Health inspection·May 12, 2023

F689 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES §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 assistance and supervision for Resident 1. The facility failed to implement the self- care deficit care plan when certified nursing assistant C (CNA C) did not assist Resident 1 during toileting and left Resident 1 unsupervised inside the resident restroom. This failure resulted to Resident 1's fall with right intertrochanteric (hip) fracture and a decline in toilet use. Review of Resident 1's face sheet (a document that gives a resident's information) indicated, Resident 1 was admitted on 7/2022 with diagnoses including fracture (broken) of right pubis (pubic bone, one of the three sections of the hipbone, together these two bones form the front of the pelvis), syncope (fainting or passing out) and collapse (fall down), paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and history of falling. Review of Resident 1's fall risk assessment, dated 7/16/2022, score of 80 (High Risk score 45 and higher), indicating Resident 1 was a high risk for falling. The fall risk assessment indicated Resident 1 had history of falling, and she exhibited a weak gait (a manner of walking). Review of Resident 1's Self-Care Deficit care plan, dated 7/17/2022, indicated, "Toilet use - One person physical assist required." Review of Resident 1's admission minimum data set (MDS, an assessment tool) dated 7/19/2022, indicated brief interview for mental status (BIMS, cognition [includes memory, problem solving, and thinking skills] level) score was 14 (14 score means cognitively intact). Resident 1 required staff extensive assistance (staff provide weight-bearing support) with two-person physical assist for bed mobility, transfer, and toileting. The MDS indicated Resident 1 had a fracture related to a fall prior to entry at the facility. Review of Resident 1's Occupational therapist's notes, dated 8/24/2022, indicated, "Toilet transfers = Supervision (oversight, encouragement, or cueing was provided) or touching assistance (touching/steadying and/or contact guard assistance as resident completes activity); Toileting hygiene = Supervision or touching assistance; Toileting = Supervision or touching assistance." Review of Resident 1's significant change in status assessment MDS dated 9/7/2022, it indicated Resident 1 required extensive (resident involved in activity, staff provide weight-bearing support) assistance with one person. Review of Resident 1's fall report of incident dated 8/29/2022, indicated, "resident was found by CNA on the floor of the restroom" on 8/29/2022 at 8:15 a.m. The fall report of incident indicated, Resident 1 had an unwitnessed fall in the bathroom. The fall report of incident indicated Resident 1 "needs assistance" prior to the incident and the possible contributing factor of falling was Resident 1 "reaching to clean off toilet". Review of Resident 1's Post Fall Note 1, dated 8/29/2022 indicated, Resident 1 complained of right hip pain with shooting pain to right knee, and with limited range of motion (ROM- full movement of a joint, range of flexion and extension) to right lower leg. The Post fall Note 1 indicated, X-ray to the right hip was performed resulting to a broken hip bone. The doctor was notified about the X-ray result and ordered to send Resident 1 to the emergency department (ED). Review of Resident 1's Interdisciplinary Team's (IDT, team composed of members from different departments involved in resident's care) Fall Follow up dated 8/31/2022, indicated, "Resident was left in restroom by herself due to resident request for privacy. Resident was overconfident and got up without assist and lost balance and fell." The IDT Fall Follow up indicated, "...IDT recommendation CNA will give privacy, and will stand outside the door of restroom with frequent checks." Review of Resident 1's clinical records from the hospital titled, "Emergency Room Report," dated 8/29/2022, indicated, "Stated Complaint: FALL, RIGHT HIP PAIN...X-ray of hip bones Acute (present or experienced in a severe degree) right intertrochanteric (hip bone) fracture." During a phone interview with CNA C on 3/1/2023 at 9:30 a.m., CNA C confirmed she was assigned to assist Resident 1 to the resident's bathroom for toileting on 8/29/2022. CNA C stated Resident 1 required stand by assist (staff needs to be close by for safety in case the resident will lose balance or need help to maintain safety) with walking to the bathroom and limited assistance (staff provide guided maneuvering of limbs or other non-weight bearing assistance) with toileting. CNA C further stated Resident 1 asked her to go outside the resident's bathroom door. CNA C confirmed she stayed outside the resident's bathroom, but CNA C decided to leave the resident in the bathroom to get some towels outside Resident 1's room and then, she heard a loud sound from the resident's bathroom and found Resident 1 sitting on the floor. CNA C stated Resident 1 should not be left alone in the resident bathroom. CNA C further stated, "I just went out to get towels." During a phone interview with the RN D on 3/1/2023 at 10:49 a.m., RN D recalled Resident 1 fell inside the bathroom. RN D stated resident who was at risk of falling should have not been left alone in the bathroom. RN D further stated if resident requested for some privacy, staff should just stay by the bathroom door and never leave the resident. During a phone interview with the occupational therapist E (OT E) on 3/13/2023 at 3:15 p.m., OT E stated Resident 1 required a supervision (oversight, encouragement, or cueing) and touching assistance during toileting. OT E further stated Resident 1's touching assistance or stand by assist means a staff was needed to stand by during toileting to provide supervision to "prevent (her) from falling over." During a follow up phone interview with OT F on 3/13/2023 at 3:25 p.m., OT F stated Resident 1 required minimum (resident did 75 percent of activity and staff provided 25 percent assistance) to moderate (resident did 50 percent of activity and staff provided 50 percent assistance) assistance with unsupported (no use of assistive device like walker) standing balance. OT F further stated Resident 1 required supervision to stand by assistance with toileting prior to the fall. OT F stated stand by assistance was required, to have somebody with Resident 1 when she needed help. OT F stated Resident 1's fall could have been prevented if someone stayed with her inside the bathroom. During an interview with the restorative nursing assistant (RNA, healthcare professionals who are responsible for providing restorative and rehabilitation care for residents to maintain or regain physical, mental, and emotional well-being) on 1/12/2023 at 12:20 p.m., the RNA stated she would get report from their supervisor if a resident was at risk of falling. RNA further stated she should never leave a resident alone in the bathroom if they were at risk of falling. During an interview with the director of staff development (DSD - a licensed nurse that provides in-service orientation for all nursing and facility personnel to include federal and state mandated education) on 1/12/2023 at 1:00 p.m., the DSD stated staff should not leave a resident alone in the bathroom if they were at risk of falling. During an interview with the licensed vocational nurse A (LVN A) on 1/12/2023 at 1:32 p.m., LVN A stated nurses did the fall risk assessment to determine if a resident was at risk of falling. LVN A further stated nurses would check for resident's history of falling, diagnoses and balance while walking. LVN A stated CNA's should not leave a resident alone in the bathroom especially with history of falling and injury from a fall. LVN A confirmed she helped the staff when they found Resident 1 on the floor inside the bathroom. LVN A stated she was aware Resident 1 had history of falling with previous fracture. During an interview with CNA B on 1/12/2023 at 2:00 p.m., CNA B stated she would stay with a resident at risk of falling inside the bathroom to prevent from falling by providing assistance or supervision. Review of the facility's policy and procedure titled, "Falls Management," dated October 2010, indicated, "PURPOSE * To evaluate risk factors and provide interventions to minimize risk, injury, and occurrences." This failure had direct relationship or immediate relationship to the health, and safety of the resident.