**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 prevent accidents related to falls for 1 resident (Resident #45) of 5 residents reviewed for falls when effective and appropriate interventions to prevent falls were not implemented which resulted in actual harm to Resident #45. The findings include: Review of the facility's policy titled, Accidents and Supervision, updated on 8/21/2023, showed .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes .Identifying hazards(s) and risk(s) .Implementing interventions to reduce hazard(s) and risk(s) .Monitoring effectiveness and modifying interventions when necessary .The facility shall establish and utilize a systematic approach to address resident risk .to minimize the likelihood of accidents .Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk .Implementation of Interventions .using specific interventions to try to reduce a resident's risks from hazards in the environment .Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents . Resident #45 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Encephalopathy (a brain disease that alters brain function), Subsequent Encounter for Fall, Dementia, Muscle Weakness, Abnormalities of Gait and Mobility, Difficulty in Walking, and Cognitive Communication Deficit. Review of the admission assessment dated [DATE], showed Resident #45 had short and long term memory problems. Resident #45 had 3 or more falls in the last 3 months, required assistance for ambulation, had unstable balance, intermittent confusion, and gait problems while standing and while walking. The Resident's Fall Risk Assessment score was 20, which indicated the resident was at high risk for falls. Review of the care plan dated 1/6/2024, showed .Has risk factors for falls: Assistive Devices walker and wheelchair. Needs assist for transfer Limited assist of one. Poor safety awareness elder has memory issues .Assist w/ [with] transfers using assist as needed .Assist w/ambulation using assist as necessary to complete task safely. Ensure use of assistive device used for ambulation if necessary .Wheelchair for mobility thru home .Keep call light within reach; keep floors clean, dry and free of clutter; keep assistive devices within reach; keep personal articles used frequently within reach while in bed .provide adequate lighting; encourage wearing of non-skid shoes or slippers for all transfers/ambulation .Assess behavioral issues that place Elder at risk for fall/injury, cognitive deficits and accommodate forgetfulness regarding safety and environmental hazards .Redirect as needed to maintain safety. Accommodate routine or approaches to minimize safety risks .Fall at home. Need for skilled nursing monitoring .Refer to PT [physical therapy], OT [occupational therapy] .for evaluation and treatment for decline in ability . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #45 required a walker for mobility. The resident required partial/moderate assistance for walking, sit to stand, roll left and right, chair to bed/bed to chair transfers, sit to lying, toilet transfers, tub/shower transfers, and lying to sitting on the side of the bed. The resident was dependent on staff for picking up objects. The resident was always continent of urine and occasionally incontinent of bowel. Resident #45 had a fall prior to admission and had no falls since admission to the facility. The resident received speech therapy, occupational therapy and physical therapy. Review of the facility investigation documentation showed Resident #45 had an unwitnessed fall on 1/14/2024 at 6:15 PM, in her room. The resident was found on the right side of the bed in front of the recliner. It was noted .Resident stated that she was attempting to get out of her recliner, in order to close her blinds, scooted down the chair and slipped out of it, onto the floor. Declines hitting her head during incident .Nurse closed residents [resident's] blinds and reeducated resident on call light use, following that, nurse assisted into a lying position .Reminder signs, and Stop signs put up in view of patient .No Apparent Injury . Review of the care plan updated on 1/14/2024, showed .At risk for injurious falls related to weakness, unsteadiness, impaired balance .1/14/24 Keep call bell [call bell was an intervention on 1/6/2024], fluids, and personal items within [Resident #45's] reach [an intervention in place on 1/6/2024] .Put reminder signs in room. Resident states she sees them and understands .Reminder & [and] Stop signs placed withing [within] Elder's view to remind Elder to call for assistance when she needs help . Review of the care plan updated on 1/16/2024, showed Impaired Cognition .Related to Dementia .Orient as needed throughout conversation .Mobility, Impaired physical .Related To .frequent falls . Review of the Nursing Interdisciplinary Notes dated 1/22/2024, showed .Heard Call from housekeeping staff, elder noted to be on ground, fall suspected, not witnessed .small s/t [skin tear] noted to right elbow. no other .injury noted. elder wasn't using assistive device and encouraged to . Review of the facility's investigation documentation showed the resident had an unwitnessed fall on 1/22/2024 at 6:40 AM, in the hallway. It was noted .Location Specifics: front of nurse's station wellness 1 .Resident's Description: I don't know why I fell or why I'm here .elder assessed for injury, assisted to room .Contributing/Environmental Factors: Ambulation WITHOUT Gait Device . Review of the care plan updated on 1/22/2024, showed .1/22/24 Keep bed in lowest position at all times when not working at the bedside [the resident fell in the hallway and not from the bed]. Encourage resident to use her walker . Review of the Speech Therapy Treatment Encounter Note dated 1/25/2024, showed .SLP [Speech Language Pathologist] used principles of spaced retrieval to increase carryover for use of call button. Pt [patient] achieved 0% acc [augmentative and alternative communication] on this date. Re-education and repetition did not benefit .Pt achieved 0% acc for identification for reasons to use call button with education again not beneficial . Review of the Nursing Interdisciplinary Notes dated 1/26/2024, showed .Elder found in floor at 0545 [5:45 AM]. No injuries/pain noted, no changes in LOC [level of consciousness]. When asked what elder was doing, stated 'trying to go to bathroom.' Elder stated she hit her head .Neuro checks initiated. Education provided to call for assistance for ambulation/transfers/toileting .