Other·August 13, 2021

F689: §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; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure one of two sampled residents (Resident 1) remained free from accident hazards. * The Certified Nursing Assistant (CNA) improperly positioned Resident 1 on the side of the bed with a low air loss mattress (LALM, a mattress used for prevention or treatment of skin breakdown) while independently providing incontinence care to Resident 1. Resident 1 subsequently fell off the LALM onto the floor and sustained a cervical fracture (a bone is broken in the neck of the spine). * Resident 1's Fall Risk care plan showed an intervention for the implementation of bilateral floor mats. When Resident 1 fell off the LALM onto the floor and sustained a cervical fracture, the bilateral floor mats were not in place. * Before the fall in which Resident 1 sustained a cervical fracture, Resident 1 had a prior fall at the facility from the bed with the LALM. As a result of the facility's fall investigation for Resident 1's initial fall, the facility identified the use of a LALM as a risk for falls for Resident 1 and subsequently discontinued the LALM. When the facility reconstituted a LALM for use by Resident 1, the facility failed to implement the measures/interventions to reduce Resident 1's risk for another fall from the bed with the LALM. After the facility reinstituted the bed with the LALM, Resident 1 sustained another fall, at which time she suffered a cervical fracture. * After Resident 1's initial fall at the facility from the bed with the LALM, the facility conducted a Post Fall Evaluation which showed the nursing intervention (to be implemented in Resident 1's care plan) to provide Resident 1 with two-staff assistance. Review of Resident 1's care plans failed to show any revisions were made for the nursing interventions to provide two-staff assistance. These failures resulted in Resident 1's fall in which Resident 1 sustained a cervical fracture. Findings: Review of the facility's policy and procedure (P&P) titled Resident Centered Fall Prevention Plan revised 10/24/19, showed a fall risk screening is completed for all residents to identify current or future fall risk. An individualized fall prevention program is implemented for each resident to ensure the safest environment possible. After review of the fall risk evaluation is completed the care plan is developed as appropriate. Review of the facility's P&P titled Post Fall Assessment revised 10/24/20, showed all residents will be assessed immediately who fall, to identify causative factors that may be related to the fall. Upon this assessment, actions will be taken to decrease the potential for future falls. Review of the facility's P&P titled Comprehensive Care Plans revised 10/28/20, showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. Medical record review for Resident 1 was initiated on 5/25/21. Resident 1 was admitted to the facility on 9/27/16. On 6/15/21 at 1149 hours, a telephone interview and concurrent facility document review was conducted with the Director of Nursing (DON). Review of the facility's Occurrence Report dated 4/23/19, showed on 4/23/19, Resident 1 fell from her bed with the LALM onto the floor. Resident 1 was observed sitting on a floor mat with her back leaning on the bed. Resident 1 was unable to state how the fall had occurred due to impaired cognition associated with her diagnosis of dementia. The DON stated Resident 1 had a behavioral history of sitting on the edge of the LALM and sliding onto the floor, as the LALM cover sheet fabric was slippery. The facility's Occurrence Report dated 4/23/19, showed after Resident 1's fall from the bed with the LALM, the facility recommended to discontinue the LALM due to the slippery cover sheets. The DON verified Resident 1's LALM was discontinued after Resident 1 fell from her LALM bed on 4/23/19. Review of Resident 1's Post Fall Evaluation dated 4/24/19, showed the nursing interventions in Resident 1's care plan included two-staff assistance. Review of Resident 1's plan of care showed a care plan problem initiated 12/6/16, addressing the resident's self-care deficits. The interventions included one to two person total assist with bed mobility, with the effective date of 12/30/16. Review of Resident 1's plan of care failed to show any revisions were made on 4/24/19, after the post fall evaluation was conducted for the nursing interventions to show two-staff assistance. The DON verified the findings. The DON was then asked if the need for two-staff assistance (as specified in Post Fall Evaluation dated 4/24/19) referred to the level of staff assistance required for Resident 1 for bed mobility. The DON stated she was uncertain as no revisions were made to Resident 1's care plan for bed mobility after Resident 1 fell on 4/23/19. Review of the physician's order dated 1/8/21, showed the facility reinstituted a bed with a LALM for Resident 1's skin management. Review of Resident 1's plan of care failed to show the interventions to reduce Resident 1's identified fall risks associated with the use of a LALM. On 6/9/21 at 1101 hours, a telephone interview and concurrent medical record review was conducted with the DON. The DON verified a LALM was reinstituted for Resident 1 on 1/8/21. The DON was asked if Resident 1 was at risk for falls from a LALM due to Resident 1 had previously fell from a LALM on 4/26/19. The DON stated Resident 1 was at risk for another fall from a LALM due to Resident 1's prior fall from a LALM on 4/26/19, and Resident 1's past behavior of sliding off the LALM onto the floor. The DON was asked what interventions were implemented by the facility when Resident 1's LALM was reinstituted on 1/8/21, in order to reduce Resident 1's identified fall risk associated with the use of LALM. The DON stated the interventions would include ensuring Resident 1 to be positioned in the center of the LALM when one staff member was providing care to Resident 1. The DON stated positioning Resident 1's body weight on the side of the LALM (versus the center) could cause the mattress to collapse resulting in Resident 1 falling onto the floor, or result in Resident 1 slipping off the mattress onto the floor. The DON stated an additional intervention was to ensure the facility staff first pulled Resident 1 toward the staff before turning Resident 1 onto her side to ensure Resident 1 once turned was positioned in the center of the bed rather than on the side of the bed. The DON stated when Resident 1's LALM was reinstituted on 1/8/21, the interventions the DON described to reduce the risk of another fall from a LALM would be documented on Resident 1's care plans. The DON reviewed Resident 1's care plans from 1/8/21 (date LALM reinstituted) through 5/14/21, (date of Resident 1's fall from LALM, with fracture) and verified Resident 1's care plans failed to show the interventions the DON described were implemented. The DON was asked if these interventions had been implemented by CNA 1, Resident 1's fall on 5/14/21, could have been avoided, to which she replied yes. Review of Resident 1's plan of care showed a care plan problem dated 12/6/16, addressing Resident 1's risk for falls as evidenced by dementia, muscle weakness, and poor safety awareness. The interventions included to apply the bilateral floor mats, effective 2/3/19. Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool) dated 3/12/21, showed Resident 1 had severely impaired cognition and required extensive two-person physical assistance with bed mobility. Review of Resident 1's Physical Therapy Treatment Encounter Notes dated 4/30/21, showed after approximately 10 minutes of sitting on edge of bed, Resident 1 started sliding and due to the LALM, Resident 1 was high risk for sliding off the bed. Review of Resident 1's Physical Therapy Progress Report dated 5/10/21, showed the precautions included risk for falls. Resident 1 was assessed to have the following impairments: decreased functional capacity, deficits in judgement, decreased static balance, strength impairments, safety awareness deficits, and body awareness deficits. Review of Resident 1's Physical Therapy Treatment Encounter Notes dated 5/14/21, showed Resident 1 was totally dependent on staff for bed mobility without attempts to initiate. Review of Resident 1's Psychotherapy Note dated 3/5/21, showed Resident 1 had a diagnosis of dementia with severe cognitive decline. Review of Resident 1's Fall Risk evaluation dated 3/12/21, showed Resident 1's risk factors for falls included impaired mobility, poor vision, impaired cognition, and diminished safety awareness. The Fall Risk evaluation showed if Resident 1 had at least one fall risk factor, to ensure a fall care plan was in place. Review of the LALM User Manual (undated) for Resident 1's LALM showed the following warning: when using therapy mattress system, always ensure that the resident is positioned properly within the confines of the bed. The resident's head should be positioned in the center of the top section of the therapy mattress. Review of Resident 1's Clinical Notes completed by Licensed Vocational Nurse (LVN) 1 dated 5/14/21 at 1627 hours, showed Resident 1 fell from her bed with a LALM onto the floor on 5/14/21. Resident 1 was observed on the floor and sustained a laceration to her forehead, which measured 2.5 centimeter (length) x 0.5 centimeter (width). Resident 1's physician was notified of the fall and Resident 1 was then transferred to Acute Care Hospital 1 for further evaluation. Review of Resident 1's medical record from Acute Care Hospital 1 showed a CT (computed tomography, a scan of the body as part of the diagnosis or treatment of illness) scan of Resident 1's Cervical Spine was performed on 5/14/21. The results of the CT scan showed Resident 1 sustained an acute type II odontoid fracture (cervical spine fracture). On 5/25/21 at 1053 hours, an observation was conducted of Resident 1. Resident 1 was observed lying in her bed with a cervical collar immobilization device placed around her neck. Resident 1 was also observed with a bandage on her forehead. Resident 1 was nonverbal. On 5/25/21 at 1331 hours, an interview was conducted with CNA 2. CNA 2 stated he witnessed Resident 1 lying on the floor after having fallen out of bed on 5/14/21. CNA 2 stated on 5/14/21, CNA 2 heard CNA 1 calling for assistance after Resident 1 had fallen out of