**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R4 was admitted on [DATE] and current diagnoses included, in part, type 2 diabetes mellitus with diabetic nephropathy, epilepsy, age-related osteoporosis, peripheral vascular disease, congestive heart failure, malignant neuroendocrine tumors, malignant neoplasm of liver, chronic kidney disease stage 3b and depression. Review of MDS dated [DATE] an annual assessment documented Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R4 is cognitively intact. R4 has no impairments to upper or lower extremities, R4 requires staff to setup assistance for upper and lower dressing, and personal hygiene. R4 requires maximum staff assistance to apply footwear. The MDS documented R4 having 1 fall with no injury, 1 fall with injury not major and 2 or more with major injury. Review of R4's care plan documented in part: R4 is High, risk for falls r/t Confusion , Gait/balance problems, Incontinence, Vision/hearing problems R4 does not always recall to lock her brakes which has resulted in falls. R4 requires re-educated for using call light for staff assist during transfers. 1/30/25 Lost balance while getting into lounge chair. Date Initiated: 04/08/2024 Revision on: 01/30/2025 Approaches in part: -12/20/23 Educate R4 on locking brakes before transfers. Date Initiated: 07/15/2024 Revision on: 07/16/2024 -12/20/23 Educate R4 on locking w/c brakes prior to transferring to the toilet. Date Initiated: 04/08/2024 Revision on: 07/16/2024 -1/26/24 Staff to check w/c brakes are on when R4 is sitting in recliner Date Initiated: 07/15/2024 Revision on: 07/15/2024 -1/27/24 Gripper socks on resident feet to help prevent her from slipping Date Initiated: 07/15/2024 Revision on: 01/31/2025 -1/30/25 Reeducated on necessity of wearing gripper socks. Date Initiated: 01/31/2025 -1/31/24 Educated on safe transfers, R4 was able to teach back safe transfers Date Initiated: 07/15/2024 Revision on: 07/16/2024 -1/31/24 OT reeducated R4 that her wheelchair brakes are working, R4 provided teach back. Date Initiated: 07/15/2024 Revision on: 07/16/2024 -2/5/24 Offer R4 to rest in recliner at approx. 2100 to prevent her from falling asleep in wheelchair causing her to fall to floor Date Initiated: 07/15/2024 Revision on: 07/15/2024 -3/22/24 PT to eval and treat due to recent falling. Date Initiated: 07/15/2024 Revision on: 07/16/2024 -4/18/24 Staff to check on R4 at start of NOC shift to assist with getting R4 into recliner safely. Date Initiated: 07/15/2024 Revision on: 07/15/2024 -4/6/24 Check brakes for proper functioning when locking. Date Initiated: 07/15/2024 -4/7/24 Brake extensions added to wheelchair brakes. Date Initiated: 07/15/2024 Revision on: 07/16/2024 -6/30/24 Dycem in recliner and wheelchair. Date Initiated: 07/15/2024 -6/4/24 Staff to check on R4 hourly when in recliner to assure w/c is locked and in proper placement next to recliner Date Initiated: 07/15/2024 Revision on: 07/15/2024 -9/10/24 Encourage R4 to leave door open for better visualization when not on isolation precautions. Date Initiated: 02/05/2025 -Be sure R4's call light is within reach and encourage her to use it for assistance as needed. R4 needs prompt response to all requests for assistance. 1/30/25 Call light placed closer to resident for calling for staff assistance. Date Initiated: 07/16/2024 Revision on: 01/30/2025 -Make sure R4 has both socks on prior to transfers and to call for assistance if she notices that she is missing her sock. Date Initiated: 09/25/2024 -Non-Skid strips applied to floor in front of recliner to aid in prevention of fall. Date Initiated: 07/16/2024 Revision on: 07/16/2024 On 01/30/25, a post fall investigation fall risk assessment score of 75 meaning at high risk for falls. Review of R4's fall investigations: On 01/26/24 at 1:15 a.m., R4 fell in room was found sitting on the floor with no injuries. R4 stated transferring from recliner to wheelchair and missed the wheelchair and sat on the floor. R4 was barefoot and her wheelchair brakes were not locked. Care plan was updated for staff to ensure wheelchair brakes are on when resident is sitting in recliner. On 01/27/24 at 10:36 p.m., R4 fell in room from wheelchair with no injuries. R4 took socks off and wheelchair was not locked. The care plan intervention from 1/26/24 was not followed. On 01/31/24 at 12:05 a.m., R4 fell in room and found sitting on the floor in front of her recliner with no injuries. Wheelchair in front of resident and brakes were on. R4 stated she was just trying to transfer from recliner to wheelchair but she stood up and slid out and she sat on the floor. R4 was wearing grippy socks at the time. R4 then demonstrated how she transfers from recliner to wheelchair on her own and did correctly. Care plan was updated on 01/31/24 to include educated on safe transfers. The facility did not determine a root cause of the fall as to why R4 was self transferring. On 03/21/24 at 9:48 p.m., R4 fell in room sitting upright on the floor next to her recliner with no injuries. On 03/22/24, physical therapy to evaluate and treat due to recent falling. The facility did not determine a root cause of the fall, no new interventions were initiated and no documented therapy recommendations. On 04/6/24 at 9:40 p.m., R4 fell in room found between her recliner and her wheelchair with no injuries. Wheelchair right brake was locked and left brake partially locked. Facility determined wheelchair brakes were not fully engaged. Interventions to check brakes for proper functioning when locking. On 04/7/24 at 10:25 p.m., R4 fell in room while transferring from recliner to bathroom. R4 hit the back of her head. R4 had one sock on right foot and no sock on the left and wheelchair was not locked and brakes were not tight enough. Brake extensions added to wheelchair brakes. This fall has the same issue with functioning of wheelchair brakes. On 04/18/24 at 11:05 p.m., R4 fell in room while transferring from recliner to wheelchair with no injuries R4 was wearing gripper socks and wheelchair brakes were locked. Care plan update Staff to check on resident at start of NOC shift to assist with getting resident into recliner safely. The facility did not determine the root cause of the fall. On 06/4/24 at 12:10 a.m., R4 fell in room out of recliner and wheelchair was not locked. R4 had no injuries. Care plan was updated with Staff to check on R4 hourly when in recliner to assure wheelchair is locked and in proper placement next to recliner. Care plan intervention of locking w/c brakes was not followed. On 06/30/24 at 11:25 p.m., R4 fell in room in front of her recliner with no injuries. R4 was not wearing nonslip footwear. R4 was wearing one regular sock on right foot and left foot bare as resident had removed her leg wrap and socks prior to self-transfer. R4 did not use walker for transfer. R4 stated that she did try to grab onto her wheelchair, but the brakes were not on the wheelchair and it moved with her as she slid to the floor. Care plan updated to have dycem non-slip into seat of resident recliner chair and wheelchair to help prevent resident from slipping off of surfaces. The facility did not investigate to determine if staff followed the care plan of hourly checks of wheelchair placement and locked, and proper footwear. On 09/10/24 at 9:15 p.m., R4 fell in room was found lying next to recliner with no injuries. A small bump to the top of R4's head. Intervention was to keep track of hours of sleep. The facility did not identify a root cause of the fall and did not evaluate hours of sleep to determine further interventions. On 09/23/24 at 8:45 p.m., R4 fell in room and was found lying in front of recliner with no injuries. The root cause was R4 not wearing shoes or socks at the time of fall, wheelchair brakes were locked and R4 uses many blankets when sitting in her recliner. Therapy assessed and R4 is independent to transfer. Resident education on importance of making sure that she had both socks on prior to transfers and to call for assistance. On 01/30/25 at 10:00 p.m., R4 fell in room was found sitting in front of recliner with no injuries. Facility's intervention was to re-educate R4 on the importance of wearing her gripper socks for safety when transferring. The facility did not identify a root cause of the fall and did not assess the repeated intervention of wearing socks to be appropriate. Surveyor's review of R4's falls identified the facility did not complete a full investigation of when staff last observed the resident, determine if staff followed plan of care, determine root cause of the fall, review for patterns/trends, and re-assess the plan of care. On 02/05/25 at 2:15 PM, Surveyor interviewed Director of Nursing (DON) B about the fall root cause. The consulting company came in to assist in September and found where to document in risk management. The root cause is noted at the bottom of the incident report. Surveyor reviewed with DON B, R4's incident reports from 09/10/24 documented on 09/16/24 Nursing to follow up on the bump on top of her head. Resident denied pain over the weekend. Nursing is also keeping track of the hours of sleep that she is getting on every shift since resident has been known to fall asleep frequently while in wheelchair. Resident has previously refused sleep studies. Surveyor asked when you collected the data of hours of sleep did you assess the data and what was the response and any changes. DON B said she will get that information. On 02/06/25 at 8:50 AM, Surveyor interviewed Assistant Director of Nursing (ADON) D about fall investigations with root cause and interventions. ADON D indicated the root cause is talked about in morning meetings on every fall and they go over the interventions and will update the care plan. The care plan should be updated when staff put interventions in place and this has been missed. The consulting company is in the facility reviewing and putting things in place and showing where to document in risk management. When a fall occurs, the nurse will put the note into risk management with the intervention. The nurse will call the manager on call or DON B and will discuss what intervention to put into place and then the team will review the fall in the morning. On 02/06/25 at 12: 25 p.m., Surveyor interviewed DON B about the fall investigation, root cause, and intervention of R4. Surveyor reviewed with DON B the fall investigations are not complete and did not determine if staff are following care plan, root cause of falls, assessing interventions. DON B indicated the facility does have a plan going forward for documenting and assessing the falls. Based on interview and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 2 of 4 residents (R29, R4) reviewed for accidents. The facility did not complete a thorough investigation of falls for root cause and implement interventions to prevent further falls. R29 had a fall on 12/19/24 that resulted in a left femur fracture and surgical repair. This example is cited at actual harm. The facility did not complete a thorough investigation of falls to determine staff following plan of care, root cause, monitor for trends, and re-assess interventions to prevent further accidents for R4. This is evidenced by: The facility Fall Evaluation, Intervention, and Reporting policy updated/reviewed 10/10/24 states: All residents will be evaluated for fall risk within 24 hours of admission, with ongoing monitoring as needed, and per CMS guidelines. Residents who sustain a fall will be evaluated at time of event and the following 72 hours. Procedure: A. All residents will be evaluated for fall risk upon admission. B. Care plan to be developed with appropriate approach and interventions for all admits. C. A fall evaluation will be completed quarterly by the MDS coordinator/Nurse, with resident falls and as needed. D. Care plans are reviewed to assure appropriate interventions are in place quarterly, with every fall, and as needed. a. In the event of a resident fall: 5. Update RN/DON or designee to discuss and implement intervention. 6. Complete fall packet and update care plan. 8. Complete detailed progress note to include time of fall, location of fall, root cause of fall, residents range of motion, pain, injury, how you assisted off of floor, RN notification, MD notification, POA notification, and new intervention. 10. Open and complete fall evaluation and pain evaluation. 11. All falls will have an interdisciplinary team (IDT) root cause analysis to assure comprehensive care plan is appropriate and is up-to-date. Example 1 R29 was admitted to the facility on [DATE] with pertinent diagnoses of dementia, polyosteoarthritis, and macular degeneration. R29's most recent Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment, is usually understood by others, and usually understands others. R29 was noted to have lower range of motion impairment on one side, used assistive devices of a walker and wheelchair, and was a dependent assist with walking 10 feet. R29 had 2 or more falls since admission with no injury and no falls with minor or major injury. R29 had a recent surgery repair of fractures of the hip. R29's care plan dated 11/10/24 included the following: PROBLEM: Activity of daily living (ADL) self-care performance deficit related to dementia. GOAL: R29 will maintain current level of function in cares through review date (01/21/25). INTERVENTIONS: Assist of 1 and front wheel walker for stand pivot transfer and ambulation, use cues for each step of turning sequence, and check on resident frequently. PROBLEM: R29 has had an actual fall with minor injury due to unsteady gait. GOAL: R29 will resume usual activities without further incident through review date. INTERVENTIONS: - 02/12/24: Offer toileting approx. q2hr (every 2 hours). - 04/29/24: Keep bed at mid to low height as R29 likes to sit on the edge of it. - 05/11/24: Wear gripper socks to bed at night to prevent slipping when getting up. - 08/18/24: Educate resident to ensure that she can feel the bed on the back of her legs prior to sitting. - 08/29/24: PM (evening)- Non-skid strips added to floor by bed where R29 stands to get out of bed. - 08/29/24: AM (morning)- Signage hung on wall to remind staff to make sure R29 has gripper socks on, as R29 sometimes dresses herself and does not remember to put on gripper socks. - 09/4/24: Use NH (nursing home) gripper socks at all times when in bed as they have better grip than one resident had on. - 09/9/24: Discuss with family potential of moving resident's room closer to staff for more frequent visualization. (Family declines change of room as they feel it would increase confusion and it is further for her to walk to the dining room. - 10/1/24: Staff to ensure that R29's walker is next to her bed when resident is in bed. - 10/2/2024: Hourly Checks initiated. - Fall on 10/13/24: Sleep study to start at midnight tonight (10/14) so staff can schedule NOC (night) toileting. - 10/24/24: Re-educate staff on new toileting schedule. - 12/28/24: Leave bathroom door cracked and light now at nighttime so resident can locate bathroom easily. - Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. - Sleep study initiated to establish toileting program. - Staff to check on R29 hourly and document. Surveyor reviewed R29's falls documentation and noted the following: The facility utilized a falls documentation system that included incident location, incident description, immediate action taken, injuries, pain, level of consciousness, predisposing environmental factors, physiological factors, situation factors, witness statements, and notifications. R29's falls are documented as follows in part . 09/19/24 at 11:12 PM; fall without injury. MD (Medical Doctor)/POA (Power of Attorney) notified. Investigation determined poor lighting as possible cause. Of note: No intervention was put into place and care plan was not updated. 10/02/24 at 7:01 AM; fall with swelling noted on back of head; MD/POA notified and declined evaluation at hospital. No other injuries noted. Care plan updated to include hourly checks. Of note: No investigation completed to determine root cause. Surveyor was unable to verify hourly checks were completed as noted being initiated on care plan on 10/02/24 or thereafter. 10/13/24 at 5:50 AM; fall with complaint of bilateral leg pain. MD/POA notified. No other injuries noted. Sleep study ordered with plan to implement overnight toileting schedule. Of note: No investigation completed to determine root cause of fall. Care plan not updated. No documentation provided of results of sleep study. 10/24/24 at 2:00 AM; fall without injury. MD/POA notified. Care plan stated to educate staff on new toileting schedule, but no schedule noted. Of note: No investigation completed to determine root cause. No new/revised intervention implemented to prevent further falls. Care plan not updated. 10/30/24 at 2:45 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised intervention implemented to prevent further falls. Care plan was not updated. 11/24/24 at 9:49 PM; fall without injury. MD/POA notified. Determined walker and wheelchair were not in reach. Implemented every 2 hour toileting schedule. Of note: Toileting schedule was already in place on 02/12/24. No new/revised interventions implemented to prevent further falls. Care plan was not updated. 12/05/24 at 1:41 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised interventions implemented to prevent further falls. 12/10/24 at 8:31 AM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised interventions implemented to prevent further falls. 12/19/24 at 10:54 PM; fall with major injury. R29 was found on floor in dining room. Sent to ER for evaluation and found left femur fracture. admitted to hospital for surgical repair. MD/POA notified. R29's hospital record for emergency room visit, states in part . On 12/20/24 at 6:04 a.m. History of present illness: Her workup in the emergency room .remarkable for findings of left femoral neck base fracture on one view x-ray . Surgical report dated 12/21/24 states in part . Open Reduction Internal Fixation (ORIF) left hip Of note: R29 had 8 falls prior to the fall on 12/19/24 with no investigation of root cause and/or new/revised interventions to prevent falls. This resulted in R29's fall on 12/19/24 causing a femoral neck fracture. R29 returned to the facility on [DATE]. 12/27/24 at 9:47 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. Care plan updated to leave bathroom door cracked and light now at nighttime so resident can locate bathroom easily. 01/02/25 at 2:00 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised interventions implemented to prevent further falls. 01/15/25 at 5:00 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised interventions implemented to prevent further falls. On 02/06/25 at 2:21 PM, Surveyor interviewed Director of Nursing (DON) B regarding falls documentation. DON B stated that prior to the start of survey on 02/04/25, the facility did not have a procedure in place for investigating resident falls to determine root cause and implement appropriate interventions. DON B stated she recognized that not having a fall investigation process in place likely contributed to R29's repeated falls. DON B stated that a new plan of correction was being worked on and would be discussed with Quality Assurance Performance Improvement (QAPI) team to ensure falls are investigated to include root cause analysis, interventions, and follow-up for efficacy.