**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to update residents' care plans after a fall with new and appropriate interventions for 3 residents (Residents #1, #86 and #93), and the facility's failure resulted in the potential for harm for Resident #1 by failing to develop and implement appropriate interventions after a fall with major injury on 8/5/2022, and resulted in actual harm when Resident #86 sustained a right hip fracture after a fall on 10/6/2023, Resident #93 sustained a close head injury after a fall on 10/18/2023, and Resident #93 fell again on 10/19/2023 and was sent to the Emergency Department (ED) for Altered Mental Status (AMS). The facility failed to give Certified Nursing Assistants (CNA) access to the care plans in the electronic medical record and failed to have a person-centered care plan for 11 residents (Residents #1, #3, #6, #20, #86, #88, #93, #134, #136, #137, and #138) of 16 residents reviewed for care plans. The facility's failure placed Residents #1, #86 and #93 in immediate jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) and had the potential or likelihood to affect all 40 residents in the facility. The Administrator, Administrator in Training (AIT), [NAME] President (VP) of Quality and Compliance, and the Health Information Services (HIS) Director and Privacy Officer were notified of the Immediate Jeopardy (IJ) on 10/24/2023 at 6:00 PM, in the [NAME] Boardroom/Conference Room. The facility was cited Immediate Jeopardy at F-656. The facility was cited at F-656 at a scope and severity of L. Addendum 3/5/2024: The scope and severity of citation F-656 has been amended and decreased as F656 (K). The Immediate Jeopardy began on 8/5/2022 and was removed on 10/27/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 10/29/2023 at 8:05 AM, and the corrective actions were validated onsite by the surveyors on 10/29/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Nursing Plan of Care, dated on 4/21/2023, showed .Each rehabilitation patient will have an individualized Nursing Plan of Care that is initiated on admission, maintained and updated, up to time of discharge .Registered nurses [RN] initiate Nursing Plans of Care to identify teaching and discharge needs. Both RNs and LPNs [licensed practical nurses] may maintain/update Nursing Plan of Cares [plans of care]. RNs are to supervise LPN care and documentation on the Nursing Plan of Care .The Care Plan is to be reassessed no less than weekly and updated or resolved by assigned nurse .For Subacute and LTC [long term care] patients [residents], the baseline care plan is done in the first 24 hours. The complete care plan is completed within 72 hours .The Nursing Plan of Care reflects nursing interventions and responses .Procedure .Problem/Need - Check one choice; 'actual' or 'potential' .Date Initiated - Date the Interventions selected .Interventions - Check the interventions you have selected and enter date .Updates will be done anytime there is a significant change in patient condition and/or weekly .Goals/Outcomes - Select the goals/outcomes that are appropriate for this patient. Otherwise check 'NA' .Date Resolved - Place the number of the intervention/goal and the date the patient no longer has the problem/need . Review of the facility's policy titled, Care plan preparation, long-term care, revised on 5/22/2023, showed .A care plan is an individualized, written action plan for a resident's care, treatment, and services that is based on the resident's .needs and preferences. The care plan must be person-specific .An interdisciplinary team works together to create a comprehensive care plan that guides a resident's care from admission to discharge .A review of the resident's medical history and condition should occur before planning the resident's care .ELEMENTS OF A CARE PLAN .driven by a resident's conditions and issues as well as a resident's unique characteristics. Each resident's care plan should be based on an assessment of the resident .each care plan should .evaluate each patient as an individual and include unique characteristics and strengths; use Minimum Data Set [MDS] to evaluate distinct functional areas .regarding functional status .provide a strong understanding of the patient .organize information to identify potential issues or conditions, such as triggers, for the resident .clarify potential issues by looking at causes and risks using the care area assessment process .be based on assessment information with necessary monitoring and follow-up .include information regarding ways to address causes and risks associated with issues and conditions to allow for resident's highest level of well-being .must develop a baseline care plan within 48 hours after the resident's admission to the facility .The interdisciplinary team then collaborates with the resident and reviews and revises the care, as necessary, to meet the resident's needs .The care plan for each resident must include .resident's goals, expressed in measurable objectives .to meet the resident's .needs identified in the comprehensive assessment .interventions describing the services the interdisciplinary team employs to maintain the resident's highest practicable .well-being .Implementation .Review the resident's medical record including .assessments .diagnostic test results .medical treatment plan, and other information that may affect the resident's care .Based on analysis of the data determine the nursing diagnoses that will guide the resident's care. Be sure to address all the resident's significant needs when determining the person-centered care plan .Select interventions that will help the resident achieve the stated outcome for each goal. Include specific information .Evaluate the resident's progress, and revise the care plan as appropriate .The care plan should reflect elements of person-centered care .and identify what daily routines are important to each resident .Documentation .Documentation associated with care plan preparation includes .all pertinent resident problems .expected outcomes .interventions . Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Dementia, Anxiety, Depression, Unspecified Fall Subsequent Encounter, Displ (Displaced) Intertroch (intertrochanteric) Fx (fracture) l (Left) Femr (Femur), and History of Urinary Tract Infection (UTI). Review of the change in status MDS assessment dated [DATE] showed Resident #1 was severely cognitively impaired and required extensive assist of 1 staff member for bed mobility, toileting, dressing and transfers. Resident used a manual wheelchair for locomotion on the unit. Resident had a prior fall that required surgical intervention was documented. Review of Resident #1's comprehensive care plan revealed .problem onset on 8/29/2012 of potential for injury from falls . the documentation showed the following interventions in place .call light in reach .Assist with ambulation .Keep room free of clutter .Encourage and frequently remind .to call for assistance and transfers .Assist with toileting .Staff will complete the [name of facility] fall risk tab in .Daily Assessment Every 24 hours .Perform Fall Risk Assessment .initiated 12/2/2022 by the Assistant Director of Nursing (ADON) . The documented intervention after the resident's fall with major injury on 8/5/2022 was .send to [local hospital name] for evaluation. No follow up interventions were implemented upon the resident's return to the facility on 8/9/2022 to prevent future fall recurrence. Review of Resident #1's nurses' notes showed on 8/5/2022, the resident suffered a fall where she was found by staff on the floor in her room lying on her left side. Resident #1 was asked what she was doing before the fall and stated .she wanted her shoes, then she fell down . During an assessment, Resident #1 was unable to tolerate touch to her left leg; and an order was obtained to send her to the emergency department (ED) for evaluation and treatment. Further review revealed Resident #1 was re-admitted to the facility on [DATE]. Review of the facility documentation (Event Report for fall #1) dated 8/5/2022 at 12:15 AM, reported by Licensed Practical Nurse (LPN) #7 showed Resident #1 had an unwitnessed fall .heard resident making noise and went into residents room and she was lying in the floor crying . Physician Assistant (PA) was notified, and an order was given to send to the ER for evaluation.Additional monitoring, treatment or interventions have been taken as a result of this event .Called MD for order to send patient out for evaluation for possible FX [fracture] of left hip . Resident #1's family was notified. The resident was assessed by 3 staff members LPN #7; Certified Nursing Assistant (CNA) #8; and the Supervisor).What type of injury was sustained in the fall? .Fracture .Prior to the fall was the patient determined to be at risk through the risk assessment process? .Yes .At the time of the fall, were any .risk factors present .History of previous fall .Sensory impairment .other (blank) .What protocols/interventions were in place, or being used, to prevent fall for this patient? .Assistive devices .bed in low position .Call light/personal items within reach .non-slip footwear .Recommendation for System Improvement .none at this time. Resident was sleeping on last round-very unlikely this resident to attempt to get up during nighttime hours .Likelihood of Event Recurrence .Remote .Severity/Harm Caused by Event .Temporary harm to the patient required initial/prolonged hospitalization . The Quality Department section of the event report showed the event could likely not have been prevented. The event report did not reflect it had been reviewed by the Assistant Director of Nursing (ADON), Director of Nursing (DON), Administrator to implement interventions to prevent future falls. Review of Resident #1's Orthopaedic Surgery Operative Note, dated 8/5/2022 at 3:02 PM, showed a .Closed comminuted intertrochanteric fracture of left femur [a type of hip fracture] . and an implant was used to correct the fractured left femur. Review of Resident #1's current comprehensive Care Plan undated, showed fall evaluations were completed daily, no numerical identification was noted as to the severity of risk nor was the resident classified with Green, Yellow, Orange or Red risk as indicated on the safe care and mobility card (used to determine the level a resident needs with assistance/ambulation) as indicated by the facility's policy and the fall risk assessments were not documented every shift per the facility's policy. Review of the annual MDS assessment dated [DATE] showed Resident #1 was severely cognitively impaired and required extensive assist of 1 staff member for bed mobility, toileting, dressing and transfers. Resident used a manual wheelchair for locomotion on the unit. During an interview on 10/20/2023 at 10:50 AM, Certified Nursing Assistant (CNA) #13 stated she had worked on 8/5/2022 after Resident #1's fall. The CNA stated resident's shoes were moved out of sight out of sight, so the resident was not tempted to get them. Further interview revealed CNA's did not have access to view the residents' care plan in the electronic medical record to view the interventions in place. The CNA stated .fall interventions were discussed in report at the beginning of shift .or she would ask the nurse . CNA #13 stated the red lights (above the resident's doors) were also used to identify residents who are at risk for falls or had fallen. The CNA stated they were very familiar with the patients. The CNA's attempt to move the resident's shoes out of sight was not added to the care plan as an intervention to prevent future falls During an interview on 10/20/2023 at 12:42 PM, Licensed Practical Nurse (LPN) #5 stated there was no SBAR (situation, background, assessment and recommendations communication form) printed at shift change for nurses because they are long term patients and .we know them . The LPN stated she also works with subacute residents, and at shift change for subacute resident care, the outgoing nurse prints the SBAR and gives report. Nursing does not do walking rounds with the oncoming nurses at shift change; however, CNAs do. The LPN stated fall interventions were known by staff for the long-term care residents, and she knows the residents and their needs. She stated those residents have beds low, call light in reach, Red light outside of the door to indicate previous falls, non-skid socks and safety precautions. The LPN stated the sub-acute residents have the fall risk written on a white board if they are a high fall risk, and there is a tag [safe care and mobility card] on their wheelchairs to indicate falls precautions. LPN stated .I don't think they [the LTC residents] have a tag on their chair .or white boards they were used for the subacute residents. Continued interview revealed new interventions are put on the care plan, and CNAs know what interventions are in place for residents because .the nurse tells them . The LPN stated rounds on residents are performed .all through the day . and explained the colored lights above the door in the hallway indicated the residents' level of fall risk. During an observation and interview on 10/20/2023 at 12:54 PM LPN #5 revealed Resident #1 was seated in the dining/activity room eating lunch in a wheelchair. LPN #5 confirmed no tag or cards were present on the wheelchair indicating fall precautions. During an observation on the 3rd floor on 10/20/2023 at 12:56 PM, no resident rooms had red lights illuminated above the door in the hallway. During an observation of Resident #1's room on 10/20/2023 at 12:58 PM, no communication white board was found in the room. No red light was illuminated above the door in the hallway. During an interview on 10/23/2023 at 9:16 AM, LPN #5 confirmed the safe care and mobility cards were not used and she was not aware they were to be used with the long-term care residents. During an interview on 10/23/2023 at 12:15 PM, the Director of Nursing (DON) confirmed Resident #1's care plan had not been updated to include new interventions to prevent further falls for the resident after she sustained a fall on 8/5/2022 that resulted in a left hip fracture. Resident #86 was admitted to the facility on [DATE], readmitted on [DATE] with diagnoses including Right Hip Fracture (10/7/2023), Dementia, Osteoarthritis, and Lumbar Compression Fractures. Review of Resident #86's baseline care plan dated 9/26/2023, showed the Safety section of the care plan was blank. Continued review showed Cognition .Orientation .to person .to place .Therapy Services .Physical (PT) .Occupational (OT) . Review of Resident #86's comprehensive care plan dated 9/26/2023, showed .ALTERATION IN SAFETY; RISK FOR INJURY (ACTUAL) .Related to: New Environment .PATIENT WILL NOT EXPERIENCE ANY INJURY OF UNKNOWN OR UNTOWARD EVENTS DURING HOSPITALIZATION .COMPLETE AND IMPLEMENT THE FALL RISK SCREEN .UPDATE AND IMPLEMENT FALL RISK SCREEN EACH WEEK .UPDATE AND IMPLEMENT FALL RISK SCREEN AFTER ANY EVENT INCLUDING FALL, MEDICATION CHANGE, OR CHANGE IN PATIENT CONDITION .EVALUATE MENTAL STATUS/ORIENTATION .PROVIDE CUES (WRITTEN INSTRUCTIONS OR PICTURES) TO FACILITATE A SAFE ENVIRONMENT. USE COMPENSATORY METHODS TO REINFORCE COGNITIVE OR PHYSICAL DEFICITS .RESPOND TO CALL LIGHTS PROMPTLY .ANTICIPATE THE PATIENT'S NEEDS (TOILETING, EATING, DRINKING) TO MINIMIZE IMPULSIVE MOVEMENT .ENSURE CALL BELL & PHONE WITHIN REACH, BED LOCKED AND IN LOW POSITION, BED ALARMS ACTIVATED (LOW BED IN THE