**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, video footage review and interview, the facility failed to implement an effective fall prevention program for 2 residents (Resident #8, and #15) reviewed for falls. On [DATE], Resident #8, a resident with a history of seizures, was left alone during a seizure with his bed in a high position. The resident fell from the bed and sustained a fractured neck, which resulted in the resident's death on [DATE]. The facility's failures placed Resident #8, and #15 in Immediate Jeopardy. Immediate Jeopardy (IJ) is 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 and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-689, during the complaint investigation on [DATE] at 9:37 AM, and on [DATE] at 10:44 AM, in the Conference Room. The facility was cited Immediate Jeopardy at, F-689 The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from [DATE] and is ongoing. The findings include: 1. Review of the facility's undated policy titled, Fall Risk Assessment, revealed, It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified .An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly .the At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk for an accident .Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice . Review of the facility's undated policy titled, Head Injury, revealed, It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury .Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician . Review of the facility's policy titled, Assessing Falls and Their Causes, revised 10/2010, revealed, .The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .After a Fall .If a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to head, neck, spine and extremities . 2. Review of the medical record revealed Resident #8 was admitted on [DATE], with diagnoses of Polyneuropathy, Cerebral Infarction, Hypertension, Seizures, and Aneurysm. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #8 was assessed with a Brief Interview for Mental Status score (BIMs) of 15, which indicated that Resident #8 was cognitively intact, required limited assistance from 1 staff member for bed mobility, and had Range of Motion (ROM) limitations to both sides on the lower extremities. Review of Resident #8's Care Plan dated [DATE], revealed .anticoagulant therapy with potential complications .at risk for falls due to impaired balance, and HX [history of] falls .keep bed in low position and brakes locked when in bed .ADL [activities of daily living] self-care performance deficit .has a seizure disorder with potential for complications .Advance Directive on record .Resuscitate/Full code/CPR .Initiate CPR if I am found without respiration and /or pulse . Review of an Unwitnessed Fall Incident Report for Resident #8 dated [DATE], revealed .Unwitnessed .Date XXX[DATE] 22:28 [10:28 PM] .Incident Location .Resident's Room .Incident Description .At the 2000 [8:00 PM] hour the aide [CNA #11] yelled out for me to come and assist with resident in room [Resident #8's room]. Once I entered the room I observed resident on the floor unresponsive and blood near the resident's head. I asked aide what happened, aide stated he was yelling out to alert me of a status change in [Resident #8]. He stated that he stepped to the door to call for me and when he turned around resident was on the floor .Resident Description .Resident Unable to give Description .Immediate Action Taken .I called for the second nurse, who alerted the 3rd nurse to get crash cart, code was called and CPR was started, 911 [emergency call number] and CPR was continued until the paramedics arrived .Level of Consciousness .Comatose [Un-arousable to verbal or physical stimuli] . Review of the video footage dated [DATE], revealed CNA #11 at 7:50:29 PM entered Resident #8's room. At 7:51:06 PM, a nurse exited the resident's room with a white piece of paper in her hand. At 7:51:47 PM, CNA #11 was in hallway by the linen cart and then he reentered Resident #8's room. At 7:52:40 PM, CNA #11 exited Resident #8's room, entered the room next door, walked out of the room with sheets in his hand and reentered Resident #8's room at 7:53:10 PM. At 8:01:04 PM, CNA #11 exited Resident #8's room walking fast down the hallway passing the nursing station and turned the corner to the left out of the camera sight. At 8:01:26 PM, CNA #11 walked back around the corner with a nurse behind him and both entered Resident #8's room [ROOM NUMBER]:01:37. At 8:02 PM, a nurse and another staff member entered the resident's room. At 8:03 PM, a nurse exited Resident #8's room, the nurse turned to the left and entered the nursing station. At 8:08 PM, a nursing staff member was observed walking down the hallway with the crash cart. At 8:14 PM, EMS arrived in Resident #8's room. At 8:35 EMS exited the resident's room with Resident #8 on a stretcher. Review of the facility's Skilled Nursing Facility (SNF) / Nursing Facility (NF) Hospital Transfer Form dated [DATE], revealed Resident #8's vital signs were .BP [blood pressure] 134/78 .HR [heart rate] 76 .Temp [temperature] 97.4 .Sent To . [Named Hospital] .Date of Transfer XXX[DATE] 20:41 [8:41 PM] .Date Transferred to hospital