[reminder signs to call for assistance were placed in the resident's sight on 1/14/2024 and resident was encouraged to use walker after 1/22/2024 fall] [Medical Director] notified at 0558 [5:58 AM] . Review of the facility's investigation documentation showed the resident had an unwitnessed fall on 1/26/2024 at 5:45 AM, in the resident's room. It was noted .elder found in floor next to heater, no injuries noted, skin check completed, no pain noted at this time .Resident's Description: 'I was trying to go to bathroom' elder stated 'I hit my head' .no pain noted .neuro checks initiated .doctor notified .Contributing/Environmental factors: Unassisted Ambulation . Review of the care plan updated on 1/26/2024, showed .1/26/24 Reminder to push call light [reminder signs placed within resident's sight on 1/14/2024] and Keep room well lit and clutter free [previous intervention dated 1/6/2024, no new intervention put into place]. Resident often prefers lights out . Review of the facility's fall investigation documentation showed the resident had an unwitnessed fall in the resident's room on 2/6/2024 at 12:30 AM, .Location Specifics: In front of the window .This nurse and CNA [Certified Nursing Assistant] on shift heard a single loud thud that came from this residents room. Staff entered residents room to find her on the floor sitting with her left arm supporting her and her right hand up to her nose. Nurse assessed resident and found superficial skin tear to midline nasal dorsum, as well as mild epistaxis [nosebleed] from left nostril. Light pressure applied to affected area. Nurse inquired with resident if she had hit her head during the incident, to which she confirmed that she did. Resident voiced c/o [complaints of] headache, and declined pain elsewhere. No other injuries were noted .Staff assisted resident to her feet, and transferred her to her bed in a seated position. CNA remained with resident, while this nurse began notifying appropriate personnel. @ [at] 0035 [12:35 AM] M.D. [Medical Doctor] ordered this resident to be sent to ER [Emergency Room] for further evaluation .Resident's Description: Resident stated that she was attempting to ambulate to the large chair next to the window, but lost her balance. She stated that she hit her head during the incident, and complained of headache like pain .Contributing/Environment factors: Lost Balance . Review of the hospital Emergency Documentation dated 2/6/2024, showed XXX[AGE] year-old FEMALE TO THE EMERGENCY DEPARTMENT BY AMBULANCE FROM NURSING HOME WITH REPORT OF FALL WITNESSED TONIGHT. FELL FACE FORWARD. NO SPECIFIC PRECIPATING EVENT. ABRASION ON BRIDGE OF NOSE. HISTORY OF GAIT INSTABILITY AND FREQUENT FALLS .NO ACTIVE BLEEDING. NO OTHER ACUTE COMPLAINTS .PATIENT WITH HISTORY OF ADVANCED DEMENTIA .Physical Exam .Head .ABRASION TO NOSE .CT [Computed Tomography] Brain/Head .FINDINGS .IMPRESSION .No definite acute intracranial abnormality .No hemorrhage .Diagnosis: Abrasion of nose; Ground-level fall; Unsteady gait .CONTINUE ALL CURRENT MEDICATION. CONTINUE MEASURES TO PREVENT FUTURE FALLS . The resident was discharged back to the facility on 2/6/2024 at 4:05 AM. Review of the care plan updated on 2/6/2024, showed .2/6/24 Personal alarm in place for safety. New clip alarm after 4th fall to assist staff in being able to respond to resident quicker. Previous attempt for caution signs unsuccessful . Review of the advanced practice nurse's Progress Note dated 2/6/2024, showed .Chief Complaint/Nature of Presenting Problem: Follow-up falls with weakness .history of falls. Apparently she had a fall resulting in an ER visit. She was found to have an abrasion but no other acute injuries .continues to be weak and she is receiving skilled rehabilitation. On today's exam she denies pain .PHYSCIAL EXAM .Alert, NAD [No acute distress] .Generalized weakness. No evidence of pain with passive ROM [range of motion] .No neurological deficits noted .Awake alert confused to place and time .DIAGNOSIS, ASSESSMENT AND PLAN .History of fall .Facility protocol .Cognitive impairment .Chronic, continue provide supportive care .Generalized weakness .PT OT as recommended . Review of the Skin Evaluation Form dated 2/6/2024, showed .small skin tear to midline nasal dorsum following fall . During an observation and interview on 2/12/2024 at 12:46 PM, Resident #45 was seated in the recliner in her room. There was a walker at the bedside and the resident's bed had 1/4 bilateral upper siderails. The resident had an alarm on the chair and was wearing non-skid socks. The resident had a band aid over her nose. There were 2 signs posted on the closet door, the first sign read .Stop Ask for help . and the 2nd sign read, .Reminder Push your call light before trying to get up on your own . This surveyor asked the resident what the signs said and the resident verbalized that the signs were to remind her to call for help before getting up. During an observation on 2/13/2024 at 5:55 AM, Resident #45 was lying in bed sleeping. Resident #45 had 1/4 bilateral upper side rails up on bed, a walker at the bedside, and a bed alarm on. The bed was low and locked, call light was in reach, and reminder signs to call for help were posted on the resident's closet door. During an interview and review of facility documentation and Resident #45's medical record on 2/13/2024 