LOWEST POSITION) .EDUCATE PATIENT/FAMILY ON MEDICATIONS THAT POTENTIALLY AFFECT THE PATIENT'S SAFETY .EDUCATE PATIENT AND/OR FAMILY IN METHODS FOR SAFELY USING ASSISTIVE DEVICES (WHEELCHAIR, [NAME], NON-SLIP SHOES) AND THE MANAGEMENT OF A SAFE ENVIRONMENT (TRIPPING HAZARDS, SIDE RAILS, ADQUATE LIGHTING) .ENCORAGE PATIENT TO VERBALIZE HOW THEY CAN CONTRIBUTE TO THEIR SAFETY .ADVISE PATIENT TO USE PROPER FOOTWEAR AND ENSURE NON SKID FOOTWEAR IS AVAILABLE .UPDATE CARE PLAN EVERY WEEK .UPDATE CARE PLAN EVERY SUNDAY .STAFF WILL COMPLETE THE [NAME] FALL RISK TAB IN SW DAILY ASSESSMENT EVERY 24 HOURS .PERFORM FALL RISK ASSESSMENT .DAILY . Review of the facility documentation (Event Report for fall #1) dated 9/28/2023 at 3:30 PM, reported by Registered Nurse (RN) #5 showed Resident #86 had an unwitnessed fall .got up from bed .walked to restroom. When he was walking back to the bed he fell forward .has 2 skin tears on his left arm and .nose. Patient said he wanted to go the restroom and .forgot to use call light. Patient was placed back in bed with call light within reach .Was the patient harmed? .Yes .How was this event discovered? .Assessment after event .Result of Event .Laceraton . Physician was notified and assessed resident at the bedside.Additional monitoring, treatment or interventions have been taken as a result of this event? .Not answered . Resident #86's family was notified. The resident was assisted back to bed by 3 staff members (Licensed Practical Nurse (LPN) #5; Certified Nursing Assistant (CNA) #11; and RN #5), the Nurse Practitioner was at the bedside and assessed the resident.What type of injury was sustained in the fall? .Skin tear, avulsion, hematoma or significant bruising .Prior to the fall was the patient determined to be at risk through the risk assessment process? .Yes .At the time of the fall, were any .risk factors present .Unknown .What protocols/interventions were in place, or being used, to prevent fall for this patient? .Unknown .Recommendation for System Improvement .Not answered .Likelihood of Event Recurrence .Remote .Severity/Harm Caused by Event .Temporary harm to the patient requiring intervention . (The facility Event Report did not reflect any new interventions were put in place after the fall.) Review of the nurses note dated 9/28/2023 at 3:30 PM, showed .Patient got out of bed and fell leaving the bathroom. Patient has decreased cognition and forgot to call for assistance. Placed bed in lowest position and call light within reach . Review of the comprehensive care plan updated on 9/28/2023, showed .Patient got out of bed and fell leaving the bathroom. Patient has decreased cognition and forgot to call for assistance. Placed bed in lowest position and call light within reach . (The bed in lowest position and call light within reach were interventions already in place prior to the fall. Resident #86 fell returning from the bathroom, not from the bed.) Review of the 5-day scheduled MDS assessment dated [DATE], showed Resident #86 was cognitively intact with a BIMS score of 15, prior functioning for everyday activities the resident was independent with self-care, indoor mobility with a walker, functional cognition, and no impairment with upper and lower range of motion. On admission the resident was independent with eating and rolling left to right; needed assistance with oral hygiene; dependent with toileting hygiene, lying to sitting on bedside, and sit to stand; required partial to moderate assistance with sit to lying, chair to bed transfers, and toileting transfer. The resident was frequently incontinent of bladder, and always continent of bowel. Continued review showed Resident #83 had a fall with fracture prior to admission without surgery and had a fall with injury since admission. The resident received therapy services. Review of the facility documentation (Event report for fall #2) dated 10/5/2023 at 5:00 PM, reported by CNA #12 showed Resident #86 had an unassisted fall and stated, .Found PT [patient] up in bathroom alone. Sit PT down to floor. Transfer Pt to Wc [wheelchair] and back to bed .Was the patient harmed .No .How was this evet discovered .Report by staff member .Type of event .Fall .Additional monitoring, treatment or interventions have been taken as a result of this event .Leave PT door open check on PT hourly .Was the fall observed .No .Prior to the fall, what was the patient doing or trying to do .Toileting-related activities .Prior to the fall was the patient determined to be at risk through the risk assessment process .Yes .At the time of the fall, were any of the following risk factors present .History of previous fall .What protocols/interventions were in place, or being used, to prevent fall for this patient .Bed in low position .Call light personal items within reach .Non-slip footwear .Other .Door kept open for observation .Likelihood of Event Recurrence .Remote .Severity/Harm Caused by Event .Reached patient & [and] required monitoring/intervention to confirm no patient harm . Review of the Comprehensive Care Plan updated on 10/5/2023, showed .Patient to have bed in low position while in bed. High fall risk on at patient's door . The bed position was not a new intervention. Resident #86 fell in the bathroom, so the intervention was not specific to the situation. There was no signage placed on residents' doors; there was a red light turned on and off by staff above door in the hallway to indicate the resident had fallen. The interventions listed in the Event Report dated 10/5/2023 to leave the resident's door open and monitor hourly was verbally reported to the nurse on duty, but the interventions were not reflected on the care plan. Review of a Nurses Note dated 10/5/2023 at 6:05 PM, showed .Patient found walking in room unsupervised by the CNA. Patient fell when he noticed the CNA enter the room. Patient was assisted back to chair. No additional skin breakdown seen after the fall. Patient was instructed to please call for assistance for ADLs .Patient is alert and oriented x [times] 2 . Review of the facility documentation (Event report for fall #3) by LPN #6 dated 10/6/2023 at 5:00 PM, showed Resident #86 had an unwitnessed fall while getting out of bed.Charge nurse came to notify nurse of pt [patient] experiencing an unwitnessed fall trying to get out of bed without assistance. CNA assisted pt back to WC. VS WNL .Pt states he did call for assistance but call light never went off. Pt c/o increased R hip pain r/t fall/. STAT XR through mobile imaging ordered. X ray confirmed FX of R hip. pt sent out on night shift for further eval .Was the patient harmed .Yes .How was this event discovered .Report by staff member .Type of Event .Fall .Result of Event .Fracture .Additional monitoring, treatment or interventions have been taken as a result of this event .acute transfer to .hospital .for further eval after confirmation of R [right] hip fx from mobile imaging .Was the fall observed .No .What type of injury was sustained in the fall .Fracture .Prior to the fall, what was the patient doing or trying to do .Ambulating without assistance and without assistive device or medical equipment .Prior to the fall was the patient determined to be at risk through the risk assessment process .Yes .At the time of the fall, were any of the following risk factors present .History of previous fall .What protocols/interventions were in place, or being used, to prevent fall for this patient .Bed in low position .Call light/personal items within reach .Injury Details .Fracture/dislocation (per radiology) .Action(s) Taken and Treatment Provided .Documented issue .Notified provider .Radiographic studies ordered .Follow-Up Notes from Triage and Investigation .Patient was reminded frequently to use call light when he wanted to get up. Call light was in reach. Patient had fallen the evening before and fall risk assessment indicated he should be monitored .Patient transferred to acute care once it was determined a fracture had occurred .Recommendations for System Improvement .Not answered .Likelihood of Event Recurrence .Occasional .Severity/Harm Caused by Event .Temporary harm to the patient that required initial/prolonged hospitalization . Review of a Nurses Note dated 10/6/2023 at 5:00 PM, showed .Charge nurse came to notify nurse of pt experiencing a unwitnessed fall trying to get out of bed without assistance. CNA assisted pt back into WC. VS WNL [Vital Signs Within Normal Limits]. BP [blood pressure] 132/75, HR [heartrate] 104, O2 [oxygen saturation] 95% [percent]. Pt c/o [complained of] increased R hip pain r/t [related to] fall. STAT XR [x-ray] of R hip ordered through mobile imaging. Night shift awaiting mobile imaging. passed along in report to night shift nurse . Review of the Comprehensive Care Plan updated on 10/6/2023, showed .pt experienced unwitnessed fall. c/o increased pain to R hip. XR ordered through mobile imaging . Review of a Nurses Note dated 10/6/2023 at 7:30 PM, showed .Patient [Resident #86] had fallen at 5:00pm and per mobile imaging had fractured .right hip. Patient sent to [name of hospital] per Dr [doctor] .at 1930 [7:30 PM]. Patient was complaining of pain in .right hip and back . Review of the ED Notes dated 10/6/2023, showed XXX[AGE] year old male with history of recent lumbar fracture was .getting rehabilitation, fell from chair and now coming in for right-sided hip fracture. Patient states his pain is well controlled, he is able to feel his leg and move his toes. He denies any head trauma. He denies any other symptoms at this time .Past Medical History .Memory deficit .Physical Exam [examination] .Tenderness, deformity and signs of injury present .R leg is shortened and externally rotated .Ortho Exam .x-ray shows acute right hip fracture .will admit to orthopedic service .Clinical Impression .Closed fracture of right hip, initial encounter .Disposition .Admit . Review of the Hospitalist Consult Note dated 10/7/2023, showed .admission Date: 10/6/2023 9:52 PM .Reason for Consultation: presurgical clearance .Chief Complaint .Right hip fracture .84 y.o. male, with history of dementia and HTN .chief complaint of right hip fracture s/p [status post] fall. Patient was recently admitted here 9/22/23 - 9/26/23 for weakness related to lumbar compression fracture and was discharged to .subacute rehab where he has been up until today. Unfortunately patient had a fall from his chair onto his right side and outside hip x-rays shows right hip fracture .sent to .ER [Emergency Room] for further evaluation .In the ER repeat hip x-ray confirms an acute right hip fracture .patient is unable to give any significant history as he is oriented only to name .patient initially did not know where he was but then after talking about him falling at [name of rehab facility], patient then was adamant he was at [name of rehab facility] .unsure why he is here even after being told he is fallen and broken his hip. When asked what month it was patient thought it was March or April .being admitted today pending surgical evaluation and treatment of his right hip fracture and hospitalist have been consulted to assist with preop optimization .Physical Exam .Ext - RLE [extremity-Right Lower Extremity] shortened and externally rotated .overall very confused .Radiology Results .CT [Computed Tomography-a type of x-ray exam] Head Without Contrast .10/7/2023 12:13 AM .IMPRESSION: No acute intracranial abnormalities .XR HIP 2 VIEW WITH PELVIS RIGHT .10/6/23 2244 .IMPRESSION .Acute right hip fracture .Assessment & [and] Plan .Principal Problem: Closed fracture of right hip .Active Problems .AMS (altered mental status) .Dementia .Closed Right hip fracture .Defer to primary team .AMS .ammonia, US [ultrasound-a type of x-ray exam] and stat head CT .per [name of rehab facility] paperwork patient baseline is A&O [Alert and Oriented] x 3 just 'forgetful' however currently only oriented to self. Is able to follow simple instructions but does not seem to follow along with with our discussion in general and does not understand the situation even after repeatedly explaining situation to him .Dementia .continue Namenda [a medication used to treat dementia] .minimize delirium inducing medications . Review of the OPERATIVE NOTE dated 10/7/2023, showed .Surgery Date: 10/7/2023 .Pre-Procedure Diagnosis: right hip intertrochanteric femur fracture . Review of the Orthopaedic Discharge summary dated [DATE], showed .admission Date: 10/6/2023 9:52 PM .Procedure Performed .RIGHT OPEN REDUCTION INTERNAL FIXATION, INTRAMEDULLARY NAIL .ORIF, FEMUR Right 10/7/2023 .discharge date : [DATE] .Diagnoses at discharge: Closed fracture of right hip .84 .year old male admitted with right hip intertrochanteric femur fracture .Hospital Course: S/p IM [intramedullary] nail [a metal rod inserted into a broken bone for solid support] for intertrochanteric femur fracture .on 10/7/2023 .Stable condition .Disposition: Lying in bed. AA&O [alert and oriented] .Pain well controlled .Continue to mobilize with PT .D/c [discharge] to SNF [skilled nursing facility] today . During an interview on 10/18/23 01:55 PM, LPN #5 stated she was not the nurse who completed the falls event report for Resident #86 on 9/28/2023 (fall #1), but she did go and assist getting the resident out of the floor. Resident #86's wheelchair was bedside the bed (unable to say if locked), bed was in lowest position, had on non skid socks, and call light was within reach. The resident stated he was trying to go to the bathroom. LPN #5 stated no new interventions were put in place after the fall. Continued interview with LPN #5 revealed she was the nurse who cared for Resident #86 on 10/6/2023, when the resident sustained fall #3. LPN #5 stated when report was handed off at the beginning of the shift, it was reported Resident #86 had a fall on 10/5/2023 but was not informed of any new interventions in place and was not informed the resident needed to be monitored hourly. The LPN was informed by CNA #11 around 5:00 PM, that Resident #86 had fallen, and the CNA had gotten the resident out of the floor. CNA #11 was probably doing .rounds when .resident was found . LPN #5 stated CNA #11 informed the resident was .ok .and was complaining of right hip pain . The LPN further stated she walked across the hallway, notified the physician, and immediately ordered an x-ray. LPN #5 continued to state when Resident #86 was assessed he stated he was trying to go to the bathroom, had pushed his call light, and the call light did not work. LPN #5 stated she did not test the call light to test functionality and did not recall if the call light was on or had been on. LPN #5 stated mobile images arrived prior to shift change (around 6:45 PM) to complete the ordered x-ray, the technician reported the fracture, the physician was notified, and ordered for Resident #86 to be transferred to the ER for evaluation and treatment. During a telephone interview on 10/18/2023 at 2:33 PM, RN #5 stated she had cared for Resident #86 on 9/28/2023 when the resident suffered a fall (fall #1). The resident told the RN that he had to go to the bathroom and did not turn the call light on for assistance. RN #5 stated the resident had not attempted to get out of bed prior to the fall. Interventions in place prior to fall were bed in low position, call light within reach, and non-skid socks. RN #5 stated Resident #86's bed was lower than before to prevent the resident from getting out of the bed. During an interview on 10/18/2023 at 2:57 PM, CNA #12 stated she