**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, policy review and review of facility documents, the facility failed to ensure two (Residents (R)1 and R3), of ten sampled residents were free of accidents. Specifically, R1 fell to the floor while unsupervised and sustained a fracture requiring surgical intervention, and R3 fell to the floor while unsupervised which resulted in a head laceration requiring medical treatment. In addition, both R1 and R3 were not provided individual interventions on their care plans to prevent the falls from occurring. The failure to provide adequate supervision and individual fall risk interventions placed R1 and R3 at risk for falls with injury. Findings include: Review of the facility's policy titled Falls with a revision date 05/17/23 indicated Residents have the right to be mobile and free from physical restraints with minimal risk for injury. The goal is to reduce falls as much as possible, and to reduce the risk of serious injury . all residents will be assessed for their fall risk upon admission . risk factors will be identified . interdisciplinary interventions will be identified and included on the plan of care. 1. Review of R1's Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab indicated R1 was admitted on [DATE] with diagnoses including subcortical compression of the brain, generalized muscle weakness with lack of coordination, left-side paralysis, and cognitive communication deficit. Hospital records provided to the facility during R1's hospitalization post stroke indicate in the physical therapy details: (Name of R1) .she requires max assist x (times) 2 and verbal cues for task sequencing, but able to assist with her right upper extremity. Remaining deficits include impaired cognition, decreased insight into current deficits, impaired safety awareness, impulsivity, impaired judgement, pain, weakness, impaired balance, and limited activity tolerance . The admission Fall Risk Data Collection Tool dated 06/20/23 located in the EMR under the Reports tab, indicated R1 was High Risk for falls due to intermittent confusion, confined to chair, totally unable to ambulate without assist, history of falls, and wheelchair with footrests needed during transport. The fall risk data collection tool also indicates R1 has cardiovascular issues - cardiac dysrhythmia, Neuromuscular/functional issues - loss of limb movement, decline in functional, incontinence, hypotension, CVA (cerebral vascular accident), hemiplegia/hemiparesis, parkinson's, seizure disorder, syncope, unsteady gait, Psychiatric or cognitive - delirium, decline in cognitive skills, manic depression, alzheimer's disease, other dementia, Orthopedic - joint pain, fracture of hip, missing limb, osteoporosis - contributing factors scoring - 4 or more present. The assessment section for indicate care plan action taken indicates continue plan of care: description notes indicate: Staff aware of resident being high fall risk. Maintain low bed at all times. fall mat in place with LAL (low air loss) mattress/bolsters. PRN (as needed) Lorazepam for restlessness and agitation - hospice patient. The baseline admission Care Plan dated 06/21/23 located in the EMR under the RAI tab indicated, Resident is at risk for falling related to decrease in mobility secondary to left sided weakness and an initial fall score at high risk . client will remain free from injury. Approaches included, encourage resident to assume a standing position slowly, keep call light in reach at all times, give verbal reminders not to ambulate/transfer without assistance, keep personal items within reach and obtain therapy consult for strength training, positioning, transfer training, gait training, and mobility devices. Based on the information gathered by the facility upon admission and the fall risk assessment, the baseline Care Plan included approaches that did not meet the cognitive and physical needs of R1's fall risk. R1 could not stand, could not use a call light, and could not cognitively be reminded to ask for assistance due to diagnoses listed on admission. (refer to F655) Surveyor noted the baseline care plan did not include the interventions of maintain low bed at all times, fall mat in place with LAL (low air loss) mattress/bolsters. PRN (as needed) Lorazepam for restlessness and agitation - hospice patient. or include interventions for R1's restlessness/agitation. Additionally, the baseline care plan did not address the deficit unawareness or impulsivity that was included in the hospital discharge paperwork regarding R1 as a possible risk factor for R1 falling. R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/25/23, located in the EMR under the RAI tab, indicated R1's Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated R1's cognition was moderately impaired and was dependent on staff for bed mobility and transfer. R1 was unable to ambulate due to left-side paralysis. R1 was transferred with a Hoyer lift. During an interview on 10/17/23 at 10:17 AM, R1's attending physician stated The resident (referring to R1) fell at home, was high risk for falls on admission due to cognitive loss and general weakness due to the brain injury. The resident was not aware that independent ambulation is not possible. R1's record indicates on 6/23/23 R1 experienced a change in condition that included R1's oxygen levels to drop to 86% with a low grade temperature. R1 was provided with oxygen at 4L (liters) via a nasal cannula. Orders were obtained for a stat chest x-ray, blood cultures, CBC (complete blood count), and BMP (basic metabolic