Other·September 10, 2021

72311 (a)(2) Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to provide minimum required number of staff (two) to safely assist Resident 20 during a transfer from the bathroom to the bed. This failure resulted to Resident 20's accidental fall resulting in a re-fracture of her left leg requiring re-hospitalization and surgical repair. Resident 20 was a 95-year-old female who was originally admitted to the facility on 09/12/18, with a diagnosis of left open ankle fracture with surgical application of an external fixator (a framework of metal to hold bone in place); Advanced Dementia; Depression and Hypertension. Resident 20 was sent back to the acute hospital on 09/30/18, for Urinary Tract Infection and Dehydration. A review of Resident 20's Profile Face Sheet indicated Resident 20 was readmitted to the facility on 10/05/18. A review of the Operative Reports from the Acute Care Hospital, dated 10/17/18, indicated Resident 20 underwent an external fixator removal on 10/17/18. Post-operative plan indicated, "[Resident 20] will be non-weight bearing (no weight can be placed on the operated leg) to her left lower extremity." A review of Resident 20's Minimum Data Set (MDS - an assessment tool), dated 11/02/18, indicated Resident 20 required the assistance of two or more persons for transfers to and from the bathroom. A review of Resident 20's Care Plan for Fall, dated 09/24/18, indicated a goal for Resident 20 to, "be free from injury related to falls." Care Plan approach also indicated to, "consult with therapy regarding current functional status and follow all recommendations and the restorative programs." A review of Resident 20's Care Plan for Fall prevention, dated 11/24/18, indicated, "Resident will be assisted with two-person to prevent any future falls. (A) Use two-person assist for safe transfer." A review of the Fall Risk Assessment, dated 11/24/18, indicated Resident 20 had a total score of 16, indicating Resident 20 was a medium risk for fall. A review of the Interdisciplinary Team notes, dated 11/25/18, at 12:55 p.m., indicated, "...Resident use wheelchair to transfer and requires two-person assist with ADL's (Activities of Daily Living) and transfers." A review of the Interdisciplinary Team notes dated 11/30/18, at 8:34 p.m., indicated Resident 20 had an assisted fall at approximately 6:55 p.m. License Nurse O's note indicated CNA G and Resident 20 were returning from the bathroom back to bed. When CNA G assisted Resident 20 to stand from the wheelchair using a front-wheel walker, CNA G noticed Resident 20's left leg began to shake. CNA G then assisted Resident 20 to sit on the floor. Licensed Nurse O's note indicated Resident 20's, "gray boot" was on her foot, but the Velcro straps were undone. Licensed Nurse O's note indicated, "attempted to adjust patients left leg to attach straps and noticed active bleeding on floor approximately 1/2 ounce of bright red blood below left leg, at this time [Resident 20] complained of pain when leg was slightly adjusted." Licensed Nurse O's assessment also revealed right and left leg, "were not symmetrical," prompting Licensed Nurse to send Resident 20 to the Emergency Room. A review of the Operative Reports from the Acute Care Hospital, dated 12/01/18, indicated Resident 20 sustained a, "re-fracture of her distal tibia (larger of the two bones between the knee and the ankle) just proximal (nearest to) her previous hardware (fixation device)." The record indicated, Resident 20 underwent left tibia and fibula (smaller of the two bones between the knee and the ankle) open reduction and internal fixation (ORIF- surgical procedure to fix severely broken bones). A review of PT (Physical Therapy) Patient Discharge Instructions, dated 11/30/18, indicated, "Patient and caregiver education on safety with all OOB (out of bed) activities, transfer technique with 2-person assistance." During an interview on 12/18/18, at 2:10 p.m., Physical Therapist M stated, "with [Resident 20's] Dementia, she required constant verbal cues when making a transfer, and I would consider her to have been a two-person assist for those transfers while she has been here up until she left for the hospital this last time." The facility Policy and Procedure titled, "Care Plans," dated 11/24/14, indicated, "The care plan identifies the individual needs and problems of the resident, states the resident's goals in measurable terms, and documents realistic approaches that the interdisciplinary team will employ the achieve the desired outcomes." Therefore, the facility failed to provide minimum required number of staff (two) to safely assist Resident 20 during a transfer from the bathroom to the bed. This failure resulted to Resident 20's accidental fall resulting in a re-fracture of her left leg requiring re-hospitalization and surgical repair. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 20.