comple[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #86 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Right Hip Fracture (10/7/2023), Dementia, Osteoarthritis, and Lumbar Compression Fractures. Review of Resident #86's baseline care plan dated 9/26/2023, showed the Safety section of the care plan was blank. Continued review showed Cognition .Orientation .to person .to place .Therapy Services .Physical (PT) .Occupational (OT) . Review of Resident #86's comprehensive care plan dated 9/26/2023, showed .ALTERATION IN SAFETY; RISK FOR INJURY (ACTUAL) .Related to: New Environment .PATIENT WILL NOT EXPERIENCE ANY INJURY OF UNKNOWN OR UNTOWARD EVENTS DURING HOSPITALIZATION .COMPLETE AND IMPLEMENT THE FALL RISK SCREEN .UPDATE AND IMPLEMENT FALL RISK SCREEN EACH WEEK .UPDATE AND IMPLEMENT FALL RISK SCREEN AFTER ANY EVENT INCLUDING FALL, MEDICATION CHANGE, OR CHANGE IN PATIENT CONDITION .EVALUATE MENTAL STATUS/ORIENTATION .PROVIDE CUES (WRITTEN INSTRUCTIONS OR PICTURES) TO FACILITATE A SAFE ENVIRONMENT. USE COMPENSATORY METHODS TO REINFORCE COGNITIVE OR PHYSICAL DEFICITS .RESPOND TO CALL LIGHTS PROMPTLY .ANTICIPATE THE PATIENT'S NEEDS (TOILETING, EATING, DRINKING) TO MINIMIZE IMPULSIVE MOVEMENT .ENSURE CALL BELL & PHONE WITHIN REACH, BED LOCKED AND IN LOW POSITION, BED ALARMS ACTIVATED (LOW BED IN THE LOWEST POSITION) .EDUCATE PATIENT/FAMILY ON MEDICATIONS THAT POTENTIALLY AFFECT THE PATIENT'S SAFETY .EDUCATE PATIENT AND/OR FAMILY IN METHODS FOR SAFELY USING ASSISTIVE DEVICES (WHEELCHAIR, [NAME] [walker], NON-SLIP SHOES) AND THE MANAGEMENT OF A SAFE ENVIRONMENT (TRIPPING HAZARDS, SIDE RAILS, ADEQUATE LIGHTING) .ENCOURAGE PATIENT TO VERBALIZE HOW THEY CAN CONTRIBUTE TO THEIR SAFETY .ADVISE PATIENT TO USE PROPER FOOTWEAR AND ENSURE NON SKID FOOTWEAR IS AVAILABLE .UPDATE CARE PLAN EVERY WEEK .UPDATE CARE PLAN EVERY SUNDAY .STAFF WILL COMPLETE THE .FALL RISK TAB .DAILY ASSESSMENT EVERY 24 HOURS .PERFORM FALL RISK ASSESSMENT .DAILY . Review of the nursing documentation dated 9/27/2023 at 10:09 AM, showed Resident #86 had a fall risk score of 5, indicating .YELLOW-LOW FALL RISK-The patient must let staff know when they are up and moving . Review of the nursing documentation dated 9/27/2023 at 4:38 PM, showed Resident #86 had a fall risk score of 15, indicating an .ORANGE-MODERATE FALL RISK-Must have assistance toileting. Does not require staff to be in the restroom with toileting but does require them to be in the patient's room and ready to assist immediately . Review of Resident #86's nurses note dated 9/28/2023 at 3:30 PM, showed .Patient got out of bed and fell leaving the bathroom. Patient has decreased cognition and forgot to call for assistance. Placed bed in lowest position and call light within reach . Further review showed a repeat assessment and fall risk score was not completed after the fall. Review of the facility documentation (Event Report for fall #1) dated 9/28/2023 at 3:30 PM, reported by RN #5 showed Resident #86 had an unwitnessed fall .got up from bed .walked to restroom. When he was walking back to the bed he fell forward .has 2 skin tears on his left arm and .nose. Patient said he wanted to go the restroom and .forgot to use call light. Patient was placed back in bed with call light within reach .Was the patient harmed .Yes .How was this event discovered .Assessment after event .Result of Event .Laceration . Physician was notified and assessed resident at the bedside.Additional monitoring, treatment or interventions have been taken as a result of this event .Not answered . Resident #86's family was notified. The resident was assisted back to bed by 3 staff members (Licensed Practical Nurse (LPN) #6; CNA #11; and RN #5), the Nurse Practitioner was at the bedside and assessed the resident.What type of injury was sustained in the fall .Skin tear, avulsion, hematoma or significant bruising .Prior to the fall was the patient determined to be at risk through the risk assessment process .Yes .At the time of the fall, were any .risk factors present .Unknown .What protocols/interventions were in place, or being used, to prevent fall for this patient .Unknown .Recommendation for System Improvement .Not answered .Likelihood of Event Recurrence .Remote .Severity/Harm Caused by Event .Temporary harm to the patient requiring intervention . The rest of the Event Report was Not answered, did not reflect any new interventions were put in place, and had not been review by the ADON, DON, AIT, or Quality to ensure appropriate fall interventions had been implemented. Review of Resident #86's comprehensive care plan updated on 9/28/2023, showed .Patient got out of bed and fell leaving the bathroom. Patient has decreased cognition and forgot to call for assistance. Placed bed in lowest position and call light within reach . The bed in lowest position and call light within reach were interventions already in place prior to the fall. Resident #86 fell returning from the bathroom, not from the bed. Review of Resident #86's nursing documentation dated 9/28/2023 at 9:25 PM, showed Resident #86 had a nursing assessment and had a fall risk score of 30, always indicating .RED-HIGH FALL RISK- Eyes and hands on the patient when up and moving. The patient must have assistance with toileting. The patient is NOT to be left alone when toileting . Review of the nursing documentation dated 9/28/2023 at 9:42 PM, showed Resident #86 had a nursing assessment and had a fall risk score of 30, indicating .RED-HIGH FALL RISK- Eyes and hands on the patient when up and moving. The patient must have assistance with toileting. The patient is NOT to be left alone when toileting . Review of Resident #86's nurse practitioner progress note dated 9/29/2023, showed .History/Reason for visit: s/p [status post] fall 9/28 - doesn't Remember .fall - PT/OT Rehab .wedge comp [compression] fx [fracture] - Lumbar .memory loss . Review of Resident #86's nursing documentation dated 9/29/2023 at 8:29 PM, showed Resident #86 had a nursing assessment and had a fall risk score of 30, indicating .RED-HIGH FALL RISK- Eyes and hands on the patient when up and moving. The patient must have assistance with toileting. The patient is NOT to be left alone when toileting . Review of Resident #86's nursing documentation dated 10/1/2023 at 11:10 AM, showed Resident #86 had a nursing assessment and had a fall risk score of 30, indicating .RED-HIGH FALL RISK- Eyes and hands on the patient when up and moving. The patient must have assistance with toileting. The patient is NOT to be left alone when toileting . Review of the 5 day scheduled MDS assessment dated [DATE], showed Resident #86 was independent with rolling left to right and dependent with toileting hygiene, lying to sitting on bedside, and sit to stand. The reisdnet required partial to moderate assistance with sit to lying, chair to bed transfers, and toileting transfer. The resident was frequently incontinent of bladder, and always continent of bowel. Continued review showed Resident #86 had a fall with fracture prior to admission without surgery and had a fall with injury since admission. The resident received therapy services. Record review showed Resident #86 did not have a nursing assessment or a fall risk score completed for 10/2/2023. Review of the nursing documentation dated 10/3/2023 at 10:22 AM, showed Resident #86 has a nursing assessment and had a fall risk score of 20, indicating an .ORANGE-MODERATE FALL RISK-Must have assistance toileting. Does not require staff to be in the restroom with toileting but does require them to be in the patient's room and ready to assist immediately . Review of the nursing documentation dated 10/3/2023 at 8:53 PM, showed Resident #86 has a nursing assessment and had a fall risk score of 20, indicating an .ORANGE-MODERATE FALL RISK-Must have assistance toileting. Does not require staff to be in the restroom with toileting but does require them to be in the patient's room and ready to assist immediately . Review of the nursing documentation dated 10/4/2023 at 9:29 AM, showed Resident #86 has a nursing assessment and had a fall risk score of 5, indicating .YELLOW-LOW FALL RISK-The patient must let staff know when they are up and moving . Review of the nursing documentation dated 10/4/2023 at 8:50 PM, showed Resident #86 has a nursing assessment and had a fall risk score of 15, indicating an .ORANGE-MODERATE FALL RISK-Must have assistance toileting. Does not require staff to be in the restroom with toileting but does require them to be in the patient's room and ready to assist immediately . Review of the nursing documentation dated 10/5/2023 at 11:26 AM, showed Resident #86 had a fall risk score of 5, indicating .YELLOW-LOW FALL RISK-The patient must let staff know when they are up and moving . Review of the facility documentation (Event report for fall #2) dated 10/5/2023 at 5:00 PM, reported by CNA #12 showed Resident #86 had an assisted fall .Found PT [patient] up in bathroom alone. Sit PT down to floor. Transfer Pt to Wc [wheelchair] and back to bed .Was the patient harmed .No .How was this event discovered .Report by staff member .Type of event .Fall .Additional monitoring, treatment or interventions have been taken as a result of this event .Leave PT door open check on PT hourly .Was the fall observed .No .Prior to the fall, what was the patient doing or trying to do .Toileting-related activities .Prior to the fall was the patient determined to be at risk through the risk assessment process .Yes .At the time of the fall, were any of the following risk factors present .History of previous fall .What protocols/interventions were in place, or being used, to prevent fall for this patient .Bed in low position .Call light personal items within reach .Non-slip footwear .Other .Door kept open for observation .Likelihood of Event Recurrence .Remote .Severity/Harm Caused by Event .Reached patient & [and] required monitoring/intervention to confirm no patient harm . The rest of the Event Report was Not answered. A new intervention to .Leave PT door open check on PT hourly . was documented in the Event Report by CNA #12, but RN #1 did not place the new intervention on the care plan. There was no documentation in the medical record Resident #86 was rounded on hourly. The Event Report had not been reviewed by the ADON, DON, AIT, or Quality to ensure appropriate fall interventions had been implemented. Review of Resident #86's Comprehensive Care Plan updated on 10/5/2023, showed .Patient to have bed in low position while in bed. High fall risk on at patient's door . (The bed in low position was already on the care plan and there is no signage placed on residents' doors, there is a red light turned on and off by staff above the outside door frame to indicate the resident had fallen.) Review of Resident #86's Nurses Note dated 10/5/2023 at 6:05 PM, showed .Patient found walking in room unsupervised by the CNA. Patient fell when he noticed the CNA enter the room. Patient was assisted back to chair. No additional skin breakdown seen after the fall. Patient was instructed to please call for assistance for ADLs [activities of daily living] .Message was left for the patient's daughter on her phone. Patient is calm and resting at this time. Patient is alert and oriented x [times] 2 . Further review showed RN #1 had completed a repeat assessment, and a fall risk score was not completed after the fall. Review of the night shift nursing documentation dated 10/5/2023 at 8:47 PM, showed Resident #86 had a fall risk score of 30, indicating .RED-HIGH FALL RISK- Eyes and hands on the patient when up and moving. The patient must have assistance with toileting. The patient is NOT to be left alone when toileting . Review of the nursing documentation dated 10/6/2023 at 5:00 PM, showed Resident #86 had a fall risk score of 48, indicating .RED-HIGH FALL RISK- Eyes and hands on the patient when up and moving. The patient must have assistance with toileting. The patient is NOT to be left alone when toileting . Review of Resident #86's Nurses Note dated 10/6/2023 at 5:00 PM, showed .Charge nurse came to notify nurse of pt experiencing a unwitnessed fall trying to get out of bed without assistance. CNA assisted pt back into WC. VS WNL. BP 132/75, HR 104, O2 95%. Pt c/o increased R hip pain r/t fall. STAT XR of R hip ordered through mobile imaging. Night shift awaiting mobile imaging. passed along in report to night shift nurse . Review of the facility documentation (Event report for fall #3) dated 10/6/2023 at 5:00 PM, reported by LPN #6 showed Resident #86 had an unwitnessed fall while getting out of bed.Charge nurse came to notify nurse of pt [patient] experiencing a unwitnessed fall trying to get out of bed without assistance. CNA assisted pt back to WC. VS WNL .Pt states he did call for assistance but call light never went off. Pt c/o increased R hip pain r/t fall/. STAT XR through mobile imaging ordered. X ray confirmed FX of R hip. pt sent out on night shift for further eval .Was the patient harmed .Yes .How was this event discovered .Report by staff member .Type of Event .Fall .Result of Event .Fracture .Additional monitoring, treatment or interventions have been taken as a result of this event .acute transfer to .hospital .for further eval after confirmation of R [right] hip fx from mobile imaging .Was the fall observed .No .What type of injury was sustained in the fall .Fracture .Prior to the fall, what was the patient doing or trying to do .Ambulating without assistance and without assistive device or medical equipment .Prior to the fall was the patient determined to be at risk through the risk assessment process .Yes .At the time of the fall, were any of the following risk factors present .History of previous fall .What protocols/interventions were in place, or being used, to prevent fall for this patient .Bed in low position .Call light/personal items within reach .Injury Details .Fracture/dislocation (per radiology) .Action(s) Taken and Treatment Provided .Documented issue .Notified provider .Radiographic studies ordered .Follow-Up Notes from Triage and Investigation .Patient was reminded frequently to use call light when he wanted to get up. Call light was in reach. Patient had fallen the evening before and fall risk assessment indicated he should be monitored .Patient transferred to acute care once it was determined a fracture had occurred .Recommendations for System Improvement .Not answered .Likelihood of Event Recurrence .Occasional .Severity/Harm Caused by Event .Temporary harm to the patient that required initial/prolonged hospitalization . The Quality Department did a brief .Respectful Mgmt [Management] Checklist ., but it was not completed. Review of the Comprehensive Care Plan updated on 10/6/2023, showed .pt experienced unwitnessed fall. c/o increased pain to R hip. XR ordered through mobile imaging . Review of a Nurses Note dated 10/6/2023 at 7:30 PM, showed .Patient [Resident #86] had fallen at 5:00pm and per mobile imaging had fractured .right hip. Patient sent to [name of hospital] per Dr [doctor] .at 1930 [7:30 PM]. Patient was complaining of pain in .right hip and back . Review of the discharge MDS assessment dated [DATE] showed Resident #86 had an unplanned discharge to hospital with return anticipated. Review of Resident #86's ED [Emergency Department] Notes dated 10/6/2023, showed XXX[AGE] year old male with history of recent lumbar fracture was .getting rehabilitation, fell .coming in for right-sided hip fracture. Patient states his pain is