panel) labs. Lung sounds were clear at this time. Oxygen levels improved and the oxygen was lowered to 2L via nasal cannula and a rapid covid test was negative. It is noted the facility activated R1's power of attorney for healthcare on this date. R1 was placed in isolation at this time. Surveyor noted there was no review of R1's need for supervision or assessment for possible changes to fall risk with the change in condition and need for isolation. The Event Report provided by the Administrator dated 06/23/23 at 3:30 PM indicated R1 had an unwitnessed fall from a recliner while in the bedroom. According to the Event Report R1 was found face down on the floor with a bump on the head and complained of left hip pain. During an interview on 10/17/23 at 11:30 AM, Registered Nurse (RN) 3 stated R1 was unable to communicate because of confusion and cognitive loss. RN3 stated that prior to the fall, nursing staff used a mechanical lift for transfers and R1 was unable to walk due to left-side paralysis. During an interview on 10/18/23 at 8:00 AM, the Director of Nursing (DON) stated, The fall (referring to the event report dated 06/23/23) was unwitnessed. The resident was in the bedroom in a recliner and was found face down on the floor. I'm not sure how it happened, the first X-ray taken of the hip showed no fracture but a few days later she had swelling and bruising above the left knee and a second X-ray showed a fracture. We try to keep residents who are high risk for falls in the common area where there is more supervision especially during staffing challenges. Resident Progress Notes dated 06/23/23 at 05:10 PM located in the EMR under Resident tab indicated, Was called to resident's room at 1520 and upon arrival to room, nurse manager, RN on unit and LPN (licensed Practical Nurse) assisting resident to transfer resident off the floor to bed with the use of a Hoyer lift. Per staff resident was found face down. Noted about a quarter size bump/bruise to left forehead and faint bruise to right forehead. Resident is alert and denies pain. No c/o (complaint of) headache, no nausea/vomiting. No other injury noted. Ice pack applied. Neuro check is within normal. Has left sided weakness d/t hx (history) of CVA (cerebral vascular accident) and recent stroke. Bed in low position, and floor mat next to bed. Call light clip to chest and reminded to call for assistance as needed. Spoke with (name of) NP (nurse Practitioner) updated on the event with head injury, no new order. Spoke with POAHC (power of attorney for health care), stated she knew it that she would fall because resident is forgetful and tries to get up and walk unassisted. Resident just had a recent fall before she went to the hospital. Informed her that we need to keep resident then in the common area d/t history of fall and impulsiveness. She was ok to keep resident in place that needed supervision. The Summary of Incident dated 06/27/23 provided by the Administrator, indicated on 06/27/23 the resident complained of left knee pain. Upon assessment the knee was observed to be swollen with bruising on the inner aspect. An X-ray was ordered and completed on 06/28/23 and showed an acute distal femoral fracture. According to the Summary of Incident the resident was transferred to the hospital. The summary indicated Based on the findings of the investigation, it was determined that the injury to the left knee is consistent with resident falling on 06/23/23, R1 was transferred to the hospital on [DATE]. Review of a hospital Patient Report dated 06/28/23 located in the EMR under the reports tab indicated Left Knee . Acute distal femoral fracture. Orthopedic evaluation is recommended. Progress Notes dated 07/05/23 at 5:33 PM located in the EMR under the RAI tab indicated, Client re-admitted to facility from hospital via ambulance. Client s/p [status post] ORIF [Open Reduction Internal Fixation]. According to the Treatment Administration Record (TAR) dated 07/05/23 located in the EMR under the Orders tab, R1 was re-admitted to the facility following orthopedic surgery and had staples to the left hip/knee [thigh]. During an interview on 10/19/23 at 8:30 AM the DON stated, The admission care plan did not include the use of Dycem, a Broda chair in the reclining position or increased supervision in the common area because these approaches were not added until 6/26/23, after R1's fall on 06/23/23. 2. R3's Face Sheet located in the EMR under Resident discharged chart, indicated an initial admission on [DATE] with a re-admission date of 07/11/23 and diagnoses included dementia and polyosteoarthritis. R3's quarterly MDS with an ARD of 04/28/23 found in the EMR under the RAI indicated a BIMS score of 99 which indicated R3 was unable to be interviewed, had memory loss with moderately impaired cognitive skills. R3 was unable to walk and was totally dependent on staff for dressing, eating, toilet use, personal hygiene, and bathing. R3 used a wheelchair for mobility with assistance from staff. Review of R3's Care Plan dated 04/17/23 located in the EMR under the RAI tab indicated, Potential for injury safety related to history of falls, immobility, weakness, and diagnosis of corticobasal degeneration . resident will be free of injuries due to falls, target date 11/30/23. Approaches included: 4/17/23 bed in lowest position when not completing cares. 1/23/22: unwitnessed fall from Broda chair - staff to monitor resident's position in Broda chair. Staff should lower the height of Broda chair after meals . 