**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, resident interview, and staff interview the facility failed to ensure a resident who has an indwelling urinary catheter receives the care and services needed to ensure the resident did not develop complications related to the indwelling urinary catheter. The facility staff failed to ensure an anchor device was on Resident #105's catheter to prevent it from becoming dislodged. In addition, the nursing staff failed to identify and/or address serious problems with Resident #105's catheter prior to surveyor intervention on two (2) separate occasions on 05/09/23 and again on 05/10/23. In addition Resident #105 suffered a change in mental status which was also not identified by nursing staff until it was pointed out by the surveyor. Also, nursing staff failed to follow all physician directives pertaining to Resident #105's catheter and his urinary status within a timely manner. Resident #105 suffered actual physical harm as the result of these failures. He was sent to the emergency room (ER) and returned to the facility with comfort measures in place and a referral to hospice services. When the resident returned to the facility, his diagnosis included: Septic Shock, Pyelonerhritis (an inflammation of the kidney due to a bacterial infection.). A CT (Computed Tomography) of his abdomen while at the hospital showed moderate bilateral hydroureteronephrosis (The swelling of a kidney due to build up of urine. This happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction.) The State Agency (SA) determined these failures posed an immediate risk to Resident #105 and placed him in an immediate jeopardy (IJ) situation in addition to the actual harm he had already suffered. The SA notified the facility of the IJ at 1:30 PM on 05/10/23. The facility submitted their first plan of correction (POC) at 4:17 PM. The SA requested changes to the POC. The second POC was submitted at 5:00 PM. The POC was accepted by the SA at 5:00 PM. This immediate Jeopardy began on the morning of 05/09/23. The facility Plan of Correction read as follows: F690 Resident #105 returned to the facility from the hospital at 2:00 PM on 05/10/23. The medical director assessed Resident #105 on 05/10/23 at 2:00 PM. All residents with indwelling catheters of the facility have the potential to be affected. The Unit Manager conducted an audit on all indwelling catheters at 1:50 PM on 05/10/23 to ensure all residents with an indwelling urinary catheter to ensure a secured device is in place, proper way to palpate for bladder distention, monitoring urine output color and notification to medical provider regarding abnormal changes, and if medical provider orders related to urinary catheters for possible occlusion are followed as soon as possible (ASAP) with any corrective action immediately upon discovery. Re-education was provided by the director of nursing (DON)/Designee to all licensed nurses on 05/10/23 at 2:30 PM to ensure all resident with an indwelling urinary catheter received the care and services to ensure the resident did not develop complications related to the indwelling catheter, including ensuring a secured devices was in place, proper way to palpate for bladder distention, monitoring urine output color and notification to medical provider regarding abnormal changes, and medical provider orders related to urinary catheters for possible occlusion are followed as soon as possible (ASAP) . A post-test was done to validate understanding. Any licensed nurses not available during this time frame were provided re-education, including post test and return demonstration by DON/designee upon the beginning of their next shift to work. New Licensed nurses was provided education including post-test during orientation by the DON/designee. Annual in servicing was also provided to licensed nurses regarding the care of indwelling urinary catheters. The Unit managers (UM) /Designee conducted observations starting on 05/10/23 at 4:00 PM to ensure all residents with an indwelling urinary catheter received the care and services to ensure a secured device is in place, monitor urine output color and notify medical provider of abnormal changes and if orders were received for occlusion, they were followed ASP daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly there after. Results of observations were to be reported by the Unit Manager (UM)/Designee monthly to the Quality Improvement Committee (QIC) for any additional follow up and or inservicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. After observation for implementation of the POC the IJ was abated at 6:00 PM on 05/10/23. It was at this time the IJ ended. After the immediacy was removed a deficient practice remained, therefore the scope and severity was reduced from a J to a G because of the actual harm suffered by Resident #105. A deficient practice also remained for Resident #110 related to a diagnosis of a Urinary Tract Infection and the staff failing to get the results of the Urinalysis Culture and Sensitivity to ensure Resident #110 was treated with the correct antibiotic. These failed practices were true for two (2) of three (3) residents reviewed for the