Rehab & Nursing Ctr Greater Pittsburgh

Review of Resident R1's clinical record nursing progress note dated 5/5/26, revealed during interdisciplinary team meeting held on 5/4/26, review of current fall on 5/2/26, interventions, and care plan completed. On 5/2/26 at approximately 3:30 p.m., staff were called to the resident's room.

The registered nurse observed resident on the floor next to her bed. A laceration was noted to the left side of forehead and a hematoma noted to the center.

Laceration was bleeding, pressure applied, vital signs stable.

Resident was noted with baseline confusion.

Resident was transferred to hospital and was admitted with a brain bleed.

Resident weighs only 143 pounds and per last MDS on 4/15/26, and is partial/mod assist with mobility rolling left to right.

Statement obtained from nurse aide who was assisting resident while in bed, resident was changed for an incontinent episode, during the change the nurse aide noticed the sheet was wet and also required changed.

The nurse aide reported he rolled her onto her right side, with her left leg over her right, and she was holding onto the bed as he had tucked the sheet under her when he went to move onto the other side of the bed the resident started to fall out of bed and he could not prevent the fall.

Review of Resident R1's Hospital After Visit Summary dated 5/8/26, revealed the resident was admitted to the hospital for a subarachnoid hemorrhage and facial laceration. It was indicated for the resident to pause taking 2.5 mg Eliquis until doctor or other care provider tells you to start again.

During a phone interview on 5/28/26, at 9:49 a.m. NA, Employee E1 stated he entered into Resident R1's room on 5/2/26, to conduct rounds and placed the resident's bed up to waist height. As NA, Employee E1 went to roll Resident R1, he didn't realize how far she was on side of bed.

The nurse aide had his hand on her, to try to make sure she didn't fall, however as he went to the corner of the bed she started to roll the opposite direction, and started falling head first and her head hit the foot of the bed.

Once she was rolled off the bed frame, we noticed blood coming from her head. NA, Employee E1 confirmed he failed to use the correct level of assistance for Resident R1's bed mobility and rolled the resident away from himself.

During an interview on 5/28/26, at 10:20 a.m. LPN, Employee E2 stated staff can check a resident's transfer status and bed mobility in their plan of care. It was indicated staff should always roll residents towards them and not away to prevent them from falling off bed. LPN, Employee E2 confirmed Resident R1 was on blood thinners at time of incident and there was a good bit of blood.

Interviews with direct care staff to include Registered Nurses (RN).

Licensed Practical Nurses (LPN), and Nurse Aides (NA), indicated that when providing care to always roll the residents toward your person.

Only this staff had received re-education on proper bed mobility and assistance.

During an interview on 5/28/26, at 10:28 a.m.

Resident R1 was observed lying in bed with a scabbed area located on the resident's left side of her head.

During an interview on 5/28/26, at 10:34 a.m.

Director of Therapy revealed Resident R1 was a moderate assist of two person at the time on the fall that occurred on 5/2/26.

The Director of Therapy confirmed therapy staff is considered direct care staff, and confirmed the therapy department has not been educated since Resident R1's incident.

Interview on 5/28/26, at 12:03 p.m. with the Nursing Home Administrator confirmed the facility failed to make certain each resident received adequate supervision and assistance for bed mobility to prevent accidents which resulted in actual harm of a head bleed for one of three residents (Resident R1). 28 Pa.

Code 201.14(a) Responsibility of Licensee.28 Pa.

Code 201.18(b)(1)(3) Management.28 Pa.

Code 201.29(a)(c) Resident Rights28 Pa.

Code 211.10(c)(d) Resident Care Policies.28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services.