**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, interview, medical record review, and policy review, the facility failed to provide adequate supervision to prevent accidents for two of four residents (Resident (R)13 and R7) reviewed for accidents in a total sample of 41 residents. The facility's failure to utilize two staff, during the use of a mechanical lift, resulted in harm when R13 sustained a distal right femur (leg) fracture. Findings include: 1.Review of facility-reported incident, provided to the survey team by the Administrator, dated 7/5/2023, revealed the following: [Certified Nursing Assistant (CNA)12] reported that on 6/26/2023, she was attempting to transfer [R13] from her bed to her wheelchair using the sit-to-stand lift when the patient became weak and slid back against the lift harness. After attempts to complete the transfer, [CNA12] slid the patient to a sitting position and went and got help to complete the transfer .The patient did not report pain nor obvious signs of a fracture and sat up in her wheelchair for a while before being placed back into her bed. Review of R13's Resident Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed an admission date of 12/21/2022 with diagnoses of hemiplegia and hemiparesis (partial paralysis and weakness on one side of the body), and osteoarthritis of the right knee. Review of R13's quarterly Minimum Data Set (MDS), located in the EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 6/19/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R13 was cognitively intact. This same MDS indicated R13's transfer ability was an extensive assistance, with support from two staff. Review of R13's Care Plan, dated 1/3/2023, located in the EMR revealed R13 was at a risk for falls due to hemiplegia and hemiparesis. Review of R13's Nurse Practitioner (NP) note, dated 6/28/2023, located in the EMR under the Resident tab, indicated, .seen today for follow-up after a fall. She tells me she slid down to the floor when they were trying to move her from the sit to stand to her chair. She denies any injuries. She says she landed on her bottom and did not hit her head. She has no other concerns today. Review of R13's NP note, dated 6/30/2023, located in the EMR under the Resident tab, indicated, .seen today for right knee pain. She tells me that she has had right knee pain for the past couple of days. She did have a fall earlier this week with no apparent injuries at the time of her fall. She is not sure if her knee pain is related to her fall or not. She denies hitting her knee when she fell. She does have rheumatoid arthritis. She also complains of poor appetite. During an interview on 10/11/2023 at 9:45 AM, the Assistant Director of Nursing (ADON) stated on 6/29/2023, Family (F)13 reported to her that R13 reported she had a fall the other day. The ADON stated she assessed R13 and R13 was complaining of right knee pain and an x-ray was ordered. The ADON stated the facility initially thought the fall was unwitnessed due to having no reports of a fall. The ADON stated, through investigation, the facility discovered R13 had a witnessed fall from a sit-to-stand lift, while being transferred by CNA12. The ADON stated CNA12 did not report the fall to staff. Review of R13's X-ray results, located in the EMR under the Resident tab, dated 6/30/2023, indicated, Impression: Acute comminuted [splintered], mildly displaced fracture distal femoral metaphysis [area near knee]. During an interview on 10/11/2023 at 11:45 AM, F13 stated R13 reported to her that she had a fall from a sit-to-stand lift when CNA12 attempted to transfer her. F13 stated she reported the incident to the nursing staff and requested an x-ray for R13. During an interview on 10/11/2023 at 4:16 PM, CNA12 stated on 6/26/2023, she attempted to transfer R13 from her bed to her wheelchair by using the sit-to-stand lift and R13 slid out of the lift. CNA12 stated R13 did not hit the floor. CNA12 stated she asked another CNA to assist her in getting R13 up and she reported the incident to Licensed Practical Nurse (LPN)12. CNA12 stated R13 did not complain of pain at the time of the fall. During an interview on 10/11/2023 at 4:49 PM, LPN12 stated CNA12 never reported R13 had fallen. LPN12 stated, although she was the nurse on shift at the time of the incident, she was unaware of the fall until she was interviewed a couple of days after it had happened. 