well controlled, he is able to feel his leg and move his toes. He denies any head trauma. He denies any other symptoms at this time .Past Medical History .Memory deficit .Physical Exam [examination] .Tenderness, deformity and signs of injury present .R leg is shortened and externally rotated .Ortho Exam .x-ray shows acute right hip fracture .will admit to orthopedic service .Clinical Impression .Closed fracture of right hip, initial encounter .Disposition .Admit . Review of Resident #86's Hospitalist Consult Note dated 10/7/2023, showed .admission Date: 10/6/2023 9:52 PM .Reason for Consultation: presurgical clearance .Chief Complaint .Right hip fracture .84 y.o. male, with history of dementia .chief complaint of right hip fracture s/p [status post] fall. Patient was recently admitted here 9/22/23 - 9/26/23 for weakness related to lumbar compression fracture and was discharged to .subacute rehab where he has been up until today. Unfortunately patient had a fall .onto his right side and outside hip x-rays shows right hip fracture .sent to .ER [Emergency Room] for further evaluation .In the ER repeat hip x-ray confirms an acute right hip fracture .patient is unable to give any significant history as he is oriented only to name .patient initially did not know where he was but then after talking about him falling at [name of rehab facility], patient then was adamant he was at [name of rehab facility] .unsure why he is here even after being told he is fallen and broken his hip. When asked what month it was patient thought it was March or April .being admitted today pending surgical evaluation and treatment of his right hip fracture and hospitalist have been consulted to assist with preop optimization .Physical Exam .Ext - RLE [extremity-Right Lower Extremity] shortened and externally rotated .overall very confused .Radiology Results .CT [Computed Tomography-a type of x-ray exam] Head Without Contrast .10/7/2023 12:13 AM .IMPRESSION: No acute intracranial abnormalities .XR HIP 2 VIEW WITH PELVIS RIGHT .10/6/23 2244 [10:44 PM] .IMPRESSION .Acute right hip fracture .Assessment & [and] Plan .Principal Problem: Closed fracture of right hip .Active Problems .AMS (altered mental status) .Dementia .Closed Right hip fracture .per [name of rehab facility] paperwork patient baseline is A&O [Alert and Oriented] x 3 just 'forgetful' however currently only oriented to self. Is able to follow simple instructions but does not seem to follow along with our discussion in general and does not understand the situation even after repeatedly explaining situation to him .Dementia . Review of Resident #86's OPERATIVE NOTE dated 10/7/2023, showed .Surgery Date: 10/7/2023 .Pre-Procedure Diagnosis: right hip intertrochanteric femur fracture . Review of Resident #86's Orthopaedic Discharge summary dated [DATE], showed .admission Date: 10/6/2023 9:52 PM .Procedure Performed .RIGHT OPEN REDUCTION INTERNAL FIXATION [ORIF], INTRAMEDULLARY NAIL [a metal rod inserted into a broken bone for solid support] .ORIF, FEMUR Right 10/7/2023 .discharge date : [DATE] .Diagnoses at discharge: Closed fracture of right hip .84 .year old male admitted with right hip intertrochanteric femur fracture .Hospital Course: S/p IM [intramedullary] nail for intertrochanteric femur fracture .on 10/7/2023 .Stable condition .Disposition .Continue to mobilize with PT .D/c [discharge] to SNF [skilled nursing facility] today . During an interview on 10/17/2023 at 6:05 PM, the HIS Director and Privacy Officer reviewed the medical records and confirmed hourly monitoring was not completed or documented after the fall on 10/5/2023 (fall #2). During an interview on 10/18/2023 at 1:55 PM, LPN #6 stated she was not the nurse who completed the falls event report for Resident #86 on 9/28/2023 (fall #1), but she did go and assist getting the resident out of the floor. LPN #6 stated a family member from room [ROOM NUMBER] (another resident's family member) came by the nurse's desk and informed staff Resident #86 was in the floor. The LPN continued with .it was insanely busy on the unit at the time of the fall .the resident was found face down .with blood coming from the nose . Resident #86 had fallen forward; with feet were towards the bathroom and head towards the center of the room; it appeared he was coming from the bathroom. There were no x-rays ordered at this time. The resident did not complain of pain. Resident #86 was able to respond to staff, but was dazed; .this was his normal state . The resident was placed in the bed and a head to toe assessment was completed by the resident's nurse (RN #5). Resident #86's wheelchair was bedside the bed (unable to say if locked), bed was in lowest position, had on non skid socks, and call light was within reach. The resident stated he was trying to go to the bathroom. LPN #6 stated no new interventions were put in place after the fall. The Nurse Practitioner was notified of the fall and came to the bedside to assess the resident, by the time she arrived Resident #86's nose had stopped bleeding; no new orders were received. Continued interview with LPN #6 revealed she was the nurse who cared for Resident #86 on 10/6/2023, when the resident sustained fall #3. LPN #6 stated when report was handed off at the beginning of the shift, it was reported Resident #86 had a fall on 10/5/2023 but was not informed of any new interventions in place and was not informed the resident needed to be monitored hourly. The LPN was informed by CNA #11 around 5:00 PM, Resident #86 had fallen and the CNA had gotten the resident out of the floor. CNA #11 was probably doing .rounds when .resident was found . LPN #6 stated CNA #11 informed the resident was .ok .and was complaining of right hip pain . The LPN further stated she walked across the hallway, notified the physician, and immediately ordered an x-ray. LPN #6 continued to state when Resident #86 was assessed he stated he was trying to go to the bathroom, had pushed his call light, and the call light did not work. LPN #6 stated she did not test the call light to test functionality and did not recall if the call light was on or had been on. LPN #6 stated mobile images arrived prior to shift change (around 6:45 PM) to complete the ordered x-ray, the technician reported the fracture, the physician was notified, and ordered for Resident #86 to be transferred to the ER for evaluation and treatment. LPN #6 stated she was unaware of a post fall huddle form being used and had not had any post fall discussions with the ADON or DON. During a telephone interview on 10/18/2023 at 2:23 PM, RN #2 stated she arrived on shift on 10/6/2023 at 6:30 PM, received report from LPN #6, and was informed Resident #86 had sustained a fall, an x-ray had been ordered for right hip pain. RN #2 continued to state the technician reported after the x-ray that the resident had a fracture, the physician was informed and ordered for the resident to be sent to the ER for evaluation and treatment, the house supervisor was notified, and transport was called. During a telephone interview on 10/18/2023 at 2:33 PM, RN #5 stated she had cared for Resident #86 on 9/28/2023 when the resident suffered a fall (fall #1). The resident was in room [ROOM NUMBER], the CNAs had completed rounds on the other residents, when CNA #11 reported Resident #86 had fallen coming out of the bathroom. CNA #11 informed RN #5 that Resident #86 was found face down and the walker was several feet away from the resident. RN #5 stated CNA #1 and LPN #6 assisted the resident out of the floor and back to bed. The resident's nose was bleeding, the Nurse Practitioner was notified, and came to the room to assess the resident. Resident #86 stated that he had to go to the bathroom and did not turn the call light on for assistance. She stated interventions in place prior to fall were bed in low position, call light within reach, and non skid socks. RN #5 continued to stated Resident #86's bed was lowered even lower than before to prevent the resident from getting out of the bed. Resident #85 did not complain of pain after the fall and the nose had stopped bleeding by the time the Nurse Practitioner assessed the resident in the room. Continued interview revealed in the past the facility had Post Fall Huddle Form that was completed after a fall, but the form had not been utilized in .several months .maybe closer to a year . RN #5 stated she was informed the facility was no longer using the form, all the information was in the Event reporting system the facility used and there was no need to duplicate. During an interview on 10/18/2023 at 2:57 PM, CNA #12 stated she completed the Event Report on 10/5/2023 (fall #2) involving Resident #86. CNA #12 stated the resident had an witnessed assisted fall in the bathroom. CNA #12 stated she had performed resident rounding, while in another resident's room, noticed Resident #86's wheelchair and chair was slid across the room, entered Resident #86's room and walked past the bathroom door, noticed Resident #86 standing at the sink in the bathroom, when asked what the resident was doing, the resident lost balance and started to fall, the CNA got behind the resident and assisted to the floor. Resident #86 suffered no injuries and denied pain after the assisted fall. CNA #12 stated they check on the residents every 2 hours and at times more frequently. Resident #86 had on non skid socks at the time of the fall. The CNA stated she re-educated the resident to call for assistance before getting up to go to the bathroom. CNA #12 continued she documented the intervention on the Event Report to monitor the resident hourly and leave the door open, she informed the charge nurse (RN #1) of the fall and she would monitor Resident #86 more closely; she also informed the physician of the fall. CNA #12 stated CNAs were allowed to completed Event Reports and she had not been told to put the intervention in the Event Report, she .did that herself . CNA #12 confirmed the CNAs could not updated the care plans, .we don't have access to the care plans . Further interview revealed CNA #12 reported to the oncoming shift Resident #86 had fallen and needed to be checked on hourly. CNA #12 stated she did not document the resident had fallen or the hourly checks in the medical record, .there is nowhere for us to document stuff like that .we just know to do it . During an interview on 10/18/2023 at 3:10 PM, RN #1 stated he was the nurse on duty on 10/5/2023 when CNA #12 informed him that Resident #86 had a fall (fall #2). CNA #12 reported she was making rounds and went to check on the resident, found him in the bathroom, and assisted the resident to the floor. RN #1 stated Resident #86 was assessed and no injuries were noted. RN #1 stated CNA #12 informed him she would .just watch him [Resident #86] more closely . RN #1 stated he turned the red light on outside the resident's room, that indicated the resident had fallen. Continued interview revealed RN #1 reported to the oncoming shift Resident #86 had fallen and to .keep an eye on him . RN #1 reviewed the computer documentation of the care plan; it showed .Evaluated on 10/5/2023 at 6:03 PM .at risk for injury .bed in low position while in bed, high fall risk is on patient's door . RN #1 stated no signage was placed on the doors; the red light turned on indicated the resident had fallen. He stated he did not revise the care plan to leave the door open and to monitor the resident hourly. During an interview on 10/18/2023 at 3:34 PM, the ADON reviewed the 3 Event Reports and stated Resident #86 had a fall on 9/28/2023 at 3:30 PM (fall #1) per incident report. The care plan dated 9/28/2023 reflected to place bed in lowest position but was not in incident report. She stated when a lower bed is needed the staff have to request and she orders the bed. The ADON confirmed the interventions listed after the fall on 9/28/2023 were already in place and a new intervention had not implemented. The ADON stated Resident #86 needed more frequent monitoring. The 2nd fall on 10/5/2023 revealed the intervention CNA #12 had listed on the Event Report to leave the resident's door open and monitor hourly was not carried over to the care plan, .that was a good intervention, but it did not get put on the care plan . Continue interview with the ADON confirmed the facility no longer utilized the Post Fall Huddle Form; .in the past after a fall the Post Fall Huddle Form was completed and turned in, it was reviewed and discussed with the staff for appropriate interventions, care plan update, and documentation in the nurses notes about the fall . The facility stopped using the Post Fall Huddle Form .some time back .the same information was being duplicated on the Event Report .nursing staff were having a massive problem with redundancy .nursing staff made their wishes known it was too much and the form was taken away .we should have continued with the fall huddle groups .we got good information from them .the huddle form was the only thing they [administration] could take away from the nurses . The ADON stated she was .way behind on reviewing and updating Event Reports .at least a couple of months . The ADON stated only the nurses can update the care plans, the CNAs do not have access to the care plans, and she was unaware if the CNAs are able to review the care plans. The ADON confirmed Resident #86's care plans were not updated to reflect new and appropriate fall interventions; Resident #86 suffered harm from the fall on 10/6/2023, but there was no way of knowing if interventions had been put in place if the fall could have been prevented. The ADON stated the CNAs could documents frequent monitoring of residents on the vital signs page but did not have access to make notes. After the 2nd fall on 10/5/2023, Resident #86 .should have been on hourly rounding and a toileting program .that would have been an appropriate intervention .his falls were to or from the bathroom, not from the bed . Continue interview with the ADON confirmed the facility no longer utilized the Post Fall Huddle Form; .in the past after a fall the Post Fall Huddle Form was completed and turned in, it was reviewed and discussed with the staff for appropriate interventions, care plan update, and documentation in the nurses notes about the fall . The facility stopped using the Post Fall Huddle Form .some time back .the same information was being duplicated on the Event Report .nursing staff were having a massive problem with redundancy .nursing staff made their wishes known it was too much and the form was taken away .we should have continued with the fall huddle groups .we got good information from them .the huddle form was the only thing they [administration] could take away from the nurses . The ADON stated she was .way behind on reviewing and updating Event Reports . The ADON stated only the nurses can update the care plans, the CNAs do not have access to the care plans, and she was unaware if the CNAs are able to review the care plans. The ADON confirmed Resident #86's care plans had not been updated to reflect new and appropriate fall interventions and Resident #86 suffered harm from the fall on 10/6/2023. During an interview on 10/18/2023 at 4:40 PM, the DON confirmed Resident #86's care plans had not been updated to reflect new and appropriate fall prevention interventions after the falls on 9/28/2023 and 10/5/2023; Resident #86 sustained a 3rd fall on 10/6/2023 that resulted in a hip fracture. She confirmed the facility was not following it's falls policy, and the fall Event Reports were not complete and thorough investigations in prevention of falls. During an interview on 10/19/2023 at 8:03 AM, the ADM, AIT, and the VP of Quality and Compliance confirmed that Resident #86 suffered [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of facility documentation, observation and interview, the Administration failed to provide effective leadership and oversight to ensure effective systems were in place to address falls which resulted in fall with injuries for Residents #1, #86, and #93. The Administration's failure to identify serious outcomes related to falls, address the concerns in QAPI, ensure direct care staff members had access to the care planned falls interventions , and ensure fall investigations were reviewed and complete resulted in an immediate jeopardy for Resident #1, #86, and #93 and had the potential or likelihood to affect all 40 residents of the facility. (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Administrator in Training, [NAME] President(VP)of Compliance, and the Director of Health Information Services and Privacy Officer were notified of the Immediate Jeopardy (IJ) on 10/24/2023 at 6:00 PM, in the [NAME] Boardroom/Conference Room. The facility was cited Immediate Jeopardy at F835 (L). Addendum 3/5/2024: The scope and severity of citation F-835 has been amended and decreased as F835 (K). The Immediate Jeopardy began on 8/5/2022 and was removed 10/26/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 10/28/2023 at 9:35 AM, and the corrective actions were validated onsite by the surveyors on 10/29/2023. The facility is required to submit a Plan of Correction. The findings include : Review of the facility policy titled , .