**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 communicate and document two pressure ulcers causing a delay in care for 6 days. The facility deficient practice resulted in the worsening of 2 pressure ulcers assessed and staged at a 2 on 6/4/19 then again on 6/10/19 at a Stage 4 for 1 of 16 (#55) residents with pressure ulcers resulting in Neglect. The findings include: Review of the facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/17 revealed .Medical and emotional support will be made immediately available to any individual suffering either alleged abuse, neglect, misappropriation of patient property or expolitation Neglect: the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Endometrium, Secondary Malignant Neoplasm of Genital Organs, Encounter for Attention to Colostomy, Type 2 Diabetes Mellitus, Edema, and Difficulty in Walking. Medical record review of the Braden Scale for Predicting Pressure Sore Risk, dated 5/7/19, revealed a total Braden Score of 13 indicating Resident #55 was at a moderate risk for developing a pressure ulcer. Medical record review of the admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #55 was cognitively intact, understood others with clear comprehension, had adequate vision-saw fine detail, wore glasses, and had no behaviors. Resident required extensive assistance with bed mobility using 1 person, limited assistance with transfers using 2 persons, had a urinary catheter and a colostomy, and had no Pressure Ulcer's on admission to the facility. Medical record review of the Nursing Care Plan, revised 5/27/19, revealed .Pt [patient] at risk for bed sores [pressure ulcers] and increased pain due to immobility from metastatic/reoccurrence cancer .Decrease pt pain and maintain bed mobility .Implement exercise program that targets strength, ROM [range of motion] .Pt is likely to have pain and pressure areas develop without AROM [active range of motion]/strength maintenance. Pt has metastatic cancer . Medical record review of the Weekly Skin Assessment, undated, posted at the 3rd floor nurses station, revealed Resident #55 was scheduled to have a skin assessment every Saturday by the resident's nurse. Medical record review of the Hospice Communication Form admission note, dated 6/4/19, at 5:08 PM revealed .met with pt nurse [Licensed Practical Nurse (LPN) #1] .collaborated POC [plan of care] with pt, facility nurse [LPN #1] et [and] this RN [Registered Nurse] .wound stage 2 coccyx . Medical record review of the Hospice Communication Form, dated 6/5/19, revealed .stage II [Pressure Ulcer] [partial thickness skin loss involving eprdermis, dermis, or both .superficial and presents as an abrasion or blister] to bilateral [both] buttocks .care collaborated .continue with current POC . Medical record review of the Certified Nursing Assistant (CNA) skin assessments, dated 6/1/19 to 6/10/19, revealed no documentation of PU's for Resident #55. Medical record review of Wound Care notes, dated 6/10/19, revealed .While competing weekly assessment of patient [resident], [resident] c/o [complained of] 'butt hurting'. Had patient turn to right and two pressure ulcers were noted; one to coccyx and one to the right gluteal. Medical record review of the Wound Management note, dated 6/10/19, revealed Pressure Ulcer on coccyx assessed to be 2 centimeters (cm) long x 1 cm wide x 0.3 cm deep with light exudate (drainage) that was serous (clear, amber, thin and watery), with no odor, unstageable with slough and/or eschar (dead tissue) 95%, granulation tissue (healthy tissue) 5%. PU on right buttock assessed to be 1.2 cm long x 1.8 cm wide x 0.2 cm deep with light exudate that was serous, without odor, unstageable with slough and/or eschar 100%. Review of the Nursing Care Plan dated 6/10/19 revealed .Resident has a pressure ulcer R/T [related to] decreased mobility .unstageable pressure ulcers [ulcer covered with slough or eschar] to coccyx and right gluteal .Start Date: 6/12/2019 Apply dressings per MD [medical doctor] order .See wound care orders .Assess resident for pain related to pressure ulcer or its treatment .Prevent or treat pain by repositioning, redirection, medication .Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin weekly and PRN .Conduct a systematic skin inspection weekly .Report any signs of any further skin breakdown (sore, tender, red, or broken areas) .Instruct resident to reposition self every 1-2 hours when resident is in bed .Keep clean and dry as possible .Minimize skin exposure to moisture .Keep linens clean, dry, and wrinkle free .Keep resident off coccyx and right gluteal .Reduce friction injuries by using lubricants, protective films, protective dressings, protective padding, etc .Supplements: see Dietary orders .Use moisture barrier product to perineal area .Use support surface when resident in bed: pressure reducing mattress . Interview with Hospice Registered Nurse (RN) #3, on 6/12/19 at 10:15 AM in the 3rd floor hallway revealed she assessed Resident #55 on 6/5/19 with 2 Stage 2 Pressure Ulcers. Continued interview confirmed a Hospice Care Plan was not available to the facility at this time. Interview with RN #1, identified as the Wound Care nurse, on 6/12/19 at 10:20 AM in the 3rd floor hallway revealed she was not informed of the PU's on Resident #55 and was unaware of them until her assessment on 6/10/19. Continued interview revealed she depended on the weekly skin assessments by the nurses and daily skin assessments by the CNAs (Certified Nursing Asssitants) done with resident care each shift to inform her of developing Pressure Ulcers. Continued interview also revealed she expected the hospice nurse to inform her of developing Pressure Ulcers. Interview with RN #2, identified as the 3rd floor Unit Manager and Assistant Director of Nursing (ADON), on 6/12/19 at 2:50 PM at the 3rd floor nurses station revealed the Hospital Report Sheet (transfer form with information about the resident] was initiated on admission and kept at the nurses station for the CNAs and nurses to use for report. Continued interview revealed .it [Hospital Report Sheet] is updated daily by the Unit Clerk or the nurse . CNA Skin assessment forms are filled out each shift and left in the Wound Care Nurses' office. Continued interview confirmed .I expect the CNAs to do a skin assessment with all care .bedbaths .diaper changes .and notify the nurse . Continued interview confirmed there was no documentation of Pressure Ulcer's on Resident #55's Hospital Report Sheet. Interview with CNA #3 on 6/12/19 at 3:10 PM in the 3rd floor dining room revealed the CNAs .do skin assessments every time we do care like a bedbath or a diaper change [adult briefs] .we have sheets we fill out and give to the wound care nurse .or we tell the nurse if we need to . Interview with the DON on 6/12/19 at 5:45 PM at the 3rd floor nurses station confirmed she expected the nurses to do skin assessments with all care, document them, and let the Wound Care Nurse know about changes. Continued interview revealed the facility failed to prevent the worsening of pressure ulcers by failing to treat 2 pressure ulcers which was assessed and staged at a 2 on 6/4/19 by hospice, and rediscovered by the facility on 6/10/19 at a Stage 4 (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer, slough or eschar may be visible) for 1 of 16 (#55) residents with pressure ulcers resulting in HARM

**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 communicate, document and treat the presence of 2 pressure pressure ulcers assessed and staged at a 2 on 6/4/19 by a Hospice Nurse and later by the facility on 6/10/19 at a Stage 4 for 1 of 16 (#55) residents with pressure ulcers resulting in HARM. The findings include: Review of facility policy, Skin Integrity Prevention and Management Assessment, dated 1/1/03 revealed .skin assessments are completed on all patients by the licensed nurse and documented using the Weekly Skin Assessment Record . Review of facility policy, Skin Monitoring Assessment Guidelines, dated 1/1/03, revealed .daily monitoring will enable staff to remain alert to potential changes in the skin condition . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Endometrium, Secondary Malignant Neoplasm of Genital Organs, Encounter for Attention to Colostomy, Type 2 Diabetes Mellitus, Edema, and Difficulty in Walking. Medical record review of the Braden Scale for Predicting Pressure Sore Risk, dated 5/7/19, revealed a total Braden Score of 13 indicating Resident #55 was at a moderate risk for developing a pressure ulcer. Medical record review of the admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #55 was cognitively intact, understood others with clear comprehension, had adequate vision-saw fine detail, wore glasses, and had no behaviors. Resident required extensive assistance with bed mobility using 1 person, limited assistance with transfers using 2 persons, had a urinary catheter and a colostomy, and had no Pressure Ulcer's on admission to the facility. Medical record review of the Nursing Care Plan, revised 5/27/19, revealed .Pt [patient] at risk for bed sores [pressure ulcers] and increased pain due to immobility from metastatic/reoccurrence cancer .Decrease pt pain and maintain bed mobility .Implement exercise program that targets strength, ROM [range of motion] .Pt is likely to have pain and pressure areas develop without AROM [active range of motion]/strength maintenance. Pt has metastatic cancer . Medical record review of the Weekly Skin Assessment, undated, posted at the 3rd floor nurses station, revealed Resident #55 was scheduled to have a skin assessment every Saturday by the resident's nurse. Medical record review of the Hospice Communication Form admission note, dated 6/4/19, at 5:08 PM revealed .met with pt nurse [Licensed Practical Nurse (LPN) #1] .collaborated POC [plan of care] with pt, facility nurse [LPN #1] et [and] this RN [Registered Nurse] .wound stage 2 coccyx . Medical record review of the Hospice Communication Form, dated 6/5/19, revealed .stage II [Pressure Ulcer] [partial thickness skin loss involving eprdermis, dermis, or both .superficial and presents as an abrasion or blister] to bilateral [both] buttocks .care collaborated .continue with current POC . Medical record review of the Certified Nursing Assistant (CNA) skin assessments, dated 6/1/19 to 6/10/19, revealed no documentation of PU's for Resident #55. Medical record review of the Wound Management note, dated 6/10/19, revealed Pressure Ulcer on coccyx assessed to be 2 centimeters (cm) long x 1 cm wide x 0.3 cm deep with light exudate (drainage) that was serous (clear, amber, thin and watery), with no odor, unstageable with slough and/or eschar (dead tissue) 95%, granulation tissue (healthy tissue) 5%. PU on right buttock assessed to be 1.2 cm long x 1.8 cm wide x 0.2 cm deep with light exudate that was serous, without odor, unstageable with slough and/or eschar 100%. Review of the Nursing Care Plan dated 6/10/19 revealed .Resident has a pressure ulcer R/T [related to] decreased mobility .unstageable pressure ulcers [ulcer covered with slough or eschar] to coccyx and right gluteal .Start Date: 6/12/2019 Apply dressings per MD [medical doctor] order .See wound care orders .Assess resident for pain related to pressure ulcer or its treatment .Prevent or treat pain by repositioning, redirection, medication .Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin weekly and PRN .Conduct a systematic skin inspection weekly .Report any signs of any further skin breakdown (sore, tender, red, or broken areas) .Instruct resident to reposition self every 1-2 hours when resident is in bed .Keep clean and dry as possible .Minimize skin exposure to moisture .Keep linens clean, dry, and wrinkle free .Keep resident off coccyx and right gluteal .Reduce friction injuries by using lubricants, protective films, protective dressings, protective padding, etc .Supplements: see Dietary orders .Use moisture barrier product to perineal area .Use support surface when resident in bed: pressure reducing mattress . Medical record review of the Skilled Nursing Notes, dated 6/1/19-6/12/19, revealed no Pressure Ulcer's were documented for Resident #55. Observation and interview with Resident #55 on 6/11/19 at 10:45 AM in the resident's room revealed the resident was sitting in the wheelchair and stated, .it's my own fault because I refuse to get up in my chair and off my back .I like to watch TV in bed all day . Interview with RN #1, identified as the Wound Care nurse, on 6/12/19 at 10:20 AM in the 3rd floor hallway revealed she was not informed of the PU's on Resident #55 and was unaware of them until her assessment on 6/10/19. Continued interview revealed she depended on the weekly skin assessments by the nurses and daily skin assessments by the CNAs done with resident care each shift to inform her of developing Pressure Ulcers. Continued interview also revealed she expected the hospice nurse to inform her of developing Pressure Ulcers. Observation of Resident #55 on 6/12/19 at 10:30 AM in the resident's room revealed resident able to assist turning herself to the side by using upper body strength and the side rails during wound care. Interview with RN #2, identified as the 3rd floor Unit Manager and Assistant Director of Nursing (ADON), on 6/12/19 at 2:50 PM at the 3rd floor nurses station revealed the Hospital Report Sheet (transfer form with information about the resident] was initiated on admission and kept at the nurses station for the CNAs and nurses to use for report. Continued interview revealed .it [Hospital Report Sheet] is updated daily by the Unit Clerk or the nurse . CNA Skin assessment forms are filled out each shift and left in the Wound Care Nurses' office. Continued interview confirmed .I expect the CNAs to do a skin assessment with all care .bedbaths .diaper changes .and notify the nurse . Continued interview confirmed there was no documentation of Pressure Ulcer's on Resident #55's Hospital Report Sheet. Interview with CNA #3 on 6/12/19 at 3:10 PM in the 3rd floor dining room revealed the CNAs .do skin assessments every time we do care like a bedbath or a diaper change [adult briefs] .we have sheets we fill out and give to the wound care nurse .or we tell the nurse if we need to . Interview with the DON on 6/12/19 at 5:45 PM at the 3rd floor nurses station confirmed she expected the nurses to do skin assessments with all care, document them, and let the Wound Care Nurse know about changes. Continued interview revealed the facility failed to prevent the worsening of pressure ulcers by failing to treat 2 pressure ulcers which was assessed and staged at a 2 on 6/4/19 by hospice, and rediscovered by the facility on 6/10/19 at a Stage 4 (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer, slough or eschar may be visible) for 1 of 16 (#55) residents with pressure ulcers resulting in Harm. Interview with LPN #1 on 6/13/19 at 8:15 AM on the 3rd floor hallway revealed .I remember the hospice nurse talking to me about [Resident #55] on 6/4/19 but she didn't tell me about Pressure Ulcer's .I would have put a dressing on them and called the wound care nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of the facility investigation, review of hospital data, observation and interview, the facility failed to provide supervision to prevent a fall; and failed to provide a complete investigation of the fall for 1 of 20 residents (#36) with falls. The findings include: Review of the facility policy, Accidents and Incidents-Investigation and Reporting, revised 7/2017, revealed .All accidents and incidents involving residents .occurring on our premises shall be investigated . Further review revealed .The following data, as applicable, shall be included on the Report of Incident/Accident form .The circumstances surrounding the accident or incident .The disposition of the injury (i.e. transferred to hospital .) .Any corrective action taken .Follow-up information .Other pertinent data as necessary or required . Review of the facility policy, Administering Medications through a Small Volume (handheld) Nebulizer, revised 10/2010, revealed .remain with the resident for the treatment unless determined to be safe for self-administration . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses which included Pneumonia, Chronic Obstructive Pulmonary Disease, Anxiety, Psychosis, and History of Falling. Medical record review of the Fall Risk Assessment Tool dated 3/27/19 revealed the score of 17, indicating Resident #36 was at High Risk for falls, (score over 13 is high risk). Medical record review of the baseline Care Plan dated 3/27/19 revealed Resident #36 was .at risk for falls related to .Fall Risk Assessment Tool .history of falls . with approaches including .medication review by nurse, pharmacy, MD/NP [Medical Doctor/Nurse Practitioner] as needed .OT [Occupational Therapy] .PT [Physical Therapy] referral and treat as needed . Medical record review of the admission orders dated 3/27/19 revealed Occupational and Physical Therapy were ordered and continued until the therapy was discontinued on 6/10/19. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #36 had short and long term memory impairment; required extensive 2 person assistance for bed mobility; required extensive 1 person assistance for transferring, locomotion on the unit, dressing, and toileting; required limited 1 person assistance for locomotion off the unit and personal hygiene; was frequently incontinent of bowel and bladder; and on 1 or 2 occasions walked in room or corridor with 1 person assistance. Further review revealed the resident had a fall 2-6 months prior to the admission to the facility and had had no falls after admission to the facility. Medical record review of the 14 day MDS dated [DATE] revealed Resident #36 had a Brief Interview for Mental Status (BIMS) of 15/15, indicating the resident was cognitively intact. Resident #36 exhibited no delirium, moods, psychosis, or behaviors; required extensive 2 person assistance for bed mobility; required extensive 1 person assistance for transferring, locomotion on and off the unit, dressing, toileting and bathing; required limited 1 person assistance for walking in the room; and walking in the corridor did not occur. Resident #36 was frequently incontinent of bladder, occasionally incontinent of bowel; and had no falls since admission. Medical record review of the Occupational Therapy (OT) Daily Treatment Note revealed the following: On 4/22/19 and 4/23/19 Resident #36 .required supervision from therapist to ensure safe body mechanics to target specific muscle groups to avoid injury . Further review of the 4/23/19 note revealed .Cont'd [Continued] edu [education]/retraining utilizing rollator [mobility device] within facility/room environment . On 4/24/19 Resident #36 .requiring supervision with 35% verbal and visual cues for sequencing through safe rollator placement, for locking/unlocking brakes appropriately, and overall safety awareness .pt hopes to return to [home] Friday, April 26 . Medical record review of the Physical Therapy (PT) Daily Treatment Note revealed the following: On 4/22/19 Resident #36 .ambulated over 400 feet with RW [rolling walker/rollator] at Moderate [Mod] 1 level demonstrating safety awareness with ascending/descending to rollator seat . Medical record review of the Resident Progress Note dated 4/25/19 revealed .Pt [Patient] found on floor in doorway of bathroom. Pt states .was trying to use bathroom. Pt hit head; knot noted to back of head . Medical record review of the Event Report dated 4/25/19 revealed Resident #36 was resting in the bed prior to the fall, was found on the bathroom floor, and had pain to the back of the head at an intensity of 4 out of 10 indicating moderate pain. Further review revealed the .Location of Injury .Knot noted to back of head .Note any injury to the head .Bump/Hematoma .Range of Motion [ROM] x [times] 4 [extremities] Without Pain/Limitation .Position of Extremities .No Rotation/Deformity/Shortening Noted .Mental Status .No Changes .Vitals [Vital Signs] Blood Pressure 170/76 .Notes .Pt found on floor in doorway of bathroom. Pt states .trying to use the bathroom. Pt hit head; Knot noted to back of head. Neurochecks initiated . Review of the Event form of the Neuro Checks revealed they were within normal limits. Further review revealed the .Intervention immediate measure taken .rest .education . Further review revealed the .Orders .Fall with Suspected Head Trauma: Initiate Neurochecks per facility protocol; Fall: Initiate Fall Prevention Program; and Fall: Monitor status for 72 hours for bruising, change in mental status, pain, or other injuries related to fall . Review of the facility investigation revealed Resident #36 had an unwitnessed fall on 4/25/19 at 6:30 AM, and was found .laying on floor in doorway of bathroom ., the fall was related to toileting, had no falls in last 3 months, no new medication or significant increase within 1 week, required no medical attention, and fell while walking in the resident's bathroom. The Root Cause determination revealed .getting out of bed without assistance, weakness, pt needing to use restroom, and did not use call light . The Root Cause revealed .getting out of bed without assistance . The intervention based on root cause revealed .Educate pt to call for assistance . Further review revealed when the family was notified of the fall, the family .requesting a MRI [Magnetic Resonance Imaging- strong magnetic field and radio waves to create detailed images of organs and tissues within the body], NP notified . Further review of the investigation revealed no identification of staff assigned to the resident, no staff interviews or statements of the fall scene or observation/interaction with resident on 4/25/19; no description of the environment of the fall scene; no data regarding right shoulder issue; no data of the hospitalization or the results from the hospitalization; and no review of medication or laboratory data. Medical record review of the April 2019 Treatment Administration Record revealed on every shift, the neurochecks were completed for 2 days, the resident was monitored for 72 hours, and the fall prevention program was initiated and monitored for 5 days. Review of the Fall Risk Assessment Tool dated 4/25/19 revealed a score of 9, Moderate Fall Risk (moderate range was 6-13). Medical record review of the NP Progress Note dated 4/25/19 revealed .Pt seen at request of staff due to fall at approx [approximately] 630 this AM in which pt struck .head on the tile and bathroom. Pt has large hematoma to occipital lobe. Pt has no alteration in mental status .is alert and oriented and states .was going to the bathroom and .'does not know what happened' but .'fell backwards striking .head.' Pt states [name NP], this is terrible because I am supposed to discharge tomorrow.' I explained that we would contact .daughter .but due to the size of the hematoma on back of .head, we would be sending .to the emergency room for additional evaluation. I have a concern for subdural hematoma. Pt verbalizes understanding .Assessment Plan 1. Fall with head injury-new onset-pt states .was ambulating in bathroom and fell backwards striking .head on floor. Pt had large hematoma noted to occipital lobe. Pt is alert and oriented with no change in mental status .Pt will be transported .emergency room for further evaluation and treatment due to concern for subdural hematoma . Continued review revealed .Follow-Up: Pt was returning early afternoon- Per .Hospital CT [Computed tomography-combination of x-rays and computer to create pictures of organs, bones, and other tissue] head was negative. Pt did return with right upper extremity in sling. Per hospital records pt has evidence of possible fracture noted to right forearm. Recommendation is that pt follow-up with orthopedic service for additional examination. Instructed staff to please obtain appointment for pt with orthopedic service as soon as possible. Pt will be kept at nonweight bearing status to right upper extremity until follow up with orthopedic. Right upper extremity will be kept in sling until follow up with orthopedic. Therapy notified of change in pt's status and that pt will not be able to discharge as planned tomorrow . Medical record review of the Nursing Home to Hospital Transfer Form dated 4/25/19 revealed the transfer was related to Fall-Hit head, knot on back of head. Review of the hospital Final Report dated 4/25/19 revealed .pt presents after a fall .going to bathroom with [resident's] walker .let go of the walker to reach for the bar, missed, and fell backwards .hit .head, but not lose consciousness . Review of the Medical Decision Making: revealed .CT scan of head demonstrated scalp hematoma, but no intracranial abnormality. Xrays right shoulder and humerus demonstrated possible nondisplaced fracture distally. I have low clinical suspicion of fracture as pt had no swelling or deformity on examination, but a sling was ordered as precaution .pt given Tylenol for headache . Medical record review of Resident #36's Care Plan initiated on 3/27/19 was at risk for falls approaches, updated on 4/25/19, revealed .educate patient on need to call for assistance . Medical record review of the Orthopedic Surgeon report dated 4/29/19 at 2:20 PM revealed .Chief Complaint: Follow up on right shoulder pain and new complaint right arm pain . Further review revealed Resident #36 .returns to the clinic today .fell recently .stated .fell backwards and landed on .head .performed x-rays of .shoulder and arm at that time. [Resident] was told .could have a crack in .arm . Continued review of the .Physical Exam demonstrates supple motion of .elbow .has no tenderness along .elbow .is neurovascularly intact. In regard to .shoulder .continues to have pain with passive and active motion . Further review of the .Imaging from 4/25/19 of .humerus is normal. The shoulder demonstrates severe arthritis again .Assessment: Shoulder arthritis .Plan: has significant shoulder arthritis .discussed options .wants to try another injection .steroid injected right shoulder 1 ml [milliter] Depo-Medrol and 4 ml of 1% [percent] lidocaine .procedure tolerated well as needed . Medical record review of the Fall Risk Assessment Tool dated 4/29/19 at 2:21 AM revealed a score of 18 indicating Resident #36 was a high risk for fall. Medical record review of the Event Report dated 4/29/19 revealed Resident #36 was receiving a nebulizer treatment prior to the unwitnessed fall. The resident was found on the floor in the resident's room and the .Pt heard yelling 'HELP' shortly after nebulizer tx [treatment] was administered and found lying on floor next to .wheelchair . Further review revealed the .Pain Observation .Does resident exhibit or complain of pain related to the fall? .Yes, right shoulder . with the intensity of .6/10 . in the moderate/severe range; the range of Motion was .painful/limited upper extremity Neurological Check .was the same as the 4/25/19 neurological check except the left and right lower extremity movement was weak. The vital signs dated 4/29/19 at 8:51 PM revealed 96% O2 Sat [oxygen saturation] while resting with O2 in use at 2 lpm [liters per minute] and blood pressure of 126/86. Review of the Possible Contributing factors revealed the resident complained of or experienced tripping prior to the fall. Further review revealed .Additional Information .X ray shows fracture to right shoulder . and the .Interventions Immediate measures taken .Analgesic, cold, and rest . Review of the facility fall investigation revealed Resident #36 fell while standing or attempting to stand in the resident's room on 4/29/19, Monday, at approximately 8:30 PM and required .medical attention, no hospitalization .was on restorative caseload . received .purposeful rounding . had .2 falls in last 3 months . and .no new medication or increases within 1 week . Review revealed the root cause determination included .Pt got up from wheelchair without assistance and did not use call light, pt tripped over footrest on wheelchair, and didn't move foot rest . with the root cause of .pt attempted ambulation without assistance . Further review revealed the intervention based on root cause was .reinforce using call light to ask for assistance-Pt demonstrates understanding verbally and agrees to comply . Further review revealed the investigation failed to include the identification of staff assigned to the resident, had no staff interview or statements of the fall scene or observation/interaction with resident on 4/29/19; no description of the environment of the fall scene; had no reference regarding second issue with right shoulder, had no data of the hospitalization or the results from the hospitalization; and had no review of medication or laboratory data. Medical record review of the Radiology Report dated 4/30/19 of the right shoulder revealed .Results .There is a fracture involving humeral neck with displacement . Observation on 6/10/19 at 10:00 AM of Resident #36 in the resident's room revealed the right arm in a sling. When asked why the arm was in a sling the resident stated .fell in facility once and hurt my right arm . Observation at 9:14 AM revealed the resident was in the room in the wheelchair with a sling for the right arm and had non-skid socks on. When asked why the resident was wearing a sling the resident stated .was trying to stand up and went to fast and fell on my face .no staff there but were there right away .told me to stick to my wheelchair and not to walk without staff and to call for help . Telephone interview with Licensed Practical Nurse (LPN) #2 on 6/13/19 at 8:57 AM regarding the 4/29/19 fall involving Resident #36 confirmed the LPN was the assigned nurse to the resident and responded to the fall. LPN #2 stated he had administered a nebulizer treatment to the resident in the resident's room and the resident was in a wheelchair. The LPN stated under .ideal circumstances the nurse stays with the resident during the administration but he had to step out of the room to the medication cart about 10 feet away . The LPN stated the .resident was behind a privacy curtain and not in direct site . The LPN stated a Certified Nurse Aide (CNA) was doing rounds and entered the room no more than 5 minutes from when he left the room. The CNA yelled out the resident was on the floor and the LPN went in to see the resident on the floor. The LPN stated the .resident said [the resident] stood up and was turning off the nebulizer and tripped . Telephone interview with CNA #2 on 6/13/19 at 9:02 AM and 9:05 AM revealed she was not on duty on 4/29/19 and .was not there .I didn't find it [resident on floor] . When informed she was on duty, was providing care to the resident per the time sheet and ADL [Activities of Daily Living] report, the CNA stated she did not recall assisting the nurse getting resident off the floor. Further interview at 10:28 AM revealed the CNA .wanted to clarify what was said earlier and did not mean to indicate .I was not working that night but that I did not recall the incident . Interview with the Director of Nursing (DON) on 6/13/19 starting at 9:12 AM in the conference room confirmed the investigation .had no statements from staff regarding the fall, the investigation failed to identify staff on duty, and the investigation was not complete . When asked how the root cause was determined, the DON stated the Charge Nurse on duty at the time of the fall determined the root cause and then it was reviewed the next day by the team for additional thoughts. The DON suggested and obtained medication review by the psychiatric nurse and orthopedic services who agreed to trial decrease/discontinue medications. Since then the resident had become more alert and the resident's daughter took the resident to a personal psychiatrist who did change the medication and would monitor also. Further interview confirmed all the issues discussed were not included in the investigation information. Further interview revealed .Our FOLLOW-UP addressed what the circumstances of the fall was, the intervention, how the intervention worked, the resident fell involving the same shoulder on both falls; [orthopedic] interventions as well as medication reviews decreased in antipsychotic use, resident has a long history of antipsychotic use. We thought the cause of the first fall was due to training/knowledge of the resident .in that we know [resident was told to use call light and at times [resident] would and other times not. Resident knew was going home Friday [April 26, 2019] and thought .could walk to bathroom on .own so we felt reminding [resident] after fall would emphasize why to call us and [resident] was compliant most of time . The cause of the second fall, 4/29/19, was miscommunication or failure to communicate .resident not calling to get us to help . Interview with the DON and Registered Nurse (RN) #6 on 6/13/19 at 2:40 PM and 3:00 PM in the conference room revealed the RN was the unit clerk on 4/25/19 and wrote the Event Report. Further interview with the RN and DON revealed at the time of the 4/25/19 fall .we felt [Resident #36] was excited regarding leaving on Friday and was trying to do more for self so we felt reminding the resident to use the call light for help was enough at the time. Initially the resident was compliant but not 100% and staff reminded the resident to call so not fall. The resident remained alert and oriented and did what the resident thinks the resident could or can do for self . When asked regarding the follow-up to intervention process the DON stated .We would have followed up in a meeting a week after the fall. From what I was told on 4/29/19 the resident was going to turn off the nebulizer, got up from the wheelchair to do that unassisted . When asked do you feel the facility failed to provide adequate supervision to prevent the fall, the DON stated .If the nurse would have stayed in the room during the treatment as stated in the policy the fall may not have happened . When asked if would agree the investigation did not include who responded to the fall, statements or interviews by staff responding and other staff on duty to determine what staff was aware of on the days of the falls, failed to identify the same shoulder was involved in both falls, the hospital data 4/25/19, the orthopedic results, and the failure of LPN #2 not remaining with the resident while a nebulizer treatment was administered in order to have a complete investigation to determine the root cause, the DON confirmed .I agree the investigation lacked information . The facility failed to provide a thorough investigation to determine the root cause of both falls to place interventions in place to prevent the second fall that resulted in a fracture. On 4/25/19 the resident got out of bed by self and ambulated to the bathroom where resident fell backwards hitting back of head resulting in a scalp hematoma. The facility determined the root cause to be the resident getting out of bed without assistance and educate pt to call for assistance. On 4/29/19 the resident was receiving a nebulizer treatment prior to the fall. Facility policy revealed the Nurse set up the nebulizer while resident in wheelchair with foot pedals and left the resident even though facility policy was to stay during administration of medication with a nebulizer. The Nurse left the resident and went back to the medication cart with curtain pulled and Resident stood up from wheelchair without assistance and tripped over the foot pedals and fell resulting a fracture to the right shoulder and HARM.