XXX[DATE] . Review of the facility's Situation, Background, Assessment, Recommendation (SBAR) Communication Form revealed .Mental Status Evaluation .Increased confusion or disorientation . Review of the facility's Nurses Note dated [DATE], revealed .THIS NURSE CALLED TO [Resident #8's] ROOM BY HIS NURSE STATES [the resident] HAD FALLEN OUT OF BED, NURSE AND CNA [certified nursing assistant] AT BEDSIDE WITH RESIDENT, RESIDENT NOTED LYING ON THE BED ON HIS BACK NEXT TO BED, BLEEDING NOTED FROM HEAD, RESIDENT WAS NOT BREATHING NO PULSE NOTED CPR STARTED, OTHER SECOND FLOOR NURSE ENTERED ROOM WITH CRASH CART AND CPR CONTINUED USING COMPRESSIONS .911 CALLED AT BEDSIDE PER THIS NURSE AT 8:03 PM, CPR CONTINUED UNTIL PARAMEDICS ARRIVED AND TOOK OVER, RESIDENT TRANSFERRED TO [named hospital] AT 2037 [8:37 PM], RESIDENTS NURSE SPOKE WITH RESIDENTS BROTHER .THIS NURSE CALLED AND INFORMED DON OF FALL AND TRANSFER . Review of a Hospital's Emergency / Urgent Care Record Addendum for Resident #8 dated [DATE], revealed . [Resident #8] in the emergency department and critically ill with cervical spine fracture and on ventilator .History of Present Illness .was brought to the emergency department by EMS after cardiac arrest, EMS reports that the nursing home staff states they were changing the patient and he fell and hit his head. They found the patient to be in cardiac arrest when they checked on him. CPR was started by nursing home staff. EMS reports that once they arrived on the scene 2 epis [epinephrine- a medication given during CPR to stimulate the heart] and 1 bicarb [sodium bicarbonate-medication given during CPR to maintain carbon monoxide levels] were given .after approximately 20 minutes of downtime .EMS reported that the patient arrested again shortly prior to arrival to the emergency department .They state that the resident was in PEA [pulseless electrical activity] (a serious medical condition characterized by unresponsiveness and no pulse) .HEAD .Hematoma and abrasion right forehead .Procedure .Endotracheal intubation [a medical procedure where a plastic tube is placed in the airway to promote air for a patient that cannot breath on their own] .Indication .Respiratory failure, Airway protection .CT [computed tomography scan - an in depth xray of the body] of head shows no acute findings .Differential Diagnosis .Intracranial hemorrhage [bleeding within the brain], cervical spine fracture .CT scan of head shows no obvious acute findings. CT cervical spine shows C2 fracture with dislocation as well as C1 fracture .Disposition .Patient is being admitted to ICU [Intensive Care Unit]. Patient is in neurogenic shock [a condition caused from a injury or condition that cause central nervous system damage or spinal cord injury, which regulates breathing and other automatic bodily functions] .Patient has significant cervical spine fracture and dislocation. Very poor prognosis .Impression / Plan .Cervical spine fracture, Cardiac arrest, Neurogenic shock . Review of Consultation Notes dated [DATE], revealed, .Assessment .[Resident #8] with a C2 fracture .and fracture .C1 and C2 s/p [status post] fall with devastating quadriplegia secondary to traumatic subluxation [joint dislocation] and code event in the field .given patient age and devastating neurologic injury, he is not a candidate for surgical intervention .Recommend palliative care and consideration of withdrawal of life supporting measures .palliative care once family is ready . Review of Resident #8's hospital Discharge Summary, dated [DATE], revealed, .Date of admission XXX[DATE] .Date of Discharge XXX[DATE] 0345 TOD [time of death] .Discharge Diagnosis .Traumatic subluxation and presumed cord injury s/p fall at nursing home with C2 Cervical spine fracture and . C1-2 .fractures .Cardiac arrest with prolonged downtime .Neurogenic shock .Acute Hypoxic Respiratory Failure-intubated . Review of Resident #8's medical record revealed no documentation the facility completed a Root Cause Analysis for the fall that occurred on [DATE] until [DATE], 4 days later after the surveyors brought it to their attention. 3. Review of the medical record revealed Resident #15 was readmitted on [DATE], with diagnoses of Displaced Comminuted Fracture of Shaft of Right Femur, Orthopedic Aftercare, Anxiety, Adult Failure to Thrive, Disorder of Bone, Fall, Lack of Coordination, and Dementia. Review of a facility's Witnessed Fall Report dated [DATE], revealed .Incident Location .Resident's Room .Incident Description .Notified by CNA [Certified Nursing Assistant] that resident fell from bed when she [CNA] was turning resident over while dressing her and she fell out of bed. It was noted that a hematoma [hematoma] developed on left side of forehead. NP [Nurse Practitioner] notified .new order noted to obtain a X-ray of skull .Resident unable to give description . Review of a Nurses Note dated [DATE], revealed Notified by CNA that resident fell from bed when she [CNA] was turning resident over while dressing her and she fell out of bed. It was noted that a hematoma developed on left side of forehead . Review of the Resident#15's comprehensive care plan revealed . Witness Fall from bed [DATE]. Intervention: Educate