**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 8 residents (Resident #2) reviewed for accidents. The facility failed to use an appropriate transfer for Resident #2 which resulted in a fall for Resident #2 and caused Resident #2's surgical wound from a below the right knee amputation to bleed. This failure could place residents at risk for harm and further injuries. The findings included: Record review of Resident #2's undated face sheet reflected Resident #2 was a [AGE] year-old male whose current admission date was on 2/4/2021, and a readmission to the facility on 4/7/24. Resident #2 had the following diagnoses: chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), muscle weakness, acquired absence of right leg below knee (partial amputation of the right leg), complete traumatic amputation at knee level, left lower leg, subsequent encounter (partial amputation of the left leg), unspecified systolic (congestive) heart failure (heart condition), essential primary hypertension (high blood pressure), mood disorder (mental health condition), Anxiety disorder due to known physiological condition (mental health condition), and chronic kidney disease (gradual loss of kidney function). Record review of Resident #2's clinical record reflected his comprehensive MDS assessment was completed on 4/10/2024 listing him with a BIMS score of 13, which indicated he was moderately cognitively intact. Additionally, section GG - Functional Abilities and Goals revealed Resident #2 is dependent- requires supervision or touching assistance - Helper does all of 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. For chair/bed-to-chair transfers. Record review of Resident #2's physician orders dated 4/01/24 to 4/30/24 revealed an order dated 4/09/24 to maintain ace bandage to right stump until appointment on 4/17/20 and to monitor for bleeding and signs of complication during every shift. Physician orders further revealed an order dated 4/23/24 to change dressing to stump 3 times a week and to monitor for bleeding and signs of complication during every shift. Record Review of Resident #2's Care Plan, dated 4/25/24, revealed Resident #2 had a below the knee amputation. Interventions included the use of a sliding board for transfers or mechanical lift for transfers PRN. Evaluation notes dated 06/19/24 revealed Resident #2 was able to transfer themselves from the bed to the wheelchair with or without the use of a sliding board and that Resident #2 declined to use the mechanical lift. Record review of Resident #2's progress notes from 4/1/24 to 6/26/24 revealed no documentation of the fall described by the resident or facility staff. During an interview on 6/25/24 at 12:03 PM the DON stated LVN B presented her with a letter she received in the mail from the Texas Board of Nursing that stated she was being investigated for allowing a resident to fall causing an injury. The DON stated she was not aware the allegations listed in the letter against LVN B until being shown the letter as it was not reported to her by staff or the resident. During an interview on 6/25/24 at 1:37 PM, Admin D stated he spoke with LVN B about the letter she had received from the BON and the details in the letter, one was an allegation of an improper transfer that resulted in a fall. He stated the LVN B did try to transfer a resident and a fall happened. During an interview on 6/25/24 at 2:16 PM the corporate nurse stated she could not locate any documentation or any other records in the electronic health record referencing the fall involving Resident #2 and LVN B. During an interview on 6/25/24 at 3:36 PM, CNA E stated she witnessed LVN B and Resident #2 fall during a transfer. She stated she was not able to determine the date or time frame of when this incident occurred, but she believed it was shortly after Resident #2's surgery of when his leg was amputated a couple of months ago. She stated she could not recall the time of when it occurred, but she believed it would have happened between 3:00 PM and 7:00 PM. She stated on the day of the incident she, CNA F, and another staff were all asked to go into Resident #2's bedroom to assist with transferring him from the wheelchair to his bed. LVN B was asked if they were going to use the mechanical lift and LVN B replied she was going to transfer Resident #2 by bear hugging him and lifting him from the wheelchair to the bed. CNA E stated she observed LVN B bear hug Resident #2 face to face, then she stumbled backwards while lifting him, and then both she and Resident #2 fell backwards into a refrigerator, and then onto the floor. CNA E stated Resident #2 hit the incision on his right leg on the floor then it started to bleed. CNA E stated Resident #2 was on top of LVN B CNA E with his arms around her and his legs straddled around her body. CNA E stated she could not recall how LVN B got out from under resident #2. CNA E stated afterwards, they all worked together to lift Resident #2 off the ground and onto his bed. CNA E stated she left about 10 minutes later to return to her assigned hall to assist other residents. CNA E stated Resident #2 has never refused a transfer with a sliding board or the mechanical lift. CNA E stated Resident #2 used the sliding board to transfer himself or instructed staff to push his chair against his bed to transfer himself. During an interview on 6/25/24 at 3:54 PM CNA F stated she witnessed LVN B and Resident #2 fall during a transfer. She stated she could not determine the date or time frame of when this incident occurred, but she believed it was shortly after Resident #2's surgery of when his leg was amputated a couple of months ago (04/2024). CNA F stated she believed the incident occurred before 7:00 PM on the day it occurred. CNA F stated Resident #2 used his call light and told her he needed assistance with a transfer from his wheelchair to his bed. CNA F stated LVN B had transferred Resident #2 into his wheelchair earlier that day, so she understood that was why she was responsible to transfer him back to his bed. CNA F stated LVN B bear-hugged Resident #2 and picked him up from his wheelchair and stumbled and fell back into the refrigerator, and then they both fell onto the floor. CNA F stated they all helped get Resident #2 up and into bed by grabbing under his legs and arms and his leg when she saw blood on his leg. CNA F stated LVN B then went to get supplies for the blood and called the DON. CNA F stated the DON came and helped put new dressing on Resident #2's leg. CNA F stated Resident #2 moaned and made noises but did not say anything. CNA F stated Resident #2 asked about the blood, but he had not say he was in pain. CNA F stated she could not remember how LVN B got Residents #2 off her. CNA F stated Resident #2 was not taken to the hospital nor was emergency assistance called after the incident. During an interview on 6/25/24 at 4:47 PM, LVN C stated she was the charge nurse on the day LVN B and Resident #2 fell during a transfer. She stated she could not to determine the date or time frame of when this incident occurred, but she believed it may have been on a day that was not her regular workday that she came in to fill a shift. She stated the incident may have been two or three days after Resident #2's surgery of when his leg was amputated a couple of months ago. She stated she was aware that Resident #2's surgical incision had been bleeding when he readmitted from the hospital. She stated Resident #2 wanted to get in his wheelchair, but he refused to be transferred with the lift. She stated staff told Resident #2 that they must use the lift for transfers, but he refused again. She stated she had not wanted to transfer Resident #2 as it would not have been safe to transfer him without the lift. She stated she had been concerned that there would not have been any male staff on shift in the evening to help put him back in bed. LVN C stated she went on her lunch break. She stated she observed Resident #2 in his wheelchair when she returned from her lunch break. She stated staff told her that Resident #2 asked LVN B to transfer him into his wheelchair when she had walked by coming back from a smoke break. LVN C stated Resident #2 was ready to get back in bed later that evening, so she told CNA F to get LVN B, who was the charge nurse on a different unit, and to tell her she needed to put Resident #2 back in bed, and then she went to chart records. She stated LVN B approached her and asked why her staff could not complete the transfer, in which she replied to LVN B that since she was the one to take him out of bed then she needed to figure out how to put him back in bed. LVN C stated LVN B walked away. LVN C stated she had been charting records when she heard a loud commotion. She stated CNA E, CNA F, and another staff came and told her that LVN B hit the refrigerator and dropped Resident #2 on the floor. She stated LVN B said she called the DON due to the blood. She stated staff went to get supplies and the DON arrived about that time. She stated she observed blood on his bed the size of a soccer ball and that his bandage was soaked with blood. She stated the DON called the surgeon and was advised to monitor the incision for infection, and to call back if infection appeared. She stated she then left for the evening. She stated Resident #2 had not been taken to the hospital for this incident. She stated the next day, she was told not to document the incident in the post log by the DON because it was considered a transfer and not a fall. She stated there had not been any documentation completed to record the incident. She stated she helped apply the new dressing and observed the incision to be opened about one inch. She stated she helped put pressure on the incision and put a bandage on it. She stated she helped apply gauze and they were able to get the bleeding to stop after wrapping it for the third time. She stated Resident #2 already had an appointment that was scheduled shortly after (possibly a week's time), and that was the first time the incision was observed by a physician after the incident. She stated they received new orders from the physician and that they physician applied additional dressing on it. She stated at that time, there was not an order to use a mechanical lift for transfers, but she felt it was best to use it. She stated Resident #2 seemed to like to use the sliding board for transfers and that he refused the mechanical lift. Record review of a facility in-service dated 6/19/24 titled Falls and use of gait belt revealed: 26 staff signed. Record review of letter signed by ADM D on 6/20/24 titled LVN B Interview revealed: I interviewed LVN B on June 20, 2024. In response to the allegations contained in the letter that she received from the Board of Nursing, she reported the following: 2. As to Resident #2's fall, LVN B told me that she was working on the secured unit when the aides came and asked for her help in transferring Resident #2 into his bed. She had successfully transferred him to his wheelchair earlier that day. She left the unit to help them with the transfer. She entered Resident #2's room and attempted to lift him from his chair and into his bed. As she was doing this, he began kicking the stumps of his legs and this threw her off balance. She stumbled backwards and both of them landed on the floor with him on top of her. His brief was soaked with urine, and it went all over her scrubs. After that she helped the aides get him off the floor and into his bed. His stump was bleeding, and she told LVN C, his charge nurse about it bleeding. LVN C told LVN B that she had urine all over her and she shouldn't be changing his dressing. LVN B then gathered the supplies she needed and went to change Resident #2's dressing. LVN B then returned to the secured unit. She did not call the D.O.N. at that time to come in to help with the dressing. LVN B said she did call the DON the day that Resident #2 returned from the hospital after his amputation. He needed his dressing changed and she wasn't sure how to change it properly. She called the DON, and the DON came to the facility and helped her change the dressing. This was prior to when the fall occurred. The fall occurred one afternoon while the DON came to the facility one night to help with the dressing change . Record review of competency skills checklist and competency evaluation form dated 6/21/24 revealed LVN B demonstrated competencies met on transfers from bed to wheelchair using transfer belt and slide board transfer. LVN B also demonstrated competencies met on all but one competency on the assessment for lifting machine, using a mechanical. Record review of the facility in-service dated 6/24/24 titled Slide board transfer training revealed: 8 staff signed. Record review of the facility in-service dated 6/25/24 titled Abuse/Neglect/Exploitation/Misappropriation revealed: 22 staff signed. Record review of the facility in-service dated 6/25/24 titled Abuse, and neglect, and reporting revealed: 2 staff signed. Record review of letter signed by LVN C on 6/19/24 titled LVN C Interviewed revealed: On June 29, 2024, at approximately 1 :45 p.m., I interviewed LVN C about any information she may have concerning the allegations the facility had received about LVN B . LVN B also said that she was aware of Resident #2 falling soon after returning from the hospital from having his leg amputated. She stated that earlier in the day, LVN B had transferred him without using a lift. Resident #2 does not like to use the lift for transfer. Later in the day, he wanted to transfer again. LVN B again came to transfer him by herself without using a lift. At this time, when she lifted him, she stumbled backwards, hit the small refrigerator in his room, and both of them fell to the floor. She said that CNA F, CNA E, and another CNA had witnessed the fall. She had not. During an interview on 6/25/24 at 5:47 PM ADM A stated a bear hug transfer was an improper transfer and that staff were not trained to complete bear hug transfers on residents. During an interview on 6/25/24 at 5:55 PM, the Corporate Nurse stated their policy did not instruct staff to use bear hug transfers and that staff should not have done a bear hug transfer on Resident #2. She stated she was not able to locate any documentation referencing the fall. She stated LVN C was the charge nurse on Resident #2's hall and LVN B was the charge nurse on a different unit during the time of that incident. She stated she was able to determine LVN C was on lunch when LVN B transferred Resident #2 to his wheelchair that day. She stated LVN B was his preferred staff, so she helped. She stated he did not like the mechanical lift and sometimes he did not like use the sliding board for transfers. She stated they could not determine when it happened. She stated Resident #2 has said the lift chokes him and he refuses it. She stated a bear hug was not an appropriate transfer. She stated in that situation, she would have done a two person transfer with a sheet due to his weight. During an interview on 6/25/24 at 5:55 PM, the DON stated she used an Ace bandage and the bleeding resolved. She stated there was nothing more she needed to do. The DON she would not have transferred Resident #2 that day, but she cannot speak for LVN B on why she transferred him. She stated she preferred for Therapy to evaluate him before he was transferred, but they were not there that day. She stated it was not required for Therapy to assess the resident before he can be transferred but she would have used the mechanical lift instead. She stated LVN B was not told to transfer him that way. During an interview on 6/25/24 at 6:15 PM, LVN B stated she could not recall the date of the fall with Resident #2 but recalled the fall. LVN B stated staff asked her to transfer Resident #2 to bed. She stated she went in the room and Resident #2 refused the Hoyer, so she decided to lift him on her own. LVN B stated she stood in front of Resident #2 and he bear hugged her. LVN B stated, Resident #2 placed his arms around her neck and she placed her arms under his arms around his body and she lifted him up. LVN B stated, she stepped backwards lost her balance and fell and Resident #2 landed on top of her, straddling her. She stated Resident #2 pushed himself up with his hands and she scooted out from under him. She stated three staff assisted him off the floor and back in bed. LVN B stated Resident #2's stump was bleeding. She stated she had been trained on how to complete a proper transfer, but Resident #2 refused the Hoyer and she attempted to lift him herself to transfer him. During an interview on 6/26/24 at 1:00 PM, Resident #2 stated he recalled a fall where LVN B transferred him from his chair to his bed. Resident #2 stated he could not recall the date of this fall. Resident #2 stated LVN B transferred him by herself, without assistance from another staff. Resident #2 stated LVN B instructed him to put his arms around her, and LVN B wrapped her arms around his torso and lifted him. Resident #2 stated LVN B was supposed to turn and place him on the bed, but LVN B lost her balance and fell back, into his refrigerator. Resident #2 stated he fell on top of LVN B, straddling her. Resident #2 stated he was face to face with LVN B and was very close to her. Resident #2 stated he scooted himself off LVN B by pushing himself with his hands on LVN B's stomach until he reached the floor, in between LVN's legs. Resident #2 stated he hit both of his legs, on his stumps, when he fell with LVN B. Resident #2 stated it was painful on his right leg that had been recently amputated. Resident #2 stated the incision site, on his right leg bled after the fall, but he stated that it was not a lot. Resident #2 stated the DON and LVN B checked the incision site on his right leg and changed the dressings. Resident #2 stated he was usually transferred with two staff, using a sliding board. Resident #2 stated he did not like using the Hoyer lift because he felt claustrophobic and [NAME] as if he was choking. Resident #2 stated he could not remember exactly who was present during the fall, but he recalled CNA E, was present. Resident #2 stated LVN B did not ask for help when she transferred him from the CNA's that were present, and he did not know why. Resident #2 stated LVN B said she thought she could do it on her own, and he thought she could do it also. Resident #2 stated he has never been transferred by just one person before. Resident #2 stated LVN B did not say anything to him after the fall. During an interview on 6/26/24 at 1:59 PM, the COTA was asked if she would consider Resident #2 to be a safe one-person transfer and she stated, Absolutely not, it would not be safe. He was too heavy, and it could hurt the resident or myself. The COTA stated Resident #2 should never be transferred using a bear hug method due to having bilateral below the knee amputations and not being able to pivot to assist the person transferring him. Record review of facility provided policy titled, Falls and Fall Risks, Managing dated 07/2019, revealed: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Definition: According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not a s a result of an overwhelming external force (e.g. a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Challenging a resident's balance and training him/her to recover form loss of balance is an intentional therapeutic intervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall. Fall Risk Factors: 1. Environmental factors that contribute to the risk of falls include: a. Wet floors; b. Poor lighting; c. Incorrect bed height or width; d. Obstacles in the footpath e. Improperly filled or maintained wheelchairs, and f. Footwear that is unsafe or absent 2. Resident conditions that may contribute to the risk of falls include: a. Fever; b. Infection; c. Delirium and other cognitive impairment; d. Pain; e. Lower extremity weakness; f. Poor grip strength; g. Medication side effects; h. Orthostatic hypotension; i. Functional impairments; j. Visual deficits, and k. Incontinence 3. Medical factors that contribute to the risk of falls include: a. Arthritis; b. Heart failure; c. Anemia; d. Neurological disorders; and e. Balance and gait disorders; etc. Resident Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Monitoring Subsequent Falls and Fall Risk 1. The staff with monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. Record review of facility provided policy titled, Assessing Falls and Their Causes dated 3/2018, revealed: The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Steps in the Procedure After a Fall: 3. If there is evidence of injury, provide appropriate first aid and obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying or standing position, and then document relevant details. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility, and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 7. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. Defining Detains of Falls: 1. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. 2. For each individual, distinguish falls in the following categories: a. Rolling, sliding or dropping from an object (e.g., from bed or chair or floor) b. Falling while attempting to stand up from a sitting or lying position, or c. Falling while already standing and trying to ambulate Identifying Causes of a Fall or Fall Risk 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident specific chains of events or circumstances proceeding a recent fall, including : a. Time of day of the fall; b. Time of the last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching, or transferring from one position to another; e. Whether the resident was among other persons or alone; f. whether any environmental risk factors were involved (e.g. slippery floor, poor lighting, furniture, or objects in the way) and/or g. Whether the resident was trying to get to the toilet h. whether there is a pattern of this balls for this resident 3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. 4. as indicated, the attending physician will examine the resident or may initiate testing to try to identify causes. 5. consult with the attending physician or medical director to confirm specific causes from among multiple possibilities. when possible, document the basis for identifying specific factors as the cause. 6. if the cause is unknown but no additional evaluation is done, the physician or nursing staff should note why (e.g. workup already done, finding A cause would not change the approach, etc.). Documentation When a resident falls, the following information should be recorded in the residence medical record: 1. The condition in which the resident was found (e.g resident found lying on the floor between bed and chair) 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a fall risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. Reporting 1. Notify the following individuals when a resident falls: a. The resident's family b. The attending physician (timing of notification may vary depending on whether injury was involved); c. The director of nursing services and d. The nursing supervisor on duty 2. Report other information in accordance with facility policy and professional standards of practice. Record review of facility provided policy titled, Falls - Clinical Protocol dated 3/2018, revealed: Assessment and recognition: 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in condition or level of consciousness; e. Neurological status; f. pain; g. Frequency and number of falls since the last position visit; h. Precipitating factors; details on how far all occurred; i. All current medications, especially those associated with dizziness or lethargy; and j. All active diagnosis 5. The staff will evaluate and document falls that occur while they invent individual is in the facility, for example when and where they happen, any observations of the event, etc. 6. All should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed on the floor 7. Falls should also be identified as witnessed or unwitnessed events Record review of facility provided policy titled, Fall Prevention - Potential Interventions dated 5/2019, revealed: Intervention: Assistive Devices; Description: Other Intervention: Mobility; Description: Review transfer status Record review of facility provided policy titled, Safe Lifting and Movement of Residents dated 3/31/2023, revealed: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of resident. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff in conjunction with the real habilitation staff, shall assess individual residents needs 4 transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Residents' preferences for assistance, b. Residents' mobility (degree of dependency), c. Resident size, d. Weight bearing ability, e. Cognitive status, f. Whether the resident is usually cooperative with staff, and g. The residents' goal for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/ transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents.