Other·November 5, 2025

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. Based on interview, medical record review, facility document review, and facility P&P (Policy and Procedures) review, the facility failed to provide the necessary care and services to ensure one of three sampled patients (Patient 1) was free from accident hazards. * Patient 1 had an unwitnessed fall incident on 9/18/25. The facility failed to investigate Patient 1's family member's grievance regarding Patient 1's position near the edge of the bed on 9/16/25. Patient 1's fall risk assessment was inaccurate resulting in an incorrect fall risk score status. In addition, the facility failed to update Patient 1's care plan addressing the patient's risk for fall and his behavior of dangling his legs off the bed prior to his fall incident. These failures resulted in Patient 1 sustaining a subdural hematoma (a collection of blood that accumulates between the brain and the inner layer of the skull) and hospitalization. Findings: Review of the facility's P&P titled Grievance/Complaint Log revised 4/2008 showed the Social Services will be responsible for the grievance log. The following information as a minimum must be recorded: a) The date the grievance/complaint was received; b) The name and room number of the patient following the grievance complaint; c) The name and relationship of the person filing the grievance/complaint in behalf of the patient; d) The date the alleged incident took place; e) The name of the person (s) investigating the incident; f) The disposition of the grievance (i.e., resolved, dispute, etc.,). Review of the facility's Fall Program: Falling (Yellow) Star Program (undated) showed the IDT (Interdisciplinary Team) will review appropriate interventions for the patients identified as a fall risk; interventions will be based on the patient's fall risk factors from assessments, history of falls, and other fall risk determinants. The DON (Director of Nursing) and DSD (Director of Staff Development) will re-educate the nursing staff about the Falling Star Program which will include the frequency of monitoring the patients and interventions to minimize injuries from a potential fall. a. Medical record review for Patient 1 was initiated on 10/1/25. Patient 1 was admitted to the facility on 12/10/24. Patient 1 had diagnoses which included diffuse traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow or jolt to the head), history of falling, and anoxic brain damage (a condition where the brain was deprived of oxygen for a period of time). In addition, Patient 1 was hospitalized on 9/18/25, and returned to the facility on 9/25/25. Review of Patient 1's H&P (History and Physical) examination dated 4/24/25, showed Patient 1 was nonverbal and had no capacity to make medical decisions. Review of Patient 1's MDS (Minimum Data Set- an assessment tool) assessment dated 8/1/25, showed Patient 1 was dependent on the facility staff assistance to roll from lying on his back, to the left and right sides, and return to lying on his back on the bed. Further review of Patient 1's MDS assessment showed to code the patient dependent when the patient did not provide any effort to complete the activity, or the assistance of two or more helpers were required for the patient to complete the activity. In addition, the MDS assessment showed Patient 1 had an impairment on both upper and lower extremities that interfered with daily functions. Review of Patient 1's Grievance / Complaint Report Form dated 9/16/25, showed the department manager would investigate the allegations and submit a written report of the findings to the Administrator within five working days of receiving the grievance. Patient 1's grievance form showed Patient 1's family member complained regarding the patient's legs positioned towards the edge of the bed and informing a CNA (Certified Nursing Aide) to reposition the patient. Under the sections for witnesses and employees to describe the incident and to describe the findings of the incident showed "N/A (Not Applicable)" was documented. Under the Recommendations/Corrective Action Taken section showed an in-service was initiated for the licensed nurses and CNAs on 9/17/25, about proper positioning in bed. However, further review of Patient 1's medical record failed to show documentation the facility monitored and/or provided additional interventions to prevent the patient from falling after the grievance from the patient's family member was filed. Review of Patient 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 9/18/25, showed Patient 1 had an unwitnessed fall incident, where he was found lying on the floor near the right side of his bed. Patient 1 was noted to have a bump on the right side of his forehead. Patient 1 was on an anticoagulant (blood thinner) medication and the physician ordered