Health inspection·July 27, 2021

F689 483.25(d)(1)(2) 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 ensure an accident-free environment for 10 of 18 residents reviewed for fall, when: 1. Resident 10 had no fall risk assessment and neuro-checks (evaluation of person's nervous system) completed after she fell on the floor on 1/10/21 and 2/07/21 while she was turning on her bed. Also, staff did not develop a new fall prevention intervention to prevent fall recurrence. Resident 10 complained of headache, neck and back pain and was transferred to the hospital for evaluation. 2. For Resident 19, there were no fall risk assessment and neurochecks completed after each fall episode. Also, Resident 19's fall care plan did not develop new interventions to prevent fall recurrence. Resident 19 fell on the floor from the wheelchair in her room on 5/6/21 while attempting to use the restroom. She stood up then lost her balance and slid to the floor which resulted in an abrasion on her midback. 3. For Resident 68, the facility did not complete fall risk assessments after each fall, and did not develop a new fall prevention intervention after her recent fall on 4/4/21. Resident 68 fell on the floor in her room on 4/4/21 and sustained subdural hematoma (type of bleed that occurs within the skull of head), hence transferred to the hospital for observation. 4. For Resident 83, the facility did not complete a fall risk assessment after each fall and did not develop a new fall prevention intervention after his latest fall. 5. For Residents 40, 43, 46, 82 and 337, there were no post fall risk assessments completed after each resident's fall episodes. 6. For Resident 342, there was no SBAR done when Resident 342 fell on the floor in the shower room on 7/04/21. Also, staff did not notify the physician about this fall incident. 1. During review of Resident 10's clinical record, Resident 10 was admitted on 10/27/20 with diagnoses included cerebrovascular disease (stroke, damage to the brain from interruption of its blood supply), acquired absence of left leg above knee, and muscle weakness. Review of the quarterly MDS dated 4/15/21, indicated Resident 10 required extensive assistance with two-person physical assist during activities of daily living. During interview with Resident 10 on 07/09/21, at 9:10 a.m., Resident 10 stated, "it hurts so bad especially in my right leg. I hope I'll not fall again. I guess we'd have to be more careful." During review of Resident 10's SBAR dated 1/10/21 indicated, "...at 0700 am, found on floor next to bed, attempting to turn over and slid from bed, complained of headache, left rib and hip pain. transferred to hospital." Review of Resident 10's SBAR dated 2/07/21, indicated Resident 10 fell at 0030 from bed which occurred during self-transfer in her room while she was turning onto side. She then hit her head twice on the armchair and fell on the floor. Resident 10 complained of headache, neck and back pain. Resident was immobilized and 911 call was initiated. Review of Resident 10's clinical record indicated there was no fall risk assessment and neurochecks completed after Resident 10 fell on 1/10/21 and 2/07/21. Also, Resident 10's fall care plan did not develop new interventions to prevent fall recurrence. During interview with LVN L on 7/9/21 at 12:15 p.m., LVN L acknowledged the above findings, and stated it should have been done after the fall incidents. LVN L also stated the staff nurse did not develop new interventions to prevent fall recurrence. The facility's policy and procedure, "Fall Management" dated 8/2014, procedure for responding to a fall indicated "...2. Initiate neurological checks for any unwitnessed falls and falls with actual or suspected head trauma/injury." 2. During review of Resident 19's clinical record, Resident 19 was admitted on 1/28/19 with diagnoses included heart failure, diabetes mellitus (high blood sugar), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). During review of quarterly MDS dated 6/7/21, indicated Resident 19 required extensive assistance with one-person physical assist during bed mobility, transfers and toilet use. During review of Resident 19's SBAR notes indicated the following: a. On 1/12/21, "Patient noted with increased confusion was trying to walk outside her room and just slipped to the floor, witnessed by CNA and nurse." b. On 1/30/21, "CNA alerted nurse that patient was in bathroom standing and stated she had fallen in bathroom on her bottom and hit back of her head., then complained of pain at the bottom." c. On 2/4/21, "Resident found on floor next to bed." d. On 2/8/21, "Resident found lying on floor in the middle of the room. Walker was beside her. No injuries noted. Resident was able to stand w/min assist." e. On 2/15/21, "at 6:50 p.m., CNA found resident lying on her left side in her room." f. On 2/16/21, "Resident was found in the bathroom on the floor next to the toilet." g. On 2/19/21, "[Resident 19] was attempting to go to the BR. Legs weak and leg buckles. States she hit her head, but no obvious trauma noted to head. Awake and alert per her usual. VSS. Able to move all extremities while sitting on the floor. Assisted back to bed. Denies losing consciousness." h. On 2/22/21, "Resident found sitting on floor in the room beside bed and in front of wheelchair." i. On 3/1/21, "Resident found sitting beside bed, in front of walker and wheelchair. j. On 3/2/21, "per CNA reported that she was entering to resident's room when she saw resident ambulate and fell sitting on floor in front of tv wall. Writer assessed resident who denies hitting head. Able to move all extremities, eye reactive to light, no changes on LOC alert and verbally responsive. Hands grasps equal. Denies pain or discomfort. Resident very involved when CNA assisted with transfer to w/c. chair alarm activated, call light within reach. Reminded resident to use call light for help." k. On 3/15/21, laundry staff reported resident sitting on floor mat next to bed. l. On 4/19/21, CNA heard alarm during shift change and when she entered the room, Resident 19 was sitting on the floor between her chair and bed. Licensed nurse (LN) asked resident what happened, and she stated that while she was reaching for a bag of food on her bed, her left leg got caught on the wheel of her wheelchair. She stated that she was stepping over, lost balance and sat to the floor. Resident denies hitting head and c/o mild pain to the back of her LLE behind the thigh. m. On 5/6/21, indicated "...at 1428, [Resident 19] fell from wheelchair in her room while attempting to use restroom. She stood up then lost her balance and slid to the floor. Abrasion noted to mid spine." Review of Resident 19's clinical record indicated there was no fall risk assessment and neurochecks completed after each fall episodes. Also, Resident 19's fall care plan did not develop new interventions to prevent fall recurrence. During interview with LVN L on 7/9/21 at 12:17 pm, LVN L acknowledged the above findings, and stated it should have been done after the fall incident. LVN L also stated the staff nurse did not develop new interventions to prevent fall recurrence. 3. During review of Resident 68's clinical record, Resident 68 was admitted on 4/16/21 with diagnoses included subarachnoid hemorrhage (bleeding into the space surrounding the brain), Parkinson's disease, aphasia (loss of ability to understand or express speech, caused by brain damage) and dysphagia (difficulty swallowing). During review of Resident 68's SBAR notes it indicated the following: a. on 1/12/21, "Resident fell on floor in her room while attempting to go the bathroom." b. on 1/14/21, "Resident was seen sitting on the floor, by the bed and she stated to go to the bathroom, denies hitting head." c. on 2/11/21, "Resident was found on floor sitting next to bed." d. on 3/4/21, "Writer found resident sitting on floor mat with head resting on bed." e. on 4/4/21, "[Resident 68] was found on the floor facing down. When asked, resident stated that she was trying to go swimming. Three CNAs including licensed nurse assisted her to get up in the chair. [Resident 68] seemed more confused, slightly lethargic, and had bruise on the forehead..." Review of Resident 68's clinical record, indicated there was no fall risk assessment done for every after fall episodes, and the staff did not develop new interventions to prevent fall recurrences. During interview with LVN L on 7/9/21 at 12:17 p.m., LVN L acknowledged the lack of Resident 68's fall risk assessments after every fall incident. LVN L also stated the staff nurse did not develop new interventions to prevent fall recurrence. During interview with CNA R on 7/09/21 at 12:07 p.m., CNA R stated it happened when she was giving report to incoming CNA at the time, she overlooked the resident stood up from her wheelchair and then fell on the floor. Review of Resident 68's hospital discharge summary dated 4/16/21, indicated "...Per staff patient is bedbound and total care but was found to have an unwitnessed fall and sustained a bruise on her forehead. As patient is on anticoagulant for atrial fibrillation, she was sent to emergency department (ED) for further evaluation. Computerized scan (CT) in ED showed a very small subdural hematoma, hence being admitted for observation...." Review of the facility's policy, "Fall Management," dated 8/2014, indicated "Initiate a fall prevention care plan when appropriate with strategies to minimize risk and potential for injuries. Review, revise, and evaluate care plan effectiveness at minimizing falls and injuries during IDT walking rounds and as needed." 4. Review of Resident 83's clinical record indicated he was admitted on 2/20/21. Review of Resident 83's Fall Risk Assessment, dated 2/20/21, indicated a score of 41 (a score of 25 to 44 indicates moderate risk for falling). The instructions printed on the Fall Risk Assessment indicated, "Complete on admission, quarterly, at change of condition, and after a fall." Further review of Resident 83's clinical record indicated the facility completed a Fall Report of Incident, indicating the resident fell, on 3/8/21, 3/13/21, and 5/5/21. There was no documentation that the facility completed a Fall Risk Assessment after each of these falls. Review of Resident 83's Fall Report of Incident, dated 5/5/21 indicated, "Resident's roommate called out for help because resident fell and hit his head." The Fall Report of Incident further indicated the interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) recommended, "Sent