2. Review of the undated Face Sheet, in the EMR under the Resident tab, revealed R7 was admitted to the facility on [DATE] with diagnoses including cancer of the colon, brain, ovaries, and lungs; weakness, and a history of falls. R7 passed away in the facility on 6/13/2023. Review of the significant change MDS with an ARD of 5/24/2023 in the EMR revealed R7 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 2 out of 15 (score of 0-7 indicates severe impairment). R7 required extensive assistance for bed mobility, dressing, hygiene, and toilet use. R7 had 2 or more falls since the prior MDS assessment without injury. Review of the Incident Reports, provided by the facility, revealed R7 experienced nine falls within a three-month period. The facility failed to implement new interventions after falls, implement existing interventions, analyze patterns, and determine the root cause of falls as follows: 1. Review of the Incident Report, dated 3/8/2023 provided by the facility, revealed on this date at 8:59 AM, R7 was standing to be weighed, she became weak, sat back on the bed and the weight technician lowered the resident to the floor. R7 was in her bare feet and an immediate intervention was to implement safe footwear. No injury was sustained. Staff were educated on safety with transfers. 2. Review of the Incident Report, dated 3/31/2023 and provided by the facility, revealed R7 fell on this date (Friday) at 6:20 AM. The fall was unwitnessed and R7 was found on the floor in bare feet, laying between the air conditioning unit and the bed. The call light was in reach. R7 stated she slid out of bed and denied hitting her head; she stated she was experiencing mild pain. The immediate intervention was to apply nonskid socks. The prior fall that occurred on 3/8/2023 resulted in staff implementing safe footwear as the resident was in bare feet. This was not implemented as R7 was again found in bare feet when this fall occurred. Although the call light was within R7's reach, there was no documentation to show whether it had been activated. There was no assessment of what the root cause was, i.e., what was the resident trying to do at the time of the fall. 3. Review of the Incident Report, dated 4/14/2023 (Friday) at 6:32 AM provided by the facility, revealed R7 was found on the floor in her room, having experienced an unwitnessed fall. She had been trying to get out of bed and was bare feet. R7 was laying on the floor between the air conditioning unit and the bed with her left arm supporting her head. R7 denied hitting her head. No injury was sustained. The call light was in reach. The immediate measure taken was implementation of a bed pressure alarm, and safety mats were applied to the floor. This was the third fall in which R7 did not have non-skid socks on that were identified as an intervention after the falls occurring on 3/8/2023 and 3/31/2023. There was no indication if the call light was sounding. There was no assessment of what the resident was trying to do at the time of the falls to determine the root cause. 4. Review of the Incident Report, dated 4/14/2023 (Friday) at 3:20 PM and provided by the facility, revealed R7 was found on the floor in her room between the bed and the heating unit in bare feet. R7 denied hitting her head; however, she experienced an unwitnessed fall. Intervention included adaptive equipment (equipment not specified). The family and physician were notified. The resident was re-educated about use of her call button for assistance and a bed alarm was placed. This was the fourth fall in which R7 did not have non-skid socks on that were previously identified as an intervention. A bed alarm was listed as a new intervention; however, the Incident Report for the fall that occurred earlier this day at 6:32 AM indicated a bed alarm was an immediate measure taken at that time. 5. Review of the Incident Report, dated 4/15/2023 (Saturday) at 2:00 AM and provided by the facility, revealed R7's alarm was sounding. She had experienced an unwitnessed fall and was found on the floor by the window on the floor mat in a sitting position. No injury was noted. R7 was put back to bed with the clip alarm in place. She was in bare feet. The call light was within reach and R7 was instructed to use it and the bed was in the low position. Mild pain was noted and the resident was lethargic/drowsy. Intervention included pain management and the bed pad/tab alarm. This was the fifth fall in which R7 was found in bare feet. There was no assessment of what the resident was trying to do at the time of the fall to determine the root cause. Review of a Nurse Practitioner (NP) Visit Form, dated 4/17/2023 and provided by the facility, revealed R7 was evaluated on this date. The Visit Form read, .seen today for follow up after multiple falls over the weekend. Per nurse, her family was also concerned with altered mental status, so she was also sent to ER per on call provider for evaluation. She had pelvis x-ray that was negative for any fracture .Repeated falls - continue precautions, monitoring .Secondary malignant neoplasm - CT showed hemorrhagic intercranial metastases, no herniation. She is not on any anticoagulants, unclear if she hit head when she fell . 