[NAME] Hospital Falls Precautions ([NAME] Fall Risk) ., reviewed 8/24/2022, showed .proactively decrease or prevent the risk of patient falls utilizing an interdisciplinary team approach .report patient falls should they occur .mitigating strategies employed. Data on patient falls will be tracked .Complete Post Fall Huddle Form .Update the Care Plan .Complete nurse/therapy note .Update .Fall Risk . Review of the facility's assessment tool, dated 10/24/2022, revealed the facility identified the need to provide services and general care based on resident's needs which included mobility and fall/fall with injury prevention with the specific care or practices of transfers, ambulation, physical therapy, occupational therapy, and restorative nursing, supporting resident independence in doing as much of these activities by himself/herself. Review of the Administrator's (ADM) job description undated, included, .management for the organization's subacute unit to ensure that high quality services are provided .including .delivery of care .documentation of services .management for all aspects of the subacute program .Works with department directors .to resolve performance issues as they arise .Reports to the Senior [NAME] President for all daily operating and management decisions .Directs the Performance Improvement activities .Demonstrates initiative in .implementing performance improvement strategies .demonstrates a clear understanding of the program, for resources utilized to outcomes produced, as evidenced by smooth program operation, policy and procedure development and actions taken to correct problems .ensures development of appropriate program evaluation components such as assessment of patient outcomes . Review of the medical records for 3 residents (Resident #1, Resident #86, and Resident #93) revealed Resident #1 did not have a falls care plan revised to include appropriate interventions after her fall with major injury on 8/5/2022 when she underwent surgical intervention to correct a fractured Left hip. Resident #86 was admitted to the facility on [DATE] for rehabilitation from compression lumbar fractures from a previous fall at home. Resident #86 had confusion, restlessness, and impulsiveness. The resident suffered fall #1 on 9/28/2023 (bathroom related), which resulted in skin tears, and a bloody nose; the intervention implemented was previously on the care plan, which included bed in lower position, and educate on the use of call light for assistance when getting out of bed. Resident #86 experienced a second fall on 10/5/2023, with no injury, again bathroom related; the CNA wrote on the incident report to leave the resident's door open and to monitor hourly, but the intervention was verbally reported to the nurse on duty and did not get placed on the care plan. The intervention placed on the care plan was to put a red alert on the resident's door. There was no signage placed on the resident's door, only a red light turned on by staff to alert other staff members the resident had fallen. The facility staff failed to recognize each fall was bathroom related and to implement appropriate interventions, as a result, Resident #86 sustained fall #3 on 10/6/2023, which resulted in a right hip fracture that required surgical intervention and prolonged the resident's SNF (skilled Nursing Facility) stay. Resident #93 was admitted to the facility on [DATE] for rehabilitation for surgical after care. Resident #93 had confusion and impulsiveness. Resident #93 suffered 6 falls from 10/6/2023-10/19/2023. Fall #1 occurred on 10/6/2023, with no injury, this was a witnessed assisted fall with staff. The intervention implemented after the fall was to educate the resident to sit in a chair, if she felt she was going to fall. Fall #2, unwitnessed, occurred on 10/7/2023, with no injury, Resident #93 transferred self from wheelchair to bed and slid to floor. The interventions according to the fall event report included re-education to call and wait for assistance before getting up, and to move the resident to the nurse's station for observation; the care plan was not updated, and the interventions did not get placed on the care plan. Resident #93 suffered fall #3 on 10/7/2023 (2nd fall for this dated), this fall was unwitnessed with no injury. The resident rolled out of bed reaching for a trash can to vomit into, the intervention implanted and placed on the care plan was to ensure items were within reach (already previously on the care plan). Fall #4 occurred on 10/13/2023, Resident #93 had gotten up without assistance and fell in the bathroom (the fall actually occurred on 10/14/2023 at 4:00 AM but was recorded in the event report and electronic medical record on 10/13/2023), with no injury; the interventions implemented after the fall included to re-educate the resident to use the call light and wait for assistance (previous care plan interventions), notified the provider, and continue to monitor. Fall #5 occurred on 10/18/2023, Resident #93 was observed in room, in the floor next to bed. The resident suffered a change in mental status and vomited after placed in bed, the provider was notified, and the resident was sent to the emergency department (ED) for evaluation and treatment; Resident #93 was diagnosed with a closed head injury and upon return to the facility was moved to a room closer to the nurse's station for closer observation. The resident's fall risk score increased, part of the interventions was not to be left alone in the bathroom and fall mat to floor beside bed. Resident #93 suffered fall #6 on 10/19/2023, after being left alone in the bathroom and suffered a vasovagal response (a sudden drop in heart rate and blood pressure, leading to fainting). The resident was transferred to the ED for evaluation and treatment, returned to the facility with diagnoses of vascular catastrophes (a condition caused by blocked blood vessels, resulting in low blood pressures, and fainting), and the intervention included to re-educated staff to not leave residents with high fall risk scores alone in the bathroom. The facility failed to recognize Resident #93's impulsiveness and lack of retention to education and re-education, as a result appropriate interventions were not implemented and Resident #93 suffered 4 falls, fall #5 resulted in a closed head injury, and upon return to the facility the resident suffered fall #6 after being left unattended in the bathroom. Review of QAPI council minutes revealed the falls for Residents #1, #86, and #93 were not thoroughly investigated so root cause analyses and contributing factors were not identified. The falls of residents' (#1, #86, and #93) falls were not documented in the QAPI minutes as to have been discussed and analyzed by the QAPI program, the falls information presented by the VP of Compliance and Quality and reported to QAPI was not individualized or resident specific, only the total number of falls and if a fall resulted in injury was captured. No identifiable efforts to obtain a root cause of the incident and no devised plan for implementing interventions was noted in the documentation. During an interview/observation of QAPI Council meeting minutes on 10/20/2023 at 3:15 PM, with the Administrator, who attended QAPI regularly stated, .a falls committee was established 2 years ago .the falls huddle form was discontinued about a year ago . unsure why .they[QAPI Committee] receive fall data [sub-acute patient falls for fiscal year 2024] collected from the VP of Quality and Compliance .falls have been an ongoing problem .presently no PIP [performance improvement plan] had been developed by the QAPI committee to address fall prevention . Review with the Administrator of the data presented to the falls committee [sub-committee of the Governing Body] sub-acute falls for fiscal year 2024, showed the lack of attempts by the QAPI program to prioritize and implement a project to curtail falls by the committee. Further interview revealed the Administrator confirmed development and/or revision of care plans with appropriate interventions had not been identified as a problem in the QAPI process as related to falls. The Administrator confirmed the facility's QAPI had been ineffective with prioritizing and identifying problems related to falls, as well as developing an organized plan to address fall prevention. During an interview on 10/20/23 at 3:41-5:30 PM, the [NAME] President of Quality and Compliance confirmed it was his expectation that nurses are charting [fall risk assessments] on residents every shift according to the facility's policy, because the residents' status waxes and wanes. He further stated some residents had fall risk assessments completed weekly, then some weeks are missed. There was not consistency in documentation. Continued interview revealed the VP confirmed there was no system in place to automatically audit resident assessments. He was unaware if they were being audited manually. He confirmed he was aware of nursing assessments and fall risk assessments were not being done according to policy, no remedies were mentioned of how Administration was going to address the concern. The VP of Quality and Compliance did not voice remedies to address charting in the electronic medical record, ways to improve the completeness and timeliness of event/incident reviews, why the facility did not allow the ability to CNA's to view the care plans in the electronic medical record so they know what interventions were in place for each resident. Administration was oblivious as to where the break down was as they related to documentation in the electronic medical record, resident assessments, implementation of appropriate falls interventions documented for residents' with falls and analyzing the fall data to incorporate the findings to promote better outcomes. During an interview on 10/21/2023 at 5:29 AM, CNA #5 stated they were aware of specific resident needs and fall interventions from verbal shift report. CNAs did not have access to the resident's care plan. During an interview on 10/21/2023 at 5:49 AM, CNA #7 stated they were aware of resident needs and falls interventions from the card in the back of the resident's wheelchairs and by the red lights outside the resident's doors. CNA #7 stated .I have never seen a care plan . Red lights meant the resident was at high risk for falls and needed rounded on more often than the normal every 2 hours. During an interview on 10/21/2023 at 5:55 AM, CNA #6 stated they knew what fall interventions were in place for residents by the card in the back of the wheelchair, red lights outside the rooms, and from verbal report. CNA #6 stated they did not have access to the care plan. The red light outside the room meant the resident was at high risk for falls and needed a gait belt, shoes, and socks. The Administration failed to provide effective leadership and oversight to ensure effective systems were in place to address falls which resulted in fall with injuries for Residents #1, #86, and #93. The Administration's failure to identify serious outcomes related to falls, address the concerns in QAPI, ensure direct care staff members had access to the care planned falls interventions, and ensure fall investigations were reviewed and complete resulted in an immediate jeopardy for Residents #1, #86, and #93 and had the potential or likelihood to affect all 40 residents of the facility. Refer to F656, F657, F689, 837 and 867 . Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 10/29/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. The electronic medical record was modified on 10/25/2023 to allow access to CNAs to the care plans, and the DON conducted education with all CNAs who had worked up to 10/29/2023 on how to access and use the care plans for resident specific care. This was verified through staff interviews and demonstrations on the resident units by surveyor. 2. An ad hoc QAPI meeting was held on 10/26/2023 and the QAPI Committee was educated on policy and procedure revisions by the VP of Quality and Compliance. 3. Policies for falls, care plans, QAPI, administration, and governing body were revised by the VP of Quality and Compliance and reviewed by QAPI committee on 10/26/2023 and was verified through meeting minutes and sign-in sheets. 4. Education on updated policies for falls, care plans, QAPI, administration, and governing body was conducted by the VP of Quality and Compliance on 10/26/2023 with the Administrator, Assistant Administrator and DON, and that education was verified through sign-in sheets and interviews. 5. On 10/25/2023, the Governing Body was informed by the Administrator and the VP of Quality and Compliance of the findings related to the survey and causes and the remedial actions to be taken. This was verified by meeting minutes and sign-in sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility documents, observation and interviews, The facility's governing body failed to provide effective leadership, oversight to the Administrator, establish, develop, revise and implement an effective fall program to include CNA (Certified Nursing Assistant) access to care plans to include fall interventions, and failed to oversee and maintain an effective QAPI (Quality Assessment Performance Improvement) program. The facility's failure placed Resident #1, #86, and #93 in immediate jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) and had the potential or likelihood to affect all 40 residents in the facility. The Administrator, Administrator in Training, [NAME] President of Compliance, and the Director of Health Information Services and Privacy Officer was notified of the Immediate Jeopardy (IJ) on 10/24/2023 at 6:00 PM, in the [NAME] Boardroom/Conference Room. The facility was cited Immediate Jeopardy at F-837. The facility was cited at F-837 at a scope and severity of L. Addendum 3/5/2024: The scope and severity of citation F-837 has been amended and decreased as F837 (K). The Immediate Jeopardy began on 8/5/2022 and was removed 10/26/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 10/28/2023 at 9:35 AM, and the corrective actions were validated onsite by the surveyors on 10/29/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility documentation titled, CORPORATE BYLAWS OF .HOSPITAL FOR PHYSICAL REHABILITATION, INC. revised June 21, 2022, showed .CORPORATE PURPOSES .to serve the region by providing .physically compromised persons to optimal levels of independent living .Emphasis is placed on the development of efficient, effective health care delivery systems .Duties of the Board of Directors .shall manage all of the affairs .shall have the duty and authority to ensure and execute all acts consistent with these Bylaws .Responsibilities in Relation to this Corporation .Board of Directors shall .develop overall policy for .management and operation .to establish a forum .to keep abreast of and to remain in compliance with federal and state legislative actions and laws .to provide oversight and review of the Corporation's ongoing compliance program assuring the adequacy .evaluation of the performance of those developing and executing the program and assuring that all levels of management are committed to the implementation, effectiveness and maintenance of the program . Review of the facility policy titled, .[Name of Facility] Falls Precautions, reviewed 8/24/2022, showed .provide interventions to proactively decrease or prevent the risk of patient falls utilizing an interdisciplinary team approach .all disciplines: nursing, PT [physical therapy], OT [occupational therapy], and ST [speech therapy] .will assess patients for fall risk utilizing the .Risk Determination Tool (SFRDT) .will also be completed with each nursing shift assessment .clinical staff will evaluate patients for changes that would affect the patient's fall risk .staff will document .report patient falls should they occur .mitigating strategies employed. Data on patient falls will be tracked .aggregated as part of the hospital's ongoing quality efforts to reduce or eliminate patient falls .At admission, nursing will .Assess patient's fall risk utilizing SFRDT .The patient will be assigned a fall risk level based on the following scores .Therapist determines patient is independent and documents on safe care and mobility care .Green .Score of 0-10 .yellow .Score of 11-20 .orange .Score of > 20 .Red .Write fall risk level on Communication Board .Document patient fall risk level on the Patient Care and Mobility card attached to the wheelchair .Standard Fall Prevention Guidelines for All Patients .Clear the patient environment of all hazards .Ensure all needs are within reach (e.g., call light, room phone, cell phone, remote, water pitcher, urinal, walker, etc.) .Encourage open room doors .Lock all moveable equipment .Place bed in low position .Nursing will .Purposeful rounding on patients to assess .patient needs .Implement bowel .bladder protocols if ordered .patient's fall risk level will be a required item in the shift change report for nursing to enhance shift change communication and patient safety .All clinical staff will .Follow No Pass Zone .It requires staff to respond to patients or visitors in need .During transfer, ambulation .upright standing activities .Utilize non-skid footwear .Utilize gait belt .Ensure all equipment is in locked position .Remove or swing away wheelchair leg rests .Instruct patient to call for staff assistance during transfers . Review of the facility's policy titled, Nursing Plan of Care, reviewed on 4/21/2023, showed .Each rehabilitation patient will have an individualized Nursing Plan of Care that is initiated on admission, maintained and updated, up to time of discharge .Registered nurses initiate Nursing Plans of Care to identify teaching and discharge needs. Both RNs and LPNs may maintain/update Nursing Plan of Cares. RNs are to supervise LPN care and documentation on the Nursing Plan of Care .The Care Plan is to be reassessed no less than weekly and updated or resolved by assigned nurse .For Subacute and LTC patients, the baseline care plan is done in the first 24 hours. The complete care plan is completed within 72 hours .The Nursing Plan of Care reflects nursing interventions and responses .Procedure .Problem/Need - Check one choice; actual or potential .Date Initiated - Date the Interventions selected .Interventions - Check the interventions you have selected and enter date .Updates will be done anytime there is a significant change in patient condition and/or weekly .Goals/Outcomes - Select the goals/outcomes that are appropriate for this patient. Otherwise check NA .Date Resolved - Place the number of the intervention/goal and the date the patient no longer has the problem/need . Review of the facility's policy titled, Care plan preparation, long-term care, revised on 5/22/2023, showed .A care plan is an individualized, written action plan for a resident's care, treatment, and services that is based on the resident's .needs and preferences. The care plan must be person-specific .An interdisciplinary team works together to create a comprehensive care plan that guides a resident's care from admission to discharge .A review of the resident's medical history and condition should occur before planning the resident's care .ELEMENTS OF A CARE PLAN .driven by a resident's conditions and issues as well as a resident's unique characteristics. Each resident's care plan should be based on an assessment of the resident .each care plan should .evaluate each patient as an individual and include unique characteristics and strengths; use Minimum Data Set to evaluate distinct functional areas .regarding functional status .provide a strong understanding of the patient .organize information to identify potential issues or conditions, such as triggers, for the resident .clarify potential issues by looking at causes and risks using the care area assessment process .be based on assessment information with necessary monitoring and follow-up .include information regarding ways to address causes and risks associated with issues and conditions to allow for resident's highest level of well-being .must develop a baseline care plan within 48 hours after the resident's admission to the facility .The interdisciplinary team then collaborates with the resident and reviews and revises the care, as necessary, to meet the resident's needs .The care plan for each resident must include .resident's goals, expressed in measurable objectives .to meet the resident's .needs identified in the comprehensive assessment .interventions describing the services the interdisciplinary team employs to maintain the resident's highest practicable .well-being .Implementation .Review the resident's medical record including .assessments .diagnostic test results .medical treatment plan, and other information that may affect the resident's care .Based on analysis of the data determine the nursing diagnoses that will guide the resident's care. Be sure to address all the resident's significant needs when determining the person-centered care plan .Select interventions that will help the resident achieve the stated outcome for each goal. Include specific information .Evaluate the resident's progress, and revise the care plan as appropriate .The care plan should reflect elements of person-centered care .and identify what daily routines are important to each resident .Documentation .Documentation associated with care plan preparation includes .all pertinent resident problems .expected outcomes .interventions . Review of the Administrator's (ADM) job description undated, included, .management for the organization's subacute unit to ensure that high quality services are provided .including .delivery of care .documentation of services .management for all aspects of the subacute program .Works with department directors .to resolve performance issues as they arise .Reports to the Senior [NAME] President for all daily operating and management decisions .Directs the Performance Improvement activities .Demonstrates initiative in .implementing performance improvement strategies .demonstrates a clear understanding of the program, for resources utilized to outcomes produced, as evidenced by smooth program operation, policy and procedure development and actions taken to correct problems .ensures development of appropriate program evaluation components such as assessment of patient outcomes . Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Dementia, Anxiety, Depression, Unspecified Fall Subsequent Encounter, Displ (Displaced) Intertroch (intertrochanteric) Fx (fracture) l (Left) Femr (Femur), and History of Urinary Tract Infection (UTI). Review of the change in status MDS assessment dated [DATE] showed Resident #1 was severely cognitively impaired and required extensive assist of 1 staff member for bed mobility, toileting, dressing and transfers. Resident used a manual wheelchair for locomotion on the unit. Resident had a prior fall that required surgical intervention was documented. Review of Resident #1's comprehensive care plan revealed .problem onset on 8/29/2012 of potential for injury from falls . the documentation showed the following interventions in place .call light in reach .Assist with ambulation .Keep room free of clutter .Encourage and frequently remind .to call for assistance and transfers .Assist with toileting .Staff will complete the [name of facility] fall risk tab in .Daily Assessment Every 24 hours .Perform Fall Risk Assessment .initiated 12/2/2022 by the Assistant Director of Nursing (ADON) . The documented intervention after the resident's fall with major injury on 8/5/2022 was .send to [local hospital name] for evaluation. Review of Resident #1's comprehensive care plan revealed the intervention implemented documented after the resident's fall on 8/5/2022, was send to local hospital for evaluation and treatment. No follow up interventions were implemented upon the residents' return to the facility on. Review of the facility documentation (Event Report for fall #1) dated 8/5/2022 at 12:15 AM, reported by Licensed Practical Nurse (LPN) #7 showed Resident #1 had an unwitnessed fall .heard resident making noise and went into residents room and she was lying in the floor crying . Physician Assistant (PA) was notified, and an order was given to send to the ER for evaluation.Additional monitoring, treatment or interventions have been taken as a result of this event .Called MD for order to send patient out for evaluation for possible FX [fracture] of left hip . Resident #1's family was notified. The resident was assessed by 3 staff members LPN #7; Certified Nursing Assistant (CNA) #8; and the Supervisor).What type of injury was sustained in the fall? .Fracture .Prior to the fall was the patient determined to be at risk through the risk assessment process? .Yes .At the time of the fall, were any .risk factors present .History of previous fall .Sensory impairment .other (blank) .What protocols/interventions were in place, or being used, to prevent fall for this patient? .Assistive devices .bed in low position .Call light/personal items within reach .non-slip footwear .Recommendation for System Improvement .none at this time. Resident was sleeping on last round-very unlikely this resident to attempt to get up during nighttime hours .Likelihood of Event Recurrence .Remote .Severity/Harm Caused by Event .Temporary harm to the patient required initial/prolonged hospitalization . The Quality Department section of the event report showed the event could likely not have been prevented. The event report did not reflect it had been reviewed by the Assistant Director of Nursing (ADON), Director of Nursing (DON), Administrator to implement interventions to prevent future falls. Review of Resident #1's Orthopaedic Surgery Operative Note, dated 8/5/2022 at 3:02 PM, showed a .Closed comminuted intertrochanteric fracture of left femur [a type of hip fracture] . and an implant was used to correct the fractured left femur. Review of Resident #1's current comprehensive Care Plan undated, showed fall evaluations were completed daily, no numerical identification was noted as to the severity of risk nor was the resident classified with Green, Yellow, Orange or Red risk as indicated on the safe care and mobility card (used to determine the level a resident needs with assistance/ambulation) as indicated by the facility's policy and the fall risk assessments were not documented every shift per the facility's policy. During an interview on 10/20/2023 at 10:50 AM, Certified Nursing Assistant (CNA) #13 stated she had worked on 8/5/2022 after Resident #1's fall. The CNA stated resident's shoes were moved out of sight out of sight, so the resident was not tempted to get them. Further interview revealed CNA's did not have access to view the residents' care plan in the electronic medical record to view the interventions in place. The CNA stated .fall interventions were discussed in report at the beginning of shift .or she would ask the nurse . CNA #13 stated the red lights (above the resident's doors) were also used to identify residents who are at risk for falls or had fallen. The CNA stated they were very familiar with the patients. During an interview on 10/20/2023 at 12:42 PM, Licensed Practical Nurse (LPN) #5 stated there was no SBAR (situation, background, assessment and recommendations communication form) printed at shift change for nurses because they are long term patients and .we know them . The LPN stated she also works with subacute residents, and at shift change for subacute resident care, the outgoing nurse prints the SBAR and gives report. Nursing does not do walking rounds with the oncoming nurses at shift change; however, CNAs do. The LPN stated fall interventions were known by staff for the long-term care residents, and she knows the residents and their needs. She stated those residents have beds low, call light in reach, Red light outside of the door to indicate previous falls, non-skid socks and safety precautions. The LPN stated the sub-acute residents have the fall risk written on a white board if they are a high fall risk, and there is a tag [safe care and mobility card] on their wheelchairs to indicate falls precautions. LPN stated .I don't think they [the LTC residents] have a tag on their chair .or white boards they were used for the subacute residents. Continued interview revealed new interventions are put on the care plan, and CNAs know what interventions are in place for residents because .the nurse tells them . The LPN stated rounds on residents are performed .all through the day . and explained the colored lights above the door in the hallway indicated the residents' level of fall risk. During an observation/interview on 10/20/2023 at 12:54 PM with LPN #5 revealed Resident #1 seated in the dining/activity room eating lunch in wheelchair. LPN #5 confirmed no tag or cards present in the wheelchair indicating fall precautions. During an observation on the 3rd floor on 10/20/2023 at 12:56 PM, revealed no resident rooms with red lights on. During an observation of Resident #1's room on 10/20/2023 at 12:58 PM, revealed no red light on outside of room. During an interview/observation on 10/20/2023 at 3:15 PM, the Administrator stated, .a falls committee was established 2 years ago .they receive fall data collected from the VP of Quality and Compliance .falls are ongoing problem .presently no PIP [performance improvement plan] had been developed by the QAPI committee . Review of the data presented to the falls committee [sub-committee of the Governing Body] for fiscal year 2023 showed no attempt of prioritizing and implementing a plan to prevent falls by the committee. Further observation/interview revealed the development and/or revision of care plans with appropriate interventions had not been identified as a problem in the QAPI process. The Administrator confirmed the facility's QAPI committee and Administration had been ineffective with prioritizing and identifying problems as well as developing an organized plan to address identified concerns. During an interview on 10/20/23 at 3:41-5:30 PM, the [NAME] President of Quality and Compliance confirmed it was his expectation that nurses are charting [fall risk assessments] on residents every shift, because the residents' status waxes and wanes. He further stated some residents' had fall risk assessments completed weekly, then some weeks are missed. Continued interview revealed the VP confirmed there was no system for automatically auditing resident assessments. He was unaware if they were being auditing manually. He confirmed that nursing assessments and fall risk assessments were not being done according to policy. During an interview on 10/21/2023 at 5:29 AM, CNA #5 stated .CNAs did not have access to the resident's care plan . During an interview on 10/21/2023 at 5:49 AM, CNA #7 stated .I have never seen a care plan . During an interview on 10/21/2023 at 5:55 AM, CNA #6 stated stated they did not have access to the care plan. The red light outside the room meant the resident was at high risk for falls and needed a gait belt, shoes, and socks. During an interview on 10/21/2023 at 6:23 AM, CNA #8 stated she had worked at the facility for 15 years. CNA stated fall interventions communicated via an armband indicates the resident is at risk for falls, there is also a card in the back of the wheelchair. There are different color systems [on the card], red means high risk for falls, orange- moderate risk, yellow- good. CNA #8 stated .CNA's do not have access to the care plan.There is nowhere to look to see what fall interventions are in place . During an interview on 10/23/23 at 9:16 AM, LPN #5 confirmed the safe care and mobility cards were not used with the long-term care residents and was unaware the cards were to be used with the long-term care residents. The LPN confirmed falls risk assessments were performed weekly for the long-term care residents and daily for the sub-acute (rehab. residents), she was unaware the fall risk assessments were to be completed every shift. During an interview on 10/23/23 at 9:16 AM, the Health Information Services Director confirmed no falls risk assessments were completed on Resident #1 before or after her fall. She further stated no falls risk assessments were completed on the long-term care residents (5) until the current electronic medical record system was utilized in 12/2022. During an interview on 10/23/2023 at 12:15 PM, the Director of Nursing (DON) confirmed the falls risk assessments were completed weekly for Resident #1, the DON stated .they treat the long-term care (LTC) people different .that's why it's a problem .there's policies for LTC and policies for Rehab. patients . The DON confirmed the fall risk assessments completed by nursing should have been conducted every shift and staff were not following the facility's policy. The DON also confirmed Resident #1's care plan was not updated to include intervention(s) to ensure Resident #1's safety after a fall. The resident suffered a left hip fracture as a result of the fall. Resident #86 was admitted to the facility on [DATE], readmitted on [DATE] with diagnoses including Right Hip Fracture (10/7/2023), Dementia, Osteoarthritis, and Lumbar Compression Fractures. Review of Resident #86's baseline care plan dated 9/26/2023, showed the Safety section of the care plan was blank. Continued review showed Cognition .Orientation .to person .to place .Therapy Services .Physical (PT) .Occupational (OT) . Review of Resident #86's comprehensive care plan dated 9/26/2023, showed .ALTERATION IN SAFETY; RISK FOR INJURY (ACTUAL) .Related to: New Environment .PATIENT WILL NOT EXPERIENCE ANY INJURY OF UNKNOWN OR UNTOWARD EVENTS DURING HOSPITALIZATION .COMPLETE AND IMPLEMENT THE FALL RISK SCREEN .UPDATE AND IMPLEMENT FALL RISK SCREEN EACH WEEK .UPDATE AND IMPLEMENT FALL RISK SCREEN AFTER ANY EVENT INCLUDING FALL, MEDICATION CHANGE, OR CHANGE IN PATIENT CONDITION .EVALUATE MENTAL STATUS/ORIENTATION .PROVIDE CUES (WRITTEN INSTRUCTIONS OR PICTURES) TO FACILITATE A SAFE ENVIRONMENT. USE COMPENSATORY METHODS TO REINFORCE COGNITIVE OR PHYSICAL DEFICITS .RESPOND TO CALL LIGHTS PROMPTLY .ANTICIPATE THE PATIENT'S NEEDS (TOILETING, EATING, DRINKING) TO MINIMIZE IMPULSIVE MOVEMENT .ENSURE CALL BELL & PHONE WITHIN REACH, BED LOCKED AND IN LOW POSITION, BED ALARMS ACTIVATED (LOW BED IN THE LOWEST POSITION) .EDUCATE PATIENT/FAMILY ON MEDICATIONS THAT POTENTIALLY AFFECT THE PATIENT'S SAFETY .EDUCATE PATIENT AND/OR FAMILY IN METHODS FOR SAFELY USING ASSISTIVE DEVICES (WHEELCHAIR, [NAME], NON-SLIP SHOES) AND THE MANAGEMENT OF A SAFE ENVIRONMENT (TRIPPING HAZARDS, SIDE RAILS, ADQUATE LIGHTING) .ENCORAGE PATIENT TO VERBALIZE HOW THEY CAN CONTRIBUTE TO THEIR SAFETY .ADVISE PATIENT TO USE PROPER FOOTWEAR AND ENSURE NON SKID FOOTWEAR IS AVAILABLE .UPDATE CARE PLAN EVERY WEEK .UPDATE CARE PLAN EVERY SUNDAY .STAFF WILL COMPLETE THE [NAME] FALL RISK TAB IN SW DAILY ASSESSMENT EVERY 24 HOURS .PERFORM FALL RISK ASSESSMENT .DAILY . Review of the facility documentation (Event Report for fall #1) dated 9/28/2023 at 3:30 PM, reported by Registered Nurse (RN) #5 showed Resident #86 had an unwitnessed fall .got up from bed .walked to restroom. When he was walking back to the bed, he fell forward .has 2 skin tears on his left arm and .nose. Patient said he wanted to go the restroom and .forgot to use call light. Patient was placed back in bed with call light within reach .Was the patient harmed? .Yes .How was this event discovered? .Assessment after event .Result of Event .Laceration . Physician was notified and assessed resident at the bedside.Additional monitoring, treatment or interventions have been taken as a result of this event? .Not answered . Resident #86's family was notified. The resident was assisted back to bed by 3 staff members (Licensed Practical Nurse (LPN) #5; Certified Nursing Assistant (CNA) #11; and RN #5), the Nurse Practitioner was at the bedside and assessed the resident.What type of injury was sustained in the fall? .Skin tear, avulsion, hematoma or significant bruising .Prior to the fall was the patient determined to be at risk through the risk assessment process? .Yes .At the time of the fall, were any .risk factors present .Unknown .What protocols/interventions were in place, or being used, to prevent fall for this patient? .Unknown .Recommendation for System Improvement .Not answered .Likelihood of Event Recurrence .Remote .Severity/Harm Caused by Event .Temporary harm to the patient requiring intervention . (The facility Event Report did not reflect any new interventions were put in place after the fall.) Review of the nurses note dated 9/28/2023 at 3:30 PM, showed .Patient got out of bed and fell leaving the bathroom. Patient has decreased cognition and forgot to call for assistance. Placed bed in lowest position and call light within reach . Further review showed a repeat assessment and fall risk score was not completed after the fall. Review of the comprehensive care plan updated on 9/28/2023, showed .Patient got out of bed and fell leaving the bathroom. Patient has decreased cognition and forgot to call for assistance. Placed bed in lowest position and call light within reach . The bed in lowest position and call light within reach were interventions already in place prior to the fall. Resident #86 fell returning from the bathroom, not from the bed. Review of the nurse practitioner progress note dated 9/29/2023, showed .History/Reason for visit: s/p fall 9/28 - doesn't Remember .fall - PT/OT Rehab .wedge comp [compression] fx [fracture] - Lumbar .memory loss . Review of the 5-day scheduled MDS assessment dated [DATE], showed Resident #86 was cognitively intact with a BIMS score of 15, prior functioning for everyday activities the resident was independent with self-care, indoor mobility with a walker, functional cognition, and no impairment with upper and lower range of motion. On admission the resident was independent with eating and rolling left to right; needed assistance with oral hygiene; dependent with toileting hygiene, lying to sitting on bedside, and sit to stand; required partial to moderate assistance with sit to lying, chair to bed transfers, and toileting transfer. The resident was frequently incontinent of bladder, and always continent of bowel. Continued review showed Resident #83 had a fall with fracture prior to admission without surgery and had a fall with injury since admission. The resident received therapy services. Record review showed Resident #86 did not have a nursing assessment or a fall risk score completed for 10/2/2023. Review of the nursing documentation dated 10/4/2023 at 8:50 PM, showed Resident #86 has a nursing assessment and had a fall risk score of 15, indicating an orange-moderate fall risk. Review of the nursing documentation dated 10/5/2023 at 11:26 AM, showed Resident #86 had a fall risk score of 5, indicating a yellow-low fall risk. Review of the facility documentation (Event report for fall #2) dated 10/5/2023 at 5:00 PM, reported by CNA #12 showed Resident #86 had an unassisted fall and stated, .Found PT [patient] up in bathroom alone. Sit PT down to floor. Transfer Pt to Wc [wheelchair] and back to bed .Was the patient harmed .No .How was this evet discovered .Report by staff member .Type of event .Fall .Additional monitoring, treatment or interventions have been taken as a result of this event .Leave PT door open check on PT hourly .Was the fall observed .No .Prior to the fall, what was the patient doing or trying to do .Toileting-related activities .Prior to the fall was the patient determined to be at risk through the risk assessment process .Yes .At the time of the fall, were any of the following risk factors present .History of previous fall .What protocols/interventions were in place, or being used, to prevent fall for this patient .Bed in low position .Call light personal items within reach .Non-slip footwear .Other .Door kept open for observation .Likelihood of Event Recurrence .Remote .Severity/Harm Caused by Event .Reached patient & [and] required monitoring/intervention to confirm no patient harm . Review of the nursing documentation dated 10/5/2023 at 8:47 PM, showed Resident #86 had a fall risk score of 30, indicating a red-high fall risk. Review of the Comprehensive Care Plan updated on 10/5/2023, showed .Patient to have bed in low position while in bed. High fall risk on at patient's door . The bed position was not a new intervention. Resident #86 fell in the bathroom, so the intervention was not specific to the situation. There was no signage placed on residents' doors; there was a red light turned on and off by staff above door in the hallway to indicate the resident had fallen. The interventions listed in the Event Report dated 10/5/2023 to leave the resident's door open and monitor hourly was verbally reported to the nurse on duty, but the interventions were not reflected on the care plan. Review of the facility documentation (Event report for fall #3) dated 10/6/2023 at 5:00 PM, reported by LPN #6 showed Resident #83 had an unwitnessed fall while getting out of bed.Charge nurse came to notify nurse of pt [patient] experiencing a unwitnessed fall trying to get out of bed without assistance. CNA assisted pt back to WC. VS WNL .Pt states he did call for assistance but call light never went off. Pt c/o increased R hip pain r/t fall/. STAT XR through mobile imaging ordered. X ray confirmed FX of R hip. pt sent out on night shift for further eval .Was the patient harmed .Yes .How was this event discovered .Report by staff member .Type of Event .Fall .Result of Event .Fracture .Additional monitoring, treatment or interventions have been taken as a result of this event .acute transfer to .hospital .for further eval after confirmation of R [right] hip fx from mobile imaging .Was the fall observed .No .What type of injury was sustained in the fall .Fracture .Prior to the fall, what was the patient doing or trying to do .Ambulating without assistance and without assistive device or medical equipment .Prior to the fall was the patient determined to be at risk through the risk assessment process .Yes .At the time of the fall, were any of the following risk factors present .History of previous fall .What protocols/interventions were in place, or being used, to prevent fall for this patient .Bed in low position .Call light/personal items within reach .Injury Details .Fracture/dislocation (per radiology) .Action(s) Taken and Treatment Provided .Documented issue .Notified provider .Radiographic studies ordered .Follow-Up Notes from Triage and Investigation .Patient was reminded frequently to use call light when he wanted to get up. Call light was in reach. Patient had fallen the evening before and fall risk assessment indicated he should be monitored .Patient transferred to acute care once it was determined a fracture had occurred .Recommendations for System Improvement .Not answered .Likelihood of Event Recurrence .Occasional .Severity/Harm Caused by Event .Temporary harm to the patient that required initial/prolonged hospitalization . The Quality Department did a brief .Respectful Mgmt [Management] Checklist ., but it was not completed. Review of the nursing documentation dated 10/6/2023 at 5:00 PM, showed Resident #86 had a fall risk score of 48, indicating a red-high fall risk. Review of a Nurses Note dated 10/6/2023 at 5:00 PM, showed .Charge nurse came to notify nurse of pt experiencing an unwitnessed fall trying to get out of bed without assistance. CNA assisted pt back into WC. VS WNL [Vital Signs Within Normal Limits]. BP [blood pressure] 132/75, HR [heartrate] 104, O2 [oxygen saturation] 95% [percent]. Pt c/o [complained of] increased R hip pain r/t [related to][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility documentation review, medical record review, observation and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to reassess, monitor ongoing concerns, and perform a root cause analysis related with falls for Residents #1, #86, and #93. The facility failed develop an effective QAPI program that recognized concerns to ensure systems and processes were in place and consistently followed by staff to prevent falls for Residents #1, #86, and #93. The failure of the QAPI Committee to ensure a safe environment and develop corrective action plans for falls resulted in an immediate jeopardy for Resident #1, #86, and #93 and had the potential or likelihood to affect all 40 residents of the facility. (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Administrator in Training, [NAME] President (VP) of Compliance, and the Director of Health Information Services and Privacy