catheter/UTI (Urinary Tract Infection) care area during the long term care survey process. Resident Identifiers: #105 and #110. Facility Census: 117 Findings Included: A) Resident #105 On 05/0923 at 11:10 am, Resident #105 was observed lying in his bed. His indwelling urinary catheter tubing was red in color and appeared to have dark blood toward the top of the tubing which appeared to be a blood clot. The resident on observation appeared to be uncomfortable. The surveyor entered Resident #105's room after obtaining his permission at 11:13 AM. Resident #105 was then asked how he was doing. Resident #105 stated, I am not doing too good. I was taking myself to the restroom this morning and my catheter pulled real hard. It felt like it was going to come out of me. Ever since then I have had a lot of pain and discomfort down there. Resident #105 was asked if he had told the staff about this incident. He stated, I told them, but they have not done anything yet. He further stated It felt like that ball just pulled right out of me but I can still feel it so I know it didn't. At 11:15 AM on 05/09/23 Licensed Practical Nurse (LPN) #126 was asked to accompany the surveyor to Resident #105's room. LPN #126 stated she was aware of Resident #105 pulling his catheter this morning and there was minimal bleeding and she notified the nurse practitioner of the incident. Upon entering Resident #105's room, LPN #126 was asked to observe Residents #105's catheter tubing with Nurse Surveyor 39751 present. She agreed there was a blood clot in the tubing below the Y- point of the catheter which was blocking urine flow. She stated, We will have to get an order to change the catheter. Again Resident #105 voiced to LPN #126 he was experiencing pain related to his catheter and the incident which happened this morning. LPN #126 confirmed at this time the resident did not have an anchor device on his leg to anchor the tubing to keep it from pulling and dislodging upon movement. Nurse Surveyor 39751 noted the Y-point of the catheter tubing was down to Resident #105's knee. This would indicate the catheter had dislodged from it previous location because the Y-Connecter is usually located in the upper thigh region. A review of the medical record found the following progress notes related to Resident #105's condition from 11:15 am on 05/09/23 until the surveyors returned to the facility on [DATE]: -- Note dated 05/09/23 at 9:00 am written by LPN #126 read as follows: Resident reports pain to Foley catheter site, blood tinged urine noted to catheter tubing and BSD (Bed side Draining) bag. Reported to NP (Nurse Practitioner). N/O (new order) to monitor Foley catheter for increased bleeding/pain. RR (responsible party) aware. --Note dated 05/09/23 at 10:00 am written by LPN #126 read as follows: Foley Catheter patent with blood tinged urine draining to BSD (Bed Side Draining) bad [SIC]. The notes with the times of 9:00 am and 10:00 am were both entered into the EMR (Electronic Medical Record) after the nurse was requested in the Room of Resident #105 by the surveyors. -- Note dated 05/09/23 at 11:15 am written by LPN #126 read as follows: Resident c/o increased pain to Foley catheter site, catheter not draining, increased bleeding/blood clots noted to tubing. Reported to NP. N/O to change Foley Catheter. -- A note written by the Nurse Practitioner dated 05/09/23 signed at 11:59 AM read as follows: .Chief complaint /nature of presenting problem Seen today to evaluate hematuria per nurse request. History of present illness: Resident with urinary retention, Foley placed in hospital. Now with hematuria, with some small clots after pulling on Foley, causing some urethral pain as well. Medications reviewed, currently taking aspirin 81 mg daily. Resident with poor safety awareness and some confusion related to dementia Plan: Discontinue Foley today, monitor for voiding. If unable to void, replace per urologist orders. Follow up with urologist as scheduled. Hold aspirin 81 mg X 5 days, monitor hematuria. -- Note dated 05/09/23 at 1:14 PM written by LPN #126 read as follows: New order to D/C Foley catheter. Resident tolerated well, small amount of blood discharge noted to urethra. Resident has no complaints of pain or discomfort at this time. Will monitor urine output. -- Note Dated 05/09/23 at 5:51 PM written by LPN #94 read as follows: New orders noted: Straight cath X 1 if resident unable to void after 8 hour (7:45 PM) If resident does not void within 8 hours after straight cath, Approx 3:45 am (on 05/10/23) reinsert indwelling Foley cath. -- Note dated 05/09/23 at 6:00 PM written by LPN #126 read as follows: Resident has not voided this shift, order obtained to straight cath X 1 if resident is unable to void after 8 hours (7:45 PM) if resident does not void within 8 hours after straight cath, 3:45 am reinsert indwelling Foley cath. -- Note dated 05/09/23 at 6:25 PM written by LPN #126 read as follows: LATE ENTRY:Resident stated to this nurse that he felt like he needed to void, urinal given to resident. Resident stated that it will take him a few minutes. This nurse passed on to night shift that resident is attempting to void in urinal at this time and if not voided by 7:45 