**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure physician services to provide orders for immediate care and needs for one (R)356 of three reviewed for injuries of unknown origin in a total sample of 35 residents, as evidenced by failing to assess and identify the cause of increased pain and swelling after an unwitnessed fall. R356 sustained an unwitnessed fall on 10/06/21 resulting in increasing pain and edema to the right leg and the facility medical director (R356's attending physician) failed to obtain an x-ray for six days after receiving negative doppler (ultrasonography used to evaluate the direction and pattern of blood flow) results ruling out a deep vein thrombosis (DVT; type of blood clot). The failure to ensure the resident received proper and adequate care resulted in harm. Findings include: Review of electronic medical record (EMR) revealed, under tab, Face Sheet, revealed R356 was admitted to facility on 07/10/19 with multiples diagnoses to included paraplegia and dementia. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/11/21 located in the EMR MDS tab revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. The assessment documented R356 required extensive assistance from two or more staff members for bed mobility and was totally dependent on staff for transfers, dressing, toilet use, and personal hygiene. Review of the facility-provided document titled, Care Plan with a revision date of 10/06/21 revealed a Problem/Need of, At risk for injury/falls related to Dementia, L3 Spinal cord injury, paraplegia, vitamin D deficiency, psychotropic med [medication] use, bowel incontinence .incontinence of bladder .resident places self on floor and refuses to allow staff to assist him up. Throws his legs over side of bed . Approaches listed on the care plan included but were not limited to observe routinely, offer time out of bed, bed in low position, fall mat to bedside, monitor for behaviors including placing self on floor, ensure resident is positioned in middle of bed, offer snack, encourage to call for assistance, offer early morning get up, bed alarm, check placement and function of bed alarm every shift, keep personal items in reach, and offer weighted blanket. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/06/21 documented R356 sustained an unwitnessed fall and was assessed by the nurse. R356 was sitting on the floor with his back against the bed. When asked how he got on the floor he reported he wanted to get off the bed. Neurological assessments were initiated and within normal limits. The note documented, PROM [passive range of motion] completed to BLE [bilateral lower extremities] and no complaints of pain or deformities noted. Res [resident] able to move both arms WNL [within normal limits]. Resident offered to get in the chair but stated he wanted to go back to bed. MD [Medical Director (R356's attending physician)] notified. Weighted blanket applied. The facility-provided paper document titled PHYSICIAN'S TELEPHONE ORDERS, dated 10/07/21, revealed Tramadol [narcotic analgesic] 50 mg po [by mouth] TID [three times a day] prn (pain) .venous us [ultrasound] RLE [right lower extremity] (rule out DVT) [deep vein thrombus] swelling. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/07/21 which documented R356's right leg was observed to be swollen. An order was received for a doppler to right leg and to begin tramadol (type of pain medication). The note documented tramadol was effective to control R356's pain. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/08/21 which documented a new order transport R356 to obtain the doppler due to the mobile radiology company not available at this time. A follow up note dated 10/08/21 revealed when transportation arrived to the facility the resident refused to go. The note stated, RN [Registered Nurse] was on floor and attempted to convince him, but he would not be swayed. RN and this nurse compared bilat [bilateral] lower legs; determined there was no color or size difference. No fever to Right lower leg [sic]. RN called Admin [facility administrator] and it was determined risk of xport [sic; transport] would outweigh benefit at this time . The original order for the mobile radiology group to come to facility and obtain ordered doppler was still scheduled. The physician was notified. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/12/21 revealed R356 reported his leg was extremely painful. The note also documented edema was noted from the knee up and his skin was described as shiny and tight from the ankle up .The resident did not eat his dinner, stated his stomach would not let him. Review of the facility-provided document titled, DOPPLER REPORT dated 10/12/21 revealed, Conclusion: No evidence of right lower extremity deep venous thrombosis [DVT], and was electronically signed by the by the interpreting physician at 5:37 PM. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/13/21 which documented the physician was notified of the doppler results and no new orders were received. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/14/21 which documented R356 was displaying behaviors of attempting to hang his legs off the side of the bed, was yelling and screaming, refused to allow staff to complete a body audit, and staff were unsuccessful in repositioning him even after several attempts. The nurse notified the supervisor. The notes lacked evidence of any additional orders provided by the physician. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/15/21 which documented R356 had increased pain and edema to his right leg. The hospice Certified Nursing Aide (CNA) reported difficulty completing activities of daily living with the resident due to his pain. The resident did not eat the breakfast or lunch meal. A new order was received to change R356's pain medication. The note lacked evidence that R356 was assessed by the physician due to the increase pain and swelling and no evidence that any new diagnostic orders were received. The facility-provided paper document titled NURSE'S MEDICATION NOTES, revealed PRN Tramadol was administered to R356 eight times from 10/07/21-10/15/21 with effective results. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/17/21 which documented R356 was making multiple attempts to throw his legs over the side of the bed. The note also documented his right leg edema continued and staff identified the right leg was warmer than the left with a reddened area. The note documented the physician was notified but lacked evidence that the physician completed an assessment or provided any new orders. Review of facility-provided paper document titled Departmental Notes, revealed a note dated 10/18/21 at 12:00 PM which showed a new order to obtain a stat x-ray of R356's right leg was received due to right leg swelling. A note dated 10/18/21 at 2:00 PM documented R356 continued to complain of pain. A note dated 10/18/21 at 3:36 PM revealed the ordered x-ray was completed and were reviewed by the physician. The note documented new orders were received but did not indicate what the order stated. A note date 10/18/21 at 4:04 PM documented R356 was transported to the hospital. A note dated 10/18/21 at 8:47 PM documented, LE [late entry]: 4:15pm X-ray results of right pelvis and right femur received: Results of right pelvis: right hip degenerative changes. No acute osseous [bone] abnormality. Results right femur - acute distal femur fracture. MD notified. [sic] The facility-provided paper document titled NURSE'S MEDICATION NOTES, revealed PRN Norco was administered to R356 six times from 10/15/21-10/18/21 with effective results. During an interview that was conducted on 01/11/22 at 4:45 PM, DON (Director of Nursing) confirmed R356 sustained an unwitnessed fall on 10/06/21. She confirmed a doppler was obtained on 10/12/21 with negative results for a DVT, the resident continued to display pain and swelling, and an x-ray was not ordered until 10/18/21. During an interview that was conducted on 01/12/22 at 10:25 AM, CNA15 reported she worked with R356 in October 2021. She recalled that his leg was swollen, he complained of pain, and he had a decline in his ability to assist with bed mobility prior to transferring to the hospital. CNA15 also recalled he was eating less during that time and nursing staff was aware of the edema in his leg. An interview was conducted on 1/12/22 at 11:30 AM with a family member of R356's. They confirmed they were notified he had an unwitnessed fall in early October 2021 and that he passed away at the hospital shortly after going there stating, his organs shut down because of blood loss. During an interview on 01/12/22 at 01:09 PM Licensed Practical Nurse (LPN)7 reported staff were aware of R356's right leg edema that developed following his fall on 10/06/21. She confirmed the physician was made aware of the resident's increased pain and edema. An interview was conducted on 01/12/22 at 1:48 PM, Unit Leader (UL)3 verified a diagnostic X-ray would be indicated for a resident with complaints of right leg pain and signs of swelling following an unwitnessed fall. UL3 confirmed diagnosis/treatment (x-ray) conducted/performed eleven days after a resident complained of pain and swelling following an unwitnessed fall would be considered a delay in diagnosis/treatment. An interview was conducted on 01/12/22 at 2:40 PM with the Medical Director (R356's attending physician). The MD did not recall being notified by facility staff of R356's increased pain following the 10/06/21 unwitnessed fall and said she reviewed this case multiple times. The MD reported the facility's nursing documentation was inconsistent. The MD said the resident received a surgery that she would not have recommended which she felt lead to his decline. She said she had not expected the x-ray would reveal a fracture and felt it was possible the fracture was caused by one of his numerous previous falls or possibly a hairline fracture worsened over time. During a follow-up interview on 01/12/22 at 3:47 PM the MD confirmed a doppler of the right leg was completed on 10/12/21, showed negative results, and the x-ray was not ordered until 10/18/21. The MD reported that she assessed R356 on the unit but did not complete a progress note every time. She said she was never given the impression by the nursing staff that something was horribly wrong with the resident. She further stated that when she looked at the whole scenario, she suspected that R356 had a hairline fracture that may not have been seen on a previous x-ray and that the edema she saw during this timeframe was not impressively different. When asked why there was a delay in ordering an x-ray after receiving the negative doppler results she said, You treat the symptoms. She further explained that R356's edema continued so that is why she ordered the x-ray, however, a DVT could be caused by a broken bone and immobility. The MD felt R356 sustained a more significant fall on 09/28/21 for which an x-ray was completed of his knee and showed no fracture. She went on to say that she was not informed R356 was having extreme pain because if she were, she would have examined him. The MD felt one could speculate about the cause of the fracture, but she could not know for sure. She said for someone to break the strongest bone in the body it would have to be some sort of fall and she believed the more likely cause of the fracture was his history of multiple falls. A phone interview was conducted on 01/13/22 at 10:57 AM with the MD. She reported she ordered the doppler on 10/07/21 because R356's leg was edematous and wanted to rule out a DVT. The MD confirmed the doppler was negative for a DVT and the resident still had swelling. She explained there was no underlying cause for the swelling but that swelling can be caused by soft tissue injuries as well. The MD said she got an x-ray of his knee after he fell on [DATE], which did show the top of the femur without any fracture. Copies of any physician progress notes for the month of October 2021 were requested from the physician during the 01/12/22 at 3:47 PM interview, however none were provided by the end of the survey.