2/3/15 Mat to be placed on the floor next to bed when resident is in bed. 9/17/14: Dicem (sic) placed on recliner/Broda chair seat. Staff to keep soft touch call light in lap or clipped to arm rest of recliner/Broda chair. Review of a Fall Risk Data Collection Tool dated 05/10/23 located in the EMR under the Report tab indicated R3 was high risk for falls due to mental status, visual impairment, transfer dependency, orthopedic condition, arthritis pain and neuromuscular status. Review of a Falls Event dated 07/09/23 at 2:50 PM provided by the facility indicated R3 was found in the room on the floor next to a Broda chair -head toward the bathroom door, prone with right side of head on floor, right arm under her torso. Prior to the fall R3 was up in Broda chair watching TV, was last observed at 1410 and last toileted at 1200. R3 exhibited pain in the head with laceration. The Falls Event indicated Were proper precautions taken prior to the fall? Yes or no. The No box was checked and indicated Sitting upright in Broda chair. Safety measures already in place included Dicem (sic), low bed, mat on floor next to bed, and other- recline Broda chair. Interventions to prevent recurrence include: staff to keep resident in common area when up in Broda chair. Surveyor noted the falls event does not include review of whether other relevant interventions were in place including if there was Dycem in the seat of the chair to prevent slipping and whether R3 had the call light in place as care planned or had activated it prior to the fall. Review of Resident Progress Notes dated 07/09/23 at 3:31 PM located in the EMR under the Resident tab indicated Was called to resident's room and observed resident lying on the floor with unit nurse applying pressure to the right side of forehead laceration. Also noted right cheekbone is slightly swollen. Able to control bleeding and dressing applied . order received to send resident to ER [Emergency Room] for evaluation. Review of Resident Progress Notes dated 07/11/23 at 06:43 PM located in the EMR under the Report tab indicated Client re-admitted from hospital via ambulance . discharge diagnosis unwitnessed fall with forehead laceration . resident has 4 or 5 sutures to right side of forehead . sutures to be removed in 7-10 days. During an interview on 10/18/23 at 2:50 PM the DON stated the Fall Event dated 07/09/23 was discussed at the morning meeting the day after the fall. The box that was checked No was discussed regarding the Broda chair not being reclined before the resident fell. The DON stated, I could not verify if the chair was reclined as interviews with staff some said yes and some said no. The DON agreed that the reclining Broda chair was an intervention that was indicated as a proper precaution not in place on the Falls Event dated 07/09/23. According to all of the operating manuals for the different Broda seating models under hazards: 2.5 Hazards 2.5.1 Position of Chair - Danger of Falling After a resident is transferred into a chair, assess the amount of tilt required. We recommend that the chair's seat be tilted sufficiently to help prevent the resident from sliding or falling forward off the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. 2.5.2 Position of Seat Tilt - Danger of Tipping We recommend that the chair's seat be tilted sufficiently to prevent an agitated resident from tipping the chair forward or backward, or from slumping and sliding in the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. Always ensure that the resident is properly positioned before operating the seat tilt. 2.5.3 Location of Chair - Danger of Tipping or Falling Objects We recommend that when a resident has been moved to their destination, the chair is placed where the resident cannot reach handrails or other objects, fixed or movable. This is to prevent the resident from pulling the chair over or pulling themselves off the seating surface and to prevent the resident from pulling movable objects onto the chair and themselves. We recommend that the chair be used in a supervised area to prevent untrained residents, caregivers, or third parties from unauthorized operation, movement, or unsafe actions such as sitting or leaning on the reclined back, elevated footrest, or the armrests. These actions, if not prevented, put the chair at risk of tipping or damage to the chair. We recommend that a chair only be located on a level surface to minimize the risk of tipping over. 2.5.4 Total Lock Wheel Brakes - Danger of Falling The special casters found on the BRODA chair have total lock brakes which prevent the wheels from turning and swiveling. The brakes must always be applied when: 1) the chair is not in use; 2) a resident is being transferred (moved) into or out of the chair. It is important to note that if the wheel brakes are applied while the resident is in the chair, that the caregiver does not leave the resident unattended, especially those residents who have the capability or tendency to move the chair and/or those who may be agitated. This could cause harm to the resident if they attempt to move the chair while the wheel brakes are applied. Note that removing and attaching the footrest may be easier for the caregiver with the brakes applied Failure to follow these instructions will unnecessarily increase the risk of serious falls by residents, caregivers, or third parties caused by the chair unintentionally moving. 2.5.5 Re-Positioning of Resident - Danger of Clamping BRODA Pedal Chairs offer the benefits of seat tilt and height adjustable arms. During the movement of any of these functions, the following safety measures must be observed: