Other·February 14, 2022

F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. On 1/24/2022 at 8:30 a.m., an unannounced visit was conducted at the facility. The facility failed to follow its own policy and procedure to evaluate patients' fall risk, to investigate the fall, to implement patient centered care plan, to revise the fall care plan and/or place the effective interventions to prevent four of 17 sampled patients (Patient 1, 24, 37 and 38) from multiple falls recurring when: 1. For Patient 1, the facility did not revise the fall care plan, did not implement fall care plan intervention, or evaluate the patient's fall risk. Patient 1 had eights unwitnessed falls from 5/21/2020 to 1/25/2022. 2.For Patient 24, the facility did not revise the fall care plan, did not implement fall care plan intervention, or evaluate the patient's fall risk. Patient 24 had 4 unwitnessed falls from 9/11/2021 to 1/8/2022 3. For Patient 37, staff failed implement the fall care plan intervention to provide dycem (non-slip mat) on his wheelchair, which had resulted to Patient 37 had slid onto his wheelchair and fell on the floor on 8/17/21, Patient 37 sustained abrasion on his chin. Patient 37 had eight falls from 8/16/21 to 1/23/22. 4. For Patient 38, staff failed to provide frequent checks on Patient 38, which had resulted to Patient 38's fall on the floor lying on her back and sustained hematoma (a bad bruise, it happens when an injury causes blood to collect and pull under the skin) on her right scalp on 6/17/21. Patient had nine falls from 5/20/21 to 12/31/21. These failures resulted in patients continued falls and resulted in fall injuries. Patient 1 had left humerus fracture (upper arm break) from the 6th fall on 6/21/2, a head contusion (a bruise) from the seventh fall on 11/19/21 and head laceration from the eighth fall on 1/25/22. Patient 24 had a fourth fall on 1/8/22 with a closed fracture of second thoracic vertebra (middle part of back that connects to ribs). Patient 37 had a sustained abrasion on the chin from the fall on 8/17/21. Patient 38 had a sustained hematoma on the right scalp from the fall on 6/17/21. Review of Patient 1's clinical record, the clinical record indicated she was admitted with multiple diagnoses including hypertension (high blood pressure), dementia with behavior disturbance (decline in mental capacity affecting daily function and impairs reasoning), unspecified psychosis (a mental disorder characterized by a disconnection from reality). During a review of Patient 1's Minimum Data Set (MDS, an assessment tool) dated 12/2/21, the MDS indicated Patient 1's mental status evaluation revealed moderate impairment. During a review of Patient 1's clinical record, the clinical record indicated Patient 1 had falls on the following dates: 5/21/20, 9/4/20, 10/29/20, 1/22/21, 3/12/21, 6/21/21, 11/19/21 and 1/25/22. During a review of Patient 1's clinical record, the fall risk assessments dated 4/9/20, 7/17/20, 5/21/20, 9/5/20, 10/17/20, 10/29/20, 3/12/21, 4/17/21, 6/21/2, 11/19/21, and 1/30/22 indicated Patient 1 was a high risk for falls. Patient 1's 1/22/21 fall risk assessment indicated low risk for falls. During a review of Patient 1's MDS dated 4/17/21, the annual review indicated Patient 1 was able to perform ADL's (Activities of daily living) with supervision and set-up to one person assist. Following the fall on 6/21/21 the MDS dated 6/28/21 indicated performance of ADL's was extensive assistance and 2 person assist with total dependence. During a review of Patient 1's fall risk care plan dated 4/9/20 indicated Patient 1 is high risk for falls, interventions included 1. Anticipate patient's needs. 2. Be sure the patients call light is within reach and encourage the patient to use it for assistance as needed. The patient needs prompt response to all request for assistance. 3. Educate patients the use of call button for assistance and not to get up from bed or wheelchair unassisted 4. Refer to rehab. 5. Ensure nonskid socks when ambulating or mobilizing in wheelchair. 6. The patient needs a safe environment with even floors free from spills and/or clutter, adequate, glare free light, a working and reachable call light, the bed in low position at night, side rails as ordered, handrails on walls, personal items within reach. 7. The patient's bed will keep in the lowest position. During a review of Patient 1's Interdisciplinary Team (IDT a group of health care professionals from diverse fields who work toward a common goal for patients) note dated 5/22/20 at 1:00 p.m., indicated Patient 1 had an unwitnessed fall on 5/21/20 at 5:10 p.m., " Patient 1 was found sitting on the floor of her room. Patient stated, "I was getting my rosary under my bed, but I slid on the floor". No injuries. Predisposing diseases indicated Dementia /Alzheimer's disease and other: difficulty in walking, muscle weakness. Conditions that contributed to the fall were listed as: unsteady gait. IDT recommendations indicated " Patient is alert and wishes to be independent. She has weakness on her bilateral lower extremities and is at high risk for fall. Patient is educated on the use of call light and not to get up unassisted". Care plan revision and referral to physical therapy. Other intervention recommendations: PT (physical therapy) evaluation with focus on safety, recommended and given a reacher (tool for reaching), educated how to use. Frequent reminders to call for assistance when she drops something on the floor, not to attempt to pick it up. During a review of Patient 1's clinical record, the Fall Risk assessment dated 5/21/20 at 10:45 p.m. indicated Patient 1's level of consciousness (awareness)/mental state was alert, had 1-2 falls in past three months and was a high risk for falls. During a review of Patient 1's fall risk care plan dated 5/21/20 and 5/22/20 indicated Patient 1 was found on the floor, beside her bed, interventions included 1. Frequent reminders to call for assistance if she drops something on the floor and not to attempt to reach down for it. 2. Keep personal items within easy reach. 3. Assess neurological (brain) status and vital signs, notify MD for any significant abnormal changes. 4. Assess patients immediate needs for toileting, need for food, thirst or in pain, reaching for something, educate patient the use of call light for assistance and not to get up unassisted 5. Provide patient with a reacher and educate her on how to use it. 6. PT eval with focus on safety. During a review of Patient 1's IDT note dated 9/9/20 at 1:00 p.m., the IDT note indicated Patient 1 had an unwitnessed fall on at 9/4/20 at 4:00 p.m., Patient 1 "...had fallen in her room at the bedside sometime early evening of 9/4/20...landed on knees and had to turn to a sitting position for her to get back to bed". No injury. Predisposing diseases indicated Dementia/Alzheimer's disease and other: psychosis, difficulty walking, muscle weakness. Conditions that may contributed to the fall were listed as: history of falls, cognitive deficits (an inclusive term used to describe an impairment of how individual's mentally processes information), and recurrent dizziness with episodes of double vision. IDT recommendations indicated patient has recurrent complaint of dizziness and double vision. Also having episode of auditory and visual hallucinations (perception of something not present). Ambulatory with forward wheel walker. Care plan revision and referrals to occupational therapy. Other intervention recommendations included: occupational therapy evaluation and treat with focus on safety. Assess patient for dizziness and double vision and instruct patient to stay in bed if symptoms persist. Review of Patient 1's Fall Risk assessment dated 9/5/20 at 10:19 a.m., the fall risk assessment indicated Patient 1's level of consciousness/mental state was alert, had 1-2 falls in past three months and was a high risk for falls. During a review of Patient 1's fall risk care plan dated 9/5/20, 9/8/20 and 9/9/20, the care plan indicated Patient 1 claimed fall in her room, interventions included 1. Assess the patient and instruct her to stay in bed if dizziness and double vision present. 2. Guarantee appropriate room lighting especially during the night. 3. Move items used by patient within easy reach, such as call light ... 4. Notify MD (medical doctor) and RP (responsible party). 5. OT (occupational therapy) evaluation and treat if indicated. 5. Respond to call light as soon as possible. 