Other·April 26, 2023

Section 483.25(d) Accidents. The facility must ensure that - Section 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and Section 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 4/23/21 at 9:07 a.m., an unannounced visit was conducted at the facility to investigate FRI # CA00733760 regarding Resident 1's fall from her wheelchair. Resident 1 had bilateral above the knee amputations and was wheelchair dependent. On 4/20/21, Resident 1 fell while in her wheelchair during a physical therapy session on the facility's patio when she propelled the wheelchair over the door's threshold (a strip of wood or metal formed at the bottom of a doorway and crossed when entering a building). Resident 1 fell backwards which resulted in swelling to the back of the head. Resident 1 was sent to the hospital for further evaluation and expired on 4/23/21. The facility failed to ensure the resident environment remains as free of accident hazards as is possible, including but not limited to ensuring Resident 1 crossed the threshold between the patio and the facility safely while in her wheelchair. Resident 1's admission record indicated Resident 1 was admitted to the facility in April 2021 with diagnoses including bilateral above the knee amputations, osteoporosis (a disease that thins and weakens the bones) and rheumatoid arthritis (a condition in which the body's immune system attacks its own tissue and joints). A review of a Minimum Data Set (MDS, an assessment tool), dated 4/11/21, indicated Resident 1 had no memory problems, normally used a wheelchair to move around, and had no history of falls. A review of resident 1's "Order Summary Report", dated 6/3/21, indicated Resident 1 was unable to bear weight on both legs and had a fair rehabilitation potential. A review of a care plan initiated on 4/8/21 indicated Resident 1 had osteoporosis and rheumatoid arthritis. The goal of the care plan was for Resident 1 to remain free of injuries. Staff interventions and tasks included, "Monitor/document for risk of falls. Educate...caregivers on safety measures that need to be taken in order to reduce risk of falls..." A review of a care plan initiated on 4/10/21, indicated Resident 1 was at risk for falls and injuries related to medications Resident 1 was taking. The goal of the care plan was to decrease the risk of fall and/or minimize injuries from falls for 90 days. A review of a fall report, dated 4/20/21 at 12:28 p.m., indicated Resident 1 fell from a wheelchair during a physical therapy session on the facility's patio when Resident 1 propelled the wheelchair over the door's threshold and resulted in swelling to the back of the head. Resident 1 was sent to the hospital for further evaluation. A review of the hospital's physician note, dated 4/20/21 at 12:47 p.m. indicated, "The history provided by the [Resident 1] and EMS [Emergency Medical Services] personnel... [Resident 1] was wheeling herself on her wheelchair, when the wheels got caught on the rug causing patient to fall backwards and hitting her head..." A review of the hospital's physician notes, between 4/20/21 and 4/23/21, indicated Resident 1 obtained compression fractures in the thoracic (middle) and lumbar (lower) spine and hemorrhages (ruptured blood vessels) in three layers of the brain. Resident 1 died on 4/23/21. In an interview on 4/29/21 at 12:58 p.m., the Physical Therapy Assistant (PTA) stated, "... [Resident 1] attempted to cross the threshold of the door...he heard [Resident 1] yell as she was falling back, the wheelchair tilted back... [Resident 1] hit her head on the ground..." In an interview on 6/3/21 at 10:30 a.m., the PTA stated, "They [he and Resident 1] were outside coming in. A mat was...outside... [Resident 1] was on the wheelchair...the front of the wheelchair was right behind the mat... [Resident 1] had an impulse to propel herself...It must have been the mat." In an interview on 8/25/21 at 10:01 a.m., the PTA confirmed there was a mat in front of door from the patio to the therapy room when the resident fell. A review of a facility policy titled "Fall Management", dated 8/14, indicated, "...PURPOSE...To evaluate risk factors and provide interventions to minimize, risk, injury, and occurrences."