at 10:33 AM, with the Director of Nursing (DON) revealed the resident had 4 falls while at the facility. The resident's admission falls risk assessment score was 20 which indicated the resident was at high risk for falls. Care planned interventions to prevent falls included assistance with transfers and ambulation, keeping call light, assistive devices and personal items within reach, adequate lighting, keep floor clean and clutter free, and non-skid footwear. Resident #45 had an unwitnessed fall in her room on 1/14/2024 at 6:15 PM. The resident was found in the floor in front of her recliner and said she was trying to close her blinds. The resident had no injury from the fall. The new intervention to prevent further falls was to put reminder signs up in her room. Resident #45 had an unwitnessed fall on 1/22/2024 and was found in the hallway on the floor by housekeeping. Resident #45 obtained a skin tear on her right elbow. The new intervention to prevent further falls was to encourage the resident to use her walker. Resident #45 had an unwitnessed fall on 1/26/2024 and was found in her room on the floor next to her heater. The resident said she was trying to go to the bathroom when she fell, and she hit her head. The resident had no injury from the 3rd fall. The new intervention to prevent further falls was to remind her to use the call light and keep her room well-lit and clutter free. Resident #45 had a diagnosis of dementia and a BIMS score of 3, indicating she was severely cognitively impaired. The DON confirmed the intervention to provide adequate lighting was already in place. The DON confirmed Resident #45 had dementia, poor cognition, and multiple falls so reminding the resident to use the call light was not an appropriate intervention to prevent further falls. The DON confirmed no new appropriate interventions were implemented after the resident's 3rd fall on 1/26/2024. Resident #45 had another unwitnessed fall on 2/6/2024 in her room. The resident stated she was going to the large chair next to the window and lost her balance. The resident stated she hit her head during the incident and complained of a headache. Resident #45 was sent to the ER for further evaluation. The DON stated .we were kind of at a loss for new interventions .we had exhausted everything we knew to do . During an interview on 2/14/2024 at 11:04 AM, Licensed Practical Nurse (LPN) #3 stated he was responsible for the resident when she sustained 2 of her falls. The LPN stated he was responsible for the resident when she fell on 1/14/2024. The LPN was seated at the nurse station and heard the resident call out for help. LPN #3 entered the room and saw Resident #45 seated on the floor on her bottom. The resident stated she was trying to close the blinds when she fell. Resident #45 had no injuries. The new intervention to prevent further falls was a sign placed in her room to remind her to call for help. LPN #3 stated Resident #45 had dementia and would forget to call for help so he thought the reminder signs would be a good intervention to remind Resident #45 to call for help. LPN #3 was also responsible for the resident when she fell on 2/6/2024. The LPN and a CNA heard a loud noise from the resident's room and went to check on her. Resident #45 was in the floor and stated she was trying to get into the big chair from her bed. Resident #45's nose was bleeding, and she had a skin tear on the bridge of her nose. Resident #45 stated she hit her head and complained of a headache. LPN #3 notified the physician and received an order to send the resident to the emergency room for evaluation. The LPN had another staff member stay in the room with the resident while he notified the physician. Resident #45 returned to the facility about 6 hours later. The LPN stated he provided reminders for the resident to call for help and to use her walker every time he saw her, and the nurse on the floor comes up with the new intervention after the fall to prevent future falls. The DON then reviews the intervention to determine if it was appropriate. During a telephone interview on 2/14/2024 at 11:27 AM, Registered Nurse (RN) #1 stated Resident #45 was alert to self and situation at times, mostly just alert to self. The resident's memory .was not very good . and she would forget things after just a few minutes. RN #1 was responsible for the resident when she fell on 1/26/2024. The CNA notified RN #1 while she was getting shift report that the resident was in the floor in her room. RN #1 entered the room and found the resident on the floor. Resident #45 stated she was trying to go to the bathroom. No injury was noted immediately after the fall. The RN stated .I think my new intervention was to provide education . The RN stated providing education to the resident to call for help .probably . wasn't effective in preventing her from falling. The resident would verbalize understanding when you educated her, but she would forget shortly after. During an interview on 2/14/2024 at 3:37 PM, the DON stated nurses were responsible to come up with new interventions after a fall to prevent further falls. The Interdisciplinary Team (IDT) meets daily Monday through Friday to discuss falls and new interventions to ensure the new interventions are appropriate. The resident had dementia and a BIMS score of 3 indicating the resident had .severe dementia . The intervention to remind the resident to use the call light was not appropriate for the resident with a BIMS of 3, severe dementia, and multiple falls. The resident fell again on 2/6/2024 and was transferred to the ER and was diagnosed with an abrasion to the nose. The DON confirmed the resident was harmed as a result of the fall on 2/6/2024. During an interview on 2/14/2024 at 5:44 PM, the Administrator confirmed the resident had a diagnosis of Dementia and had a BIMS score of 3 which meant the resident had .severe memory problems . This surveyor reviewed the resident's falls and interventions with the Administrator. After the resident's first fall on 1/14/2024, the new interventions were to keep the call bell, fluids, and personal items within the resident's reach (already in place on the care plan dated 1/6/2024) and to put reminder signs in the room for the resident to call for assistance. The resident fell again on 1/22/2024, and the new intervention was to keep the bed in the lowest position at all times and to encourage the resident to use her walker. The resident fell for a 3rd time on 1/26/2024, and the new intervention to prevent further falls was to remind the resident to push the call light and to keep the room well lit and clutter free. The intervention for adequate lighting and keeping the room clutter free was already an intervention that was put into place on 1/6/2024. This surveyor asked the administrator if providing reminders to a resident with dementia and severe memory impairment with multiple falls was an appropriate fall prevention intervention and the Administrator stated .We probably should have come up with something else. It was not an appropriate intervention . The Administrator confirmed that reminding the resident to call for assistance via signage placed in her room was already an intervention put into place after the first fall and was not effective as the resident continued to get up without assistance. The resident fell for a 4th time on 2/6/2024 and obtained a nosebleed and skin tear to her nose and required transfer to the emergency room for evaluation. The Administrator confirmed the resident was harmed when she required evaluation in the emergency room and received an abrasion to her nose. During a telephone interview on 2/14/2024 at 5:59 PM, the Medical Director confirmed providing reminders to a resident with dementia .probably didn't help . and was not an appropriate intervention to prevent falls. The Medical Director stated, .Unfortunately yes. I think she was . when this surveyor asked if the resident was harmed from the fall on 2/6/2024 when the resident required transfer to the emergency department with an abrasion to the nose after the fall on 2/6/2024. During a telephone interview on 2/15/2024 at 6:33 PM, the Medical Director confirmed Resident #45's fall interventions were inappropriate for the resident's mental status. The Medical Director stated he did not believe the resident was harmed based on the definition of harm (resource unknown) from the fall on the 2/6/2024 but the resident was injured from the fall on 2/6/2024. The facility failed to implement appropriate interventions, modify fall interventions, and provide adequate supervision for a cognitively impaired resident, per the facility's policy, which resulted in actual harm to Resident #45.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, medical record review, and interview, the facility failed to notify the resident's representative and the physician of a fall on 1/14/2023 for 1 resident (#1) of 3 residents reviewed. The facility's failure resulted in the delay of treatment for surgical repair of an acute right hip fracture causing actual harm to Resident #1. The findings included: Review of a facility policy Notification of change dated 1/13/2020 showed .the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .the facility must inform the resident, consult with the residents' physician and/or notify the residents' family member or legal representative when there is a change requiring such notification .circumstances requiring notification include: 1. Accidents .b. Potential to require physician intervention . Resident #1 was admitted to the facility on admitted on [DATE], discharged [DATE] and readmitted on [DATE] with diagnoses including Syncope and Collapse, Alzheimer's Disease, Dementia, Anxiety Disorder, Major Depressive Disorder, Delusional Disorders, Dysphagia, Displaced Right Hip Fracture, and Hypertension. Review of Resident #1's 5-day Minimum Data Set (MDS) dated [DATE] showed Resident #1 was severely cognitively impaired and had short and long-term memory problems. Resident #1 required extensive assistance of 1 staff for transfers and toilet use and limited assistance of 1 staff for bed mobility, walking, dressing and personal hygiene. Review of Resident #1's Fall Incident Report dated 1/14/2023 at 11:18 PM, showed a Certified Nursing Assistant (CNA) responded to Resident #1's room after the resident's bed alarm sounded. Resident #1 reported he was uncomfortable, and the CNA assisted the resident to reposition in the bed and began to gather supplies needed to change the resident's brief. While the CNA was gathering supplies the resident sat up on the side of the bed again and attempted to stand. Resident #1 fell back on his buttocks before the CNA was able to return to the resident. Resident #1 was assessed for injury with none noted. The Fall Incident Report documented range of motion (ROM) was assessed and neurological checks were performed, and the report documented Resident #1 did not complain of pain .1/14/2023 [Saturday] 11:30 PM .attempted to call Dr [doctor] .3 times no response. Will notify Monday when Dr. comes for rounds . Continued review showed .Resident contact .wife .1/15/2023 8:30 AM . Review of Resident #1's Nurses' Progress Note dated 1/15/2023 at 12:21 PM showed .Elder noted to have swelling and right hip with mild external rotation noted, MD [medical doctor] called and new order for two view X-ray of right hip . Review of Resident #1's Nurses' Progress Note dated 1/16/2023 at 12:39 PM, showed .Elder had X-ray done, elders [elder's] R [right] hip broken Dr. seen X-ray and new orders to send to .ER [emergency room]. Wife at bed side and this nurse talked to her and explained what was going on. EMS [emergency medical services] given report, after several attempts [hospital] ER was not given repot due to not answering the phone . Review of