Other·January 9, 2024

§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. INTENT: 483.25(d) Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) remained free from accident hazards. * Resident 1 sustained 6 falls while having resided in the facility. Resident 1 sustained the falls on 9/15 (twice), 9/21, 9/26, 10/11, and 10/24/23. After Resident 1's fourth fall in the facility, the facility's IDT recommended and implemented the 1 to 1 staff supervision on Resident 1. However, the 1 to 1 supervision was not always provided to Resident 1. As a result, Resident 1 sustained another fall on 10/24/23, resulting in multiple fractured ribs which required the ORIF surgery for Resident 1's right seventh through 10th ribs. Findings: Review of the facility's P&P titled Falls Management Program revised 1/2019 showed the purpose of the fall management program is to provide residents with a hazard free environment, adequate supervision and reduce risk factors leading to falls and injury. The facility will provide residents with adequate supervision to prevent accidents. It is also the policy of the facility to investigate the circumstances surrounding the resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. The Interdisciplinary Team (IDT) will reassess the risk factors contributing to falls and (implement) interventions to minimize recurrence of falls and injury during the initial, quarterly, and annual assessment, post fall, and when a significant change of condition is identified. Review of the facility's P&P titled Safety and Supervision of Residents revised 7/2017 showed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision. Implementing interventions to reduce accident risks and hazards shall include the following: communication specific interventions to all relevant staff, assigning responsibility for carrying out interventions, and ensuring that interventions are implemented. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Closed medical record review for Resident 1 was initiated on 12/4/23. Resident 1 was admitted to the facility on 8/25/23, and discharged on 10/25/23, to the acute care hospital. Review of Resident 1's Baseline Admission Screening dated 8/25/23 at 2205 hours, showed Resident 1 was admitted to the facility with a diagnosis of status post right femur fracture and dementia. Review of Resident 1's MDS dated 8/29/23, showed Resident 1 had severely impaired cognition. Resident 1's Morse Fall Risk Screen dated 8/25/23, showed Resident 1 was a high risk for falls. Resident 1's fall risk included a history of falls, impaired gait, and an overestimation of limits of abilities to ambulate safely. Review of Resident 1's care plan titled Altered Thought Process initiated on 9/12/23, showed Resident 1 had a short-term memory problem, poor decision making, problems understanding others, and problems making her needs known. Review of Resident 1's care plan titled High Risk for Falls and Injury related to the right femur fracture, difficulty walking, and multiple falls showed an intervention initiated 10/17/23, to instruct the resident's responsible party and visitors not to leave the resident unattended during the visits and call the staff's attention before ending the visitation. Review of Resident 1's medical record showed Resident 1 had sustained 6 falls while residing in the facility. Documentation in Resident 1's medical record showed Resident 1 fell on 9/15 (twice), 9/21, 9/26, 10/11, and 10/24/23. * Review of Resident 1's SBAR dated 9/15/23 at 1740 hours, showed Resident 1 had an unwitnessed fall in her room. Resident 1 was found lying on her left side on the floor. Per Resident 1's interview, she rolled out of bed onto the floor looking for her family member. Resident 1 complained of the pain level of 3 of 10 (on the 0-10 pain scale with 0 = no pain and 10 = worst pain) on her left forehead and right hip surgery site. * Review of Resident 1's SBAR dated 9/15/23 at 2100 hours, showed Resident 1 had an unwitnessed fall. Resident 1 was found lying on the floor. Per Resident 1's interview, she rolled out of her bed, looking for her family member. Resident 1 complained of pain on her right hip and was transferred to the acute care