6. Review of the Incident Report, dated 4/2023 (Saturday) at 5:30 AM, revealed R7 experienced an unwitnessed fall and was found on the floor in her room sitting on the floor on the mat with her back against the bed. Her non-skid socks were on, she had removed the clip alarm, and it was not sounding. The resident stated she was trying to get to the cards. The immediate intervention taken was application of the bed alarm and R7 was moved to a room closer to the nursing station. There was no indication if the call light was sounding at the time of the fall. The bed alarm had already been implemented after a fall on 4/14/2023 and was not a new intervention. The resident had removed the alarm; there was no assessment of the effectiveness of this intervention or need for a different approach. 7. Review of the Incident Report, dated 5/7/2023 (Sunday) at 5:11 PM, revealed R7 experienced an unwitnessed fall and was found lying on the floor on the mat by the bed with non-skid socks in place. The resident was noted to be lethargic and drowsy. Immediate measures taken included placing bed mats on the floor on both sides of the bed and a bed alarm. R7 stated she was trying to get to the ER [emergency room]. R7 experienced a skin tear to her left forearm. A bed alarm was listed as an immediate measure in response to the fall; however, a bed alarm was documented as being implemented following her third fall on 4/14/2023. 8. Review of the Incident Report, dated 5/14/2023 (Sunday) at 3:09 AM, revealed R7 experienced an unwitnessed fall. R7 was found on the floor, in bare feet on the safety mat on the floor with the alarm sounding. Non-skid socks were documented as being an immediate intervention implemented. In addition, the resident would be evaluated for a toileting schedule. Non-skid socks should have been in place. They were first identified as an intervention after her first fall on 3/8/2023. Review of a Wound Care note, dated 05/15/23 in the EMR under the Progress Notes tab, revealed Wound Care: Multiple skin tears noted to BUE [both upper extremities]. LUE [left upper extremity] from wrist to elbow; 3.5x1x0.1, 1.5x1.2x0.1, and 2.8x7x0.1. RUE [right upper extremity] from wrist to elbow 1x1.7x0.1, 1x3x0.1, 2.5x4x0.1, 1x1.5x0.1. Clean with normal saline, apply zinc oxide and non-adherent pad, dry gauze and kerlix, then apply Geri gloves. Bruising to BUE [both upper extremities] noted. Pt has very thin, fragile skin that tears easily .Pt did have fall last week resulting in few skin tears, however, also has new areas today. 9. Review of the Incident Report, dated 5/24/2023 at 7:59 AM, revealed R7 experienced an unwitnessed fall. She was found in the prone position on the right side of the bed on the floor. R7 was wearing nonskid socks. The immediate intervention was to move belongings closer to the resident. The Incident Report did not say whether the bed alarm was sounding or if the floor mat was in place. There was no assessment of what the resident was trying to do at the time of the fall to determine the root cause. There was no evidence the facility increased supervision for R7 who had a pattern of unwitnessed falls in the morning, especially on weekends, and with repeated attempts to get out of bed. There was a lack of assessment to determine why the resident was getting out of bed such as having to toilet, being in pain, anxious, etc. Review of the Care Plan History dated 2/22/2023-10/10/2023 provided by the facility revealed the problem of Fall risk: history of falling, weakness, difficulty in walking was initiated on 2/27/2023. The goal was, Will have risk of falls with injury addressed and minimized. Approaches with dates were as follows: Patient's belongings within reach (5/24/2023) Nonskid socks (5/14/2023) Bed alarm in place while in bed (4/22/2023) Safety mats (4/14/2023) Staff education (3/9/2023) Monitor pt's [patient's] safety during 1:1 [one to one] contact, intervening when needed Bed in lowest position (2/27/2023) Call light within reach (2/27/2023) Discontinue clip alarm in place at all times (4/24/2023) Nonskid slippers (4/15/2023 and discontinued on 5/16/2023) During an interview on 10/9/2023 at 3:00 PM, family member (F)7 stated R7 had brain cancer, radiation to her brain, became confused and anxious, and kept getting out of bed resulting in multiple falls. R7 stated the