Staff on staff positioning of resident when providing care . The facility was unable to provide documentation that education or in services were conducted with staff as the intervention for the fall that occurred on [DATE], when the resident fell out of bed during care and sustained a hematoma to the left side of her head. 4. During an interview on [DATE] at 4:11 PM, Certified Nursing Assistant (CNA) #11 was asked what occurred on [DATE], when Resident #8 fell out of the bed onto the floor. CNA #11 confirmed entered Resident #8's room after gathering supplies for incontinence care and raised the bed up and provided care. CNA #11 confirmed the resident began shaking and his eyes rolled back. The CNA stated he stepped out of the room to contact the nurse and then returned to the room. The CNA stated when he returned to the room, Resident #8 was laying on the floor on his left side and blood was on his forehead. CNA # 11 was asked what did he do at that moment. CNA #11 stated that Resident #8 was still shaking and he rolled him onto his back and the resident's eyes remained closed. The CNA stated he called the Resident's named several times trying to wake him up and that is when the nurse entered the room. CNA #11 was asked what condition was Resident #8 in when you left the room to get assistance. CNA #11 confirmed on [DATE], the resident was not acting himself. The CNA stated the resident had the bed control in his mouth, was not his usual self. The CNA stated he removed the bed control from the resident's hands and mouth and walked toward the door while letting the bed down with the bed remote. CNA #11 was asked did he use the call light for assistance. CNA #11 stated that staff don't always answer the call lights in a timely manner and that is why he went to find assistance. CNA #11 confirmed Resident #8 was shaking like he was cold. CNA #11 was asked had the facility given any type of education or inservices on residents with history of seizures and what to do in an emergency. CNA #11 confirmed that he had never attended any inservices on seizures and what to do prior to that day or if any resident that has a history of seizures and what to do if they were having a seizure. CNA #11 was asked how would he be informed if there was a resident at risk for falls and what interventions that are in place to prevent a resident from having a fall. CNA #11 stated the Unit Managers and nurses would inform the CNAs and the information is on the kiosk. The CNA stated all residents' bed should be in a low position. During an interview on [DATE] at 5:03 PM, Licensed Practical Nurse (LPN) #14 confirmed she was working on [DATE], and that she was in giving care to a resident when she heard someone yell that the resident had fallen out of bed and was bleeding, I heard her yelling for me. LPN #14 was asked what did you do then. LPN #14 confirmed when she got to the room he was laying on his back on the floor with a blank stare, and that she bent over him and saw he was unresponsive and yelled code blue and I yelled for them to get [Named LPN #13] who was the 3rd nurse. LPN #14 confirmed that the Resident's assigned nurse, LPN #18, and CNA #11 both were in the room when she arrived. LPN #14 was asked where was the resident positioned. LPN #14 confirmed the resident was on his back in between his bed and the middle roommate's bed, and she had to push Resident #8's bed over toward the wall with her back and buttocks so that she could get down bedside the resident on his left side. LPN #14 confirmed that when she pushed the bed over the bed was in high position and that it hit the lower portion of her back and her buttocks when she pushed it over. LPN #14 was asked what did she do after she pushed the bed over. LPN #14 confirmed she began checking for a pulse both radial and LPN #18 was checking his carotid for a pulse and both her and LPN #13 was calling the resident's name. LPN #14 was asked what condition was the resident in at this time. LPN #14 confirmed the resident had a blank stare. LPN #14 was asked did it appear Resident #8 was having a seizure. LPN #14 confirmed that Resident #8's condition was similar, had a stare but no shaking. LPN #14 was asked if the resident had a pulse. LPN #14 confirmed no pulse was found and instructed LPN #13 to bring the crash cart and begin doing chest compressions. LPN #14 confirmed they performed CPR until EMS arrived and they then took over the process. LPN #14 was asked did he have any visible injuries. LPN #14 confirmed there was blood on the floor from his forehead but did not move him to look for any other injuries. LPN #14 was asked are staff supposed to move a resident when they find them on the floor. LPN #14 confirmed that staff are supposed to come get a nurse and let them assess the resident for injury and then if no injury and no issues the nurse and staff will assist the resident to a safe position in the bed or the chair. LPN #14 was asked if she was aware CNA #10 found Resident #8 on his left side, positioned him on his back, and then called for assistance. LPN #14 confirmed when she arrived that the resident was on his back and she was unaware that he had been laying on his left side prior. LPN #14 confirmed that if staff suspect a seizure that they are to put on call light, yell for assistance, put the bed in low position, and remain with the resident until someone arrives. During a telephone interview on [DATE] at 2:31 PM, Physician #2 was interviewed regarding Resident #8's hospital Discharge Summary and death note. Physician #2 was asked if the multiple cervical fractures contributed to or caused the death of Resident #8. Physician #2 stated the cervical fractures contributed to and ended up causing the death and definitely caused Neurogenic Shock and a devastating quadriplegia. During an interview on [DATE] at 10:50 AM, LPN #19, confirmed that if a resident falls, the resident should remain in the position found until the nurse arrives to assess and when it is determined they can be moved then the resident is assisted back into the bed or the chair or a safe position, if they are not able to move then they are to remain in the position until the EMS arrive and they will assess and move the resident to a safe position. LPN #19 was asked what if you suspect a seizure or the resident is have seizure like symptoms, lower the bed if they are in the bed, yell for help, and do not leave them alone. During an interview on [DATE] at 2:53 PM, the Assistant Director of Nursing (ADON) was asked what is the facility process when a resident falls. The ADON confirmed that the nurse will assess the resident for injury before returning the resident a safe position. The ADON confirmed that the nurse will attempt to find the root cause of the fall or injury by determining if the resident is cognitive able to report what occurred of if there was a witness to the occurrence to prevent any future falls or injury, a pain assessment will be conducted, neurological checks will be initiated if the resident had an unwitnessed fall or if it was determined that the resident hit their head, and incident report will be completed, the family and/or responsible party will well notified along with the physician. The ADON confirmed an intervention will be put into place and the care plan will be updated and revised to reflect the intervention. The ADON confirmed the nurse will also document in the progress notes what occurred and the DON will be notified of the occurrence and will give further instructions. The ADON confirmed that the fall will be discussed in the daily morning meeting with the interdisciplinary team members that include all department heads and the intervention reviewed and changed if need be and all residents that fall will receive a therapy screening. The ADON confirmed that witness statements from all staff members whether they witnessed the incident or not is part of the investigation for a thorough investigation to determine the root cause of the occurrence. The ADON was asked are these steps just for a fall or for any occurrence that a resident experiences that is unusual or out of the ordinary. The ADON confirmed that the steps are for all occurrences, falls and anything that is unusual or out of the ordinary to determine the root cause. The ADON confirmed that if any resident is found on the floor, the staff member should put on the call light, yell out for help and should not move the resident until the resident is assessed by the nurse and it is determined that the resident can be moved to a safe position. The ADON confirmed that all interventions should be placed on the care plan and should be followed by all staff. The ADON confirmed that the fall risk assessments should be completed on admission/ readmission, quarterly, and when there is a fall. The ADON confirmed that if a non-clinical staff found a resident on the floor or in a compromising position, they should alert the nurse by putting on the call light or by yelling out for help but they should not touch the resident and if they assist them up off the floor they should report it immediately to the nurse and give a witness statement. The ADON confirmed that all occurrences with residents such as falls should be documented on for 3 days and if the resident is sent out to the hospital that the neurological checks should be reinstated if they are within that 72 hour window. The ADON was asked what occurred the evening of [DATE], with Resident #8 was found on the floor. The ADON confirmed that CNA #11 was providing care to Resident #8 and he was not acting his usual self and suspected a seizure. The ADON stated the CNA turned his back, went to the door when he turned back around, the resident had fallen out of the bed. The ADON stated when the nurses arrived Resident #8 was in cardiac arrest, CPR was started, and the resident was transported out to the hospital. The ADON confirmed that the resident did not return and expired a few days later in the hospital. The ADON was asked were statements obtained from staff who were on duty that evening. The ADON confirmed the Director of Nursing was in charge of the investigation and I think she did a thorough investigation to determine the cause. The ADON was asked were you aware that CNA #11 found the resident on his left side and turned him over onto his back. The ADON confirmed she was unaware of the resident