am to straight cath per order. Night shift nurse verbalized understanding. -- Note dated 05/09/23 at 8:58 PM written by LPN #47 which read as follows: Resident was not able to void during straight Cath only blood was showing. This nurse contacted (Name of Tele health Service Name of Specific Dr.) ordered to discontinue straight cath and to Foley cath and irrigated bladder to flush out any blood. -- Tele health Evaluation note dated 05/29/23 at 9:11 PM written by Tele health Doctor read as follows: Primary chief complaint: GU Hematuria. : History of present illness: Patient is a [AGE] year old male inadvertently pulled out his Foley Yesterday and Foley was not put in but orders were given to straight cath patient if unable to void. Patient was straight catheterized and thick blood clots mixed with urine was obtained. Patient continues having problems voiding. He has no fever or chills. Diagnosis, assessment plan: Urinary retention, retention of urine, The patients condition is worsening. Put in Foley at this time because of thick clots and repeated straight cath is just damaging urethra more. Obtain UA and culture. Once Foley placed irrigate bladder with saline until clear. ** Please note the medical record was void of any indication the Urine was obtained for the UA C&S as ordered by the tele health physician. The nurse also noted that she got back blood tinged urine. There was no indication in the record she irrigated the bladder until clear as directed by the Tele health physician. -- Note dated 05/10/23 3:45 am written by LPN #47 read as follows: This nurse inserted 16' Foley catheter return yielded a bright red blood and urine mix at 350 cc's of urine. Cath bag in place with leg strap on left leg. Resident Denies pain will continue to monitor. An observation of Resident #105 on 05/10/23 at 9:00 am found the resident had an Indwelling catheter. There was a bedside drainage bag which contained less than 5 cc's of blood. The tubing of the catheter again was full of blood and appeared to be clotted. The resident was not responding to verbal stimuli as he had on the previous two (2) days. When the surveyor said his name multiple times the resident just stared at the ceiling and showed no response. LPN #126 was Resident #105's assigned nurse at this time. The surveyor requested she come to Resident #105's room with this surveyor and Nurse Surveyor #39751. Upon entering the room LPN #126 stated I know about the blood in the tubing I told the Nurse Practitioner and have an order to irrigate it I just have not got to it. Please note when the surveyor approached LPN #126 to enter resident #105's room she was preparing medications for other residents and was not in the process of gathering supplies to irrigate Resident #105's catheter which was obviously obstructed with blood clots. Her own admission revealed she knew about the blood clots but had not done anything to resolve the issue. LPN #126 was then asked about Resident #105 not responding to verbal stimuli. She stated, I was not aware he was not responding to verbal stimuli. When asked if this was normal for him she stated, No I guess that is a little bit of a change for him. She was then asked if she could irrigate the residents catheter. She left the room at 9:15 am to gather supplies to perform the irrigation. LPN #83 entered Resident #105's at 9:25 am on 05/10/23 to obtain a set of vitals for the resident. LPN #83 said Resident #105's name loudly several times which warranted no response from the resident. She then performed a sternal rub which also warranted no response from the resident. She then placed her hand under his and asked him to squeeze her hand which he did not do. LPN #83 was asked if this was normal for this resident, She stated no it is not. I have never seen him like this even when he was here previously he was never like this. I think we need to send him to the emergency room. LPN #83 obtained the following vital signs for this resident: Blood Pressure was 176/81, Temperature was 98.2 degrees Fahrenheit, his oxygen saturation was 86. LPN #83 stated, We need to get him on some oxygen. LPN #83 was then asked to palpate Resident #105's bladder to determine if it was distended. LPN #83 then began pushing on Resident #105's pelvic bones. Nurse Surveyor #39751 then instructed LPN #83 the proper way to palpate the bladder. When LPN #83 performed the palpation correctly she determined Resident #105's bladder was distended. The proper procedure to palpate the bladder is to gently palpate from the umbilicus downward toward the pelvis, feeling for a full bladder. At 9:40 am on 05/10/23 it was noted LPN #126 had not returned to irrigate Resident #105's bladder. The Director of Nursing was asked to assist LPN #126 in gathering her supplies so Resident #105 could have his catheter irrigated. At 9:45 am on 05/10/23 thirty minutes after she left the room to gather her supplies, LPN #126 returned to the room to irrigate the catheter. Nurse Surveyor #39751 observed LPN #126 irrigate the catheter. Upon irrigation she flushed in 50 ml (milliliters) of water and only received 5 ml of water on return which was blood tinged. LPN #126 received no urine in return. This indicates the catheter is possibly occluded or not in the bladder. LPN #126 stated, We got orders to send him to the emergency room. An interview with the Nurse Practitioner at 9:55 am on 05/10/23, revealed she had not completed a head to toe assessment on Resident #105. She stated, About 8:05 am this morning I stuck my head in and the resident was awake and moving. She noted nothing specific to his catheter at this time. When asked what it meant when the nurse only received back 5 ml of the 50 ml or saline she flushed into the catheter she stated, It is probably occluded. She stated, I am going in to see the patient right now. That's what I do. At 10:10 am on 05/10/23 Resident #105 was observed being loaded onto an ambulance to go to the hospital. At approximately 2:00 PM on 05/10/23 the Nursing Home Administrator stated, I noticed his catheter had blood in it this morning at about 8:30 am. I told the Nurse about it and she said she would let the Nurse Practitioner know about it. At 2:14 PM on 05/10/23, the director of nursing entered the following note, Spoke with (Name of Nurse) at (Name of Hospital) taking care of resident. Residents son is at bedside, son wants to keep resident as comfort measures. Residents lactic acid was 12, troponin was 53, D-dimer 58, CT evaluation, lesions on liver, fluid filled esophagus, No urine output at this time, the little bit they had in the tubing was nothing but blood. They are giving morphine for comfort. A nurses note dated 05/10/23 at 2:17 PM, written by LPN #126 read as follows: Resident arrived to facility via EMS (Emergency Medical Services) from (Name of Local hospital) Resident was discharged with orders to be comfort care only, resident diagnosed with septic shock, pyelonephritis, acute emphysematous cystitis. NP and MD notified. New orders to d/c maintenance medications and start end of life medications. Resident lethargic, unable to verbally respond or follow commands. Blood noted to Foley catheter tubing and BSD bag. A review of the emergency room report for Resident #105 was reviewed in the evening of 05/10/23 and the following was revealed. Resident #105 was returned to the facility with the following assessment/plan 1. Comfort Measures Only. 2. Septic Shock (life threatening condiiton caused by severe localized or system-wide infection that requires immediate medical attention). 3. Pyelonephritis (inflammation of the kideny). 4. Acute emphysematous prostatis (gas collection and purulent exudates within the prostate). 5. Acute emphysematous cystitis (a potentially life threatening infection characterized by gas within the bladder wall and lumen due to gas forming bacteria). Orders: Morphine As needed for pain. The resident had a CT of the abdomen pelvis with contrast which yielded the following results: 1. Acute emphysematous cystitis, acute emphysematous prostatis and acute bilateral pyelonephritis. 2. Moderate bilateral hydroureteronephorosis. 3. Acute diffuse colitis and proctitis. 4. Abnormal low density lesion on hepatic dome could represent a hemangioma or other begnin etiology are not excluded. MR exam of the liver without and with intravenous contrast is recommended for further evaluation, which could be performed non emergently depending on clinical scenario. Further review of the record found the facility staff talked to the son about a hospice referral for this resident. The son agreed and hospice is to evaluate the resident on 05/11/23. b) Resident #110 A record review of Resident #110's medical record found she had an outside appointment on 04/13/23 and returned to the facility with an order from that Physician for an antibiotic. While at this appointment the office obtained a urinalysis and urine culture. The script was for Cipro 500 mg bid (twice a day) x (times) 10 days d/t (due to) bacteria found in urine. Awaiting urine culture. When Resident #110 returned to the facility on 4/13/23, the nurse on duty entered the following progress note: (as copied) 04/13/2023 11:04 General Late Entry: Note: Resident returned from radiology appointment with orders for Cipro 500 mg BID x 10 days d/t bacteria found in urine. Awaiting culture at this time. NP aware. RP aware. According to documentation on the Medication Administration Record (MAR) the resident did receive all twenty (20) doses of the antibiotic from 04/13/23 through 04/23/23. A urine culture was needed to confirm if there is a need for an antibiotic and if the urine bacteria is susceptible to specific antibiotics. On 05/10/23 at 5:52 PM the Director of Nursing confirmed the facility never obtained the results of the urine culture to confirm if Resident #110 needed the antibiotic or if the resident was on the correct antibiotic for the infection. .

. Based on observation, record review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #93 was hoisted in a lift in the hall way outside of his room and then transported in the lift from the hallway to his room where he was placed in his bed by the window. Mechanical lifts are transfer devices only and are not to be used as transport devices due to the risk of serious harm and/or death to residents. The state agency (SA) determined this to be an immediate jeopardy (IJ) which placed Resident #93 at risk for serious harm and/or death. The facility was notified of the IJ at 3:41 pm on 02/08/22. The facility submitted a Plan of Correction (POC) at 5:24 pm on 02/08/22 at which time it was accepted by the SA. The plan of Correction read as follows: The Registered Nurse re educated Nurse Aide #36 and #98 on the appropriate use of the total lift with return demonstration on 02/28/22 at 1445 (2:45 pm). All resident of the facility have the potential to be affected. The Registered Nurse (RN) conducted an observation round on 02/08/22 at 1656 (4:56 pm) to ensure dependent residents who require a total lift are being transferred appropriately with corrective action upon discovery. Reeducation will be provided by the Director of Nurses (DON)/designee to all nursing staff on 02/08/22 at 5:00 pm to ensure residents who are dependent for transfers using a total lift are being transferred according to manufacturer guidelines. Posttest with return demonstration completed to validate understanding. Any nursing staff not available during this time frame will be provided reeducation, including posttest and return demonstration by DON/designee upon the beginning of next shift to work. New nursing staff will be provided education, including posttest during orientation by the DON/Designee. The unit managers (UM)/designee will conduct observations starting on 02/08/22 at 11:00 pm to residents who are dependent for transfers using a total lift are being transferred appropriately and in accordance with manufactures guidelines, appropriately daily across all shifts for 2 weeks including weekends and holidays then 3 times a week for 2 weeks then randomly thereafter. Results of observation will be reported by the Unit Manager (UM)/Designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and our in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. After observation of implementation of the POC the IJ was abated on 02/09/22 at 6:00 pm at which time a deficient practice remained and the scope and severity was decreased from a J to a G. A deficient remained for Resident #55 who sustained a hip fracture when she rolled from bed during Activities of Daily Living (ADL) care. The residents care plan did not direct the Nurse Aide (NA) to have two (2) staff members present during bed mobility therefore when the resident rolled away from the NA she rolled unto the floor fracturing her hip. This failed practice resulted in actual harm for Resident #55. Resident #93 was a random opportunity for discovery. For Resident #55 this was true for one (1) of nine (9) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifiers: #93 and #55. Facility Census: 118. Findings included: A) Resident #93 Resident #93 was observed laying on a shower bed which was parked in the hallway outside of his room at 11:06 am on 02/08/22. Nurse Aide (NA) # 36 (who was wearing a name badge indicating she was a new employee) and NA #98 was observed approaching with a full body lift. They proceeded to lift Resident #93 in the lift while still in the hall way. Once he was hoisted above the shower bed in the lift they pushed the shower bed out of the way and proceeded to push the lift with Resident #93 still hoisted in the air into his room to place him in the bed which was placed on the far side of the room. An interview with NA #36 at 11:18 am confirmed she was the NA assigned to Resident #93. She agreed she and NA #98 had transferred Resident #93 from the shower bed to his bed. When asked why they hoisted Resident #93 in the lift while he was still in the hallway she replied, Its really a tight fit to get the shower bed into his room. So we put him in the lift and pushed him in his room while in the lift. She proceeded to say, Is this a FUBAR (Fucked Up Beyond all recognition). What is this going to fall under a dignity issue. An interview with NA #23 at 11:13 am on 02/08/22, revealed when she showers Resident #93 she places the shower bed at the foot of his bed and transfers him from surface to surface with both beds in the room. She stated, I don't have any trouble getting the shower bed in his room. An interview with the Center Nurse Executive (CNE) on 02/08/22 at 11:22 am confirmed the lift should not be used to transport a resident. It is to be used to move the resident from one surface to another surface. She indicated the shower bed should have been placed in the resident's room and the resident should not have been hoisted in the lift while in the hall way. The CNE was then asked to provide the competency check list which showed NA #36 and #98 possessed the competency to operate lifts successfully. On 02/08/22 at 1:35 pm the CNE stated they do not have any evidence to show NA #36 and NA #98 was evaluated for competency to operate the lift. At 3:00 pm on 02/08/22 all competencies for all NA's was provided, and the following information was found. There was a total of 42 NAs currently working at the facility there were 4 NA's who had their competencies evaluated in the last year those included NA #12 who was evaluated on 05/25/21, NA #35 who was evaluated on 04/20/21, NA #72 who was evaluated on 05/25/21, and NA #119 who was evaluated on 05/19/21. There were seven (7) other NAs who were evaluated on the following dates: --NA #44 evaluated on 08/11/20. -- NA # 23 evaluated on 08/19/20 -- NA #19 evaluated on 08/13/20 -- NA #84 evaluated on 08/11/20 -- NA #65 evaluated on 08/19/20 -- NA #98 evaluated on 08/19/20 -- NA #122 evaluated on 08/13/20. The competencies should be completed yearly. The following NA's had no competency evaluations related to lifts at all NA #42, #33, #15, #46, #9, #39, #7, #24, #22, #4, #20, #79, #78, #60, #75, #83, #85, #86, #52, #68, #50, #49, #103, #118, and #95. At 2:13 pm on 02/08/22 the CNE provided a list of residents who require a total lift for transfers. There were a total of 54 residents who required the use of a total lift residing in the facility. A review of Resident #93's medical record found he has a required the use of a total lift since 05/10/17 according to his lift assessments. NA #36 has been an employee at this facility since 05/17/21. She was wearing a new employee badge with no name on it because she forgot her name badge at home. She has been an employee with the corporation who owns this facility since 07/29/18. A review of the Invacare Reliant 450 and 600 Battery Powered Patient Lift manual found the following information: On Page 5 of the manual the following was contained: 1.1 Symbols Warnings Signal words are used in this manual and apply to hazards or unsafe practices which could result in personal injury or property damage. See the information below for definitions of the signal words. DANGER: Danger Indicates an imminently hazardous situation which, if not avoided, will result in in death or serious injury. Warning: Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. Caution: Caution Indicates a potentially hazardous situation which, if not avoided, may result in property damage or minor injury or both . On Page 7 of the manual the following was contained: Warning: The Invacare patient lift is NOT a transport device. It is intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair). Review of the facility's policy titled, Safe Resident Handling/Transfer Equipment. the following was found, . Due to the variety of lifts used in centers, manufacturers's instructions will be used. If manufactures' instructions are not available in the center, Contact Risk Management for assistance. b) Resident #55 A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information: Root Cause/Conclusion: CNA (Nurse Aide) at bedside had asked resident, who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side underestimated the edge of the bed, and fell on right side of the bed onto the floor. Further review of Resident #55's medical record on 02/07/22 found the following Minimum Data Sets (MDS) with the Assessment Reference Dates (ARDs) of 03/23/21, 04/01/21, 07/01/21 and 10/01/21. Each MDS was coded to reflect Resident #55 required extensive assist with the assistance of two (2) staff members for bed mobility. Further review of the medical record found a care plan with an initiation date of 06/06/14 and a revision date of 12/23/21. The care plan contained the following: Focus Statement: Self care deficit related to recent hospitalization with left hip fracture s/p (status post) surgical repair, new right BKA (below knee amputation), wounds, dementia with behavioral disturbance, memory loss and the need for direction and impaired balance AEB (as evidenced by) requiring physical assistance with all aspects of care and mobility. Resident has left leg prosthesis. The goal associated with this focus was: Resident will actively participate in dressing with no more than extensive assist X 1-2 daily by next review. The interventions included: Resident requires extensive to dependent assist X 1-2 with bed mobility. This intervention was added to the care plan on 06/10/14 and revised on 10/29/14. An interview with the Corporate Registered Nurse (CRN) #123 on 02/09/22 at 11:30 am confirmed the care plan was not correct. She stated, It can't be 1-2 person assist. She indicated it needed to be revised to accurately reflect Resident #55's need for a two (2) person assist for bed mobility. She agreed the MDS assessments indicate Resident #55 has been an extensive assist of two (2) staff members since 03/23/21. She stated, We can't blame the Nurse Aide for this because the care plan directed her to use one or two person assist. Further review of the record found a Radiology report with an examination date of 11/17/21 which indicated Resident #55 had a Fracture to the LEFT femoral neck with impaction (Hip Fracture). Femoral head appropriately positioned. Joint Space narrowing. Mild Soft tissue swelling. The report date on the Radiology report was reported to the facility 11/17/21 at 2:08 pm. Further review of the record indicated Resident #55 was sent to a local hospital where her hip was surgically repaired. By failing to ensure the care plan which guides the residents care was accurate. The NA providing care on 11/16/21 was doing so by herself when the resident required a two (2) person assist for bed mobility. As a result Resident #55 fell from bed and fractured her left hip causing her to be hospitalized for a surgical repair of the hip which is actual harm. .