facility did not do enough to prevent R7 from falling. F7 stated R7 originally went to the facility for two weeks for therapy but R7 failed to improve and cancer was found on her spine. F7 stated after about three weeks R7 was moved from the rehab floor to the third floor and things went downhill. F7 stated R7 fell out of bed and sat on the floor for 20-30 minutes at a time before staff assisted her back to bed. F7 stated she asked for mats to be placed on the floor next to the bed and this was not done initially. F7 stated, eventually a mat was placed on the floor. F7 asked for bed rails and was told the facility could not implement these as they had to be signed off by a doctor. F7 stated she was desperate due to R7 experiencing so many falls. F7 stated most of the falls occurred on Fridays and Saturdays, or on the weekends and she wondered about that. During an interview on 10/11/2023 at 8:34 AM, LPN9/300-Unit Manager stated R7 was transferred to the third floor after her therapy ended. LPN9 stated fall interventions included mats on the floor and a pressure alarm on the bed. LPN9 stated R7 had cancer, was on hospice, was full of anxiety and tried to get up repeatedly. LPN9 stated R7 thought she had to take care of the kids. LPN9 stated when a fall occurred, the nurse opened an event in the EMR; vitals were done, the resident's skin was assessed and nurses should document if interventions were in place at the time of the fall. Immediate interventions were new things added in response to the fall and would get added to the care plan. Bed mats would get updated right away or the next day. LPN9 stated she looked at patterns for falls but was not aware of R7's falls primarily occurring in the morning and on Friday, Saturdays, and Sundays. LPN9 stated normally when R7 was found on the floor, her incontinence brief was wet. LPN9 stated the facility had not increased supervision as an intervention for falls such as adding 15 minutes checks or one to one supervision, although increased supervision was listed as a care plan intervention for falls. LPN9 stated, We don't increase supervision. LPN9 stated R7 sustained bruises and skin tears to her arms from the falls. During an interview on 10/11/2023 at 3:18 PM, the DON and ADON were interviewed. They stated the process for falls including the nurse opening the event in the EMR, making sure the resident was safe, determining what interventions were in place at the time of the fall, contacting the family and physician, initiating alert charting for a few days. They stated the Incident Report should include the interventions currently in place and whether they had been initiated and immediate interventions should be new interventions not previously in place. The DON and ADON stated they had not considered increased supervision for residents experiencing frequent falls such as sitters or 15-minute checks. They stated they had, however asked CNAs to be in the hallways more often to be closer to the residents. During an interview on 10/12/2023 at 8:35 AM, Certified Nurse Aide (CNA)5 stated she remembered taking care of R7 when she transferred to the third floor. CNA5 stated R7 had bed and chair alarm and mats on the floor beside the bed. CNA5 stated R7 was confused and anxious at times and tried to get out of bed. CNA5 stated R7's CNA supervision was not increased and the facility did not implement the 15-minute checks or the increased supervision as indicated as a fall intervention in R7's care plan. During an interview on 10/12/2023 at 9:13 AM, the NP stated she remembered R7 needed palliative care from the start. The NP stated R7's condition, including her mentation, declined around the time she was transferred from rehab to the third floor. The NP stated R7 had experienced falls but she did not follow her care once R7 transferred to the third floor. The NP stated when residents experienced falls, they should make sure there were no major injuries and that the resident was not in pain. Review of the Falls policy, dated 7/2/2017, provided by the facility, revealed Cause Identification: 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. 2. If the cause of a fall is unclear, if the fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician/NP [nurse practitioner] will review the situation and help identify contributing causes. 3. The staff and/or physician, NP will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Treatment/Management 1. Based on the preceding assessment the staff and/or physician NP will identify pertinent interventions to try to prevent subsequent falls and to address the serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation.