**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R17 was admitted to the facility on [DATE], with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, gastrostomy, and acute respiratory failure. R17's most recent Minimum Data Set (MDS) assessment, dated 12/11/23, indicated R17's Brief Interview for Mental Status (BIMS) scored a 13. A score of 13 indicates that the resident is cognitively intact. The MDS assessment identified R17 required extensive assistance of one person for eating. Review of R17's medical record identified an initial speech evaluation assessment dated [DATE]. The assessment indicated that R17 is NPO-tube-feeding and presents with severe oral and pharyngeal phase dysphagia. On 02/02/24, Speech-Language Pathologist (SLP) note indicates that R17 was seen for discharge from ST services as the target goal was met for the least restrictive diet, improved quality of life, and implementation of the pleasure feeding program. SLP created pleasure feeding guidelines that included specific instructions on diet recommendations to staff, and directions for facility staff to implement which included: Total 1:1 assistance for all oral intakes, R17 must be seated upright in a chair or bed and must be alert/engaged. R17 is recommended to remain NPO tube-feeding for nutrition, hydration, and medications but is allowed to pleasure feed on pureed textures and honey-thick liquids to assist with improved quality of life. R17's care plan indicates on 02/02/24 that R17 is on a pleasure feeding program. Honey thick liquids and pureed foods, need to sit upright and have 1:1 assistance feeding with small bites on a spoon. Never leave food in front of R17 unsupervised, and never give food/liquid if sleepy at all. R17's care plan indicates on 02/05/24 that R17 requires total assistance with meals and drinks, see the Certified Nurse Assistant (CNA) plan. R17's care plan indicates on 02/07/24 do not leave any fluids within reach. 1:1 assistance with honey thick liquids is only allowed when R17 is alert and sitting upright. Physician orders dated on 02/06/24 indicate R17 is on Dysphagia I pureed pleasure feeding program and honey thicken liquids. On 02/07/24 at 7:19 AM, Surveyor observed R17's call light go on. Surveyor observed R17 coughing and calling out, I need something to drink. On 02/07/24 at 7:21 AM, Surveyor went into R17's room and observed a cup on the bedside table with a straw in it. The water inside the cup was regular thin liquids. This cup was within R17's arm reach to take and drink. On 02/07/24 at 7:42 AM, Surveyor observed CNA M and CNA N go into R17's room and turn the call light off. CNA M and CNA N exited R17's room. On 02/07/24 at 7:44 AM, Surveyor interviewed CNA J and asked if she knew if R17 was to have thin liquids in the room. CNA J stated no she does not believe R17 is supposed to have any liquids in R17's room. CNA J immediately went into R17's room removed the thin liquids and stated she would notify the Registered Nurse (RN) on duty. On 02/07/24 at 8:15 AM, Surveyor interviewed RN F and asked if she knew if R17 was to have thin liquids in the room and that Surveyor observed R17 coughing and asking for water again. RN F stated she is a 1:1 assist and supervise with food and liquids. RN F indicated she would go into R17's room right away and assess R17. On 02/07/24 at 8:20 AM, Surveyor observed RN F enter R17's room and begin vitals on R17. RN F removed the cup of thin liquids and threw the cup in the trash. On 02/07/24 at 9:22 AM, Surveyor interviewed Case Manager RN D and asked about R17's diet. Case Manager RN D indicated that recently SLP has been trying to integrate foods. R17's diet is honey-thick liquids, Dysphagia III diet. Surveyor asked Case Manager RN D if it is common practice to have thin liquids sitting on the table with a honey-thick liquid diet resident. Case Manager RN D indicated that she would have to investigate who gave R17 thin liquids because thin liquids cannot be given to R17 or be left in R17's room for any reason. Based on observation, interview and record review, the facility did not ensure a resident received adequate supervision and assistance to prevent falls and injury. This occurred for 1 of 5 residents (R) reviewed for falls, (R30). The facility did not report to oncoming staff, nor change R30's care plan to reflect the change in transfer status for R30. Staff utilized a walker to transfer R30, resulting in actual harm when R30 had a fall that resulted in a fractured femur and hip requiring surgery, and fractured rib. Thin liquids were observed in R17's room, who had a dietary order for honey-thickened liquids and not to leave R17 unattended with liquids. Findings include: Example 1: The facility policy, entitled Fall Risk Recognition and Fall Prevention Program, states: .When a fall occurs, electronic medical record documentation is completed. The documentation includes specific information related to the fall so that the investigation of the fall along with the evaluation of current and additional preventative measures can be accomplished immediately . assure that immediate interventions are in place and assure that the care plan has been updated . R30 was admitted to the facility on [DATE] with diagnoses that include in part: staphylococcal arthritis right wrist, osteomyelitis right toe, rheumatoid arthritis, diabetes, atrial fibrillation with anticoagulant use, abnormalities of gait and mobility, total left hip arthroplasty (unknown when but greater than 2019). R30's Minimum Data Set (MDS) assessment, dated 11/20/23 (before the fall), indicated that R30 had impairment to both upper extremities (UE), no impairment to both lower extremities (LE). R30 was wheelchair dependent, dependent for dressing and toileting, max assist for personal hygiene and transfers. Brief Interview for Mental Status (BIMS) = 14 indicating cognitively intact. Pain = 0 (no pain). R30's MDS assessment, dated 01/14/24 (after the fall), indicated that R30 had impairment to both UE, impairment to one side LE. R30 was wheelchair dependent, dependent for toilet and dressing lower body, max assist for dress upper body, max assist for personal hygiene. R30's transfers: roll/sit to lying - not done due to condition. Lying to sitting on side of bed - max assist. Sit to stand - R30 refused. Chair/bed to chair transfer and toilet transfer - dependent. BIMS = 10 indicating moderately impaired. Pain = 4 out of 10 pain scale. Based on R30's MDS assessments, he declined after the fall requiring more dependance on staff. R30's mental status also decreased with an increase in pain. R30's fall risk assessments completed 11/14/23 and 12/13/23 both indicated R30 was at risk for falls. Assistive devices definitions: Sara Steady - non mechanical: resident uses own strength/ability to stand. Less assistance. EZ sit to stand lift - mechanical: machine lifts the resident. More assistance. R30's Care Plan, dated 12/30/23: Falls Documentation: I had a fall on 12/30/23 out of my recliner. Watch for any bruising, swelling and pain to his back area. No mention of change in transfer status to the EZ sit to stand lift that was implemented on 12/30/23. R30's Care Plan dated 12/31/23: 12/30/23 resident fall recorded this date complete neuro checks and vitals as directed. Falls documentation: I had a fall on 12/30/23. Every shift observe for any injury related to fall, any other changes in condition. Eval if new intervention is working. Intervention: [nothing listed] Again, no mention of change in transfer status to the EZ sit to stand lift that was implemented on 12/30/23. R30's Certified Nursing Assistant (CNA) Care Plan dated 12/28/23: 1 assist front wheeled walker (right green dysem to be wrapped around right handle prior to transferring). No mention of change in transfer status to the EZ sit to stand lift that was implemented on 12/30/23. R30's CNA Care Plan dated 12/31/23 at 8:23 AM: 1 assist EZ sit to stand lift. This was updated after the second fall that occurred on 12/31/23 at 8:00 AM. Case Manager Registered Nurses (RN) or floor nurses are able to make the changes to the care plan at the time changes are needed. R30's care plan was not updated after the first fall. R30's nursing notes stated on 12/30/23 at 6:45 PM, R30 fell when CNA used a Sara Steady to transfer R30 out of the recliner. R30 tried to stand up but he did not push enough with his legs and was sitting at the edge of the recliner. R30 slipped out of his recliner and slipped out of the chair between the chair and the nightstand by his bed. RN assessed R30 with no injuries noted. Intervention: to use a EZ sit to stand lift. R30's nursing notes stated on 12/31/23 at 8:00 AM, R30 was transferring from bed to wheelchair with CNA, gait belt and walker were being used to transfer. R30 states he was in a hurry and rushed to sit down, he didn't sit far enough back in the chair and immediately slid out into a sort of squatted position before crumpling to the floor. There was a loud popping and snap heard by both the resident and CNA, resident reports that left lower extremity pain began following the sound. R30's care plan was not updated to the EZ sit to stand lift resulting in the current care plan indicating R30's transfer with a walker. The oncoming CNA did not get report that R30 had fell the night before requiring him to be transferred with a EZ sit to stand lift. The CNA used a walker to transfer R30 and he fell resulting in injury. R30's 12/30/23 fall investigation completed by the facility's interdisciplinary team (IDT), dated 01/03/24 stated: CNA states that during her shift she used the Sara Steady with resident despite him being care planned as a 1 assist with 2-wheel walker because first attempt to stand with walker he was not very stedy so she felt it more safe to use the Sara Steady as this is what he was transferring with prior to being upgraded to 1 assist 2-wheel walker on 12/28/23. She states she then transferred him a couple times during the shift with a Sara Steady and he did well with this and had no safety concerns. At the time of the fall, she was going to get him out of the recliner to get him ready for bed. She states that she had the Sara Steady in front of him, gait belt on, grippy socks on and then he stood up a bit but not all the way, so he lowered back down to the recliner and did not sit far enough back so he started sliding down to floor. CNA states she grabbed the gait belt and lowered him gently to the floor and his feet remained on the Sara Steady platform pushing it away slightly. Root cause: Bilateral lower extremity weakness and weakness to right hand are root cause of fall. Resident had been consistently participating in Physical Therapy/Occupational Therapy (PT/OT) but making limited progress. He was just recently upgraded from Sara Steady transfer to 1 assist with 2-wheel walker on 12/28/23. This may have been too soon of an upgrade for transfers with nursing staff as CNA felt on 12/30/23 that resident could not safely transfer with walker. Resident may have been weaker with transfer due to fatigue as it was later in the day. R30's 12/31/23 fall investigation completed by the facility's IDT, dated 1/01/24, stated: Writer talked with CNA who was present at time of fall and lowered resident to floor. Writer asked CNA why resident was transferring with a walker when he was recently changed to a EZ sit to stand lift. CNA states that he was surprised to find out after the fall that resident was a EZ sit to stand lift versus a walker. CNA states that he did not hear this in report from previous shift or his nurse. Both CNA and LPN on duty day of the fall were educated on importance to ensure communication of status changes and falls are passed on shift to shift and from nurse to CNA. Root Cause: Believe incident related to not using EZ sit to stand lift as directed in new CNA care plan. Deep dive noted that computer was not updated after 12/30/23 fall until following day which means report and communication failure related to resident falling. CNA did not mean or intend to not follow care plan, as the care plan on him did show that he was transferring according to his status of a walker. The injury is not suspicious. Care plan not followed. Potential care giver misconduct: does not meet definition of care giver misconduct. No intent, abuse or neglect was noted. IDT reviewed fall and noted that staff made human error of failure to communicate. R30 was sent to the emergency room and admitted to the hospital to have Open Reduction and Internal Fixation (ORIF) surgery for a femur fracture of left femur and fracture left hip. ORIF is surgery to fix a broken bone. Open reduction means that the bone is moved back into the right place with surgery. Internal fixation means that hardware (such as screws, rods, or pins) is used to hold the broken bones together. R30 also had a fracture of one rib and acute posthemorrhagic anemia requiring 1 unit blood transfusion. R30's Social Worker note in November 2023 before the fall on 12/31/23, stated R30 was admitted for strengthening status post bacteremia sepsis of right wrist. He was at an assisted living facility and would like to return. He is focused on therapy and going home when able. Interviews: On 02/06/24 at 2:12 PM, Surveyor asked CNA X how she knows what the transfer status was for a resident. CNA X said she would know based on the resident's care plan. Surveyor asked CNA X if the transfer status changed for a resident overnight, how would the next CNA know. CNA X said we would give this information during shift change report. On 02/06/24 at 2:39 PM, Surveyor asked CNA Y how she knows what the transfer status was for a resident. CNA Y said she would know based on the resident's care plan. Surveyor asked CNA Y if the transfer status changed for a resident overnight, how would the next CNA know. CNA Y said we would give this information during shift change report. On 02/06/24 at 2:45 PM, Surveyor asked Licensed Practical Nurse (LPN) EE how the nurses know what the transfer status was for a resident. LPN EE said she would know based on the resident's care plan and the report sheet. Surveyor asked LPN EE if the transfer status changed for a resident overnight, how would the next nurse know. LPN EE said we would give this information during shift change report. On 2/06/23 at 2:55 PM, Surveyor asked Physical Therapy Assistant (PTA) AA what R30's transfer status was in December. PTA AA said on 12/11/23 R30's transfer status was 1 person assist EZ sit to stand lift. On 12/28/23, R30's transfer status was 1 person assist for ambulation and pivot assist with a 2-wheel walker with dysym on right hand grip. There were no other PT adjustments to the transfer status of R30 for the month of December. Surveyor asked PTA AA if staff taking care of R30 can change transfer status. PTA said they can always downgrade not upgrade. PT needs to assess to be able to upgrade the transfer status. Downgrade transfer status means the resident requires more assistance with transfer. Upgrade transfer status means the resident requires less assistance with transfer. On 02/06/24 at 3:00 PM, Surveyor asked Case Manager RN (CM) U what interventions were put into place due to R30's fall on 12/30/23. CM U said they advanced R30's transfer status to an EZ sit to stand lift because a Sara Steady was used during the fall on 12/30/23. Surveyor asked CM U who would have changed R30's care plan to indicate this change. CM U said the care plan should have been changed by the case manager or floor nurse to reflect this change and a shift-to-shift report of this change needs to be given to the nurses and CNAs. Surveyor asked CM U if the proper transfer technique was used for R30 on 12/31/23 (a 2-wheel walker with gait belt was used). RN said the CNA should have been using an EZ sit to stand lift, not a walker. On 02/06/24 at 3:40 PM, Surveyor spoke with Director of Nursing (DON) C concerning R30's falls on 12/30/23 and 12/31/23. DON C said on 12/28/23 R30 was changed to 1 assist with walker. On 12/30/23, staff was using a Sara Steady as they can increase the level of assistive device if they feel necessary. Because R30 fell using a Sara Steady, it was determined to use a EZ sit to stand lift. On 12/31/23, the CNA was following the care plan to use a walker. R30 can wax and wane and can go between using a walker or a mechanical lift. The CNA was not aware the transfer status changed after the fall the night before. The care plan was not updated until 8:23AM on 12/31/23 to the mechanical EZ lift as an intervention from the fall on 12/30/23. The CNA the night before should have reported to the oncoming CNA at shift change this resident's change in transfer status. The facility did education to the CNAs concerning communication at shift change report to notify of any change in resident status such as transfer status. The facility investigated this situation to find the CNA did not do this intentionally; he was not aware the change in transfer status for R30. Surveyor asked DON C if R30 had any diagnosis of bone disease. DON C provided R30's list of diagnoses and said R30 does not have a history of bone disease. DON C provided the education that the facility gave to the CNAs on 1/09/23, nine days after R30's fall with injury. The education included Communication: shift to shift report is essential. You must do walking rounds with your co-worker each shift to communicate changes in: care plans (transfers, Activity of Daily Living (ADL), needs, etc), appointments or planned outings, toileting needs, recent falls or other changes in conditions. On 02/06/24 at 4:40 PM, Surveyor asked LPN V if nurses can change transfer status for the residents. LPN V said nurses can change transfer equipment to require more assistance, but not change the transfer equipment to require less assistance. PT needs to assess and change the status to less assistance. CNAs cannot make the decision about using less assistive devices. They would let the nurses know how the resident was transferring and the nurse would make the decision to use more assistance for transfer. On 02/07/24 at 8:09 AM, Surveyor asked DON C if nurse education was provided for need to update the resident's care plan after an incident needing interventions placed. DON C said they did not do any education to the nurses, but to all the case managers that they need to update the care plan after the change or notify the nurse to do so. On 02/07/24 at 8:15 AM, Surveyor asked CM U how the resident care plans are updated. CM U said the floor nurses can update the care plan when filling out the fall assessment. There was a button they would click that would add new interventions to the resident's care plan. Surveyor asked CM U why the transfer status for R30 was not updated. CM U said R30 did not have the care plan updated after the first fall on 12/30/23. We found that the care plan was not updated after auditing the record. R30's care plan was updated on 12/31/23 at 8:23AM after the second fall. On 02/07/24 at 8:20 AM, Surveyor asked CNA W how R30 was before the fall compared to now. CNA W said R30 seems about the same with mood/behavior. After the fall, R30 was a little down at first, but now almost back to baseline. R30 was improving on transfer as R30 was a hoyer lift (maximum transfer) at first when he returned after the fall. Now, he was EZ lift stand with 2 CNAs. R30 was not back to the walker transfer status. He still needs work to get to that point. On 02/07/24 at 9:30 AM, Surveyor spoke with R30's Power of Attorney (POA) BB who said R30 has had cognitive decline even a little before the fall. R30 was on heavy pain meds after the fall and was more out of it. Now, R30 was getting better with pain and pain medications have decreased. POA BB said R30 was coming back now a little but can see the decline in energy and mood since the fall. R30 was at an assisted living facility but sent here to do strengthening and medical care for an infected wrist. POA BB said they were unsure where R30 will go after recovering from the fall with a broken hip/leg. We have conference on 02/21/24 to discuss this. It was still up in the air where R30 will go to. On 02/07/24 at 10:00 AM, Surveyor asked R30's Medical Doctor (MD) Z what they would have expected to happen for the transfer status of R30 on 12/31/23. MD Z said she would have expected shift change report to include the change in transfer status of R30 and the CNA to have used the mechanical lift that was the intervention after the first fall. Surveyor asked MD Z how R30's level of activity/mood changed since the fall. MD Z said upon admit initially R30 was not able to walk on his own and cognitively he was not to the level of being able to make his own decisions. Prior to the fall his cognition was improving and could vary day to day. R30 was originally planning to go back to assisted living but he was not at discharge point before the fall. The fracture did not change the discharge plan if anything R30's cognition will change the plan. The change in cognition could have changed related to having surgery, unable to say for certain. R30's diagnosis with diabetes, foot wound, balance, neuropathy created a huge risk for falls. R30 had poor insight to what he needed to do, needing queuing. The fracture was healing well and R30 was not losing weight. MD Z said she cannot say the fall was the cause of the decline. R30 was probably back to the mid level of baseline. Surveyor asked MD Z about anticoagulant use with a femur fracture if that can cause the need for a blood transfusion. MD Z said it can be a typical response. R30 did not have any issues with low blood levels before the fall and no concerns with it now.