**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to notify the physician and the resident's family after a fall, and failed to notify the physician of complaints of pain for 1 resident (#76) of 5 residents reviewed for falls, of 20 sampled residents. Resident #76 sustained pelvic fractures, which resulted in Harm. The findings include: Review of the facility's policy Accidents and Incidents, Investigating and Reporting, revised 7/2017, revealed, .all accidents or incidents involving residents .shall be investigated and reported to the Administrator .1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Continued review revealed, .The following data, as applicable, shall be included on the Report of Incident/Accident form: .g. The time the injured person's Attending Physician was notified .the date/time the injured person's family was notified and by whom . Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Recurrent Dislocation of Right Elbow, Muscle Weakness, and Repeated Falls. Medical record review of a 30 Day Minimum Data Set (MDS) dated [DATE] revealed Resident #76 scored a 9 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and hygiene. Review of a facility fall investigation, for a fall on 7/4/19, revealed Resident #76 was observed sitting on the floor at the foot of the bed. Further review revealed no documentation the Physician or the family had been notified of the fall. Medical record review of a nurse's note dated 7/4/19 revealed no documentation the Physician or the resident's family had been notified of the fall on 7/4/19. Medical record review of a nurse's note dated 7/5/19 at 4:50 PM, revealed Resident #76 complained of pain and soreness in the right hip and was offered medication to treat pain. Medical record review of the Physical Therapy (PT) Treatment Encounter Notes dated 7/5/19 revealed, .Pt [patient] declined PT .need for PT .especially after her fall in room last night . Medical record review of a nurse's note dated 7/6/19 at 11:20 AM revealed Resident #76 had increased pain to the right hip and the physician was notified of the increase in pain due to a fall. Medical record review of x-ray results dated 7/6/19 revealed Resident #76 had pelvic fractures. Interview with the Quality Assurance Registered Nurse (RN) #1 on 8/7/19 at 8:40 AM, in the conference room, confirmed the facility failed to notify the Physician, and the family of the fall on 7/4/19. Telephone interview with Licensed Practical Nurse (LPN) #1 on 8/7/19 at 3:09 PM, revealed on 7/4/19 at 6:45 PM, Resident #76 was found in the resident's room sitting on the floor at the foot of the bed. Continued interview revealed Resident #76 complained of .pain in her hip around 4 o'clock [4:00 AM on 7/5/19] . Continued interview confirmed LPN #1 failed to notify the Physician and the family of the fall on 7/4/19 and did not notify the physician of the resident's complaints of increased pain. Further interview revealed .I should have called [the Physician] .but that's my fault . Interview with the Director of Nursing (DON) on 8/7/19 at 10:08 AM, in the DON's office, confirmed the facility failed to notify the Physician and the resident's family after the fall on 7/4/19, which resulted in Resident #76 sustaining pelvic fractures. Refer to F-689

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interviews, the facility failed to implement a care plan intervention to prevent falls for 2 residents (#12, #76) of 5 residents reviewed for falls. The facility's failure to implement a fall intervention resulted in actual Harm when Resident #12 and Resident #76 sustained fractures following a fall. The findings include: Review of the facility policy, Care Planning-Interdisciplinary Team revised on 9/2013 revealed .care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team . Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Chronic Kidney Disease, Coronary Artery Disease, Gout, Hyperlipidemia, Vitamin D Deficiency, Vitamin B12 Deficiency, History of Falling, and Traumatic Brain Injury. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assist of 2 staff for bed mobility, transfers, dressing, and toileting. Medical record review of Resident #12's Comprehensive Care Plan dated 8/2/19 revealed .at risk for fall related injury as evidenced by history of previous fall .hx [history] of falls .6/26/18-Dycem [nonslip pad to prevent slipping/sliding] to chair . Observation of Resident #12 on 8/5/19 at 10:07 AM, in the resident's room, revealed the resident sitting in the wheelchair watching television. Further observation revealed the resident slid from the wheelchair onto the floor and landed on his right side. Further observation revealed the fall intervention of Dycem pad to the wheelchair was not in place at the time of the fall. Medical record review of an acute care emergency room record dated 8/6/19 revealed Resident #12 had a right hip fracture that required surgery to repair. Interview with Licensed Practical Nurse (LPN) #3 on 8/6/19 at 12:04 PM, in the resident's room, confirmed the fall intervention of Dycem pad to the wheelchair was not in place at the time of the fall. Interview with the Director of Nursing (DON) on 8/6/19 at 2:50 PM, in the DON's office, confirmed the care plan intervention of Dycem pad to the wheelchair was active on the care plan and should have been in place at the time of the fall. Further interview confirmed the facility failed to implement the care plan intervention of Dycem pad to the wheelchair. Resident #12's fall resulted in a hip fracture. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Recurrent Dislocation of Right Elbow, Muscle Weakness, and Repeated Falls. Medical record review of the Comprehensive Care Plan dated 6/13/19 revealed Resident #76 was at risk for falls. Continued review of the care plan revealed .appropriate footware [footwear] . Medical record review of a 30 Day MDS dated [DATE], revealed Resident #76 was moderately cognitively impaired and required the extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and hygiene. Medical record review of a nurse's note dated 7/2/19 revealed the resident had a fall from her bed .resident states that she was trying to get he [her] shoes and slide [slid] out of the bed . Review of the facility fall investigation dated 7/2/19 revealed the facility initiated the following intervention after the fall .non skid socks when shoes off . Review of a facility fall investigation for Resident #76 revealed the resident had a fall on 7/4/19 at 6:45 PM in her room when Resident #76 attempted to get a night gown from her closet. Continued review revealed, .Footwear at time of fall .socks . Medical record review of a nurse's note dated 7/6/19 revealed .Resident continues to complain of increased pain to right hip post fall unrelieved .requesting x-ray . Medical record review of X-Ray results dated 7/6/19 revealed the resident had pelvic fractures. Interview with the Quality Assurance Registered Nurse (QA/RN) #1 on 8/7/19 at 8:40 AM, in the conference room, confirmed the facility failed to implement the fall intervention of nonskid socks at the time of Resident #76's fall on 7/4/19. Interview with the Director of Nursing (DON) on 8/7/19 at 10:08 AM, in the DON's office, revealed the intervention of appropriate footwear initiated on Resident #76's admission to the facility included the use of nonskid socks. Continued interview revealed after the resident's fall on 7/2/19 the only intervention the facility initiated after the resident's fall was nonskid socks. Further interview with the DON confirmed Resident #76 did not have on appropriate footwear or nonskid socks at the time of the resident's fall on 7/4/19. Further interview confirmed the facility failed to implement the intervention of nonskid socks resulting in Resident #76 sustaining a pelvic fracture. Refer to F-689

**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 provide adequate supervision to prevent falls for 2 residents (#12, #76) of 5 residents reviewed for falls. Resident #12 sustained a right hip fracture and Resident #76 sustained pelvic fractures, which resulted in actual Harm to Residents #12 and #76. The findings include: Review of the facility policy Accidents and Incidents Investigating and Reporting, revised 7/2017, revealed, .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .The Nurse Supervisor/Charge Nurse .shall complete a Report of Incident/Accident form and submit .within 24 hours of the incident . Review of the facility policy Falls and Fall Risk, Managing, revised on 3/2018, revealed, .identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .implement a resident-centered fall prevention plan to reduce risk .implement interventions .to try to minimize serious consequences of falling . Review of the facility document Post Fall Checklist, undated, revealed, .Complete Fall Description Details . Immediate interventions implemented . Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Chronic Kidney Disease, Coronary Artery Disease, Gout, Hyperlipidemia, Vitamin D Deficiency, Vitamin B12 Deficiency, History of Falling, and Traumatic Brain Injury. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was moderately cognitively impaired and required the extensive assitance of 2 staff for bed mobility, transfers, dressing, and toileting. Medical record review of the Nursing Risk assessment dated [DATE] revealed Resident #12 scored a 20 on the Falls Risk Assessment, indicating the resident was high risk for falls. Medical record review of Resident #12's care plan dated 8/2/19, revealed a fall intervention of a Dycem, a nonslip pad to prevent slipping or sliding from the chair, was implemented 6/26/18. Observation of Resident #12 on 8/5/19 at 10:07 AM, in the resident's room, revealed the resident seated in the wheelchair watching television. Further observation revealed the resident slid from the wheelchair onto the floor and landed on his right side. Continued observation revealed Certified Nursing Assistant (CNA) #1 walked into the resident's room, observed the resident on the floor, and yelled for assistance. Further observation revealed the Dycem pad was not in place in the wheelchair at the time of the fall. Review of the facility fall investigation dated 8/5/19, revealed Resident #12 was admitted to the hospital with diagnosis of right hip fracture. Medical record review of an acute care emergency room record dated 8/6/19 revealed .patient [Resident#12] is having right hip pain .RIGHT femoral neck [hip] fracture .operate tomorrow [8/7/19] . Interview with Licensed Practical Nurse (LPN) #3 on 8/6/19 at 12:04 PM, in Resident #12's room, revealed, .[Resident #12] is in [the hospital] set to have surgery for a hip fracture . Further interview confirmed the fall intervention of Dycem to the wheelchair was not in place at the time of the fall. Further interview confirmed the facility failed to implement the intervention of Dycem to the wheelchair. Interview with the Director of Nursing (DON) on 8/6/19 at 2:50 PM, in the DON's office, confirmed the intervention of Dycem to the wheelchair should have been in place at the time of Resident #12's fall. Further interview confirmed the facility failed to implement the intervention of Dycem to the wheelchair, which resulted in Resident #12 sliding from the wheelchair and sustaining a fractured hip. Interview with the Physical Therapist Manager on 8/7/19 at 8:41 AM, in the therapist's office, revealed, .we typically order Dycem to wheelchairs to assist residents who are at risk for sliding out of chairs . Further interview confirmed the facility's failure to implement the Dycem to the wheelchair resulted in the resident sliding out of the wheelchair and sustaining a fractured hip. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Recurrent Dislocation of Right Elbow, Muscle Weakness, and Repeated Falls. Medical record review of the Comprehensive Care Plan dated 6/13/19 revealed Resident #76 was at risk for falls with the following intervention .appropriate footware [footwear] .review information on past falls and attempt to determine cause of falls . Medical record review of the Certified Nurse's Assistant (CNA) Care Plan, undated, revealed no documentation of fall interventions for Resident #76. Medical record review of a 30 Day MDS dated [DATE], revealed Resident #76 scored a 9 on the BIMS, indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and hygiene. Medical record review of a nurse's note dated 7/2/19 revealed, .resident states that she was trying to get he [her] shoes and slide [slid] out of the bed . Review of the facility fall investigation dated 7/2/19 revealed, .slide [slid] out of bed landing on her bottom . Continued review revealed the fall interventions initiated after the 7/2/19 fall were .non skid socks when shoes off, bed low position . Medical record review of Nursing Risk assessment dated [DATE] revealed the resident scored an 11 on the facility Nursing Risk Assessment, indicating Resident #76 was a high risk for falls. Medical record review of a Physical Therapy (PT) Treatment Encounter Note dated 7/4/19 revealed Resident #76 presented with no signs of pain. Continued review revealed, .[Resident #76] performed standing side stepping with [aide]. Standing at the bar, she performed hip abduction, marching in place, and heel raises . Review of a facility fall investigation for Resident #76 revealed the resident had a fall on 7/4/19 at 6:45 PM in the resident's room. Resident #76 was observed sitting on the floor at the foot of the bed. Continued review revealed interventions of appropriate footwear initiated on 6/13/19 and the fall intervention of nonskid socks initiated after the fall on 7/2/19 were not in place at the time of the fall on 7/4/19. Continued review revealed the falls investigation for the fall on 7/4/19 was not initiated until 7/29/19 (25 days after the fall) and the facility did not implement any new fall interventions after the fall on 7/4/19. Medical record review of a Physical Therapy Treatment Encounter Note dated 7/5/19 revealed, . Pt [patient] declined PT 2x [times] .need for PT .especially after her fall in room last night .returned to [patient] room a 3rd time and found [Resident #76] in bed .numerous refusals by [Resident #76] despite extensive education of the benefits of PT . Medical record review of a Physical Therapy Treatment Encounter Note dated 7/6/19 revealed, .due to increased amount of pain to RLE [right lower extremity] unable to perform at this time. Spoke with resident's nurse this date to aid with comfort measures, and per nurse x-rays ordered this morning to assess extent of injury to RLE from recent fall. Therapy session ended this date due to significant pain experienced by resident . Continued review revealed, .Pain with movement 9/10 [scale of 0-10, 0 = no pain, 10 = worst pain possible] . Medical record review of a nurse's note dated 7/6/19 at 11:20 AM revealed Resident #76 had increased pain to the right hip after the fall on 7/4/19 and the physician was notified with orders to obtain an x-ray. Medical record review of a Physician's Order dated 7/6/19 revealed .XRay R [Right] Hip .post fall . Medical record review of X-Ray results obtained on 7/6/19 revealed .subacute fractures .lateral right superior pubic rami and medial inferior pubic rami [pelvic fractures] . Medical record review of a nurse's note dated 7/9/19 revealed, .recent xrays abnormal revealing a pelvic fracture .[orthopedic physician] was consulted .continue to keep resident non weight bearing . Medical record review of Physical Therapy Progress Report dated 7/11/19 reveaeld prior to Resident #76's fall on 7/4/19 the resident was participating in therapy and had shown improvement .goal .will ambulate 750 [feet] with least restrictive assistive device .baseline 6/5/19 unable/dependent .6/28/19 [Resident #76] is able to walk around 200 [feet] with [caregiver] but remains fearful of walking . Further review revealed .Progress and Response to tx [treatment] .7/11/19 . Resident is currently NWB [non weight-bearing] in RLE [right lower extremity] and is awaiting further directions on [weight bearing] from ortho [orthopedic physician] . Interview with LPN #4 on 8/6/19 at 2:23 PM, at the nurse's station, revealed LPN #4 was not aware Resident #76 had any fall interventions. Interview with the Quality Assurance Registered Nurse (QA/RN) #1 on 8/7/19 at 8:40 AM, in the conference room, confirmed the fall intervention of nonskid socks or appropriate footwear was not in place at the time of the fall on 7/4/19. Interview with CNA #2 on 8/7/19 at 8:48 AM, in the conference room, revealed CNA #2 was not aware of Resident #76's fall interventions. Telephone interview with LPN #1 on 8/7/19 at 3:09 PM, revealed on 7/4/19 at 6:46 PM, Resident #76 was found in the resident's room sitting on the floor at the foot of the bed. Continued interview revealed Resident #76 was not wearing nonskid socks or appropriate footwear at the time of the fall. Further interview confirmed LPN #1 failed to initiate a fall investigation promptly after the fall on 7/4/19 and failed to implement interventions to prevent further falls after the fall on 7/4/19. Interview with the Director of Nursing (DON) on 8/7/19 at 10:08 AM, in the DON's office, revealed the intervention of appropriate footwear (implemented 6/13/19) included nonskid socks (intervention after fall on 7/2/19). Continued interview confirmed the facility failed to ensure the fall interventions of nonskid socks or appropriate footwear were implemented after the fall on 7/2/19, which resulted in the resident sustaining pelvic fractures after another fall on 7/4/19, and failed to implement any fall interventions after the fall on 7/4/19.