**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 13 residents (Resident #1) reviewed for transfers in that: CNA A failed to provide adequate supervision and transfer assistance for Resident #1 in the shower resulting in Resident #1 falling and having an open right ankle fracture with bleeding. Resident #1 had to be hospitalized and required surgical intervention. The facility failed to update the Kardex and POC to reflect current safe transfer status requirements for Resident #1 and 12 other residents. The facility failed to ensure CNAs were knowledgeable on how to locate the Kardex to determine if 1 or 2 staff were required to safely transfer/assist a resident. An IJ was identified on 06/21/24. The IJ Template was provided to the facility on [DATE] at 04:25 PM. While the IJ was removed on 06/23/2024, the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm and/or injury and contribute to avoidable accidents. Findings included: Review of Resident #1's face sheet dated 06/21/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of venous insufficiency-chronic-peripheral (a condition in which the flow of blood through the veins is blocked, causing blood to pool in the legs), other secondary parkinsonism (a condition that causes tremor, muscle movement issues, rigidity, and postural instability), Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), unspecified dementia (neurodegenerative disease characterized by a general decline in cognitive abilities that affect a person's ability to perform every day activities), repeated falls, ataxic gait (a type of walking disorder caused by damage to the cerebellum the part of the brain that controls coordination and balance- it is characterized by clumsy staggering movements with a wide base of support, difficulty walking in a straight line, poor balance, and errors in the direction, speed, and rhythm of the limbs), generalized muscle weakness (muscle weakness throughout the body resulting in an inability to perform a given task on the first attempt), and chronic venous hypertension-idiopathic (high blood pressure in the legs) with inflammation of right lower extremity. The face sheet reflected Resident #1 was discharged to the hospital 05/13/2024. Review of Resident #1's fall risk evaluation dated 02/23/24 revealed unable to independently come to a standing position. Exhibits loss of balance while standing. Decreased muscle coordination. Interventions noted: He needs a two-person assistance. Review of Resident #1's fall risk evaluation dated 03/20/24 revealed: Unable to independently come to a standing position. Exhibits loss of balance while standing. Requires hands-on assistance to move from place to place. Uses an assistive device. No interventions noted. Review of Resident #1's admission MDS dated [DATE] revealed section GG: Functional abilities tub/shower transfer was marked for total dependence, helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. The MDS assessment was missing information that would have identified if the resident was a 1 or 2 person assist; the level of care required to perform a safe transfer. Review of Resident #1's Discharge MDS dated [DATE] reflected GG: Functional abilities tub/shower transfer was marked for total dependence, helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. The MDS assessment was missing information that identified if the resident was a 1 or 2 person assist; the level of care required to perform a safe transfer. Review of Resident #1's care plan revealed: Resident is at risk for falls and is at risk for increased falls and injury r/t hx of repeated falls, anticoagulant use, weakness r/t recent hospital stay, poor vision, and cognition. Functional ability: GG Mobility: Tub/Shower transfer The care plan did not indicate if Resident #1 was a 1 or 2 person transfer assist. The care plan only referenced section GG Functional abilities of the MDS assessment which the MDS assessments (admission and discharge) reflected he was dependent on staff. The care plan also revealed therapy services to focus on shower transfers to decrease risk for falls and increase safety awareness with initiated date of 03/21/24. Review of the facility incident reports with date range of 03/20/24 to 06/20/24 revealed Resident #1 suffered a fall on 03/20/24 and 05/13/24. Review of Resident #1's nursing progress notes revealed a nurse progress note dated 03/20/24 which said Resident #1 suffered a fall during a shower transfer from the shower chair to the wheelchair on 03/20/24. The note stated there were 3 staff total present during the fall (to include CNA A), Resident #1 received an x-ray which returned negative for a fracture; redness to the left knee was noted. A separate nursing progress note dated 05/13/24 revealed Resident #1 suffered a fall during a 1-person shower transfer with CNA A that occurred on 05/13/24 which resulted in an open right ankle fracture with bleeding (an open fracture is type of bone fracture where the bone breaks through the skin). The progress note said 911 emergency services was immediately notified and a RN stayed with the resident until EMS arrived. Review of the facility's reported incident investigation forms dated 05/13/24 revealed, [Resident #1 care plan was updated. [Resident #1] is anticipated to return to the facility post-surgery of his ankle . An interview on 06/20/24 at 12:56 PM with CNA A she stated that in the fall incident that occurred on 05/13/24 with Resident #1- to her knowledge Resident #1 was a 1 person transfer assist in showers at that time. CNA A said that she obtained that information from asking PT. CNA A said she did not review residents care plans or the Kardex section of the EMR that provided information on a resident's required level of assistance to determine whether a resident was a 1 or 2 person assist and would only ask PT or another CNA. CNA A said that on 05/13/24 after Resident #1 finished his shower CNA A put his shirt on and then instructed Resident #1 to stand up and grab the shower bars because she was preparing to do a 1 person transfer. While Resident #1 was standing, CNA A stated she attempted to put his brief under his legs but Resident #1's legs became weak and in a matter of seconds he started to go down. CNA A said that she attempted to get him up but due to his size (Resident #1's recorded weight dated 05/14/24 was 244 pounds) she was unable to help him up alone. CNA A said that Resident #1's feet and legs were pointed inward, and she believed as he was falling down his positioning along with his weight caused his fracture. CNA A stated that as the resident was going down, he exclaimed, my ankle, my ankle! - but he was too far down at that point that she was unable to make any adjustments and needed to run out of the shower to get help. In the fall incident that occurred on 03/20/24, CNA A said she was also assisting Resident #1 with his shower and transfer at that time. CNA A stated that she believed Resident #1 was also a 1 person transfer at that time, but she did not verify that by looking at the care plan or Kardex. CNA A stated there were 2 other shower aides at the time in the shower with her but she said, they were standing off to the side talking about which residents they were going to shower next. CNA A said she was the only person hands on with Resident #1's shower and transfer. In the events CNA A described for the incident on 03/20/24, CNA A stated that Resident #1 lost his balance while being transferred from the shower chair to his wheelchair. CNA A said, he had his brief and everything pulled up and he lost his balance while turning and trying to sit in the wheelchair. CNA A said once again said she believed she had access to the Kardex but does not recall looking at documentation that would have said whether Resident #1 was a 1 or 2 person transfer assist and she was the only individual assisting Resident #1 on both occasions 03/20/24 and 05/13/24. CNA A said she believed if they are not sure what the transfer needs of the resident are they should ask a nurse or PT prior to a transfer. An interview on 06/20/24 at 03:04 PM with PTD she stated that in the care plan where it stated, therapy services to focus on shower transfers to decrease risk for falls and increase safety awareness initiated 03/21/24- that therapy assisted only once after Resident #1's fall on 03/20/24 to provide education to the resident and caregiver (CNA A) on shower transfers. PTD stated that only a verbal in-service was done for CNA A on the appropriate way to transfer and to her knowledge no other staff was provided education on transfers or use of the Kardex. The PTD stated after the incident on 03/20/24 with Resident #1 and CNA A they felt CNA A needed the in-service but at the time it was not thought of as a systemic concern where all staff needed to be re-inserviced. PTD stated that PT is used to assist in training staff on an as needed basis. An interview on 06/20/24 at 03:08 PM with CNA B, she stated if she needed to find out a residents transfer status, she would ask another CNA. CNA B stated she did not know of anywhere she could go in the medical records that detailed a resident's transfer status such as the Kardex and was not trained on it. An interview on 06/20/24 at 03:10 PM with CNA C, he stated he will sometimes receive a residents transfer status through verbal exchange when he starts his shift from the prior CNA. CNA C stated if he did not know a residents transfer status that he would ask one of the nurses on duty, he stated he did not know where to find a residents transfer assist requirements in the medical record or Kardex. CNA C said if he was assisting a resident in the shower and needed to put a brief, he would make sure to get additional assistance to be safe. An interview on 06/20/24 at 03:20 PM with CNA D she stated she would ask either a nurse or PT if she needed to know if a resident was a 1 or 2 person assist. CNA D said she was not trained on where to locate a resident's required level of transfer assistance in the Kardex. An interview and observation on 06/20/24 at 05:31 PM with the MDS Coordinator she stated a residents transfer assist is determined by nursing staff and PT which is communicated to her so she can update the care plans and Kardex as needed. A sticky note was observed on the MDS coordinators desk containing the names of individuals that were identified to have missing or incorrect transfer status in the care plans and Kardex which the MDS Coordinator stated she had corrected moments before this interview. The MDS Coordinator stated these residents were identified in an audit completed that day 06/20/24 by the DON and RDCO that took place for care plans and Kardex after the state incident investigation had started . She stated the Kardex is what CNAs should be accessing to determine the safe way to transfer a resident. She stated if the POC is not updated with the current transfer status or has missing transfer information that would mean it would most likely be missing from the Kardex as well. She stated it would be the DON or charge nurses that show the aides how to locate that information upon hire or as needed. She said a negative outcome to not having that information is residents would not be transferred correctly or safely. An interview and record review on 06/21/24 at 01:10 PM the RDCO stated that in a care plan/ Kardex audit that was completed 06/20/24 after the investigation had started, 12 other residents separate from Resident #1 were also identified as having transfer status that were either missing or inaccurate . The RDCO stated they were all corrected on 06/20/24 and each resident was assessed with no negative outcomes noted or reported. A record review of the 12 residents was conducted and revealed interventions were updated on all 12 residents POC. A record review of incident/ accident reports with date range from 03/20/24 to 06/20/24 revealed none of the 12 residents had a transfer related incident/ accident. An interview on 06/21/24 at 04:08 PM with the DON, she said it was the responsibility of the MDS coordinator to update the MDS as needed after admission with any changes of condition. The DON said it was her expectation that all CNAs knew where to locate the Kardex information related to a residents transfer needs. The DON said that a potential negative outcome with missing or incorrect Kardex information is that a resident would not get transferred correctly which means they would be provided the wrong care. The DON stated the aides are in-serviced upon hire on the Kardex and as needed. The DON stated the most recent in-service occurred 05/14/24 after Resident #1's incident and covered fall prevention measures, post fall response, monitoring post fall assessment, and reviewing Kardex. She was not aware at that time that there was information that had not been updated to reflect some of the residents' safe transfer information. The DON stated that in the incident that occurred on 03/20/24 only CNA A was in-serviced because they did not see it as a systemic issue and the training was done in an as needed basis. After the second incident with Resident #1 on 05/13/24, the facility saw the need to ensure more staff were properly trained. An interview on 06/21/24 at 04:15 PM with the RDCO she stated that it was her expectation that care plans and Kardex were updated to reflect the individualized needs of the resident. She stated that if the Kardex had incorrect or missing information they risk not being able to meet the residents needs and anything that does not match the residents' needs is a risk to the resident. The RDCO stated that care plans, MDS assessments, and Kardex information should be updated on admission, quarterly, and anytime there is a significant change. She stated, even if their condition improves it needs to be addressed in the MDS and care plans, and especially if they decline. An interview on 06/21/24 at 04:17 PM with the ADM he stated it was the role of the MDS coordinator to ensure MDS assessments, care plans, and Kardex are updated- but ultimately it is the IDT also. The ADM said its his expectation that Kardex and care plans are updated and accurate as soon as a change is identified. He stated he expects that all the CNAs are knowledgeable on how to access the Kardex information and that they use that as their source to determine how to safely transfer a resident. The ADM said failing to have updated accurate information or failing to look at that information to determine safe transfer status would mean they are not accurately following the residents plan of care. Review of the facility Safe Resident Handling/ Transfers policy last revised 01/2023 revealed: It is the policy of this community to ensure that patients/residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the patient/resident while keeping the team members safe in accordance with current standards and guidelines. - All patients/residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the team members that assist them. The use of mechanical lifts is a safer alternative to manual lifting for patients, residents, and caregivers. Compliance Guidelines: - The interdisciplinary team or designee will evaluate and assess individual mobility needs, considering other factors as well, such as weight and cognitive status. - The mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. - Team members will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. - Team members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. - Lifting and transferring will be performed according to the individualized plan of care. Review of the facility comprehensive assessments policy last revised 03/2023 revealed: Comprehensive resident assessment The community uses the Resident Assessment Instrument (RAI) to develop the comprehensive resident assessment. It identifies the care, services, and treatments that each resident needs to attain or maintain his or her highest practicable mental and physical functional status. The ADM. DON, and RDCO were notified on 06/21/24 at 04:25 PM that an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/23/24 at 11:00 AM and included: Plan of Removal Problem: F689 Free from Accidents/ Hazards Interventions: 1. DNS/Designee conducted a 100% Audit of all residents who reside in the community was conducted on 6/20/2024 to validate care plans and Kardex accuracy reflected the current care needed for each resident. 12 residents were identified during this process and care plan/Kardex was updated to reflect the current need of each resident identified. Date commenced: 6/20/2024 Date completed: 6/21/2024 2. All 12 residents identified with care plan updates were assessed on 6/21/2024 with no negative outcomes. Date completed: 6/21/2024 3. AdHoc meeting to address issue, correction, action plan and plan of removal with Administrator, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Operations and Medical Director was conducted on 6/22/2024. 4. DNS/ADNS/Designee (Charge Nurse) will ensure all staff on leave/agency staff /PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. In-services: 5. Regional Nurse (Director of Clinical Operations) re-educated the Director of Nursing on the following: oImportance of nursing staff reviewing the Kardex before providing care to ensure proper level of care is provided according to the resident's need and adherence to the resident's plan of care. Staff should report any concerns or inaccuracies of the care plan/Kardex to the charge nurse/licensed nurse for direction prior to care being provided, so that the licensed nurse can evaluate the resident and determine the appropriate level of care necessary as well as monitoring the resident to ensure that the appropriate care is being provided in accordance to the resident's needs; thus, updating the care plan/Kardex as indicated. The licensed nurse should ensure that the appropriate care needs are communicated across all shifts by reviewing the information with the on-coming shift nurse, in order to ensure that care provided is consistently provided in a safe manner until the plan of care/Kardex has been updated. The IDT will review and update the plan of care with necessary changes within 24-72 hrs as per the RAI, which indicates that necessary changes to the plan of care should be within a reasonable period of time. Until the plan of care has been updated the charge nurses will continue to communicate necessary care to be provided during shift-to-shift report. Preventing Accidents/Fall Prevention/Promoting a Safe Environment: identifying risk, reducing risks, and promoting an accident-free environment as indicated in the plan of care. 6. All Nursing Team Members were educated on providing care to residents were re-educated/re-trained by the Director of Nursing or Designee. Nursing staff reviewing the Kardex before providing care to ensure proper level of care is provided according to the resident's need and adherence to the resident's plan of care. Staff should report any concerns or inaccuracies of the care plan/Kardex to the charge nurse/licensed nurse for direction prior to care being provided, so that the licensed nurse can evaluate the resident and determine the appropriate level of care necessary as well as monitoring the resident to ensure that the appropriate care is being provided in accordance to the resident's needs; thus, updating the care plan/Kardex as indicated. The licensed nurse should ensure that the appropriate care needs are communicated across all shifts by reviewing the information with the on-coming shift nurse, in order to ensure that care provided is consistently provided in a safe manner until the plan of care/Kardex has been updated. The licensed nurse should ensure that the appropriate care needs are communicated across all shifts by reviewing the information with the on-coming shift nurse, in order to ensure that care provided is consistently provided in a safe manner until the plan of care/Kardex has been updated. Education provided to all Nursing Department Preventing Accidents/Fall Prevention/Promoting a Safe: identifying risk, reducing risks, and promoting an accident-free environment indicated in the plan of care by DNS/Designee. The IDT will review and update the plan of care with necessary changes within 24-72 hrs as per the RAI, which indicates that necessary changes to the plan of care should be within a reasonable period of time. Until the plan of care has been updated the charge nurses will continue to communicate necessary care to be provided during shift-to-shift report. DNS/ADNS/Designee conducted 100% audits of skills validation of accessing the Kardex by return demonstration; observing the direct care team member is has verified competency by return demonstration of accessing the Kardex to review the level of care to be provided. Date commenced: 6/20/2024 Date completed: 6/22/2024 7. All licensed nurses were re-educated on the completion and accuracy of care plans to ensure they reflect the current needs of each resident. Baseline Care plans must be completed within 48 hours of admission. Care plans must be updated as clinically indicated. Kardex must be initiated upon admission and updated as clinically indicated. Date commenced: 6/20/2024. Date completed: 6/22/2024. Risk Response: Residents who currently reside in community potentially can be affected by the deficient practice. DNS/Designee conducted a 100% Audit of all residents who reside in the community was conducted on 6/20/2024 to validate care plans and Kardex accuracy reflects the current care needs for each resident. 12 residents were identified during the review process. Careplan/Kardex were updated to reflect the current need of each resident identified. Date commenced: 6/20/2024. Date completed: 6/21/2024 The DNS (Director of Nursing) will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. The DNS will ensure administrative nursing staff will provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. The Administrator is responsible for validating that all tasks assigned and monitoring efforts (as indicated on this plan) has been achieved and that compliance is maintained. Systemic Response: 100% Direct care educated on review of the Kardex before providing care to all residents assigned to them to ensure proper assistance and interventions are utilized according to the resident's need and adherence to the resident's plan of care. Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided. 100 % Education provided to all Nursing Department Preventing Accidents/Fall Prevention/Promoting a Safe: identifying risk, reducing risks, and promoting an accident-free environment indicated in the plan of care by DNS/Designee. 100% care plans were reviewed for all residents with fall prevention interventions to ensure interventions on the Kardex are in place. 100% validation of accessing the Kardex was conducted on all nursing department. Date commenced: 6/20/2024 Date of completion: 6/22/2024 The Director of Nursing / Asst. Director of Nursing will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. DNS will ensure administrative nursing staff will provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. The Administrator is responsible for validating that all tasks assigned and monitoring efforts (as indicated on this plan) has been achieved and that compliance is maintained. Monitoring Response: The Administrator/ DNS/ designee will conduct weekly rounds to validate interventions related to fall prevention is in place 1-7 days a week for 2 months. The DNS/Designee will conduct random skills validations regarding Kardex use 3-7 days a week for 2 months to ensure direct staff is compliant with the use of the Kardex. Policies are followed to ensure the safety and wellbeing of our residents. Additional education will take place based on needs observed during this process. The Administrator is responsible for validating that all tasks assigned and monitoring efforts (as indicated on this plan) has been achieved and that compliance is maintained. All findings will be reported to the QAPI committee during monthly meeting until there is 100% compliance observed during observations. On 06/22/24 and 06/23/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: 06/22/24: In an interview on 06/22/24 at 09:15 AM with the DON, she stated she had already sent out the care feed system (a system that communicated with all staff via text) in services facility wide to all staff related to accessing Kardex, ANE, Fall Prevention and Care Plans. She stated that they have visually checked off staff prior to their shift to ensure they are able to access the Kardex system and training is ongoing and in progress. She stated Care plans were updated for the 12 residents of concern related to transfer status. Education will remain ongoing until 100% of staff are trained. Staff education: 28 staff were educated on Kardex 30 staff were educated on ANE 28 staff were educated on Fall Prevention 9 (nurses) staff were educated on Care Plans Record reviews were conducted by surveyor. 12 residents were identified during the review process by DON and RDCO. Care plans/Kardex were updated to reflect the current need of each resident identified. Surveyor verified updated care plans for 12 residents affected. QAPI committee meeting to address issue, correction, action plan and plan of removal with Administrator, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Operations and Medical Director was conducted on 6/22/2024. Sign in sheet was obtained by surveyor. An interview on 06/22/24 at 09:36 AM with RN G, she validated she knew where to find information on the care needs of the resident via the Kardex and POC. She verbalized examples of fall prevention and hazard free environment and demonstrated action to take in response to how to know about a change of condition. An interview and observation on 06/22/24 at 09:40 AM with the ADON validated training on accessing the Kardex to determine the transfer needs of the resident by accessing the Kardex and POC. The ADON was observed in return demonstration via the computer. Prevention of falls to include gait belts, ensuring correct method of transfer. The ADON stated CNAs know to consult PT when transfer needs of the resident are in question. An interview on 06/22/24 at 09:49 AM with PT H, he discussed how and when CNAs are trained and stated that they will routinely seek out PT for guidance on how best to transfer residents. An interview on 06/22/24 at 09:51 AM with CNA E verbalized the need to access Kardex to know transfer status and care needs of the resident. She stated the prevention of falls includes interventions such as appropriate socks and shoes, gait belt, get help if needed with transfers. An interview on 06/22/24 at 10:01 AM with CMA I, she confirmed recent training on Kardex and accessing information regarding the status of resident transfers. She stated she consistently assists with transfers as needed, especially in the use of the Hoyer Lift. Able to discuss various methods for fall/accident prevention: ie, appropriate shoes/socks, gait belt. An interview on 06/22/24 at 10:13 AM with CNA F she stated that was her first day working there and she was able to verbalize the process to access the Kardex and POC. An interview on 06/22/24 at 10:20 AM with LVN J she stated she had received training and then demonstrated knowledge on how to access the EMR and POC. She stated she takes that information into consideration but will also conduct her own nursing assessments. An interview on 06/22/24 at 10:45 AM with CMA K she confirmed she received training related to transfers and accessing the EMR and POC on 06/21/24. CMA K verbalized i[TRUNCATED]