being moved from his side to his back. The ADON confirmed that CNA #11 should have not repositioned Resident #8 until the nurse assessed him. The ADON confirmed that statements should have been obtained accounting for the resident's prior condition and behavior, and what occurred to provide a root cause analysis, a thorough investigation, in order to implement interventions for the prevention of future occurrences. During an interview on [DATE] at 4:12 PM, the Director of Nursing (DON) was asked what occurred on the evening of [DATE], when Resident #8 was found on the floor. The DON was unable to provide evidence a root cause analysis was completed. Resident #8's eyes were rolled to the back of his head and he was shaking. The DON confirmed Resident #8 had a history of seizures and was taking Dilantin (medication used to prevent / and or control seizures) and the resident did not have a history of falls. The DON confirmed that when a resident has a seizure or a suspected seizure staff should alarm call light, yell for assistance, stay with the resident and not leave the resident alone. The DON stated staff are to place the bed in low position if they are in the bed. The DON was asked if she was aware that CNA #11 found the resident laying on his left side and turned the resident onto his back. The DON confirmed she was unaware that CNA #11 had repositioned the resident. The DON confirmed that the resident should not have been moved until a nurse assessed the resident to determine if the resident was medically stable to be moved or repositioned. The DON stated if not then the EMS should be called and they will assess and move the resident when they arrive. The DON confirmed the root cause of the resident's fall from the bed was a result of a seizure. The DON confirmed CNA #11 told her that he went just to the door way of Resident #8's room, yelled for assistance and showed her how he found the resident laying on his side with blood on the right side of his forehead. The DON stated she was not aware CNA #11 exited the resident's room and walked down to the next room toward the nurse's desk to call for help. The DON confirmed that she was told the bed was in the low position. The DON confirmed she did obtain statements from the staff and their whereabouts during that time. The DON was asked did you speak with day shift staff and nurses to see what the resident's condition was from 7:00 AM to 3:00 PM. The DON confirmed she spoke with CNA #1 and LPN #3 but did not obtain a written statement. The DON confirmed that both CNA #1 and LPN #3 confirmed that the was himself, had no issues and did not notice anything out of the ordinary. The DON was asked did she determine a root cause for Resident #15 fall that occurred on [DATE] The DON confirmed she asked the CNA what occurred, and the CNA told her that she was giving care and the resident slid off the mattress. The DON confirmed she failed to obtain a statement from the CNA that witnessed the fall for Resident #15. The DON was asked what was the intervention that was put into place to keep the resident safe and free from falling off the bed again. The DON confirmed she said would educate staff on how staff is to position the resident when giving care. The DON confirmed she failed to document the in service that she provided. The DON was asked if she thought the investigation into the fall was a thorough investigation. The DON confirmed she did what she thought was right. The DON confirmed that the care plan should be followed at all times for the safety of the resident. The DON was asked what interventions are put in place for residents with diagnosis of seizures to ensure safety. The DON confirmed no interventions are placed because the facility is their home and that it should have been care planned that Resident #8 had a preference to keep his bed in the high position. The DON confirmed that if non-clinical staff find a resident on the floor or about to fall that they should yell for assistance and use the call light and if they do not get a quick response assist the resident and report it to the nurse immediately and write a statement of what occurred. The DON confirmed that falls are discussed weekly in PAR (patient at risk) meetings and the interventions are reviewed and change them if they are not working or not appropriate for the residents. The DON was asked who is ultimately responsible for the care, services, and safety of the residents. The DON confirmed it was her and the Administrator's responsibility that all falls be investigated, a root cause analysis be determined, and interventions put in place for the prevention of future falls to ensure the safety of the resident. The DON confirmed that fall risk assessments should be completed after each fall and neurological checks should be completed for unwitnessed falls and when there is reason to believe that a resident has hit their head or when staff has been told the resident hit their head, each fall or resident occurrence should be investigated to include witness statements, pain assessed, and incident reports completed. The DON confirmed interventions should be resident centered and appropriate for each resident.