**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 4 was admitted [DATE], readmitted [DATE] with diagnoses including: fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, anterior cord syndrome at c [cervical] 3 level of cervical spinal cord subsequent encounter, complete lesion at c4 level of cervical spinal cord subsequent encounter, complete lesion at c5 level of cervical spinal cord subsequent encounter, complete lesion at c6 level of cervical spinal cord subsequent encounter, unspecified intracranial injury without loss of consciousness subsequent encounter, and major depressive disorder recurrent in partial remission. Resident 4's medical record was reviewed from 3/11/24 through 3/12/24. Resident 4's most recent Brief Interview for Mental Status (BIMS) score on 2/18/24 from his significant change Minimum Data Set (MDS) assessment was a 10, indicating a moderate cognitive impairment. Prior to this, a quarterly assessment had been completed on 1/22/24. Resident 4's BIMS score from this assessment was a 9, indicating a moderate cognitive impairment Resident 4's nursing care plan was reviewed. A care plan dated 6/5/20 revealed a focus area of, FALL RISK [Resident 4] is at risk for falls r/t [related to] deconditioning, gait/balance problems, psychoactive drug use and paraplegia in all extremities. This focus was revised on 9/15/20 The goal documented for this focus area was, [Resident 4] will have no unaddressed falls. This goal was initiated on 6/5/20 and was revised on 2/26/24. The interventions for this care area were documented as: a. Anticipate and meet [Resident 4]'s needs. b. Be sure [Resident 4]'s call light is within reach and encourage [Resident 4] to use it for assistance as needed. c. Encourage the [Resident 4] to participate in activities that promote exercise, physical activity for strengthening and improved mobility. d.Encourage/remind [Resident 4] to use mobility aides [sic] (walker, cane, crutches, etc.) when ambulating/transferring to aide with fall prevention. e. Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room. A care plan dated 6/5/20 revealed a focus area of, ACTUAL FALL [Resident 4] has had an actual fall with no [sic] r/t [related to] poor balance, unsteady gait and hemiplegia in all extremities. This focus was revised on 11/17/23. The goal documented for this focus area was,[Resident 4] will resume usual activities without further incident within 90 days. This goal was initiated on 6/15/20 and revised on 2/26/24. The interventions for this care area were documented as: a. 1/15/24 fall Therapy to room eval [evalute] with OT [occupational therapy] r/t [related to] room transfer. b. 2/9/24 offered room change resident refused loves room [ROOM NUMBER]/9/24 fall education with staff 2/9/24 call light also attached to dresser. c. FALL 2/20/24 asked resident to move closer to nursing station refused again educated use of call light and using and NWB [non-weight bearing] status talked to sister he is very adamant to maintain independence. d. Fall 6/4/22 - OT [occupational therapy] to eval [evaluate] and treat for safety awareness. e. Fall 9/13/22- PT [physical therapy] to eval [evaluate] and treat for leg strength for safety and positioning when in wheelchair. Staff education provided to encourage [Resident 4] to use leg rests when in wheelchair. f. [Resident 4] will not be left unattended in bathroom (pt [patient] at times toilets self) d/t [due to] safety awareness. g. Monitor/document/report PRN [as needed] x 72h [hours] to MD [doctor of medicine] for s/sx [signs/symptoms]: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. h. OT [occupational therapy] to eval [evaluate] and treat for use of self releasing seat belt to assist with autonomy. i. Provide activities that promote exercise and strength building where possible. Provide 1:1 [one on one] activities if bedbound. An incident report dated 2/9/24 revealed, At 0645 res [resident] was trying to reach for his call light to be helped out of bed and slipped to the floor hurting R [right] hip. Nurse was called to evaluate, res was in grimacing pain and guardian R hip. Res was helped to his chair, he insisted on going to the dining room for breakfast. Res was then helped back into bed. Xray [sic] ordered. Dr notified, Sister [name redacted] called but left message. The incident report also noted that at the time of Resident 4's fall, his pain was rated as a 4 out of 10. A nursing progress note dated 2/9/24 revealed, At 0645 res [resident] was trying to reach for his call light to be helped out of bed and slipped to the floor hurting R [right hip]. Nurse was called to evaluate, res was in grimacing pain and guarding R hip. Res was helped to his chair, he insisted on going to the dining room for breakfast. Res was then helped back into bed. Xray [sic] ordered. Dr notified, Sister [name redacted] called but left message. A nursing progress note dated 2/9/24 revealed, Xray [sic]results reviewed, orders rec'd [recommend] to send res to hospital to more [sic] evaluation on the femual [sic] head Fx [fracture]. Res does not want any family called r/t [related to] his mother being in the hospital right now and doesn't want to [NAME] [sic] out his family further. Res took no personalitems [sic] with him. [Ambulance company redacted] transported to [hospital named redacted]. At 4:45 PM, ER called. An interdisciplinary team progress note dated 2/15/24 revealed, Event: Fall with hip injury 2/9/24 Resident status prior to event: Sleeping in bed reached for call light fell and slipped out of bed fell with hip pain Risk factors: Epilepsy, Hemiplegia, C3-C6 spinal cord injury, language barrier, immobility, Bipolar disorder Preventive measures prior to event: Bed to be placed in lowest position for safety r/t to seizure hx [history] and mattress to be placed next to his bead. Medications routinely reviewed with pharmacy Care plan risk factors and interventions: [resident 4] is atrisk [sic] for fall r/t Deconditioning, Gait/balance problems, Psychoactive drug use and paraplegia in all extremities; Anticipate and meet [Resident 4]'s needs. Be sure [Resident 4]'s call light is within reach and encourage [Resident 4] to use it for assistance as needed. New device to hook to [Resident 4] [sic] dresser to help hold call light. The following areas reviewed - -Medication Review Regimen: Senna, Miralax, Flomax, Phenobarbital, Melatonin, Carbamazepine, Tylenol - Weight Loss: no weight loss - Dehydration: Average fluid intake 1500ml (millileter)/day -Pain: Resident reported pain to hip after fall. Sent out to ER -ADL [activities of daily living]: Requires one person extensive assistance with bed mobility, transfers and toileting. Set up and supervision for meals. Resident insist [sic] on transferring self often to toilet. -Decline in mobility: Dependent on w/c [wheelchair] for mobility -Psychotropic Drug Use: Sertraline Root Cause Analysis. After further investigation this incident has been reasonably r/t call light falling and resident reaching for. Offered resident to movecloser [sic] to nursing station on main hall 100 and resident declined. Offered to hook call light to dresser also as a back up and resident liked this idea. New interventions implemented: Continue working with therapy, sat with resident on ideas to help and came up with new way to help hook cord to dresser and than [sic] bed. Attendees: ED [executive director], DON [director of nursing], ADON [assistant director of nursing], Therapy, MDS [minimum data set], Resident Advocate. A pain assessment dated [DATE] revealed that at the time of Resident 4's fall, his pain was rated as a 6 out of 10. A change in condition evaluation dated 2/9/24 revealed that at the time of assessment that Resident 4's pain was rated as a 7 out of 10. A grievance filed 1/16/24 revealed, [Resident 4] was told, [sic] in order to eat meals in the dining area, [sic] that he would have to wheel himself down. [Resident 4] is unable to do this safely, he is a fall risk. [Resident 4] stated this happened two weeks ago with the CNA's [sic] in 200 hall as well as the nurse in 200. The corrective action for the grievance dated 1/18/24 revealed, Coaching and teaching staff - (CNA's [sic]) about when the resident needs something they need to do it in a timely manner. The findings of the investigation of the grievance dated 1/18/24 revealed, The resident did indeed ask for help down to the dining room, but was told he could wheel himself down to go eat. The recommendation for corrective action for the grievance dated 1/18/24 revealed, When residents ask certain things (tasks) to be done and they need help, staff members need to act accordingly in a timely respectful manner. The results of the action taken for the grievance dated 1/18/24 revealed, Staff members (cna's [sic], nurses) know to help the resident down to the dining room when they ask for help. On 2/10/24, the facility provided an in-service on fall safety for Resident 4. The training stated, [Resident 4] Fall Training C.N.A updated reminders 1. Bed to be placed in low position at all times r/t safety and seizures 2. Floor mat next to bed 3. Seat Belt is safely in place 4. Call light placement (prefers on pillow) education on new clips if needed. (can get from maintenance) 5. Encourage [Resident 4] when rounding to let you help toilet him if needed. Management Side 1. Review chart of all previous care plan items noted in past 2. Do education with staff regarding the care plan item in place 3. Speak with [Resident 4] regarding how we can better team up with him to prevent falls 4. Follow up on seat belt orders, can be released, being used, still needs to be used 5. Offer change in room to 101 busy hall with lots of eyes on resident. On 2/24/24, the facility provided an in-service with topics including, Fall prevention: call lights close, bed side tables close, ask if we can do anything else to help, anticipate needs, ask questions, non skid socks, talk to managers if you see a risk. The training summary revealed, Falls training prevention 1. Ensure call lights are always next to resident 2. Bed side tables are close to residents 3. Anticipate needs 4. Non ski socks for resident getting up and out of bed. 5. Always say before leaving a room is there anything else I can get you 6. If you suspect some one has a change in condition or is a high fall risk please notify nurse, if no change happens notify Nurse manager. If a fall happens you are required to Nurse 1. Complete incident report, get a set of ortho static [sic] vitals and record in Progress note (updated 3/11) 3. Complete fall and pain assessment 4. Start neuro (all falls not witnessed BY STAFF 5. PN [progress note] what happened, what you did to keep resident safe, notification family, MD, Text on call manager 6. Any wound orders if required 7. Notify your abuse coordinator ASAP [name redacted] administrator if you suspect fracture or abuse in any way. C.N.A. 1. Get a nurse to assess patient 2. Start Vital signs on Neuro sheet 3. Get a set or [sic] ortho static [sic] vitals with nurse if your [sic] not trained on this please see nurse or ADON [assistant director of nursing]. The facility conducted fall audits. The audit form revealed, DON/designee will conduct random audits on 5 residents and fall preventions interventions in place weekly x 4 weeks, then monthly x 3 months or until substantial compliance has been maintained to ensure decrease in falls. For the week of 2/19/24 through 2/25/24, Resident 4 was selected to be audited. The audit form stated that Resident 4 had his fall precautions in place when facility staff entered his room. Per the audit form, Resident 4 had the comment, seatbelt, call light. For the week of 2/26/24 through 3/3/24, Resident 4 was selected to be audited. The audit form stated that Resident 4 had his fall precautions in place when facility staff entered his room. Per the audit form, Resident 4 had the comment, low bed, call light pillow. For the week of 3/4/24 through 3/10/24, Resident 4 was selected to be audited. The audit form stated that Resident 4 had his fall precautions in place when facility staff entered his room. Per the audit form, Resident 4 had the comment, seatbelt/safety reminder. For the week of 3/11/24 through 3/17/24, Resident 4 was selected to be audited. The audit form stated that Resident 4 had his fall precautions in place when facility staff entered his room. Per the audit form, Resident 4 had the comment fall mat - behind bed pt [patient] up [sic]. On 3/11/24 at 12:39 PM, an interview was conducted with Resident 4. Resident 4 stated that he remembered his fall that resulted in his hip fracture. Resident 4 stated that the night of the fall, his call light had dropped onto the floor and that the remote control for his bed had also dropped onto the floor. Resident 4 stated that he was unable to lower his bed further. Resident 4 stated that he tried to reach for his call light and fell out of bed. On 3/11/24 at 12:39 PM, an observation was made of Resident 4's room. The call light was taped to the side of his nightstand and clipped to the right side of his pillow. On 3/12/24 at 1:17 PM, an additional observation was made of Resident 4's room. Resident 4's bed was in the low position and his fall mat was behind his bed. On 3/12/24 at 1:17 PM, an interview was conducted with Resident 4. Resident 4 stated that staff stopped putting the fall mat on the floor at bedtime when he was moved from the 200 hall to the 400 hall. A review of Resident 4's room history revealed that Resident 4 was moved from the 200 hall to the 400 hall on 1/15/24. On 3/12/24 at 9:31 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that residents should be checked on every 2 hours. CNA 1 stated that he should check a resident's call light position every time he enters their room. CNA 1 stated that Resident 4 was not a high fall risk. CNA 1 stated that he has never heard of Resident 4 having experienced a fall. CNA 1 stated that he can see what fall interventions a resident had in place by looking at notes in the Resident's electronic medical record. On 3/12/24 at 1:23 PM, an additional interview was conducted with CNA 1. CNA 1 stated that to his knowledge, Resident 4 did not use a fall mat at night. CNA 1 stated that Resident 4's bed should have been in the low position. On 3/12/24 at 9:38 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that CNAs should check on residents every 2 hours. LPN 1 stated that each time a CNA completed their rounds they should check the position of each resident's call light. LPN 1 stated that Resident 4 was a high fall risk. LPN 1 stated that information about a resident's fall interventions could be found in the electronic medical record. LPN 1 stated that Resident 4 needed to be checked on more frequently due to him having an independent mindset and that he frequently tried to self transfer. On 3/12/24 at 11:28 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 was the nurse on duty the day Resident 4 fell. RN 2 stated that another staff member called her into Resident 4's room. RN 2 stated that she examined the resident and lifted him onto his bed. RN 2 stated that she notified Resident 4's physician and facility administration. RN 2 stated that an x-ray was ordered and that the x-ray staff confirmed that Resident 4 had a hip fracture. RN 2 stated she could not recall what Resident 4's fall interventions were at the time of the fall. RN 2 stated that she could not recall the location of Resident 4's call light when she entered his room. RN 2 stated that CNAs should check on residents at least every 2 hours and that anytime a CNA enters a resident's room they should check the positioning of the resident's call light. On 3/12/24 at 2:24 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should check on residents at least every 2 hours. The DON stated that staff should check the position of a resident's call light each time they enter a resident's room. The DON stated that staff can check to see what a resident's fall interventions were by looking at the [NAME] in the electronic medical record. The DON stated that Resident 4 was a fall risk due to him wanting to maintain his independence. The DON stated that Resident 4 used a fall mat at night. The DON stated that Resident 4's fall mat should have been on his care plan. (Note: the usage of a fall mat was not documented on Resident 4's care plan). The DON stated that she had interviewed Resident 4 and Resident 4 had stated that he was not sure if he had knocked his call light out of place. On 3/12/24 at 2:24 PM, an interview was conducted with the facility administrator (ADM). The ADM stated that the facility does not track exact times that facility staff exit and enter a resident's room. The ADM stated that Resident 4's call light had been attached to the bar on Resident 4's bed and had fallen onto the ground prior to Resident 4's fall. Based on observation, interview, and record review it was determined that for 2 of 7 sampled residents, that the facility did not ensure that the resident environment remains as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that a resident transported to a dialysis appointment was properly secured with a seatbelt, and subsequently sustained fractures of both of his legs. In addition, the facility did not ensure that a resident's call light was within reach and the resident reached for the call light, fell out of bed, and fractured his hip. This will be cited at a HARM. Resident Identifiers: 4, 7. Findings included: 1. Resident 7 was admitted to the facility on [DATE] with diagnosis which included encephalopathy, end stage renal disease, spinal stenosis, weakness, limitation of activities due to disability, need for assistance with personal care, and adult failure to thrive. On 3/12/24 at 9:38 AM, an interview was conducted with resident 7. Resident 7 stated that on 12/28/23 he was going to be transported to dialysis. He stated that the van driver was new and it was the van drivers 3rd or 4th day. Resident 7 stated that the van driver strapped him in the van ok, with two straps at the front of his chair and two in the back. When resident 7 was asked about a lap and shoulder seat belt, he stated he did not have one on and did not remember the van diver attempting to put a shoulder or lap seat belt on him. He stated that he did not refuse to have the seatbelts put on. Resident 7 stated that they were on the freeway, the van driver was using a GPS [Global Positioning System] map to drive to the location, the van driver said that the exit should be coming up soon. Resident 7 stated he was looking out the window and told the van driver that they were about to miss the exit, and the van driver braked had but not so hard the van squealed and darted over to the emergency lane. He stated the braking did pull him out of his chair feet first and he slammed into the back of the van drivers chair and could tell his legs were broken. Resident 7 stated he was then taken to the hospital and was told his femur bones were shattered. On 11/30/23 a quarterly Minimum Data Set (MDS) assessment documented, resident 7 had a Brief Interview for Mental Status (BIMS) of 15. The MDS also documented, resident 7 required extensive two person assistance with bed mobility, transfers, and toileting. On 9/14/21, a care plan documented resident 7 was at risk for falls related to deconditioning, gait/balance problems. Interventions included, ensure that resident 7 was wearing appropriate footwear when ambulating or mobilizing in w/c[wheelchair]. On 12/29/23 at 6:30 AM, an incident report documented, Van driver came back to facility saying [resident 7] did not make it to dialysis. Van dirvier[sic] stated that he did not fasten the safety belt because [resident 7] declined and stated he didn't need it. He stated while on highway, the driver had missed the turn off so [resident 7] shouted out and startled him so he braked. He stated [resident 7] slipped forward out of geri chair and landed on the van floor. Van driver called 911 and he was taken to [a local hospital]. Can driver called dialysis and updated dialysis center that he would not be at dialysis today due to hospital admission . Resident unable to give description. The document stated No injuries observed at time of incident. On 12/29/23 at 9:51 AM, a nursing note documented, Van driver came back to facility saying [resident 7] did not make it to Dialysis. He stated while on highway, he had missed the turn off, [resident 7] yelled at him and then he suddenly braked. He stated [resident 7] slipped forward out of geri chair and landed on the van floor. 911 was called and he was taken to [a local hospital]. Van driver called Dialysis and stated he would not be at dialysis today. On 12/29/23 at 4:33 PM, a nursing note documented, Contacted [local hospital] to see if res [resident] had been admitted to hospital. He is in the ICU [Intensive Care Unit], is receiving dialysis there, bilat [bilateral] LE [lower extremities] were affected and they both will be needing surgery. His stay will be awhile. On 1/1/24 at 8:35 AM, an administration note documented, in hospitalized [sic] A review of resident 7's hospital history and physical reports dated 12/29/23 documented, the patient is found to have bilateral femur fractures and other associated soft tissue injuries . On 3/12/24 at 10:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she had not worked with resident 7, but knew that he was a full assist and required 2 people with transfers. On 3/12/24 at 10:43 AM, interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 7 was preferably a 2 person assist with transfers and that he did not have much leg strength. She stated that he was typically transferred into a geri chair and transferred in that to dialysis. She stated she was unsure how he was typically strapped into the van. On 3/12/24 at 11:08 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that she had worked with resident 7 and that he was extremely difficult in a lot of incidences. She stated that he had depression and was frustrated and he would lash out at care givers and would refuse to cooperate. She stated that she was not present at the time he was being transported and can not say what happened. On 3/12/24 at 1:22 PM, an interview was conducted with the Van Driver (VD). The VD stated that he was new and had not received training, the only training received was to ride with another driver a couple of times. He stated that the other driver showed him how to strap a wheelchair into the van but never a geri chair. The VD stated that he arrived at the facility and a nurse brought resident 7 out to the van in the geri chair. The VD stated he thought resident 7 should not be transported like that but that he was new and was not sure. The VD stated he loaded resident 7 into the van and tied his chair down, then tried to put a shoulder strap and waist belt on resident 7, but that resident 7 refused the shoulder and waist belt. The VD stated he did not know the policy and was told that the customer was always right, and decided to transport the resident. The VD stated that on the freeway he was in the wrong land and the exit was difficult to get to. The VD stated that resident 7 told him they missed the exit. He stated he panicked and that resident 7 slid out of his chair onto the van floor. The VD stated he tried to help resident 7 back into his chair but that resident 7 refused and said to call 911 stating his legs were broken. The VD stated that the geri chair did not move, it was strapped to the van and the brakes were on. The VD stated he tried to call his supervisor and could not get a hold of him, then called dispatch to inform them of the incident. The VD stated that during his training no one said that it was mandatory to be strapped by the shoulder and lap belt and no one had informed him of the policy. The VD stated that he wanted to put the seatbelts on the resident but that the resident refused. The VD then terminated the interview. On 3/12/24 at 2:26 PM, an follow up interview was conducted with the RNC. The RNC stated that best practice was for a resident to be buckled when being transported. The RNC stated that if a resident refused, they must look at the things that were important, the residents have the right to choose. The RNC stated that with this situation the driver did attempt to do what he could with a reasonable attempt to buckle, and opted not to per resident 7's request. The RNC stated that for resident 7 dialysis was vital and that he had complications due to refusing dialysis. The RNC stated that ultimately it was best practice to secure residents in transport. On 3/13/24 at 9:22 AM, a follow up interview was conducted via telephone with the VD. The VD again stated that when he picked up resident 7, resident 7 was in a geri chair. The VD stated that technically you're not supposed to transport people in a geri chair. The VD stated that he loaded the resident in the geri chair into the van, and secured the wheels of the chair, making sure it didn't move. The VD stated that the resident refused to wear the shoulder lap belt. The VD stated that resident 7's exact words were 'I don't need it and I don't want it.' The VD stated that he had never transported someone without securing them completely. The VD stated that it was 5:00 in the morning, and I couldn't get a hold of my supervisor. The VD stated that the only training he had received prior to working alone was riding along with other van drivers. The VD stated that he was not trained on what to do if a resident refused to be secured, and was unsure if there was a specific company policy. The VD stated that he was terminated for transporting the resident without properly securing the resident. The VD stated that during the drive, resident 7 yelled out, and I reacted to his yelling, and he slid out when I hit the brakes. The VD stated that after he braked, the resident began screaming. The VD stated that he pulled over, and checked on the resident. The VD stated that the resident had slid out of the geri chair completely, and was sitting with his legs crossed in the space between the drivers seat and the geri chair, behind the driver. The VD stated that resident 7 told him to call 911.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 3 of 38 sample residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision, implement interventions nor complete interventions in an effort to prevent falls from occurring. One resident fractured each wrist, one week apart and one resident, had a fall after no interventions and fractured a wrist. Resident identifiers: 3, 30 and 41. Findings include: 1. Resident 3 was admitted to the facility on [DATE], she was discharged to the hospital and returned on 8/28/19, with diagnoses which included fracture of right wrist and hand, cystitis, fracture of left wrist and hand, acute respiratory failure, dementia, bipolar disorder, neuromuscular dysfunction of bladder, need for assistance with personal care, neuropathy, glaucoma, gastro-esophageal reflux disease, restless legs syndrome, osteoarthritis, dissociative identity disorder, pseudobulbar affect, pain in left knee, chronic obstructive pulmonary disease, encephalopathy, abnormalities of gait and mobility, dysphagia, cognitive communication deficit, sciatica, pain in right leg, generalized anxiety disorder, repeated falls, muscle weakness, hypoxemia, hyperglycemia, insomnia, obstructive sleep apnea, hypothyroidism, hyperlipidemia, and asthma. On 9/9/19 at 12:15 PM, an interview was conducted with resident 3. Resident 3 stated that she had had multiple falls at the facility, and had hit her head at least once. Resident 3's medical record was reviewed on 9/10/19 and revealed the following falls: a. On 12/28/18 resident 3 had a fall with no noted injury. A nurse's note documented Nurse was assisting resident's roommate and saw this resident standing up after using the restroom and slipped and fell into a sitting position on the floor. Resident stated that her feet started to slide and she fell to a sitting position. An intervention documented on the facility incident report and the nurse's note stated Encouraged resident to wear nonskid socks when walking or transferring. [Note: this fall and intervention were not documented on resident 3's care plan.] b. On 12/30/18 resident 3 had a fall and hit her head. A nurse's note documented Res (resident) roommate used call light, CNA (certified nurse assistant) answer and found res in rest room res was sitting on floor. Res did not have traction socks on. Ask res what happens? res stated that she was on toilet, reach for walker then started to slipping. Res stated she hit her R (right) side of head on wall, and R arm on the floor. An intervention documented on the facility incident report and the nurse's note stated educate res to used traction socks and put on for res. [Note: this was the same intervention documented for the fall that happened 2 days prior. Additionally, this fall and intervention were not documented on resident 3's care plan.] c. On 1/12/19 resident 3 had a fall and hit her head which caused a scalp hematoma. A nurse's note documented Recreation notified this nurse that she was in resident's room helping her and saw her fall to the floor and her back was leaning against the bed frame. Resident stated she was standing up and was reaching for her walker but it was too far and lost her balance and fell. She said she hit her back and her head on the bed frame. An intervention documented on the facility incident report and the nurse's note stated Encourage resident to ask for assistance. [Note: this fall and intervention were not documented on resident 3's care plan.] d. On 1/14/19 resident 3 had a fall with no noted injury. A nurse's note documented Res stated that she was in her recliner, try to get up to her walker and slipped to floor. Res was next to her recliner.Res (sic) stated she did not hit her head, and denied pain. An intervention documented in the nurse's note stated Educate res to use call light, and help res to used rest room. Another intervention documented as an Interdisciplinary Team (IDT) note stated Staff to remind and assist resident in keeping her walkerclose (sic) by. [Note: this fall and intervention were not documented on resident 3's care plan.] e. On 5/27/19 resident 3 had a fall and hit her head which caused a laceration. A nurse's note documented [Resident 3] fell in her room at approx. (approximately) 1100 (11:00 AM). She was standing and trying to sign a piece of paper for [NAME] the housekeeper. she (sic) said all of a sudden I just felt myself going down. She hit her head on the left side and has a small laceration to her left ear. An intervention documented on 5/28/18 as an IDT note stated Resident is currently on OT (occupational therapy). OT to instruct to keep one hand on a solid surface. [Note: the fall and interventions were not documented on resident 3's care plan. Additionally, an interview with staff indicated that there was not a housekeeper named Jack, nor was anyone trying to obtain a signature from resident 3.] f. On 6/29/19 resident 3 had a fall with no noted injury. A nurse's note on 6/30/19 documented [Resident 3] was using her 4 wheeled walker as a wheelchair and another resident brought her dog in. [Resident 3] leaned over to pet the dog forgetting to lock the brakes on her walker. The walker then rolled out from under her causing her to slide to her bottom. No injury noted and was witnessed by 3 other people, she did not hit her head. An intervention documented on resident 3's care plan stated Re-educate [resident 3] to use her walker as a walker and apply the brakes when moving. [Note: this was the first fall intervention documented on resident 3's care plan since 2017, which was prior to these most recent falls.] g. On 7/9/19 resident 3 had a fall with no injury noted. A nurse's note on 7/10/19 documented ~1930 (7:30 PM) Resident was found on the floor sitting on her buttock by CNA. Res stated she was going to the restroom and her legs gave out. Then she butt walked forward to let staff know. She did not hit her head, No skin injuries upon assessment. An intervention documented on resident 3's care plan stated Repair [resident 3's] electric wheelchair so she will no longer use walker as a wheelchair and remind to use call light for assistance. On 9/11/19 at 9:32 AM, an observation was made of resident 3 sitting in her recliner. Resident 3's call light was clipped to her bed and was not within reach. h. On 7/19/19 resident 3 had a fall in which she hit her head and had a change in her vital signs and level of consciousness. A nurse's note on 7/20/19 documented Res was found in he (sic) bathroom sitting on floor. Res stated she feel (sic) while standing up reaching for her wheel walker. Res wheel walker was not lock. Res has two lumps on right skull, res stated pain in R shoulder, R side of head, and R breast. Res initial vitals were WNL (within normal limits), after second vital res BP (blood pressure), O2 (oxygen) sat (saturation) begin to decline. Res become more confused. [Nurse Practitioner] gives the OK to send res toER (sic) (emergency room). Res came back from [name of hospital] at 0400 (4:00 AM), with no new orders. An intervention documented resident 3's care plan stated Putting her walker closer to her while in the bathroom and ensuring the brake is engaged. An intervention documented on the facility incident report and the nurse's note stated She continues to use her walker as a wheelchair and has had falls rt (related to) not using her walker appropriately. Resident educated regarding walker use and to call staff for assistance. [Note: this was the 2nd time these interventions were used.] i. On 7/30/19 resident 3 had a fall and hit her head. A nurse's note documented CNA heard a call for help and found [resident 3] on the floor in her room. She stated she was getting up to go to the bathroom and slipped on some water she spilled. Denies any pain. No physical injuries noted. States she slightly hit her head. An intervention documented on resident 3's care plan stated Provide [resident 3] new grippy socks for traction. [Note: this was the 3rd time this intervention was used, but the 1st time it was documented on the care plan.] On 9/10/19 at 3:12 PM, an observation was made of resident 3 with no grippy socks on. On 9/11/19 at 8:04 AM, resident 3 was observed sitting on the side of her bed with no grippy socks on. There were no grippy socks on her bed or anywhere near her to indicate that she had them on recently. On 9/11/19 at 11:26 AM, an observation was made of resident 3 in her recliner with no grippy socks on. Resident 3's spouse was in the room at that time and stated that staff never put grippy socks on resident 3 unless she requested it. j. On 8/5/19 resident 3 had a fall and hit her head which caused a laceration, she also had a left wrist fracture. A nurse's note documented This nurse and two other staff members heard resident yelling for help and went in room to find resident on ground face down at 1900 (7:00 PM) this evening. Staff members helped resident back up into her recliner. She stated she was on her way to the bathroom and tripped on her side table. She has a bump on her forehead with a small laceration, cleaned and dressed with a bandaid. She had increased pain in her left arm rated 10/10 with decreased ROM. Pain medication and ice given. MD notified and ordered x-ray for left shoulder and wrist. X-ray performed and showed fracture to left wrist. MD notified and ordered to send out for further treatment in ER. An intervention documented on resident 3's care plan stated Install grippy tape to the bathroom floor for traction in the event there is water inadvertently splashed on the floor.Install grippy tape to the foot of [resident 3's] recliner. An intervention documented on the facility incident report and the nurse's note stated Staff to apply brightly colored tape on her bedside table to assist with visual cues. On 9/10/19 at 3:12 PM, an observation was made of resident 3's bathroom with no grip tape on the floor. Resident 3's roommate stated that to her knowledge, there had never been any grip tape on the floor in the bathroom. On 9/11/19 at 9:32 AM, an observation was made of resident 3's bedside table without any brightly colored tape for visual cues. k. On 8/10/19 resident 3 had a fall with no noted injuries. A facility incident report documented CNA found res is room sitting on floor by her recliner. Res stated she slid out of recliner onto floor, and did not hit her head. An intervention documented on the facility incident report and the nurse's noted stated Grippy tape to be placed at the foot of her recliner. [Note: this was the 2nd time this intervention was used. Additionally, no updates were made to resident 3's care plan.] l. On 8/16/19 resident 3 had a fall with no noted injuries. A nurse's note documented Res more alert today, however she tried once to get up on her own at 1100 (11:00 AM), nurse found res on floor, examined res, found no injury. An intervention documented on resident 3's care plan stated PT (physical therapy) eval (evaluation) for strength and training to use bedside commode and ambulate. An intervention documented on the facility incident report and the nurse's note stated Resident educated regarding call light use. Bedside commode placed by bedside to assist resident. On 9/11/19 at 9:32 AM, an observation was made of resident 3's room with no bedside commode. m. On 8/18/19 resident 3 had a fall with a right wrist fracture. A nurse's noted documented Around 0330 (3:30 AM) CNA found res on the floor in prone position, bed was on the lowest position. Res stated she tried to get up and some how rolled out of bed. [Note: there was no intervention documented for this fall on resident 3's care plan, in the nurse's note, or in a facility incident report.] n. On 8/22/19 resident 3 had a fall with no noted injuries. A facility incident report documented RES found on floor have way to bathroom, res on R side, bed was in the lowest position r/t res trying 2 other times that morning to get out of bed. An intervention documented on the facility incident report stated that resident 3 was sent to the hospital for a psychiatric evaluation. [Note: this fall and intervention were not documented on resident 3's care plan.] A review of resident 3's care plan revealed the following interventions were initiated prior to the fall on 12/28/18: a. Resident referred to pt (physical therapy) for proper walker usage and eval (evaluation) for front wheeled walker. Initiated on 9/17/17 b. Anticipate and meet [resident 3's] needs. Initiated on 6/13/16 c. Be sure [resident 3's] call light is within reach and encourage [resident 3] to use it for assistance as needed. [Resident 3] needs prompt response to all requests for assistance. Initiated on 6/13/16 d. Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). Initiated on 6/13/16 e. [Resident 3] given education to let staff help her with toileting to prevent further falls. Initiated on 5/8/17 f. Education given to [resident 3] to ensure that she asks for assistance with bed mobility Initiated on 3/20/173 g. Staff education to check with [resident 3] frequently for toileting needs and if she needs any assistance with toileting to prevent falls. Initiated on 5/8/17 [Note: the intervention to remind resident 3 to ask for assistance and use her call light for mobility and transfers was used seven times.] On 9/9/19 at 12:15 PM, an interview was conducted with resident 3's spouse. Resident 3's spouse stated that resident 3 usually fell when trying to get up to go the bathroom because staff did not answer call lights very quickly. [Note: seven of the fourteen falls were going to or from the bathroom.] A review of call light times around resident 3's falls found: a. On 12/28/19, just prior to resident 3's fall, her call light was on for 11 minutes and 4 seconds. b. On 12/30/19, just prior to resident 3's fall, her call light was on for 8 minutes and 56 seconds. c. On 1/12/19, just prior to resident 3's fall, her call light was on for 3 minutes and 33 seconds. d. On 1/14/19, just prior to resident 3's fall, her call light was on for 4 minutes and 45 seconds. e. On 7/9/19, just prior to resident 3's fall, her call light was on for 10 minutes and 30 seconds. f. On 8/5/19, call light times surrounding this fall were not provided by the facility. g. On 8/10/19, just prior to resident 3's fall, her call light was on for 6 minutes and 42 seconds. h. On 8/16/19, call light times surrounding this fall were not provided by the facility. i. On 8/18/19, call light times surrounding this fall were not provided by the facility. j. On 8/22/19, call light times surrounding this fall were not provided by the facility. A review of the Medicare Minimum Data Set (MDS) Assessments for the previous year documented that resident 3 had a Brief Interview for Mental Status (BIMS) score of 13-15 which would indicate resident 3 was cognitively intact. Additionally, resident 3's functional status was documented as requiring one person, extensive assistance for toilet use and transfers. On 9/11/19 at 8:04 AM, an observation was made of resident 3 sitting on the side of her bed. Resident 3 stated she had a headache and was trying to call the nurse but could not figure out how to push her call light. Resident 3 was observed holding her oxygen tube in her hand and trying to push it as if it were a call light. When told that it was her oxygen tubing in her hand, resident 3 insisted it was the call light. On 9/11/19 at 10:08 AM, an interview was conducted with resident 3's Physical Therapist (PT). The PT stated that resident 3 was only oriented to person and her room. The PT stated that resident 3 was not able to retain education that was completed with her, even with practice and repetition. The PT stated that PT and OT would work with residents that were high risk for falls to identify causes. The PT stated that one of resident 3's issues was the clutter in her room. The PT stated that he assisted in initiating interventions, stated that he would talk to the floor staff about implementing those interventions. The PT stated that there was no paperwork or documentation that they use to communicate with the floor staff, stated that all communication was word of mouth. On 9/11/19 at 7:31 AM, an interview was conducted with CNA 6. CNA 6 stated that resident assistance needs were listed on their CNA report sheets. [Note: resident 3 was documented needing 2 person assistance.] CNA 6 stated that the CNA's had to ask the nurses if a resident had any fall interventions ordered. CNA 6 stated that the CNA's did not have access to any of that information. CNA 6 stated that she was very familiar with resident 3, stated that she did not know of any fall prevention interventions that were supposed to be used for resident 3. CNA 6 stated that resident 3 never refused interventions. On 9/11/19 at 7:36 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that new interventions were entered into the care plan by nurse management, stated that the interventions were also entered into the electronic charting system as an order to communicate the interventions to the staff. RN 1 stated that some examples of interventions ordered for falls were to put the resident beds in the lowest position, place fall mats on the floor by the bed, and use pressure alarms; RN 1 verified that resident 3 had no orders for fall prevention interventions. RN 1 stated that resident 3 required frequent reminders to use her call light, stated that resident 3 often forgot. RN 1 reviewed resident 3's care plan and stated that resident 3's fall interventions were to keep her room free of clutter and provide prompt nursing care. RN 1 was unable to verbalize what prompt nursing care was. RN 1 stated that resident 3 was very compliant with cares and interventions, stated that resident 3 never refused. On 9/11/19 at 11:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that all falls were followed up on by the clinical team on the next business day. The DON stated that the team tried to identify root cause and trends, stated that no trends had been identified for resident 3. The DON stated that interventions were usually entered into the resident care plans during the fall follow up meeting by the nurse management, stated the interventions were also entered as an order to communicate to the nurses. The DON stated that the CNA Coordinator would also document the interventions on the CNA report sheets immediately following the meeting. The DON stated that interventions were also documented on the resident's Kardex. The DON stated that during the fall follow up meeting past interventions were re-evaluated for effectiveness. The DON verified that the intervention of prompt nursing care for resident 3, as verbalized by the floor nurse was kind of vague and was unable to provide further clarification. The DON was unable to explain the discrepancies between the incident reports and care plan interventions. The DON stated that all of those interventions should have been implemented; the DON was unable to explain why resident 3 did not have grippy socks, the call light was not within reach, there was no grip tape on the bathroom floor, no bedside commode, nor bright tape on the bedside table. A review of resident 3's Kardex documented the following interventions: a. Anticipate and meet [resident 3's] needs. b. Be sure [resident 3's] call light is within reach and encourage [resident 3] to use it for assistance as needed. [Resident 3] needs prompt response to all requests for assistance. c. Ensure that [resident 3's] floor is free from tripping hazards and personal items. On 9/11/19 at 12:00 PM, an interview was conducted with CNA 7. CNA 7 stated that the CNA report sheets did not have any interventions documented on them. CNA 7 stated that he was very familiar with resident 3, stated that resident 3 was only oriented to person and place. CNA 7 stated that resident 3 could not remember to use her call light and ask for assistance despite reminders from staff. CNA 7 stated that CNA's could not access the nurse's notes or incident reports for any interventions documented in those places. CNA 7 stated that he did not know where to find the Kardex to review it for interventions. [Note: A copy of a CNA report sheet was obtained and verified there were no interventions listed for any residents.] On 9/11/19 at 2:57 PM, a follow up interview was conducted with RN 1. RN 1 stated that resident 3 was continent of bowel and bladder but that resident 3 had urinary urgency and could not always get to the bathroom in time. RN 1 stated that education was not effective with resident 3 because despite constant safety reminders, resident 3 never remembered them. RN 1 stated that the facility had not tired a toileting program for resident 3, stated that a toileting program would probably be a good option for resident 3 because of her urinary urgency. RN 1 stated that she did not review past nurse's notes or incident reports for interventions documented in those places. On 9/16/19, further information was provided by the facility via e-mail. A Risk vs. Benefits form dated and signed by resident 3 on 8/9/19 documented: 1. Area of concern: Using [NAME] in place of wheelchair to sit on. 2. Benefits: Autonomy in decision making. [Resident 3] had the ability to sit if she becomes fatigued when walking and has episodes of SOB (shortness of breath) or anxiety. 3. Risks related to noncompliance: [Resident 3] falls when trying to sit down on walker seat. [Resident 3] forgets to lock the brakes when using walker as appropriate, this could lead to further broken bones and critical/severe injuries up to and including death. [Note: resident 3's walker was not a factor in her falls that occurred after 8/9/19 when this form took effect.] A note from MD 1 provided by the facility stated [Resident 3] also suffered from complex psychiatric diagnoses, which include Bipolar Disorder and Dissociative Identity Disorder which was evidenced by frequent changes in her mood, cognition and tangential responses, often multiple times throughout the day. This complexity of [Resident 3's] mental health status ultimately resulted in a psychiatric crisis which made fall prevention impossible as she was impulsive, reactionary, and extremely labile in her moods and actions. MD 1 also indicated that no matter what the facility implemented to prevent a fall with [resident 3], her constant mood changes and flight of ideas would have still resulted in falls. The complexity of her Dissociative Identity Disorder would have also complicated the ability of the facility to identify an intervention because the person for which the intervention was directed to would not be effective for one of [Resident 3's] alternate personalities. Review of the facility behavior monitoring and nurse's notes did not document that the facility floor staff was aware of, or monitoring for mood changes, cognition, or tangential responses. Resident 3's Pre-admission Screening Resident Review (PASRR) Level II was provided by the facility as further information. Documented under Current Psychiatric Functioning the Licensed Clinical Social Worker (LCSW), that evaluated resident 3, documented: Pt's (patient's) husband reported pt (patient) having 5 or 6 personalities. Pt's husband stated that pt has not had many exacerbations in regards to dissociative identity disorder since admission into the SNF (skilled nursing facility). Pt was evaluated by [mental health facility] in July 2019 for counseling and medication management; pt is getting counseling ever (sic) couple weeks and medication management every few months. On 9/19/19 at 1:50 PM, a phone interview was conducted with MD 1. MD 1 stated that resident 3 arrived at the inpatient geriatric psychiatric unit on 8/22/19 very agitated and had impulsivity. MD 1 stated he was the attending physician that treated her. MD 1 stated that based on her previous information from resident 3's mental health facility he believed this psychiatric issue was an acute exacerbation and could only be a contributing factor in the most recent fall. MD 1 stated that the cases where resident 3 fell while going to and from the bathroom were not psychiatric issues. MD 1 stated that he treated resident 3's impulsivity and agitation, not tripping over things. MD 1 stated that regardless of the reason for the falls, the facility should have attempted to keep resident 3 safe with continued interventions. MD 1 stated that resident 3 required a one-on-one staff assignment to keep resident 3 safe while in the hospital. 3. Resident 30 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disorder (COPD), muscle weakness, Alzheimer disease, Gastro-Esophageal Reflux Disease (GERD) without esophagitis, dementia, dysphagia oral phase, and cognitive communication deficit. On 9/9/19 at 7:54 AM an observation was made of resident 30. Resident 30 was was observed to have a bruise above her left eye brow. On 9/11/19, resident 30's medical record was reviewed. Nursing progress notes revealed the following: a. 8/26/2019, CNA found res [resident 30] on floor in fetal position by her bathroom. Res [resident 30] was confused thinking the floor was her bed. Did skin checks, res [resident 30] have a bump and bruise on back of head, a small cut on left of ring finger. Res [resident 30] initial vitals are BP (blood pressure) 131/81, P (pulse) 63, Resp (respiration)18, Temp (temperature) 96.7, O2 (oxygen saturation) 96 RA. Res [resident 30] is in a lot of pain, clutching her hands on her head, and grimacing. Administer prn Tramadol 50 mg, cleaned res [resident 30] ring finger with wound cleanser and applied bandaid. Contact Hospice and talked to [hospice nurse] she wants us to keep an eye on her, and let Tramadol have a chance to work. If her condition changes then call back. Notify [resident 30's son][phone on file]. b. 9/3/2019, Resident had an unwitnessed fall with head injury. Staff noted a bump on her left forehead with redness, and dried blood around her lips this am. Bruising is beginning to appear on resident's right forehead. Neuro checks have been initiated and are at baseline for resident. Hospice and family notified. Supervisor also notified. c. 9/5/2019, IDT (interdisciplinary team) team met regarding residents recent falls. Social work, PT, nursing and administration present. While CNA's were doing rounds the CNA noticed [resident 30] walking around holding her blankets. At that time [resident 30] stated to the CNA that she fell out of bed. The resident bit her lip when she fell. Staff to place night light for better visualization in room. Staff also to give resident a thicker blanket so she wont get tangled in her blankets. Neuro checks were started. Resident was not complaining of any pain. Nurse and CNA were interviewed regarding residents fall. Time and situation were confirmed. Will monitor. Resident 30's medical record revealed that resident 30 had falls on 6/28/19, 6/30/19, 8/26/19 and 9/3/19. Incident reports revealed the following: a. 6/28/19, CNA found resident on the floor in her bedroom. When a nurse came to asses her, she was asleep on the floor with little bump on her head. Per the incident report, the facility initiated routine neurochecks, did assessment and informed all responsible parties. b. 6/30/19, resident 30 had another unwitnessed fall. She was found lying on the floor in her bedroom with no apparent injury. Per the incident report, the facility started the neurochecks, assessed resident 30 head to toe and notified responsible parties. c. 8/26/19, resident 30 was found on the bathroom floor in fetal position with no apparent injury. Per the incident report, the facility performed head to toe assessment, started vitals and neurochecks and informed responsible parties. d. 9/3/19, resident had unwitnessed fall with a head injury. The facility did a head to toe assessment, initiated neurochecks and notified all responsible parties. No neurological checks could be located in resident 30's medical record for the fall on 9/3/19 when she sustained an injury to the left side of her forehead. A care plan for resident 30 dated 2/19/16 with revision date of 6/14/19, revealed that resident 30 is a wanderer r/t (related to) Dementia, Impaired safety awareness, Disoriented to place. [Resident 30] has had an actual fall r/t dementia and poor safety awareness, with head injury. [Resident 30] is Moderate risk for falls r/t Confusion, weakness and hx (history) of fall. The interventions on the care plan included were for staff to ensure that resident 30 wore [TRUNCATED]