bed onto the floor. CNA 2 stated he observed Resident 1 with a cut and bump on her forehead. CNA 2 stated there were no floor mats in place at the time of Resident 1's fall. On 5/25/21 at 1351 hours, an interview was conducted with LVN 1. LVN 1 was assigned to care for Resident 1 on 5/14/21, during the time Resident 1 fell from her bed with a LALM. LVN 1 was asked to describe the circumstances regarding Resident 1's fall. LVN 1 stated she heard CNA 1 call for help, at which time LVN 1 entered Resident 1's room and saw Resident 1 lying face up on the floor. LVN 1 stated she observed Resident 1 bleeding from a laceration on her forehead. LVN 1 stated Resident 1 fell from the bed while CNA 1 was independently providing care to Resident 1. LVN 1 stated CNA 1 was changing Resident 1's adult brief and Resident 1 fell out of bed onto the floor. LVN 1 stated there were no floor mats (as per Resident 1's active care plans) in place adjacent to Resident 1's bed at the time of the fall. LVN 1 stated Resident 1's fall on 5/14/21, was the first time Resident 1 sustained a fall at the facility, and the floor mats were implemented after Resident 1's fall on 5/14/21. On 5/25/21 at 1418 hours, a follow-up interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 1's active care plan problem titled Fall Risk effective on 12/6/16, showed Resident 1 was at risk for falls (as evidenced by muscle weakness, dementia, and poor safety awareness). Resident 1's Fall Risk care plan showed an intervention for bilateral floor mats, effective as of 2/3/19. LVN 1 verified the findings and stated Resident 1 should have had the floor mats in place at the time of her fall on 5/14/21. On 5/25/21 at 1645 hours, an interview was conducted with CNA 3. CNA 3 was asked to describe the technique she utilized to turn Resident 1 on her LALM bed when providing care to Resident 1 independently. CNA 3 stated first she would ensure Resident 1 was lying on her back, then pulled Resident 1 toward her before turning Resident 1 onto her side, to ensure Resident 1 was positioned in the center of the bed once turned onto her side. CNA 3 stated once turned, if Resident 1 was improperly positioned on the side of the LALM, Resident 1's weight would cause the LALM to shift, potentially resulting in Resident 1 slipping off the mattress and falling onto the floor. On 5/27/21 at 1226 hours, an interview and concurrent facility document review was conducted with Registered Nurse (RN) 1. RN 1 verified she conducted the facility's investigation of Resident 1's fall from her bed with a LALM on 5/14/21. RN 1 documented her investigative findings on the facility's Occurrence Report dated 5/19/21. RN 1 stated she conducted an interview with CNA 1 to determine causal and contributing factors regarding Resident 1's fall. CNA 1 stated the following to RN 1: on 5/14/21, CNA 1 was changing Resident 1's disposable brief and soiled draw sheet. CNA 1 had raised Resident 1's bed waist high to protect CNA 1's back. Resident 1 was turned onto her right side and when CNA 1 was about to tuck in a clean draw sheet, Resident 1 slid off the bed onto the floor. Resident 1 was positioned on a LALM which had a slippery cover sheet, CNA 1 attempted to stop Resident 1 from rolling off the bed; however, due to Resident 1's weight and Resident 1 being positioned on the edge of the LALM, CNA 1 was unable to prevent Resident 1 from rolling off the bed. Resident 1 sustained a left forehead laceration and acute type II odontoid fracture. RN 1 stated CNA 1 verified no fall mats were in place at the time of Resident 1's fall. Review of the facility's Verification of Investigation dated 5/19/21, showed the causal and contributing factors to Resident 1's fall on 5/14/21, included Resident 1's slippery LALM and Resident 1 being positioned on the edge of the bed by CNA 1, which caused Resident 1 to roll off the bed onto the floor. RN 1 stated CNA 1's technique contributed to Resident 1's fall on 5/14/21. RN 1 stated CNA 1 was re-educated by the facility to ensure Resident 1 was first pulled closer to (CNA 1) when being turned in bed, in order to prevent Resident 1's weight being placed at the edge of the LALM. On 6/9/21 at 1101 hours, a telephone interview and concurrent facility document review was conducted with the DON. Review of the Facility's Verification of Investigation dated 5/19/21, showed the following causal/contributing factors: Resident 1 had a slippery LALM and the weight of Resident 1 was placed at the edge of the bed, that caused Resident 1 to roll off the bed onto the floor. The DON verified the Facility's Verification of Investigation findings dated 5/19/21. The DON was asked her belief as to the cause of Resident 1's fall on 5/14/21. The DON stated CNA 1 demonstrated poor technique when CNA 1 turned Resident 1. The DON stated CNA 1 was not a full-time staff member and was contracted by the facility as needed. The DON was asked if CNA 1 received education from the facility on how to properly position the residents on a LALM, or received education regarding Resident 1's risk for falls from a LALM, to which the DON replied, no not specifically. The DON was asked if Resident 1's fall on 5/14/21, could have been avoided ha