Health inspection·February 3, 2022

483.25(d) Accidents. The facility must ensure that - 483.25(d)(1) The resident environment remains as free of accident hazards as is possible. On 7/12/2021 at 10:45 a.m., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding Resident 1's witnessed fall with injury that occurred on 6/23/2021. The facility failed to ensure residents' environment remained free of accident hazards (potential to cause injury or illness) to prevent accidents when an unused extra walker (an assistive device used for support and stability when walking) was left at the end of Resident 1's bed. This failure resulted in Resident 1 tripping over the extra walker on 6/23/21, causing Resident 1 to fall onto the floor, which resulted in a left patella (kneecap) fracture (break in the bone). Resident 1 experienced a decline in mobility (the ability to move with ease) of her left leg, had a decrease in her ability to participate in activities of daily living (ADL- term used in healthcare to refer to people's daily self-care activities such as grooming/personal hygiene, dressing, toileting/continence), and experienced pain associated with physical therapy (treatment for patients who have been impaired in their movement and flexibility) for the fractured patella. Resident 1 is an 86-year-old-female, admitted to the facility on 6/7/2021. Resident 1 had diagnoses that included previous wedge compression fracture (a type of break in the bone) of first lumbar vertebra (a bone in the lower back protecting the spinal cord), muscle weakness, difficulty in walking and unspecified osteoarthritis (degeneration of joint cartilage). Resident 1 was assessed to have no cognitive deficit. During an observation on 7/12/21, at 11:10 a.m., in Resident 1's room, the area around Resident 1's bed was observed. Resident 1 laid in bed; the room was dark with the lights turned off. The area around Residents 1's bed contained a wheelchair that was placed against the wall, a four-wheeled walker (4WW-designed to assist in the ability to stabilize and balance during walking), a bedside commode (portable toilet), a front wheeled walker (FWW- an assistive device used to provide extra stability and can help individuals move) and an overbed table (an adjustable rectangular, narrow table). During a concurrent observation and interview on 7/12/21, at 11:12 a.m., with Resident 1, Resident 1 stated she had a fall, but could not remember the date. Resident 1 was alert and oriented to person and place but was confused regarding time. Resident 1 stated she was independent (not depending on others) of getting out of bed before her fall. Resident 1 stated since the fall, she has to call for help and the staff would assist Resident 1 by transferring her to the bedside commode. Resident 1 stated she had a wrap on her leg. Resident 1 pulled back her blanket and exposed an immobilizer brace (a brace to hold a bone or joint into place) on her left leg. During an interview on 7/12/21, at 12 p.m., with the Director of Rehabilitation (DOR), the DOR stated before Resident 1's fall on 6/23/21, Resident 1 was more confident in walking and was able to ambulate (walk) short distances without her walker. The DOR stated Resident 1 was able to walk to the bathroom on her own with the assistance of a front wheeled walker. The DOR stated after Resident 1's fall on 6/23/21, Resident 1 needed staff to assist her out of bed to the bedside commode. The DOR stated he had an in-service (training) with the nursing staff on how to care for Resident 1 after her injury (fall on 6/23/21). The DOR stated he showed the staff how to use the immobilizer brace, explained why the immobilizer brace needed to remain in a locked position, the importance of not bending the resident's knee and weight bearing precautions (how much weight a person puts through an injured body part). The DOR stated after Resident 1's fall, she (Resident 1) had an increase in pain, therefore, he (DOR) requested the nurses to administer pain medication to Resident 1 prior to physical therapy (aims to help patients maintain, recover or improve physical ability that may be impaired due to a condition or injury). During a review of Resident 1's "Physical Therapy (PT) Recert (recertification), Progress Report & Updated Therapy Plan" dated 6/28/21, the "Physical Therapy PT Recert, Progress Report & Updated Therapy Plan" indicated, " ...Summary of Functional Progress Since Last Certification ...Lying to sitting on the side of bed ...(6/8/2021) Partial/moderate assistance ...(6/21/2021) Supervision or touching assistance ...(6/25/2021) [post fall] partial/moderate assistance ...Sit to stand ...(6/8/2021) Supervision or touching assistance ... (6/21/2021) Supervision or touching assistance ... (6/25/2021) [post fall] Dependent (requiring assistance) ... Chair/bed-to-chair transfer ... (6/8/2021) Supervision or touching assistance ... (6/21/2021) Supervision or touching assistance ... (6/25/2021) [post fall] Dependent ... Gait (a person's manner of walking) ... (6/8/2021) Supervision or touching assistance ... (6/21/2021) Supervision or touching assistance ... (6/25/2021) [post fall] Dependent ... Precautions: fall risk, s/p (status post) kyphoplasty (surgical filling of an injured vertebrae [small bones forming the backbone]), L (left) patella fx (fracture) with associated pain-knee immobilizer ... Weight Bearing LE (lower extremity [limbs of the body]) Weight Bearing Status =Weight Bearing as Tolerated (with L knee fully extended with immobilization splint) ... Functional Skills Assessment ... Transfers ... toilet transfer = Dependent ... Ambulation ... Walk 10 feet (unit of measurement) = Not attempted due to medical conditions or safety concerns ... Assessment and Summary of Skilled Services ... Patient Progress ... Progress & Response to Treatment: Pt (patient) was making excellent progress over the past couple weeks with increase in LE strength ... independence with functional transfers ... ambulation ... sustained a fall on 6/23/21 ... Radiograph (image) revealed patella fracture ...Goals were downgraded (reduce to lower grade or level of importance) for modified (changes) transfers with the L knee immobilized as well as pain management to improve independence with mobility ... BSC (bedside commode) will be recommended when pt is read[y] for transfers ... Pt will be premedicated (using medication before some type of therapy) with nursing about 1 hour prior to PT Tx (treatment) ..." During a concurrent observation and interview on 7/12/21, at 12:52 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, Resident 1's bed area was observed. Resident 1's room was dark with the blinds closed. LVN 1 stated Resident 1 preferred to keep the room dark. LVN 1 stated Resident 1 had a 4WW, a FWW, a wheelchair, bedside commode, and a bedside table around her bed. LVN 1 stated Resident 1's room was cluttered and was a fall hazard. During a concurrent interview and record review on 8/12/21, at 12:58 p.m., with LVN 1, Resident 1's fall risk (increased susceptibility to falling that may cause physical harm) care plan (plan, document, and accomplish individualized care goals) dated 6/7/21 was reviewed. Resident 1's fall risk care plan indicated, " ...Focus ... At risk for falls related to: Fell in the past 30 days, poor safety awareness (lack of safety knowledge), generalized weakness, unsteady gait (persons manner of walking), poor balance ... Resident is non-compliant with the use of FWW in the room despite cueing (reminder) and encouragement ... Goal ... Minimize risk for fall and fall related injuries ... Interventions ... Keep environment well-lit and free of clutter ... " LVN 1 stated care plans were necessary because they were the instructions on how to keep residents safe and improve their health. During an interview on 7/12/21, at 1:15 p.m., with LVN 2, LVN 2 stated she was the LVN assigned to Resident 1 the day of Resident 1's fall. LVN 2 stated on the evening shift of 6/23/21, she (LVN 2) stood in the doorway to Resident 1's room. LVN 2 stated Resident 1 walked out of the bathroom without her FWW, and she (LVN 2) asked Resident 1 if she needed a pain pill and turned her (LVN 2) back to Resident 1 where she (LVN) faced the medication cart with her back to Resident 1. LVN 2 stated she heard the walker that was propped (positioned) at the foot of Resident 1's bed hit against the footboard (board or platform which support the foot or feet). LVN 2 stated she turned around and witnessed Resident 1's fall. LVN 2 stated she witnessed Resident 1 grab the walker that was at the foot of her bed as she fell onto the floor and landed on her left knee. LVN 2 stated Resident 1 verbalized she was mad the walker was left at the foot of her bed. LVN 2 stated the walker that was propped up against the footboard of Resident 1's bed was an extra walker Resident 1 did not use. LVN 2 stated Resident 1 already had a 4WW and a FWW in her room and LVN 2 was unsure where the third walker came from or why it was left at the foot of the bed. LVN 2 stated the third walker was left in Resident 1's path from the bathroom and caused Resident 1 to trip and fall. During a concurrent interview and record review on 7/12/21, at 2 p.m., with the Director of Nurses (DON), Resident 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) Assessment, "Section G" (Function Status) dated 6/14/21 (prior to fall on 6/23/21), was reviewed. Resident 1's MDS Assessment "Section G" indicated, " ... B. Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position ... code 2 (one-person physical assist) ... C. Walk in room-how resident walks between locations in his/her room .... Code 2 ... D. Walk in corridor-how resident walks in corridor on unit ... code 1 (Set up help only) ... I. Toilet use-how resident uses the toilet room, commode ... code 2 ..." The DON stated the MDS "Section G" indicated Resident 1 required one-person physical assistance to walk in room, bed mobility and transfers. The DON stated Resident 1 needed another person to safely ambulate in the room. The DON stated Resident 1 already had a walker in her room assigned to her by physical therapy. The DON stated Resident 1's fall was avoidable, the fall was caused by Resident 1 tripping on an extra walker left in her room by the Occupational Therapist (OT- work with patients to build or restore their abilities to perform the daily tasks of life). During a review of Resident 1's "Admission Record" (document containing resident personal information), dated 6/24/21, the "Admission Record" indicated Resident 1 was admitted to the facility on 6/7/21 with diagnoses that included, " ... wedge compression fracture (a type of break in the bone) of first lumbar vertebra (a bone in the lower back protecting the spinal cord) ...muscle weakness ...difficulty in walking ...unspecified osteoarthritis (degeneration of joint cartilage) ..." During a review of Resident 1's MDS assessment, dated 6/14/21, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 13 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 1 had no cognitive deficit. During a review of Resident 1's MDS Assessment, "Section G", dated 6/30/21 (after Resident 1's fall on 6/23/21), the MDS Assessment, "Section G" indicated, " ...C. walk in room ... code 8 (ADL activity itself did not occur) ... D. Walk in corridor ... code 8 (ADL activity itself did not occur) ... E. Locomotion on unit ... code 8 (ADL activity itself did not occur) ... F. Locomotion off unit ... code 8 (ADL activity itself did not occur) ..." During a review of the facility document titled, "IDT (Interdisciplinary Team- group of health care professionals with various areas of expertise who work together toward the goals of their patient) Review," dated 6/24/21, at 1:15 p.m., the "IDT Review" indicated " ...on 6/23/21 at 2000 (8:00 p.m.), LVN witnessed the fall, resident was ambulating without the use of assistive device (FWW) from the bathroom to the bed, tripped on the walker by the foot part of the bed, lost her balance and landed on her left knee...resident is at risk for fracture and risk for falling r/t (related to) h/o (history of) multiple falls, non-compliant with the use of FWW, poor safety awareness..." During an interview on 7/13/21, at 12:20 p.m., with the OT, the OT stated before Resident 1's fall on 6/23/21, Resident 1 had worked on becoming independent with the goal of moving to an assisted living facility (for people who need help with daily care, but not as much help as a nursing home provides). The OT stated the day Resident 1 fell, he (the OT) went into Resident 1's room and she wanted to walk, so he went out to get a walker for Resident 1 and brought it into Resident 1's room. The OT stated when he returned with a FWW, he did not realize Resident 1 already had a FWW from physical therapy in her room, so he folded up the one he had brought into the room and left it propped against the footboard of the bed. The OT stated he forgot about the FWW in Resident 1's room after therapy. During a concurrent phone interview and record review on 9/3/21, at 12:20 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 1's "Admission & baseline careplan/summary," dated 6/7/21 was reviewed. The "Admission & baseline careplan/summary" indicated, " ...Fall Risk Assessment ... 2. Falls- past three months ... 1-2 falls in past 3 months ... 5. Gait Balance ... Balance problem while walking ... Fall Risk Score ... Greater than 10 ..." The MDSC stated Resident 1's fall risk score was 11 and stated Resident 1 was at high risk for falls. During a review of Resident 1's "Event Initial Note," dated 6/23/21, at 10:06 p.m., the "Event Initial Note" indicated, " ... Event Type: PT witnessed fall ... Date of Event: 6/23/21 ... Time of event: 2000 (8:00 p.m.) ... Detailed description of event ... Res (Resident) AMB (ambulated) out of BR (bathroom) walking towards bed. Tripped on closed walker @ (at) end of bed. Landing on left knee... Patients description of event: "I tripped on walker" ... New Interventions initiated (should address any abnormal assessment findings): Ice pack applied. Order for left knee x-ray (creates pictures of the inside of your body) in am (morning) ..." During a review of Resident 1's "Radiology Report," dated 6/24/21, the "Radiology Report" indicated, " ...Knee ... Left ... Results: There is an acute (severe and sudden onset) fracture of the patella ..." During a review of the facility's policy and procedure (P&P) titled, "Falls and Fall Risk, Managing," dated 2018, the P&P indicated, "...Fall Risk Factors... 1. Environmental factors that contribute to the risk of falls include ... b. poor lighting ... obstacles in the footpath ... Resident-Centered Approaches to Managing Falls and Fall Risk ... 3. Examples of initial approaches might include ... a rearrangement of room furniture ... changing the lighting ..." In violation of the above cited standards, the facility failed to ensure Resident 1's environment remained free of accident hazards when an extra walker was left at the end of Resident 1's bed. This failure resulted in Resident 1 tripping over the extra walker on 6/23/21, causing Resident 1 to fall onto the floor, which resulted in a left patella fracture. Resident 1 experienced a decline in mobility of her left leg, had a decrease in her ability to participate in activities of daily living and experienced pain associated with physical therapy for the fractured patella. This violation presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a direct proximate cause of Resident 1's injury and constitutes an A Citation.