Other·October 19, 2021

§483.25(d) Accidents §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who was at high risk for falls, had revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. The facility also failed to follow its policy on fall prevention for residents with recurrent falls. As a result, Resident 1 suffered a fall with major injury which consisted of a fracture to the right tibia (The larger of the two bones in the lower leg) and a fracture to the right fibula (A small bone located on the outside of the lower leg), which required hospitalization and surgery. Resident 1, a 79-year-old female, was initially admitted to the facility on 11/25/17, according to an e-mail sent by the Medical Records Director on 7/15/21 at 10:34 a.m. The facility Admission Record indicated Resident 1 had medical diagnoses including Alzheimer's Disease (A condition that causes memory loss and difficulties with thinking, problem-solving or language), Repeated Falls, and Personal History of Traumatic Fracture. Record review revealed Resident 1's MDS (Minimum Data Set-A clinical assessment), dated 1/07/21, indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition) score was 3, which indicated her cognition was severely impaired. Resident 1's MDS also indicated she required extensive assistance with bed mobility, transfers and personal hygiene. In addition, Resident 1's MDS indicated Resident 1 was not steady while walking and was only able to stabilize with staff assistance. Record review showed a Fall Risk Assessment dated 8/02/19 indicated Resident 1's fall risk score was 9, which indicated she was at low risk for falls. Record review revealed a Nursing Care Plan for prevention of falls initiated on 2/07/19 included the following interventions, "ASSIST WITH AMBULATION ...ASSIST WITH TRANSFERS ...ATTEND TO RESIDENT PROMPTLY ...BED ALARM ...CALL LIGHT WITHIN REACH ...CHAIR ALARM ...ENCOURAGE RESIDENT TO BE UP IN WHEEL-CHAIR WHEN EXHIBITING RESTLESSNESS." First Fall: Record review revealed an Incident Note dated 8/27/19 at 10:56 p.m., indicated, "Resident had a witnessed fall by her bed this shift. Witness stated she tripped on foot of bedside table. Scratch noted on right arm." According to an e-mail sent by the Director of Nursing (DON) on 7/14/21 at 5:24 p.m., the Nursing Care Plan for falls was not updated after the fall on 8/27/19 because the resident evacuated the facility due to wildfires and did not return to the facility until 11/02/19. The DON confirmed through this e-mail the care plan was not updated after the fall on 8/27/19. No revisions to the care plan were identified until 3/17/20. An e-mail sent by the Medical Records Director on 7/15/21 at 10:34 a.m., indicated Resident 1 evacuated the facility on 10/27/19 (Two months after the fall) and returned to the facility on 11/02/19. Record review showed the Fall Risk Assessment was updated on 8/28/19 at 3:34 p.m., but indicated Resident 1's fall risk score was 7 (Lower than the previous assessment), which indicated Resident 1 was at low risk for falls, although, she had suffered a fall the day prior, on 8/27/19. The Fall Risk Assessment also indicated Resident 1 had no falls in the last three months, which contraindicated the Incident Note dated 8/27/19 at 10:56 a.m., which documented a fall for Resident 1. According to an e-mail sent by the Director of Nursing (DON) on 7/14/21 at 5:24 p.m., no Post-Fall Assessment was found, after the fall on 8/27/19. Second Fall: Record review revealed an Incident Note dated 4/06/20 at 12:15 a.m., indicated, "Resident standing at doorway. Reminded to use her w/c (Wheelchair) or walker when up. She was standing and locking wheelchair preparing to sit in it when it rolled, she went to her knees and sat down on to floor. She did not strike her head." Record review indicated the Fall Risk Assessment was updated on 5/12/20 at 9:51 a.m., 36 days after the fall, and indicated Resident 1 was at high risk for falls. Record review showed the Nursing Care Plan for falls was not updated or revised after the fall on 4/06/20. Record review also showed the Post Fall Risk Assessment, which was required to be completed within 72 hours after a fall per facility policy, was not completed either. During an interview on 4/07/21 at 9:50 a.m., the Director of Nursing (DON) confirmed this information. During an interview with the DON on 4/07/21 at 10:45 a.m., she stated the Medical Records Department missed auditing of the fall on 4/06/20, and as a result, the care plan to prevent further falls was not updated. Third Fall: Record review revealed an Incident Note dated 6/04/20 at 7:46 p.m., indicated, "Resident heard calling for help from her room and discovered on floor next to bed, partially sitting up complaining of right lower leg pain but refusing to allow staff to approach for assessment. Resident eventually persuaded to allow writer to lift right pan leg at which time deformity was noted along with visible movement of what appeared to be displaced bones near mid-point of right tib (Tibia- The larger of the two bones in the lower leg)/fib (Fibula- A small bone located on the outside of the lower leg) ...transfer to acute hospital for emergency treatment." Record review revealed a Skin/Wound Note dated 6/10/20 at 6:24 p.m., indicated, "admitted s/p (Status post) fall with R (Right)-tib/fib FX (Fracture) with ORIF (Open reduction and internal fixation- A type of surgery used to stabilize and heal a broken bone) ...surgical incision to RLE (Right Lower Extremity) with 4 sutures and 28 staples well approximated with min (minimal) serosang (Serosanguinous- Discharge that contains both blood and a clear yellow liquid) drainage noted." Record review showed the Fall Risk Assessment was updated on 6/09/20 at 6:15 p.m. and indicated Resident 1 was at high risk for falls, but the Post-Fall assessment was not completed. During an interview on 4/07/21 at 9:50 a.m., the DON confirmed this information. Record review indicated a root cause analysis of the incident dated 6/4/20 listed appropriate interventions to prevent further falls, but these were not documented in the nursing care plan to prevent further falls. The care plan for falls was revised after the fall on 6/04/20, but no new interventions were added. During an interview on 7/14/21 at 12:15 p.m., the DON stated the Licensed Nurse (Licensed Nurse B) who documented the Incident Note on 6/04/20 at 7:46 p.m., no longer worked for the facility. Fourth Fall: Record review revealed an Incident Note dated 6/30/20 at 4:53 a.m., indicated, "0445 (4:45 a.m.), 2 CNAs (Certified Nursing Assistants) were doing H2O (Water) pass. They heard movement from this room and walked in as resident slid from her bed onto the floor. She did not strike her head. Assisted back to bed." Record review showed the care plan for falls was updated after the fall on 6/30/20 with appropriate interventions to prevent further falls, however, the Fall Risk assessment was not updated, and the Post Fall Assessment was not completed. During an interview on 4/07/21 at 9:50 a.m., the DON confirmed this information. Fifth Fall: Record review revealed an Incident Note dated 7/25/20 at 8:05 a.m. indicated, "At 0345 (3:45 a.m.), this LN (Licensed Nurse C) heard a crash followed by resident calling out "OHHHH!" from room 27. Resident found sitting on the floor next to her bed, RT. (Right) shoulder leaning on trash can, holding onto bed rail with her L. (Left) hand." Record review showed a short-term care plan was initiated after the fall on 7/25/20 with effective interventions; however, a Post Fall Assessment could not be found, according to the DON during an interview on 4/07/21 at 9:50 a.m. The Fall Risk Assessment was not updated until 8/04/20 at 10:51 p.m. (10 days after the fall). This was confirmed by the DON through an e-mail sent on 7/12/21 at 5:29 p.m. During an interview on 3/15/21 at 10:30 a.m., MDS Nurse A stated Licensed Nurses on the floor were responsible for creating short-term care plans after residents' falls. MDS Nurse A stated he updated the long-term care plans for falls, but this was only done every three months. During an interview on 7/14/21 at 12:15 p.m., the DON stated Licensed Nurses were responsible for updating care plans after every fall, but if they could not do it, they were responsible for communicating the fall through a standard report sheet, so other members of the interdisciplinary team could update the care plans. The DON also stated the Fall Risk Assessments were required to be updated within 72-hours after a fall. Record review indicated the undated facility policy titled, "FALLS," indicated, "Residents will be assessed for risk for falls, using the "Falls Risk Assessment Tool". Residents that score a 10 or greater will be considered at risk for falls. A plan of care will be initiated to address the fall risk factors ...Residents will be re-evaluated, using the "Fall Risk Assessment Tool" on a quarterly basis, annually or with a significant change in condition ...A care plan will be started immediately after a fall, identifying the fall, goals and approaches to provide care as well as to reduce the potential for further falls ...A Post-Fall Assessment will be completed by the licensed nurse within 72 hours of the fall ...The resident's plan of care will be reviewed and updated as appropriate to reflect potential for falls and approaches to reduce the potential for future falls." In violation of the above-cited standards, the facility failed to ensure the resident environment remained as free of accidents as possible, and each resident received adequate supervision or assistance devices to prevent accidents when, including but not limited to: Facility staff did not revise and implement Resident 1’s nursing care plan to prevent falls or keep Resident 1 safe, and did not follow the facility’s policy and procedure on fall prevention for assessing residents with recurrent falls. This failure resulted in Resident 1 falling, unwitnessed, and suffering a right tibial-fibial (e.g., shin bones) fracture, which required hospitalization and surgical intervention, and created an unsafe environment for the resident. This violation presented a direct and immediate relationship to Resident 1’s health, safety, and security.