Resident #1's facility Radiology Report dated 1/16/2023 showed .HIP .Pelvis .Results: intertrochanteric Right femoral fracture with mild angulation [displacement, one bone points off in a different direction]. Mild soft tissue swelling .Conclusion: Acute intertrochanteric Right femoral fracture as noted . Review of Resident #1's emergency room History and Physical dated 1/16/2023 showed .arrives via .EMS from [facility] reports Pt. [patient] had fall yesterday with rt [right] hip pain, shortening and rotation noted. Did X-ray there and showed fx [fracture]. Has dementia. Wife at bedside .Patient recently hospitalized for pneumonia .apparently has had a fall at [facility]. He had a fall last week. He had a fall yesterday. After fall yesterday he developed pain right hip .Hip X-ray reviewed .right inter trochanteric fracture . During an interview with Licensed Practical Nurse (LPN) #5 on 5/16/2023 at 10:50 AM, he stated .I was attempting to transfer him [Resident #1] to take him to the shower during the morning of the 15th [1/15/2023] .When I was transferring him using a pivot transfer, he lifted both legs and rested on my forearms, I did not know he had a fall the night before. I would have done a pain assessment, a skin check, and alert charting .I do not recall her [LPN #6] telling me about his fall. He was not very verbal more in a whisper. I noticed immediately his reaction was not normal for him .he did not have any bruising on the affected side, and I did give him a bed bath, after he was back in the bed there were no non-verbal signs of pain .later in the day we got report [approximately 6:00 PM, end of shift] he had fallen the night before. [LPN #2] was following up later in the day on 1/15/2023 and identified swelling in his right hip and mild external rotation. We obtained an X-ray on 1/16/2023. It did show a right hip fracture and he was sent to the hospital. Hs wife was at bedside when we were getting him ready to be sent out . During an interview with Resident #1's wife on 5/16/2023 at 11:10 AM, she stated .I heard nothing about a fall on the 14th until I came in to see him on the 16th, the X-ray showed he had a broken hip. They sent him to the hospital. I don't know who they thought they called but it was not me .he went into the hospital on the 16th [1/16/2023] had surgery on the 17th [1/17/2023] returned to the nursing home on the 19th [1/19/2023] . During an interview with LPN #5 on 6/5/2023 at 8:30 AM, he stated .If I had known [Resident #1] fell on night shift on the 14th [1/14/2023] I would not have tried to transfer him .I did give him a bed bath and I did not see any swelling or rotation in his leg .I did not see any skin issues that morning .had we known he had fallen as soon as we saw the deformity in his right leg we would have gotten the X-ray sooner .I would have viewed him drawing up his legs as an indicator of pain not his Parkinson's dementia .his vital signs were stable .there was no external rotation in his leg when I did his bed bath, but without knowing he had fallen it would not have been a cardinal sign to send him out. But being ignorant to what had happened does change your judgement .I did not find out he had fallen until the 15th [1/15/2023] at the end of the shift [6:00 PM] during report. It was the nurse who worked the night before was working again . During an interview with LPN #2 on 6/5/2023 at 10:30 AM, she stated .had I known he had a fall on the 14th [1/14/2023] I would have asked doctor .to send him out. It was a very mild external rotation .he said just to get an X-ray .I think if doctor .had known he had fallen he would have likely sent him out then . During an interview with the Physician on 6/5/2023 at 12:05 PM, he stated .if the nurse had told me he had fallen and had slight swelling and mild rotation of his leg I would have sent him out .not knowing he had fallen it was appropriate to order an X-ray to see what was going on . but he did have to have pain longer due to the delay in sending him out .a fall with no apparent injury it would have been acceptable to let me know the following day . During an interview with CNA #7 on 6/6/2023 at 8:00 AM the CNA stated .his room was close to the nurses' station because he fell, he had an alarm under him because he kept getting up by himself. when I came in on 1/15/2023, I did not get in report that he had fallen [1/14/2023 night shift]. The nurse [LPN #5] went in to get him up for a shower and he said he was in pain, and we would try again later, somewhere around 11:30-11:45 [AM], I went in to get him up and I saw swelling in his right hip. When I went to roll him, he whined out. I went out and got the nurse. I don't remember which nurse but whoever it was said [Resident #1] probably needs an x-ray. When [CNA #3] [CNA from previous night] came in that night I said, 'did he fall last night?', and she said 'yes, I thought .[LPN #6] gave it in report' . During an interview with the Director of Nursing (DON) on 6/6/2023 at 1:00 PM, she stated .my concern was when he drew up his legs when he was being transferred I wondered if the fracture could have occurred with him drawing himself up .I cannot say with certainty when the fracture occurred .Currently if the nurse can't get in touch with doctor .they need to call me and call the nurse practitioner if there is a thought of injury. If there is no apparent injury it would be acceptable for the nurse to call doctor .the next day instead of the middle of the night .It should be reported during shift change .the fact the nurse did not report the fall to the oncoming shift did delay Resident #1's treatment. When the abnormality was identified with his right hip, we would have sent him out if it had been known he had a fall . During the interview the DON confirmed the facility failed to notify the physician of Resident #1's fall on 1/14/2023 resulting in harm due to a delay of treatment for Resident #1. During an interview with LPN #2 on 6/6/2023 at 3:30 PM, she stated .I was not the nurse who gave report on the 15th [1/15/2023], so I didn't know he had fallen until I came back .the 18th and I asked what happened to him and I was told he had a fall and had a fracture .I didn't tell doctor .he had fallen when I called him on the 15th because I didn't know .he did not have any bruising, redness only minimal swelling, and slight rotation. From appearance it did not look like he had fallen .his hip just looked funny it was just not his normal .it would have been hard to say it was a fracture especially not knowing he had fallen .there was nothing documented or reported about a fall so how could I have made the right decision .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, medical record review, and interview, the facility failed to implement appropriate fall interventions for 1 resident (#1) of 3 residents reviewed after the resident's first fall on 1/10/2023 and failed to implement new fall interventions after Resident #1's second fall on 1/13/2023. Resident #1 sustained a third fall on 1/14/2023 and an acute right hip fracture. The failure to develop interventions to prevent falls for Resident #1 resulted in actual harm for Resident #1. The findings included: Review of a facility policy Fall Prevention dated 1/13/2020 showed .each resident will be assessed for the risk of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .High Risk Protocols: .the resident will be placed on the facility's Fall Prevention Program .indicate fall risk on care plan .initiate fall risk flag in EHR [electronic health record ] .implement interventions from Low/Moderate Risk Protocols .Provide interventions that address unique risk factors .when any resident experiences a fall, the facility will .complete a post-fall assessment .complete an incident report .notify physician and family .review the resident's care plan and update as indicated .document all assessments and actions . Review of a facility policy Incident and Accident Policy dated 5/1/2021, showed .Assuring that appropriate and immediate interventions are implemented, and corrective actions are taken to prevent recurrences and improve the management of resident care .2. Licensed staff will report incidents/accidents and assist with completion of any investigative information to identify root causes .5. The following incidents/accidents require an incident/accident report but are not limited to .Falls .9. The nurse will contact the resident's practitioner to inform them of the incident/accident .11 .the resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital .12 .the nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence . Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Syncope and Collapse, Alzheimer's Disease, Dementia, Anxiety Disorder, Major Depressive Disorder, Delusional Disorders, Dysphagia, Displaced Intertrochanter Right Femur Fracture, and Hypertension. Review of Resident #1's admission Nursing assessment dated [DATE] showed .Fall Risk Assessment .Hx [history of] falls in last 3 months .Score 22 . Total score above 10 equaled high risk. The facility implemented fall interventions of .low bed .assist with transfers .non-skid footwear at all times .pull-tab alarm . Review of Resident #1's Interim Care Plan dated 1/6/2023 showed .assist w/[with] transfers .assist with ambulation .wheelchair for mobility thru [through] home . Review of Resident #1's Occupational Therapy (OT) Evaluation and Plan of Treatment showed Resident #1's Certification Period was 1/6/2023-2/4/2023. Review of a Physical Therapy (PT) Evaluation and Plan of Treatment showed Resident #1's Certification Period was 1/6/2023-2/4/2023. Review of Resident #1's Nurses' Progress Note dated 1/10/2023 showed .alarm sounded, and I entered the room [Resident #1's room] to find the elder laying of [with] his right side on the floor. Assisted elder to sitting position and completed a head-to-toe assessment. Moves all ext. [extremities] without difficulty. Elder did hit his head causing a small laceration with no bleeding and a small knot to right side of head. Neuro [neurological] checks started and within normal limits. Spoke with MD [physician] explained Neuro checks are within normal limits and laceration is small and no bleeding noted at this time. MD asked if he wanted him to send to ER [emergency room] and he stated, not at this time, watch him for changes in cognition and for changes in neuros, if he has any changes send him out .Spouse notified . Review of Resident #1's Fall Incident Report dated 1/10/2023 showed .alarm sounded, and I entered the room to find elder laying of [on] his right side on the floor. Assisted resident to sitting position and completed a head-to-toe assessment. Moves all ext.[extremities] without difficulty. Elder did hit his head causing a small laceration with no bleeding, and a small knot to right side of head. Neuro checks started and within normal limits . Review of Resident #1's Falls Risk assessment dated [DATE] showed .Post Fall .Disoriented .history of falls .ambulatory and incontinent .Score 20 [score of 10 or more indicates high risk] .Recommendations: low bed .non-skid footwear at all times .bed breaks locked .call light and personal belongings within reach .assist with transfers .ambulation .toileting .pull tab alarm .Appropriate referrals PT .OT .Elder has been assessed by this discipline within last 30 days . Review of Resident #1's Risk for Falls Interdisciplinary Care Plan dated 1/10/2023 showed .low bed, non-skid footwear at all times, bed brakes locked, keep call light and personal articles within reach, assist with toileting, pull-tab alarm . Continued review showed no new, resident-centered interventions were implemented after Resident #1's fall on 1/10/2023. Review of Resident #1's 5-day Minimum Data Set (MDS) dated [DATE] showed the resident was severely cognitively impaired and had short and long-term memory problems. The resident required extensive assist of 1-person with transfers and toilet use. Required limited assistance of 1-person for bed mobility, walking, locomotion, dressing, and personal hygiene. Resident #1 was always incontinent of bladder and occasionally incontinent of bowel. Review of Resident #1's Fall Incident Report dated 1/13/2023, showed .elder sitting in front of nurses' desk and just got up and got in the floor on his hands and knees. No injuries noted. This nurse witnessed occurrence .unable to tell staff what he was doing .staff assisted him back to the wheelchair and moved the chair next to the nurse while she was charting for closer supervision . Review of Resident #1's Nurses' Progress Note dated 1/13/2023 showed .Elder sittin [sitting] in front of nurse's desk, and just got up and got in the floor on his hands and knees. No injuries noted. This nurse witnessed occurrence. Elder requires one on one supervision at this time for safety. Elder is sitting with this nurse at this time . Review revealed no new interventions were implemented after the resident's fall on 1/13/2023. Review of Resident #1's Fall Incident Report dated 1/14/2023 at 11:18 PM, showed .Res. [Resident] had set off personal alarm, staff responded immediately. Res. was sitting up on side of the bed. Res. stated he was uncomfortable. Staff assisted res. in repositioning back into the bed and CNA [Certified Nurse Assistant] started gathering supplies to change Res. brief. While gathering supplies res. sat up on the other side of the bed again and proceeded to attempt standing. CNA turned to walk toward the res. and ask him to please sit on the bed. CNA stated res. knees bent and he fell back onto his buttocks. Res. remained in seated position. CNA stated he did not hit his head or any other body part with the exception of his buttocks .assessed for injury, ROM [Range of Motion] assessed. Neuro check performed. Res. denied any c/o [complaint of] pain or discomfort. Res. was then assisted back to bed VIA [by] 2 staff members with gait belt . Review of Resident #1's Risk for Falls Interdisciplinary Care Plan dated 1/14/2023 showed .¼ side rails .transfer using gait belt . Review of a Skilled Care Nursing Note dated 1/15/2023 at 9:26 AM, showed Resident #1's vital signs were within normal limits and .Pain .No .Pain Management Interventions .None required .Safety .1/4 side rails .low bed .call light within reach . Review of Resident #1's Nurses' Progress Note dated 1/15/2023 at 10:51 AM, showed .elder assisted with bed bath d/t [due to] elder having behaviors when attempting shower in the AM when he was alert and awake, elder pulled knees up to chest and hung while attempting to transfer. Elder went limp, is still talking and wound't [wouldn't] follow verbal prompts for transfer. Behaviors potentially d/t Parkinson's dementia. No further needs noted at this time .12:21 PM .Elder noted to have swelling and right hip with mild external rotation noted, MD called and new order for two view X-ray of right hip . Review of Resident #1's Nurses' Progress Note dated 1/16/2023 at 12:39 PM, showed .Elder had X-ray done, elders [elder's] R [right] hip broken Dr .seen X-ray and new orders to send to .ER [emergency room] . Review of Resident #1's facility Radiology Report dated 1/16/2023 showed .HIP .Pelvis .Results: intertrochanteric Right femoral fracture with mild angulation [displacement]. Mild soft tissue swelling .Conclusion: Acute intertrochanteric Right femoral fracture [hip fracture] as noted . Review of Resident #1's emergency room History and Physical dated 1/16/2023 showed .arrives via .EMS [emergency medical services] from [facility] reports Pt. [patient] had fall yesterday with rt [right] hip pain, shortening and rotation noted. Did X-ray there and showed fx [fracture] . Review of Resident #1's hospital Radiology Report dated 1/16/2023 showed .XR [X-ray] Hip 2-3 V [views] INC [include] Pelvis RT [Right] .Comparison CT abdomen and pelvis 10/25/2021 .There is a comminuted [a fracture in which the bone is splintered or crushed into numerous pieces] right intertrochanteric fracture. There is no displacement. No femoral head dislocation identified .the pubic symphysis and sacroiliac joints appear intact .Impression .comminuted right intertrochanteric fracture .mild flattening of the femoral heads suggestive of avascular necrosis [the death of bone tissue due to a lack of blood supply . Review of Resident #1's Hospital Consultation Progress Note dated 1/16/2023 showed .Imaging: Plain imaging of the pelvis demonstrates an intertrochanteric comminuted fracture just below the tip of the greater trochanter [top of thigh bone] of the right hip with shortening .There is mild flattening of the femoral heads consistent with questionable avascular necrosis. Remainder of the pelvis appears unremarkable for acute findings . During an interview with Licensed Practical Nurse (LPN) #5 on 5/16/2023 at 10:50 AM, he stated .I was attempting to transfer him [Resident #1] to take him to the shower during the morning of the 15th [1/15/2023] .When I was transferring him using a pivot transfer, he lifted both legs and rested on my forearms, I did not know he had a fall the night before. I would have done a pain assessment, a skin check, and alert charting .I do not recall her [LPN #6] telling me about his fall. He was not very verbal more in a whisper. I noticed immediately his reaction was not normal for him .he did not have any bruising on the affected side, and I did give him a bed bath, after he was back in the bed there were no non-verbal signs of pain .later in the day we got report [approximately 6:00 PM, end of shift] he had fallen the night before. [LPN #2] was following up later in the day on 1/15/2023 and identified swelling in his right hip and mild external rotation. We obtained an X-ray on 1/16/2023. It did show a right hip fracture and he was sent to the hospital. Hs wife was at bedside when we were getting him ready to be sent out . During an interview with LPN #2 on 5/16/2023 at 11:20 AM, she stated .[Resident #1] had a fall on 1/10/2023. I found him on his right side, no complaints of pain, no non-verbal signs of pain. He was able to move all 4 extremities without any complaints, he stood up when we were assisting him out of the floor. There were no visual signs of injury, except the small laceration and bump on the right side of his head. Neuro checks were within normal limits .MD was notified and did not want to send him out at that time, but to monitor for changes in cognition and for any changes in his neuros [neurological status]. Any changes we were to send him to the ER .I did put steri-strips on the laceration .On the 15th [1/15/2023] we were in the room doing peri-care and when we rolled him, he was moaning. There was no bruising, but he was showing signs of pain .there was mild swelling at his right hip with mild external rotation noted. The MD was notified with an order for an X-ray. He ordered a routine x-ray, not STAT [immediately]. The X-ray was obtained on the 16th [1/16/2023] and showed a right hip fracture .he was sent to the ER . During an interview with CNA #3 on 5/17/2023 at 2:30 PM, she stated .I was in the room when he fell [1/14/2023], I was getting supplies to do incontinence care and he stood up right beside the bed .his knees just bent, and he went down on his bottom .when he fell, he said 'help' .he was trying to get out of the floor by himself. I told him we had to wait on the nurse to check him out .he said he was alright, and he did not indicate he was in any pain .the nurse assessed him .we didn't see any bruises, redness, scrapes or cuts, no swelling and no non-verbal signs of pain .he did not show any signs of pain when we were getting him back in the bed .for the rest of the night he stayed in bed he would roll for me just like always .he did have a bed alarm but he would pull it off himself .the bed was in a low position .I don't remember if he had on his non-skid footwear or not . During an interview with LPN #5 on 6/5/2023 at 8:30 AM, he stated .If I had known [Resident #1] fell on night shift on the 14th [1/14/2023] I would not have tried to transfer him [1/15/2023] .I did give him a bed bath and I did not see any swelling or rotation in his leg .I did not see any skin issues that morning .had we known he had fallen as soon as we saw the deformity in his right leg we would have gotten the X-ray sooner .I would have viewed him drawing up his legs as a an indicator of pain not his Parkinson's dementia .his vital signs were stable .there was no external rotation in his leg when I did his bed bath, but without knowing he had fallen it would not have been a cardinal sign to send him out. But being ignorant to what had happened does change your judgement .I did not find out he had fallen until the 15th [1/15/2023] at the end of the shift [6:00 PM] during report . During an interview with the COTA/Rehab Manager on 6/5/2023 at 9:50 AM, she stated .he was on case load from 1/6/2023 to 1/16/2023 when he went to the hospital . During an interview with the Physician on 6/5/2023 at 12:05 PM, he stated .if the nurse had told me he had fallen and had slight swelling and mild rotation of his leg I would have sent him out .not knowing he had fallen it was appropriate to order an X-ray to see what was going on . During an interview with CNA #3 on 6/5/2023 at 4:20 PM, she stated .he didn't get up the next night [1/15/2023] .he would make a grunting noise when I would change him, and he had started to have some discoloration in his hip .he had a small blue spot .I did report it to the nurse, and I was told an X-ray was ordered . During an interview with the Director of Nursing (DON) on 6/6/2023 at 1:00 PM, she stated .there were no new interventions put into place after his fall on 1/10/2023 in effort to reduce the likelihood of future falls .After reviewing the interim care plan and his fall incident reports it appears no appropriate interventions were initiated .It would be the expectation that an effective falls interventions be initiated after any fall. There were no new interventions put into place after his fall on 1/14/2023 to prevent further falls . During the interview the DON confirmed the facility failed to implement appropriate and effective falls interventions after Resident #1's fall on 1/10/2023 and on 1/14/2023 to prevent or lessen the risk of future falls, resulting in an acute intertrochanteric right femoral fracture, and causing actual harm to Resident #1. During an interview with LPN #2 on 6/6/2023 at 3:30 PM, she stated .a fall risk assessment is completed within the admission assessment. Interventions should be placed on the interim care plan by the nurse that completes the admission assessment. If interventions are not placed on the interim care plan there is no way to know what the interventions were supposed to be. However interventions should be communicated during shift change report and his interventions of a low bed, an alarm, non-skid footwear were in place when he fell on 1/10/2023 .staff are informed of interventions through the care plan and through report .when I put an intervention in place I go out and tell the staff what the intervention is .on the 10th [1/10/2023] I put in place he was to be up in a wheelchair at the nurses' station when he became restless and attempting to get up alone but that did not make it to the interim care plan .I should have done it and apparently I did not .I was not the nurse who gave report on the 15th [1/15/2023] so I didn't know he had fallen until I came back .on the 18th [1/18/2023] and I asked what happened to him and I was told he had a fall and had a fracture .I didn't tell doctor .he had fallen when I called him on the 15th [1/15/2023] because I didn't know .