hospital. * Review of Resident 1's IDT Note dated 9/18/23 at 1335 hours, showed the IDT had met and discussed Resident 1's fall incident. The IDT's recommendations included to closely supervise the resident and put Resident 1 on the hourly checks. Resident 1's family member was interviewed and stated Resident 1 had the same behaviors at home, trying to get out of bed unassisted. * Review of Resident 1's SBAR dated 9/21/23 at 2011 hours, showed Resident 1 had an unwitnessed fall. Resident 1 stated she was trying to grab something; however, Resident 1 was unable to specifically identify what she had attempted to grab. * Review of Resident 1's SBAR dated 9/26/23 at 1226 hours, showed Resident 1 sustained a fall. Resident 1 rolled out of her bed and landed on her knees. * Review of Resident 1's IDT Note dated 9/27/23 at 1326 hours, showed the IDT had met and discussed Resident 1's fall incident. The IDT recommended to continue with the PT/OT services, encourage Resident 1 to use the call light at all times, and provide 1:1 supervision. * Review of Resident 1's SBAR dated 10/11/23 at 1330 hours, showed Resident 1 sustained a fall. The nurse immediately went into Resident 1's room after receiving a report that Resident 1 was observed to be agitated. A nurse witnessed Resident 1 trying to crawl out of bed, however, too late to intervene, and Resident 1 fell on her knees onto the floor. Resident 1 was looking for her family member. Resident 1 observed with a right knee abrasion and having pain on her lower back and neck at the pain level of 6. * Review of Resident 1's IDT Note dated 10/12/23 at 1401 hours, showed the IDT had met and discussed Resident 1's fall incident. The IDT recommended to continue PT/OT services, encourage to use the call light at all times, and provide 1:1 supervision. * Review of Resident 1's SBAR dated 10/24/23 at 2330 hours, showed Resident 1 sustained a fall. Facility staff heard a noise and immediately went to Resident 1's room and found Resident 1 on the floor. Resident 1's right trunk was leaning against the chair next to her bed. Resident 1 was interviewed and said she wanted to use the bathroom, and when she stood up, she lost her balance and fell, hitting her rib/chest on the chair handle. Resident 1 stated, "ouch my rib, it hurts when I breath." Resident 1 was in extreme pain and was subsequently transferred to Acute Care Hospital 1. Review of the Acute Care Hospital 1 Hospitalist Discharge Summary dated 10/25/23 - 10/31/23, showed Resident 1 was admitted to Acute Care Hospital 1 on 10/25/23. Hospital course/significant findings showed Resident 1 had another mechanical fall at the skilled nursing facility, resulting in fractures of the right seventh through 10th ribs. Resident 1 subsequently underwent the ORIF surgery to treat her rib fractures. On 12/11/23 at 1500 hours, an interview was conducted with Resident 1's DPOA for healthcare (Family Member 1). Family Member 1 stated LVN 1 contacted her and informed her Resident 1 sustained a fall at the facility on 10/24/23 at approximately 2330 hours. Family Member 1 stated she asked LVN 1 how Resident 1 fell, being Resident 1 was supposed to receive 1 to 1 supervision. Family Member 1 stated LVN 1 informed her that CNA 1 had left Resident 1 for a moment, at which time Resident 1 then fell. The interviews were conducted with the facility staff who observed Resident 1 after she fell on 10/24/23 at 2330 hours. On 12/5/23 at 1307 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 had fallen several times, and as a result of multiple falls at the facility, Resident 1 was provided with 1 to 1 staff supervision. The 1 to 1 staff was assigned to provide constant supervision of Resident 1, in order to prevent Resident 1 from sustaining another fall. LVN 1 stated at the time of Resident 1's fall on 10/24/23 at 2330 hours, CNA 1 was assigned as Resident 1's 1 to 1 staff. LVN 1 was asked to describe what he observed on 10/24/23 at 2330 hours, at the time Resident 1 sustained a fall. LVN 1 stated at the time of Resident 1's fall, CNA 1 (1 to 1 staff) had left Resident 1's room and had gone to obtain a blanket. LVN 1 stated when CNA 1 left Resident 1 alone, Resident 1 sustained a fall. LVN 1 stated Resident 1 was to receive constant supervision, and Resident 1 should not have been left unsupervised. LVN 1 stated after Resident 1 had fallen, he entered Resident 1's room. LVN 1 stated he saw Resident 1 hunched over a chair located next to her bed, and Resident 1 was clutching her right rib. LVN 1 stated Resident 1 was then transferred to the acute care hospital. On 12/5/23 at 1330 hours, an interview was conducted with RN 1. RN 1 stated she was assigned to care for Resident 1, at the time of her fall on 10/24/23 at 2330 hours. RN 1 stated Resident 1 was assigned a 1 to 1 sitter at the time of her fall. RN 1 stated the 1 to 1 sitter was to provide constant supervision, always having Resident 1 within sight of the assigned 1 to 1 staff. RN 1 stated constant supervision was provided to Resident 1 due to Resident 1 having episodes of confusion, forgetfulness, and being a fall risk with multiple falls in the facility. RN 1 stated if staff was not with Resident 1, Resident 1 would try to get up from her bed. RN 1 was asked to describe what she observed on 10/24/23 at 2330 hours, at the time Resident 1 sustained a fall. RN 1 stated at the time of Resident 1's fall, CNA 1 (1 to 1 staff) left Resident 1 to obtain linens, at which time Resident 1 sustained a fall. RN 1 stated Resident 1 had tried to get up to use the bathroom and Resident 1 stated she fell and hit her ribs on the armchair in her room. Resident 1 complained of pain with breathing and was subsequently transferred to the acute care hospital. RN 1 stated CNA 1 should not have left Resident 1 unsupervised. On 12/5/23 1444 hours, an interview was conducted with CNA 1. CNA 1 stated he was assigned to care for Resident 1, at the time of her fall on 10/24/23 at 2330 hours. CNA 1 stated he was assigned as Resident 1's 1 to 1 staff. CNA 1 stated Resident 1 required constant supervision, and he was required to keep Resident 1 within his sight as Resident 1 was a fall risk and had the tendency to get up out of bed on her own without assistance. CNA 1 stated at the time of Resident 1's fall, he was also assigned to care for other residents in addition to Resident 1. CNA 1 stated if he had to leave Resident 1 to provide care for other residents, CNA 1 would ensure another staff member would provide 1 to 1 observation of Resident 1 while he provided care to other residents. CNA 1 was asked to describe what had occurred on 10/24/23 at 2330 hours, at the time Resident 1 sustained a fall. CNA 1 stated another resident had activated a call light, at which time CNA 1 left Resident 1. CNA 1 stated he went to the nursing station, to locate another staff member who could provide 1 to 1 supervision for Resident 1, as to allow CNA 1 to answer the call light. CNA 1 stated he went into the nursing station for approximately one minute at which time Resident 1 fell. CNA 1 stated he could not see Resident 1 from the nursing station at the time Resident 1 fell. On 12/5/23 at 1338 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated she had attended Resident 1's IDT meetings on 9/27/23 at 1326 hours, and 10/12/23 1401 hours. The DON verified the IDT recommended Resident 1 would be provided 1 to 1 supervision. The DON stated Resident 1 was to be provided constant visual 1 to 1 supervision by the facility staff. The DON stated 1 to 1 constant supervision was implemented due to Resident 1's episodes of confusion, unsteady gait, and history of multiple falls at the facility. The DON stated Resident 1's responsible party was also informed Resident 1 was to receive constant 1 to 1 supervision by the facility staff as per the IDT meetings on 9/27 and 10/23/23. The DON stated the facility had conducted an investigation specific to Resident 1's fall sustained on 10/24/23 at 2330 hours. The DON stated CNA 1 should not have left Resident 1 unsupervised at the time of Resident 1's fall. The DON stated her expectation was CNA 1 should have ensured another staff member was in place to provide constant supervision of Resident 1 before CNA 1 left Resident 1 and/or when Resident was no longer within CNA's sight. This violation had a direct or immediate relationship to the health, safety or security of the resident.