Other·January 20, 2022

F 689 §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 Resident 1 was free from accident hazards. Resident 1 fell from the shower gurney on 10/23/21, sustaining neck and pelvis fractures, and resulting in a transfer to the acute care hospital. Findings: Review of the Manual Shower Bed's Owner's Manual dated 11/2018 showed before each use, check to ensure all casters are properly secured to the device and the device is stable. Do not use device if it appears wobbly or unstable, the casters are rusted or fail to move easily, the fabric appears torn or weak, cracks are observed in the fittings, or the device appears to be compromised in any way. If you suspect a device is not functioning as intended, do not use device. This device may not be suitable for all individuals. A skilled caregiver should always assess the appropriateness of any device for an individual on a case-by-case basis. Review of the facility's document titled Unusual Occurrence Fall dated 10/25/21, showed the facility concluded the pin holding the side rail of the shower gurney in the upright position was inserted; however, the latch was possibly not secured properly. When the resident was moving, the pin became dislodged and the resident fell when he shifted his weight to the left side. Medical record review for Resident 1 was initiated on 11/2/21. Resident 1 was readmitted to the facility on 10/24/21. Review of the Minimum Data Set (MDS - a standardized assessment tool) dated 8/16/21, showed Resident 1 had severe cognitive impairment and required total assistance from one staff with bathing. Review of the Point of Care History (Certified Nursing Assistant's [CNA) activities of daily living [ADL] flowsheet) from 10/20 to 10/23/21, showed Resident 1 received one-person assistance with bathing. Review of the plan of care showed a care plan problem dated 7/6/21, addressing Resident 1's ADL functions. The care plan showed Resident 1 was totally dependent on two-person assistance during the shower. Resident 1 would be provided with two-person assistance at all times secondary to constant moving during ADL care. Review of the Nursing Progress Notes dated 10/23/21 at 1810 hours, showed the CNA called the licensed nurse for help from the shower room. Resident 1 was found lying on the floor with a bloody forehead and nose. The documentation showed the paramedic team was called. Review of the SBAR (Situation Background Assessment Response) Communication Form dated 10/23/21 at 1820 hours, showed Resident 1's physician was notified regarding the resident's fall while being given a shower. The documentation showed Resident 1 sustained forehead and nasal bleeding. The physician ordered to transfer Resident 1 to the acute care hospital for further evaluation and treatment. Review of the acute care hospital's Emergency Department Consult dated 10/23/21, showed the following: - The CT (Computed Tomography - a diagnostic tool for detecting diseases and injuries) of the spine dated 10/23/21, showed an acute fracture of C1 (the first cervical [neck] vertebra, called the atlas, which supports the head) and associated bilateral acute non-displaced fracture of the posterior arch of C1; non-displaced fracture (the bone breaks but does not move out of alignment) of the base of the dense consistent with a type 2 odontoid fracture (break that occurs through a specific part of the second bone in the neck); a non-displaced fracture of the spinous process of C5 ( a break in a part of the spinal bone); and associated non-displaced fracture of the left interior facet of C4 (fourth bone in the neck). - The x-ray of the pelvis (lower part of the torso) dated 10/23/21, showed a possible acute non-displaced fracture of the bilateral superior public rami (pelvic bone). On 11/2/21 at 1058 hours, an observation of the shower gurney and concurrent interview was conducted with CNA 4 and Registered Nurse (RN) 2. CNA 4 stated there was a separate shower gurney for the residents on isolation in the Subacute Unit. RN 2 stated the shower gurney was kept outside to dry. RN 2 unlocked the door to go to the outside of the facility where the shower gurneys were kept. CNA 4 and RN 2 pointed to a shower gurney and stated this was the shower gurney used for isolation. CNA 4 demonstrated how to secure the side rail. CNA 4 was observed raising the side rail up, inserting the silver pin into the hole of the side rail, and shaking the side rail. CNA 4 stated when you shook the side rail, it should be secured. On 11/2/21 at 1120 hours, an interview was conducted with CNA 2. CNA 2 verified he showered Resident 1 on 10/23/21, and stated he was present during the fall. CNA 2 stated Resident 1 required total care for his ADL care, including showers. CNA 2 stated the shower gurney had bilateral side rails with a pin and locked mechanism to secure the side rail up. CNA 2 stated the side rail had a hole where the pin was placed to hold the side rail up. CNA 2 stated he placed the pin in the hole of the side rail but was unsure if the pin was locked and secured in place. CNA 2 stated with this specific shower gurney, the pin could not be seen to ensure it was secured because the pin was short. CNA 2 stated the shower gurney was so big and filled up the space in the shower, so another person could not fit. CNA 2 stated he proceeded to shower Resident 1 alone by himself while the resident was in the shower gurney. During the shower, Resident 1 kept moving from side to side, and the pin came off and the side rail fell. CNA 2 stated he could not catch Resident 1 and the resident sustained a fall. CNA 2 stated when the side rail moved, the pin could come off easily. CNA 2 stated whenever a facility equipment was broken, the staff was required to report the broken equipment to the Supervisor. CNA 2 stated he did not report his issues and concerns with the shower gurney to the Supervisor. On 11/2/21 at 1238 hours, an interview and concurrent facility document review was conducted with the Maintenance Director. The Maintenance Director stated she inspected the shower gurney monthly. Review of the facility's document titled Bed Shower Gurney Repair showed the shower gurney was inspected on 10/7, 10/24, and 10/28/21. The Maintenance Director verified she inspected the equipment on 10/24/21, after Resident 1 fell, and conducted a repair on 10/28/21, with the replacement of locking casters. On 11/2/21 at 1400 hours, an observation was conducted of Resident 1. Resident 1 was lying in bed on his back, asleep. Resident 1 was observed with a neck collar and brace around his neck. On 11/2/21 at 1410 hours, an interview was conducted with the Director of Staff Development (DSD). The DSD stated she was tasked to help conducting an investigation regarding Resident 1's fall on 10/23/21. The DSD verified the conclusion of the fall and incident was related to the defective equipment. The DSD stated during her investigation, it was verified the latch and pin securing the side rail was not fully locked or secured. The DSD stated the CNAs should check the lock and pin and verify it was secured when the shower gurney was in use. On 11/2/21 at 1440 hours, an interview was conducted with the Director of Nursing (DON). The DON verified Resident 1 sustained a fall on 10/23/21, and required a transfer to the acute care hospital. The DON stated Resident 1 sustained the neck and pelvis fracture from the fall. On 12/09/21 at 1450 hours, a telephone interview was conducted with RN 1. RN 1 stated she responded to Resident 1's fall in the shower. RN 1 stated when she arrived in the shower room, Resident 1 was lying on the floor and bleeding from the nose, and had a forehead laceration. RN 1 stated she applied pressure and a bandage to the forehead laceration and called 911. RN 1 stated when the paramedic team arrived, they transferred Resident 1 to the acute care hospital. On 12/09/21 at 1515 hours, a telephone interview was conducted with CNA 1. CNA 1 stated she witnessed Resident 1's fall on 10/23/21. CNA 1 stated when it was time for Resident 1's shower, she and CNA 2 used the hoyer lift (mobility tool used to help persons with mobility challenges get out of the bed) and placed Resident 1 in the shower gurney. CNA 1 stated she checked the side rail to make sure it was locked. CNA 1 stated during the shower, Resident 1 moved in bed and the pin fell out, the side rail dropped, and Resident 1 fell off the shower gurney. When asked if she had issues with the shower gurney, CNA 1 stated sometimes there were issues with the pin being loose, but she did not report the issues to the maintenance staff or Supervisor. CNA 1 stated the facility's policy for broken or faulty equipment was to report it to the Supervisor. The above violation either jointly, separately or in any combination had a direct or immediate relationship to the resident's healthy, safety or security.