Officer were notified of the Immediate Jeopardy (IJ) on 10/24/2023 at 6:00 PM, in the [NAME] Boardroom/Conference Room. The facility was cited Immediate Jeopardy at F 867 (L). Addendum 3/5/2024: The scope and severity of citation F867 has been amended and decreased as F867 (K). The Immediate Jeopardy began on 8/5/2022 and was removed 10/26/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 10/28/2023 at 9:35 AM, and the corrective actions were validated onsite by the surveyors on 10/29/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy Quality Assurance Performance Improvement (QAPI) Committee dated 10/29/2019, revealed, .To provide a mechanism to evaluate the quality, appropriateness and effectiveness of all patient care services rendered .The QAPI Committee is established by the Medical Staff to coordinate all quality improvement activities .in order to assure an effective and comprehensive, hospital-wide program .Annually assess the effectiveness of the Quality Assurance Performance Improvement Plan .using risk-based methodologies and annually develop a hospital-wide Quality Assurance Performance Improvement Plan .Provide oversight and support for all performance improvement activities .Establish organization-wide priorities for Quality Improvement .Oversee the coordination and review of .Quality Assurance Performance Improvement Program effectiveness .Provide oversight for the corrective and ongoing activities .Serve as the oversight body for conducting root cause analyses in the event of an unexpected incident resulting in .serious physical .injury or potential serious injury .Ongoing monitoring and information analysis .Analyze pertinent findings from specific QAPI teams .activities .monitors .recommending further actions .Annually review effectiveness of QAPI activities .make necessary revisions to the QAPI Plan as necessary .Assure appropriate documentation of QAPI activities including cumulative profiles of findings and actions .Establish priorities when identified problems could have an immediate impact on patient care . Review of the facility's assessment Tool, dated 10/24/2022 , revealed the facility identified the need to provide services and general care based on resident's needs which included Mobility and fall/fall with injury prevention with the specific care or practices of transfers, ambulation, physical therapy, occupational therapy, and restorative nursing, supporting resident independence in doing as much of these activities by himself/herself. Review of the facility policy titled , .Incident Reporting-Unusual Occurrence . reviewed 8/1/2023, showed .Purpose .To provide a written record of any unusual occurrence .to facilitate immediate corrective action as identified to prevent future occurrences of the same nature .provide documentation for statistical analysis of occurrences by risk management to assess for trends, develop corrective strategies in conjunction with appropriate responsible parties, and determine the effectiveness of those strategies through the QAPI [Quality Assurance Performance Improvement] .The unusual occurrence is then forwarded to the VP of Quality and Compliance for final review .Once all areas are completed, the VP of Quality will complete and close the event. Data from these events will be analyzed .presented through various quality committees for review, analysis, and corrective actions as indicated .In the event that a process is separately identified that appears to have potential risk for patients, a Failure Mode and Effect Analysis may be completed and presented through Quality Assurance Performance Improvement Committee. The VP of Quality and Compliance will keep .appropriate administrative staff informed of all injuries .Trends, corrective actions .mitigation strategies will be reported through the Quality Assurance Performance Improvement Committee . Review of the facility policy titled , .[name of hospital]Falls Precautions ([name of facility] Fall Risk) ., reviewed 8/24/2022, showed .provide interventions to proactively decrease or prevent the risk of patient falls utilizing an interdisciplinary team approach .Data on patient falls will be tracked .aggregated as part of the hospital's ongoing quality efforts to reduce or eliminate patient falls . Review of the medical records for 3 residents (Resident #1, Resident #86, and Resident #93) revealed Resident #1 did not have a falls care plan revised to include appropriate interventions after the fall with major injury on 8/5/2022. Resident #86 was admitted to the facility on [DATE] for rehabilitation from compression lumbar fractures from a previous fall at home. Resident #86 had confusion, restlessness, and impulsiveness. The resident suffered fall #1 on 9/28/2023 (bathroom related), which resulted in skin tears, and a bloody nose; the intervention implemented was previously on the care plan, which included bed in lower position, and educate on the use of call light for assistance when getting out of bed. Resident #86 experienced a second fall on 10/5/2023, with no injury, again bathroom related; the CNA wrote on the incident report to leave the resident's door open and to monitor hourly, but the intervention was verbally reported to the nurse on duty and did not get placed on the care plan. The intervention placed on the care plan was to put a red alert on the resident's door. There was no signage placed on the resident's door, only a red light turned on by staff to alert other staff members the resident had fallen. The facility staff failed to recognize each fall was bathroom related and to implement appropriate interventions, as a result, Resident #86 sustained fall #3 on 10/6/2023, which resulted in a right hip fracture that required surgical intervention and prolonged the resident's SNF (skilled Nursing Facility) stay. Resident #93 was admitted to the facility on [DATE] for rehabilitation for surgical after care. Resident #93 had confusion and impulsiveness. Resident #93 suffered 6 falls from 10/6/2023-10/19/2023. Fall #1 occurred on 10/6/2023, with no injury, this was a witnessed assisted fall with staff. The intervention implemented after the fall was to educate the resident to sit in a chair, if she felt she was going to fall. Fall #2, unwitnessed, occurred on 10/7/2023, with no injury, Resident #93 transferred self from wheelchair to bed and slid to floor. The interventions according to the fall event report included re-education to call and wait for assistance before getting up, and to move the resident to the nurse's station for observation; the care plan was not updated, and the interventions did not get placed on the care plan. Resident #93 suffered fall #3 on 10/7/2023 (2nd fall for this dated), this fall was unwitnessed with no injury. The resident rolled out of bed reaching for a trash can to vomit into, the intervention implanted and placed on the care plan was to ensure items were within reach (already previously on the care plan). Fall #4 occurred on 10/13/2023, Resident #93 had gotten up without assistance and fell in the bathroom (the fall actually occurred on 10/14/2023 at 4:00 AM but was recorded in the event report and electronic medical record on 10/13/2023), with no injury; the interventions implemented after the fall included to re-educate the resident to use the call light and wait for assistance (previous care plan interventions), notified the provider, and continue to monitor. Fall #5 occurred on 10/18/2023, Resident #93 was observed in room, in the floor next to bed. The resident suffered a change in mental status and vomited after placed in bed, the provider was notified, and the resident was sent to the emergency department (ED) for evaluation and treatment; Resident #93 was diagnosed with a closed head injury and upon return to the facility was moved to a room closer to the nurse's station for closer observation. The resident's fall risk score increased, part of the interventions was not to be left alone in the bathroom and fall mat to floor beside bed. Resident #93 suffered fall #6 on 10/19/2023, after being left alone in the bathroom and suffered a vasovagal response (a sudden drop-in heart rate and blood pressure, leading to fainting). The resident was transferred to the ED for evaluation and treatment, returned to the facility with diagnoses of vascular catastrophes (a condition caused by blocked blood vessels, resulting in low blood pressures, and fainting), and the intervention included to re-educated staff to not leave residents with high fall risk scores alone in the bathroom. The facility failed to recognize Resident #93's impulsiveness and lack of retention to education and re-education, as a result appropriate interventions were not implemented and Resident #93 suffered 4 falls, fall #5 resulted in a closed head injury, and upon return to the facility the resident suffered fall #6 after being left unattended in the bathroom. During an interview/observation of QAPI Council meeting minutes on 10/20/2023 at 3:15 PM, with the Administrator, who attended QAPI regularly stated, .a falls committee was established 2 years ago .the falls huddle form was discontinued about a year ago . unsure why .they[QAPI Committee] receive fall data [sub-acute patient falls for fiscal year 2024] collected from the VP of Quality and Compliance .falls have been an ongoing problem .presently no PIP [performance improvement plan] had been developed by the QAPI committee to address fall prevention . Review with the Administrator of the data presented to the falls committee [sub-committee of the Governing Body] sub-acute falls for fiscal year 2024, showed the lack of attempts by the QAPI program to prioritize and implement a project to curtail falls by the committee. Further interview revealed the Administrator confirmed development and/or revision of care plans with appropriate interventions had not been identified as a problem in the QAPI process as related to falls. The Administrator confirmed the facility's QAPI had been ineffective with prioritizing and identifying problems related to falls, as well as developing an organized plan to address fall prevention. During an interview with the VP of Quality and compliance on 10/20/2023 at 3:50 PM, stated the DON would be responsible for how nursing charts, and ultimately it would be the responsibility of Administrator to ensure compliance with the staff following the falls policy. It was the VP's expectation that all policies are followed. There is a nurse educator who goes through the orientation with each employee. Each learns expectations for shift reporting, and a majority of employees use verbal shift report. It was his expectation for all managers to review incident reports by the end of the next day, if possible, and was done well up until 3-4 weeks ago. It was his expectation that the nurse who made the report or on duty, would implement interventions and the manager make sure the interventions were appropriate and investigate. It was his expectation that root cause analysis was done for every incident. He confirmed he was behind on reviewing incident reports. Review of QAPI council minutes revealed the falls for Residents #1, #86, and #93 were not completely investigated, therefore root cause analyses and contributing factors were not identified and taken into consideration to develop fall interventions. The residents' (#1, #86, and #93) falls were not thoroughly analyzed as part of the QAPI Committee. Review of the sub-acute patient falls for fiscal year 2024 information provided by the VP of Compliance and Quality and reported to QAPI was not individualized or resident specific, only the total number of falls and falls resulting in injury were captured. Further review of the QAPI minutes revealed efforts or attempts by the QAPI program to investigate and find the root cause of the falls were absent in the QAPI minutes. No documented plan for implementing resident centered interventions or who was ultimately responsible for the care plans was observed in the QAPI Committee minutes. The sub-acute patient falls for fiscal year 2024 documentation captured raw fall data such as time of day, day of week, and what patient/resident was attempting at the time of fall was provided to the QAPI Committee, no identifiable resident was documented. The QAPI Committee failed to monitor, analyze pertinent findings, review effectiveness of QAPI activities, make necessary revisions to the QAPI Plan as necessary, assure appropriate documentation of QAPI activities including cumulative profiles of findings and actions or establish priorities when identified problems could have an immediate impact on patient care which resulted in negative outcomes with injuries for Residents #1, #86, and #93. The QAPI Committee's failure to analyze outcomes related to the falls, address the findings in QAPI meeting, ensure direct care staff members had access to the care planned falls interventions, and ensure fall investigations had appropriate immediate fall interventions, fall investigations were reviewed and complete resulted in an immediate jeopardy for Resident #1, #86, and #93 and had the potential or likelihood to affect all 40 residents of the facility. Refer to F656, F657, F689 and F835. Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 10/29/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. The surveyors verified a review was done by Administrator, Assistant Administrator, Director of Nursing (DON), [NAME] President (VP) of Compliance and Quality and Health Information Systems (HIS) Director and Therapy Coordinator of fall investigations from 8/2022 to present for Residents #1, #86 and #93. The fall investigations were complete and appropriate interventions were implemented and on the care plan, and the care plan was person centered. 2. DON updated the care plans for Residents #1 and #93 on 10/25/2023 and plans to track falls monthly and present findings to QAPI. The fall investigations for all 7 residents with falls in the facility were reviewed by the Administrator, Assistant Administrator, DON, VP of Compliance and Quality and HIS Director and Therapy Coordinator on 10/26/2023. This was verified during chart observation with HIS Director and Privacy Officer. 3. The electronic medical record was modified on 10/25/2023 to allow access for CNAs to the care plans, and the DON conducted education with all CNAs who had worked up to 10/29/2023 on how to access and use the care plans for resident specific care and how to tell the fall risk for a resident by the colored light indicators. This was verified through staff interviews and demonstrations on the resident units by surveyor. 4. Verification by observations in 7 resident rooms showed falls care plan interventions were in place in those rooms including checking beds to ensure they were low and locked on 10/29/2023. 5. Policies for falls, care plans, QAPI, administration, and governing body were reviewed by QAPI committee on 10/26/2023 and was verified through meeting minutes and sign-in sheets. 6. Education on updated policies for falls, care plans, QAPI, administration, and governing body was conducted by the VP of Compliance on 10/26/2023 with the Administrator, Assistant Administrator and DON, and the responsibilities of licensed nurses' education was conducted with licensed nurses by the DON on 10/25/2023. That education was verified through sign-in sheets and interviews. Noncompliance at F-867 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.