Other·February 24, 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 provide the necessary care and services to ensure one of two sampled residents (Resident 1) was free from accident hazards. * Resident 1 had a fall while being transferred on 9/14/20. The facility failed to investigate the fall and there were no interventions put in place to prevent Resident 1 from further falls. The Physical Therapist (PT) evaluated Resident 1 on 9/16/20, and recommended two-person assistance for transfers. This recommendation was not communicated to the nursing staff and was not implemented. This failure resulted in Resident 1 sustaining another fall during transfer on 12/5/20, with a fracture to the right leg, which required a transfer to an acute care hospital for surgical intervention. Findings: Review of the facility's initial report received from the Director of Nursing (DON) dated 12/6/20, showed Resident 1 had an assisted fall on 12/5/20 at 0920 hours, and sustained a distal femoral fracture to the right lower extremity (a fracture of the right thigh bone above the knee). Review of the facility's policy and procedure titled Fall Management System revised 2/2015 showed the fall incidents will be investigated to determine probable cause factors and the investigation will be reviewed by the interdisciplinary team (IDT). The summary of the investigation and recommendations will be documented in the resident's clinical record. Medical record review for Resident 1 was initiated on 12/11/20. Resident 1 was admitted to the facility on 9/24/19. Review of Resident 1's MDS (Minimum Data Set, an assessment tool) dated 9/23/20, showed Resident 1 had no cognitive impairment. Review of the Progress Notes showed the nursing entry dated 9/14/20, showing Resident 1 was being transferred by the Certified Nursing Assistant (CNA) from the toilet to her wheelchair and "...her legs gave way." The documentation showed the CNA held Resident 1 to prevent her from falling, and called for assistance. Another CNA came to assist with the transfer. Resident 1 was noted with a skin tear to the left lower leg. Review of the medical record failed to show documentation Resident 1's fall on 9/14/20, was investigated and reviewed by the interdisciplinary team. Review of the Rehabilitation Services Screening Tool dated 9/16/20, showed Resident 1 was seen by the PT due to a fall on 9/14/20, when transferring from the bedside commode by a CNA. The documentation showed Resident 1 was a high risk for falls with weight bearing activities. All transfers and gait training were to be performed with two CNAs or Restorative Nursing Assistants (RNA). Review of Resident 1's PT Discharge Summary dated 10/7/20, under Discharge Recommendations, showed Resident 1 required maximum assistance with two persons and a two-wheeled walker during transfers. The discharge plan showed the care planning conference was held with the interdisciplinary team to review Resident 1's functional skills and discharge plans. Review of Resident 1's plan of care showed a care plan problem addressing Resident 1's risk for complications related to activities of daily living (ADL) care and self-care performance deficit was developed on 10/6/19. The interventions included one to two staff participation with transfers. The care plan was not revised to reflect the recommendation by the PT on 9/16/20, for Resident 1 to be assisted by two CNAs or RNAs for transfers. The care plan also did not include the recommendations made by PT on the Discharge Summary dated 10/7/20, for Resident 1 to be provided with maximum assistance of two persons for ambulation using a two-wheeled walker. Cross reference to F657. Review of Resident 1's Documentation Survey Report (CNA's ADL flowsheet) from October to December 2020 showed inconsistencies of the number of persons required to assist Resident 1 during transfers. For example, for the month of October 2020, the documentation showed Resident 1 was provided with one-person physical assistance for transfers on the 0700 to 1500 hours shift from 10/1 to 10/16/20. However, on 10/17, 10/21, and 10/24/20, Resident 1 was provided with two-persons' physical assistance for transfers. Review of the Progress Notes showed an entry from RN 1 dated 12/5/20, showing the physician was notified Resident 1 had an assisted fall when she was being transferred by CNA 3 from the bed to shower chair due to her knees "...gave up." The documentation showed Resident 1's right knee was in a slightly inward position, with limited range of motion. The physician ordered a STAT (immediately) X-ray of the right knee. Review of Resident 1's right knee x-ray report dated 12/5/20, showed suspected nondisplaced supracondylar distal femoral fracture (fracture of the thigh bone at the knee). Review of Resident 1's Discharge Summary from the acute care hospital dated 12/8/20, showed Resident 1 was admitted to the acute care hospital on 12/6/20, for a closed fracture (when the bone broke but there was no open wound in the skin) of the distal end of the fibula (lower leg bone). The documentation showed Resident 1 presented to the emergency department with the right knee pain level of 10 (on a pain scale of 0 to 10 with 0 = no pain to 10 = severe pain). Resident 1 had an open reduction internal fixation of the right distal femur (surgery to stabilize and heal the right thigh bone) on 12/7/20. On 12/10/20 at 1100 hours, an interview was conducted with CNA 1. CNA 1 stated she was familiar with Resident 1's care and Resident 1 was able to stand and transfer with one-person assistance prior to the fall incident on 12/5/20. When asked if CNA 1 witnessed Resident 1 fell during a transfer from bed to shower chair on 12/5/20, CNA 1 stated no. CNA 1 stated she went into Resident 1's room after the fall incident and saw Resident 1 sitting on the floor with her legs stretched out. CNA 1 stated RN 1 came into Resident 1's room and assessed Resident 1. CNA 1 stated she assisted CNA 3 to transfer Resident 1 from the floor to the shower chair after the assessment. On 12/10/20 at 1400 hours, an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 1. CNA 2 stated she did not know the details of the fall incident but stated Resident 1 required one-person assistance for transfers prior to the fall incident. On 12/10/20 at 1430 hours, an interview was conducted with Resident 1. When asked what took place on the morning of 12/5/20, Resident 1 stated she was transferring from one chair to another with CNA 3 and her leg gave way which caused her to fall on her right side. Resident 1 stated CNA 3 tried to help her but could not. Resident 1 stated an x-ray of her right leg was done on 12/5/20, and she was transferred to the acute care hospital where she had surgery on her right leg. On 12/10/20 at 1505 hours, 1/8/2021 at 1512 hours, and 1/11/2021 at 0915 hours, an interview and concurrent medical record review was conducted with PT 1. PT 1 stated the last time she worked with Resident 1 was on 10/7/20. PT 1 verified the PT Discharge Summary dated 10/7/20, showed Resident 1 required two-person assist with a two-wheeled walker for all transfers. When asked if she communicated Resident 1's need for two-person assistance to the direct care staff, PT 1 stated no. PT 1 stated she usually communicated the resident's needs to the DSD or the charge nurse, but was unable to provide documentation to show Resident 1's needs were communicated on or after 10/7/20. PT 1 stated she completed the Rehabilitation Services Screening Tool on 9/16/20, after Resident 1 had a fall incident on 9/14/20. PT 1 stated she recommended all transfers for Resident 1 were to be performed with two CNAs/RNAs. PT 1 was unable to provide documentation to show she communicated or provided training to direct care staff after the screening tool was completed. On 12/10/20 at 1530 hours, 12/23/20 at 1509 hours, and 1/19/21 at 1016 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 1 required one-person assistance during transfers prior to the fall incident on 12/5/20. When asked if the IDT meeting was conducted for Resident 1 after the documented fall episode on 9/14/20, the DON stated no. The DON stated they did not consider the incident as a fall since the CNA prevented Resident 1 from falling when Resident 1's legs gave way during a transfer. The DON stated the incident was not investigated. When asked if a care planning conference for Resident 1 was conducted with the interdisciplinary team after Resident 1 was discharged from PT services on 10/7/20, the DON stated no. The DON verified the above findings. On 12/18/20 at 1550 hours, an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 1's care and Resident 1 required one-person assistance for transfers prior to the fall incident on 12/5/20. CNA 3 stated she assisted Resident 1 transfer from a wheelchair to a shower chair on the morning of 12/5/20. CNA 3 stated she positioned Resident 1's wheelchair and the shower chair next to each other and assisted Resident 1 from the wheelchair to a standing position. CNA 3 stated she let go of Resident 1 once Resident 1 was in a standing position and was balanced. CNA 3 stated Resident 1 attempted to transfer to the shower chair on her own from a standing position but fell. CNA 3 stated Resident 1 fell and caught herself on her bed and CNA 3 assisted her to the floor. CNA 3 stated she paged for assistance and RN Registered Nurse (RN) 1 and CNA 1 came into Resident 1's room. CNA 3 stated RN 1 assessed Resident 1. CNA 3 stated CNA 1 assisted in transferring Resident 1 from the floor to the shower chair. CNA 3 stated Resident 1 did not complain of pain after the fall. On 12/18/20 at 1630 hours, an interview was conducted with RN 1. RN 1 stated Resident 1 required one-person assistance for transfers prior to the fall incident on 12/5/20. RN 1 stated Resident 1 fell in her room on 12/5/20, while being assisted by CNA 3 to transfer from the wheelchair to the shower chair. RN 1 stated she did not witness the fall. RN 1 stated she observed Resident 1 on the floor after the fall and completed the physical assessment. RN 1 stated Resident 1's right knee was bent inward, appeared slightly larger than the left knee, but the skin was intact with no discoloration. RN 1 stated Resident 1 complained of a little pain but was able to move her right foot and toes. RN 1 stated three staff members assisted Resident 1 from the floor to the shower chair after the assessment. RN 1 stated she contacted Resident 1's physician immediately thereafter. On 1/8/2021 at 1330 hours, an interview and concurrent medical record review was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated Resident 1 required two-person assistance with more than 75 percent effort with a two-wheeled walker for all transfers. The Director of Rehabilitation stated the PT was responsible for informing and training the direct care staff as needed. When asked if Resident 1's needs and functional skills were discussed with the interdisciplinary team in October 2020, the Director of Rehabilitation stated he did not recall and was unable to provide documentation to show Resident 1's needs were communicated to the direct care staff. The above violation either jointly, separately, or in any combination, presented a direct or immediate relationship to patient health, safety, or security.