to transfer Patient 1 to the acute care hospital for an evaluation and treatment. Review of Patient 1's Admission H&P note from Acute Care Hospital A dated 9/18/25, showed Patient 1 fell around two feet from the bed onto the ground and striking his head. The CT of the head (computed tomography scan of the head is an imaging test that uses X-rays to create detailed cross-sectional images of the brain, skull, and sinuses) result showed a small 2 mm (size) right frontal subdural hematoma. b. Review of the facility's P&P titled Falls - Clinical Protocol revised 3/2018 showed the staff will identify the patient's risk factors for falls and history of falling. The nurse shall assess the patient and document the patient 's vital signs, musculoskeletal function, and observe for change in normal range of motion. In addition, the staff will identify, monitor, and document the interventions related to the patients' risk of falls and re-evaluate the current approaches as needed to prevent subsequent falls. Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective, complete, and accurate. Review of Patient 1's IDT Conference Record-RNA (Restorative Nursing Aide) Follow Up dated 4/5/25, showed Patient 1 was bed bound. Review of Patient 1's Quarterly MDS assessment dated 6/16/25, showed Patient 1 was dependent on the facility staff assistance on toileting hygiene, and was always incontinent with the urinary and bowel continence. Review of Patient 1's MAR (Medication Administration Record) for July 2025 showed Patient 1 was administered with the following medications: - from 7/1 to 7/31/25, Patient 1 was administered amlodipine (used to treat high blood pressure)10 mg one tablet via GT (Gastrostomy Tube- a tube inserted through the belly that brings nutrition directly to the stomach) in the morning for hypertension (high blood pressure); - from 7/1 to 7/31/25, Patient 1 was administered 5 ml of levetiracetam (anticonvulsant) 100 mg/ml oral solution via GT one time a day for seizures (a sudden burst of electrical activity in the brain); - on 7/17/25 at 2218 hours, Patient 1 was administered Ativan (antianxiety) 2 mg/ml intravenously every four hours as needed for seizure disorder. Review of Patient 1's N Adv - Fall Risk Evaluation dated 7/24/25 at 1604 hours, showed the following: - For the ambulation and elimination status, the documentation showed Patient 1 was chairbound/incontinent; however, Patient 1 was bedbound and incontinent. - For medications, the documentation showed Patient 1 was taking one to two of these medication classes (anesthetics, antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics) within the last seven days; however, Patient 1 was taking three of the medication classes (antihypertensive, antiseizure, and psychotropic medication) . The Fall Risk Evaluation further showed if the total score was 10 or greater, the patient would be considered at high risk for potential falls and preventions should be initiated immediately and documented on the care plan. Review of Patient 1's progress notes correlating with the N Adv - Fall Risk Evaluation dated 7/24/25 at 1604 hours, showed the patient's fall risk score was nine. On 10/2/25 at 1256 hours, a follow up interview and concurrent medical record review for Patient 1 was conducted with LVN (Licensed Vocational Nurse) 1. LVN 1 verified the Fall Risk Evaluation was inaccurate and based on the patient's MAR, the fall risk score would be higher than nine, to show Patient 1 would be at a high risk for fall. c. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed the care plan interventions are implemented after careful data gathering of the patient's problem areas and their causes. In addition, the assessments of the patients are ongoing, and care plans are revised as information about the patients change. Review of Patient 1's plan of care initiated 12/10/24, and revised 10/1/25, showed a care plan problem addressing the patient's risk for falls. The interventions included to anticipate and meet the patient's needs, review information on past falls and attempt to determine the cause of the falls, record the possible roots cause, remove potential causes (for the falls) if possible, initiate the Falling Star Program, apply the yellow wrist band on the patient, place a yellow star by the door next to the patient's name, place the patient's bed in the lowest position and place the call light within reach. The care plan failed to show a new intervention was added or modified to prevent fall after the grievance of the patient's family member regarding the patient's episode of patient's legs positioned towards the edge of the bed or the behavior of dangling his legs over the bed. Further review Patient 1's care plan showed interventions were added to the patient's care plan on 9/20/25, after the patient's fall on 9/18/25, which included providing frequent visual checks, positioning the patient in the middle of the bed, and putting pillows on the patient's sides. On 10/1/25 at 1600 hours, an interview was conducted with LVN 1. LVN 1 stated on 9/18/25 at around 0840 hours, she found Patient 1 on the floor near the right side of his bed. LVN 1 stated she assessed Patient 1 and saw a bump on his forehead, before placing him back on his bed with CNA 1's assistance. LVN 1 stated the physician ordered to transfer Patient 1 to the acute care hospital for an evaluation. When asked if LVN 1 was aware of Patient 1's behavior of dangling his legs over the bed, LVN 1 stated the patient would cross his legs near the edge of his bed and slide down on the bed, when he was on the low air loss mattress. On 10/2/25 at 1020 hours, an interview was conducted with CNA 1. CNA 1 stated Patient 1 would cross his legs all the time during his scheduled shifts. CNA 1 added the Patient 's legs would hang over the bed, and the patient would slide down on the low air loss mattress. CNA 1 stated he had informed the licensed nurses about Patient 1's behavior but was not aware if interventions were implemented for Patient 1 regarding the behavior of hanging his legs over the bed. On 10/2/25 at 1233 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she filed a grievance on 9/16/25, with the facility, because Patient 1's legs were hanging off the bed and he was close to falling from the bed. Family Member 1 stated the facility staff informed her they would speak to the DON to address Patient 1's behavior and come up with a plan. On 10/2/25 at 1256 hours, a follow up interview and concurrent medical record review for Patient 1 was conducted with LVN 1. LVN 1 stated she did not document Patient 1's ability to cross his legs in his medical record and verified there was no documentation in Patient 1's progress notes regarding his ability to cross or move his legs over the bed. LVN 1 further stated she would have initiated a care plan for Patient 1's behavior of hanging his leg over the bed so the facility staff would be aware of any interventions implemented. LVN 1 reviewed Patient 1's N Adv - Fall Risk Evaluation dated 7/24/25, and Patient 1's MAR for 7/2025. LVN 1 verified the Fall Risk Evaluation was inaccurate and based on the patient's MAR, the fall risk score would be higher and show Patient 1 would be at a high risk for fall. On 10/2/25 at 1548 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated when a grievance was filed, the SSD (Social Services Director) should notify the responsible staff who oversaw the department, interview the facility staff involved, and update the patient's care plan. The DON verified she only updated Patient 1's care plan regarding the grievance after the patient's fall incident. On 10/8/25 at 0957 hours, an interview was conducted with the Interim DSD. The Interim DSD stated the SSD spoke to her regarding Family Member 1's grievance about Patient 1's legs dangling off the bed and their concern of Patient 1 falling out of bed. The Interim DSD stated she provided an in-service to the facility staff about repositioning the patients. When asked if the Interim DSD implemented any additional interventions for Patient 1's risk for falls, the Interim DSD stated just the intervention to reposition the patient. On 10/8/25 at 1045 hours, an interview and concurrent facility document review of Patient 1's Grievance Form was conducted with the SSD. The SSD stated she was responsible for investigating the facility's grievances. When asked how the SSD investigated the grievance from Family Member 1, the SSD stated she informed the Interim DSD about Family Member 1's concern and the Interim DSD agreed to do an all-facility staff in-service about positioning the patients. The SSD verified she did not interview any facility staff members about Patient 1's behavior of hanging his legs over the bed. On 10/8/25 at 1156 hours, a follow-up interview and concurrent facility document review for Patient 1 was conducted with the DON. The DON stated based on Patient 1's Grievance Form, the documented "N/A" on the form showed the grievance was not investigated because the facility staff were not interviewed. In addition, the DON stated the facility should have implemented interventions for Patient 1 regarding Family Member 1's grievance. The DON verified Patient 1's fall risk evaluation was inaccurate and stated if the correct assessment was conducted, Patient 1's fall risk score would have increased to show the patient was high risk for fall. On 10/10/25 at 1607 hours, a telephone interview was conducted with the DON and Medical Records Director. The DON and Medical Records Director were informed and acknowledged the above findings. This violation had a direct or immediate relationship to the health, safety or security of the patients.