to acute ED [emergency department] for further evaluation. Returned same night, stable, no new order." There was no documentation in Resident 83's record that the facility developed and implemented a new fall prevention intervention after the fall on 5/5/21. During an interview with the director of nursing (DON) on 7/8/21 at 1:20 p.m., he confirmed the facility was supposed to complete a Fall Risk Assessment after each fall. He also confirmed that after each fall, the facility should develop and implement a new intervention to prevent further falls. The DON reviewed Resident 83's record and confirmed the facility did not complete a Fall Risk Assessment after the resident's three falls. He also confirmed the facility did not develop and implement a new fall prevention intervention after Resident 83 fell on 5/5/21. Review of the facility's policy titled "Fall Management," dated 8/2014 indicated, "Initiate a fall prevention care plan when appropriate with strategies to minimize risk and potential for injuries. Review, revise, and evaluate care plan effectiveness at minimizing falls and injuries during IDT walking rounds and as needed." 5. A review of Resident 40's SBAR- Fall Report of Incident indicated he had an unwitnessed fall on 12/8/2020 when he was found on the floor. A review of Resident 43's SBAR- Fall Report of Incident indicated he fell on 7/5/21 while trying to sit at the edge of the bed. A review of Resident 46"s SBAR- Fall Report of Incident indicated he had a witnessed fall on 6/10/21 when he slid on the floor while he was trying to transfer from bed to chair. A review of Resident 82's SBAR- Fall Report of Incident indicated she had unwitnessed falls on 4/24/21 and 4/26/21 when she was found sitting on the floor. A review of Resident 337's SBAR-Fall Report of Incident indicated she was found on the floor on 7/8/21. During review of Residents 40, 43, 46, 82 and 337 clinical records, indicated there were no fall risk assessments completed after each resident's fall episodes. During interview with minimum data set nurse D (MDSN D) on 7/09/21 at 8:15 a.m., MDSN D confirmed the lack of fall risk assessments and stated that it should have been completed after each resident's fall episodes. 6. During the initial tour on 7/6/21 at 12:54 p.m., with LVN F, Resident 342 was in his bed awake. Resident 342 alleged having fallen while in the shower room when one certified nursing assistant (CNA) opened the shower door and hit him on his back. During a review of Resident 342's clinical record and follow-up interview on 7/7/21 at 12:09 p.m., LVN F confirmed he did not complete the SBAR Fall Report of incident and did not notify the MD (doctor of medicine) regarding the claimed fall incident. LVN F also stated Resident 342 was self-responsible and he would notify the MD and complete the SBAR. A review of Resident 342's SBAR- Fall Report of Incident dated 7/7/21 indicated the resident claimed he fell on 7/4/21 while in the shower room. During an interview with MDSN D on 7/8/21 at 10:15 a.m., MDSN D reviewed Resident 342's clinical record and did not find any documented evidence that a care plan regarding the fall incident was developed and post fall "Fall Risk Assessment" was completed. The facility's policy and procedure, "Fall Management", dated 8/2014, indicated nursing staff and Interdisciplinary Team evaluate risk factors and provide interventions to minimize risk, injury, and occurrences. Evaluate actual and suspected causal factors to prevent recurrences. Notify the attending physician as soon as practicable. The facility failed to ensure an accident-free environment for 10 of 18 residents reviewed for fall, (Residents 10, 19, 68, 83, 40, 43, 46, 82, 337 and 342), when: 1. Resident 10 had no fall risk assessment and neuro-checks (evaluation of person's nervous system) completed after she fell on the floor on 1/10/21 and 2/07/21 while she was turning on her bed. Also, staff did not develop a new fall prevention intervention to prevent fall recurrence. Resident 10 complained of headache, neck and back pain and was transferred to the hospital for evaluation. 2. For Resident 19, there were no fall risk assessment and neurochecks completed after each fall episode. Also, Resident 19's fall care plan did not develop new interventions to prevent fall recurrence. Resident 19 fell on the floor from the wheelchair in her room on 5/6/21 while attempting to use the restroom. She stood up then lost her balance and slid to the floor which resulted in an abrasion on her midback. 3. Resident 68 was not redirected with physical assist while she stood up from her wheelchair. Resident 68 fell on the floor in her room on 4/4/21 and sustained subdural hematoma (type of bleed that occurs within the skull of head), hence was transferred to the hospital for observation. 4. For Resident 83, the facility did not complete a fall risk assessment after each fall and did not develop a new fall prevention intervention after his latest fall. 5. For Residents 40, 43, 46, 82 and 337, there were no post fall risk assessments completed after each resident's fall episode. 6. For Resident 342, there was no SBAR done when Resident 342 fell on the floor in the shower room on 7/4/21. Also, staff