assigned to provide sitting services for Resident #31, she was also assigned to the resident's roommate. CNA #10 stated when she was assigned as a sitter, she was responsible for charting resident activities, such as meals, voiding, bed mobility, and how the resident moved throughout the facility. CNA #10 stated that, before she could take a break, she let another CNA know to replace her. CNA #10 did not know how long Resident #31 had had a sitter in place. She explained that although Resident #31 had a sitter at times, the sitter could not provide one-on-one supervision because the sitter was also responsible for watching the roommate. CNA #10 stated she was assigned to watch Resident #31 and their roommate on 02/26/2023 when Resident #31 had a fall. She stated she was sitting at a dining room table with the roommate and Resident #31, who was in their wheelchair, mobilized down a hall into another resident's room. CNA #10 stated she yelled for other staff, but Resident #31 had already fallen in the room while trying to get into another resident's bed. During an interview on 04/06/2023 at 8:52 AM, Sitter #11 said when she was assigned to provide sitting services for Resident #31, she was also assigned to provide sitting services for the roommate. Sitter #11 said if one of the residents wanted to leave the room, she would notify other staff so a staff member could remain with both residents. Sitter #11 stated when Resident #31 fell on [DATE], she was in the dayroom with Resident #31's roommate, and Resident #31 was in their wheelchair mobilizing up and down the hallway. Sitter #11 said somehow Resident #31 slipped past her and went back to their room. Sitter #11 stated she did not know how Resident #31 got by her and said she wished that another staff member would have alerted her, but no one did. Sitter #11 said it was difficult to watch both residents at the same time, because Resident #31 was highly mobile, though the roommate was not. Sitter #11 said that one person could not supervise both residents and ensure the safety of both. Sitter #11 indicated she decided on her own to ask another staff to come in with the roommate if Resident #31 left the room to allow her to follow Resident #31. However, Sitter #11 said there had never been a directive that Resident #31 required one-on-one supervision. During an interview on 04/06/2023 at 9:18 AM, CNA #12 said she had started providing sitting services for Resident #31 sometime in March of 2023. She indicated when she provided sitting services for Resident #31, she also provided sitting services for their roommate. CNA #12 said the only thing she could do when Resident #31 left her sight was to go to the nurses' station to notify the nurse. During an interview on 04/06/2023 at 9:56 AM, the MDS Coordinator reviewed Resident #31's Falls care plan and stated a sitter was put into place around 12/06/2022. The MDS Coordinator was unsure when the sitter services specifically started and said Resident #31 had a sitter sometimes and other times did not. The MDS Coordinator stated that staff were always around Resident #31 and provided supervision when there was not an assigned sitter. However, she was unable to explain why a sitter was not provided every day if Resident #31 required a sitter for safety. The MDS Coordinator reviewed Resident #31's care plans related to safety and falls and agreed many of the interventions listed on the care plan were not effective or appropriate interventions, noting that any interventions that were identified should have been followed through on. During an interview on 04/06/2023 at 11:23 AM, the DON stated she tried to identify which residents needed a sitter daily but said sitter assignments were also based on staff availability. The DON confirmed Resident #31 was not assigned a sitter on 01/26/2023 when the resident fell and sustained a hip fracture and stated that it was due to staff/sitter availability. The DON stated Resident #31 had poor memory due to cognitive deficits, but that staff still tried to educate the resident. However, the DON acknowledged Resident #31 would know something one minute but would be unable to remember it the next minute. She agreed that educating or reminding Resident #31 was not appropriate and that staff should have identified additional interventions. The DON also stated there had been discussion of Resident #31 requiring one-on-one supervision but said the facility did not have the staff to accommodate that. During an interview on 04/06/2023 at 12:25 PM, the Administrator stated that when residents fell, the falls were discussed during morning meetings, and staff would try to determine what new interventions were appropriate. She said staff should be identifying other interventions aside from just educating Resident #31. The Administrator also stated the sitter was not an effective intervention since the facility did not have the staff to consistently provide Resident #31 a sitter every day.