6. Teach client how to safely ambulate (walk), including using safety measures such as handrails in bathroom. During a review of Patient 1's fall care plan dated 9/5/20, 9/8/20 and 9/9/20, the care plan indicated no evidence that the facility addressed cognitive deficits that may have contributed to the fall as indicated in IDT note dated 9/9/20 at 1:00 p.m. During review of Patient 1's IDT note dated 10/29/20 at 3:53 p.m., the IDT note indicated Patient 1 had an unwitnessed fall on 10/29/2020 at 4:00 a.m., "Staff responded to a loud noise coming from the residence room and noted the patient lying on the floor in supine position between the bed and over bed table... According to the patient she was trying to sit at the edge of her bed ... slid down to the floor. ... she complained of pain at the back of the left ear 3/10", no injury. Conditions that contributed to the fall were listed as: history of falls, cognitive deficits, and episodes of confusion (decreased alertness), dizziness, and double vision. IDT recommendations indicated: Patient has episodes of dizziness and double vision but denies having them prior to this event. Was wearing nonskid socks, floor dry, room well light and height of bed in lowest position. Care plan revision and referrals to physical therapy and occupational therapy. other intervention recommendations physical therapy and occupational therapy referral with focus on safety. During review of Patient 1's Fall Risk assessment dated 10/29/20 at 4:33 a.m., the fall risk assessment indicated Patient 1's level of consciousness /mental state was intermittent confusion, had 1-2 falls in past three months and was a high risk for falls. During review of Patient 1's fall risk care plan dated 10/29/20, the care plan indicated Patient 1 had an actual fall intervention included 1. Encourage patient to ask for assistance. 2. Neuro checks (assessment of the brain) for three days. 3. Observe/document/report PRN (as needed) for 72 hours to MD for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture (position in which someone holds their body when standing or sitting), agitation (state of anxiety or nervous excitement). 4. Place frequently used items in reach. 5. Refer to rehab PT/ OT with focus on safety. During a review of Patient 1's fall care plan dated 10/29/20, the care plan indicated no evidence that the facility addressed cognitive deficits and episodes of confusion that were indicated in the IDT note dated 10/29/20 at 3:53 p.m. as conditions that may have contributed to Patient 1's fall risk or the intermittent confusion indicated on the Fall Risk assessment dated 10/29/20 at 4:33 p.m. that increased Patient 1's risks for fall. During a review of Patient 1's fall care plan, dated, 10/29/20, the care plan indicated no evidence of new interventions were created in order to prevent future falls. During a review of Patients IDT note dated 1/22/21 at 1:50 p.m., the IDT note indicated Patient 1 had an unwitnessed fall on 1/22/21 at 1:50 p.m. " ... patient had fallen on the floor. Patient stated she wants to use the commode and cannot get anyone to help her, and she then got up from her bed unassisted and fell. No injury noted. Conditions that may have contributed to the fall were listed as: unsteady gait and history of falls. IDT recommendations indicated, "patient has generalized weakness on bilateral lower extremities. At times she wishes to be independent, impulsive and does not want to call for assistance. Care plan revision and referral to physical therapy. Other intervention recommendations encourage patient not to get up unassisted and use call bell for assistance. Anticipate patient's basic needs. During review of Patient 1's SBAR communication form dated 1/22/21 at 2:01 p.m., the SBAR indicated "things that make the condition worse are patient at risk of not using her call button or ask for help due to diagnosis of dementia". During review of Patient 1's Fall Risk assessment dated 1/22/21 at 4:14 p.m. indicated Patient 1's level of consciousness/mental state was alert, had no falls in past three months and was a low risk for falls. During review of Patient 1's fall risk care plan dated 1/22/21, the care plan indicated, Patient 1 had an unwitnessed fall, interventions included 1. Notify MD and RP. 2. Assess for injury. 3. Assessed for pain and medicate. 4. Encourage the use of call button and not to get up unassisted. 5. Anticipate and assist basic needs: toileting, food, thirst, medicate for pain, reaching out down. During review of Patient 1's clinical record no evidence was provided on how the facility anticipated Patient 1's needs for toileting, food, thirst, medicate for pain, reaching out down, an intervention indicated on care plan dated 1/22/21. During a review of Patient 1's fall care plan, dated 1/22/21, the care plan indicated no evidence of new interventions were created in order to prevent future falls. During review of Patient 1's fall care plan, dated 1/22/21, the care plan indicated no evidence the facility addressed patient at risk of not using her call button or asking for help due to diagnosis of dementia as indicated on Patient 1's SBAR dated 1/22/21 at 2:01 p.m. that contributed to the fall. During review of Patient 1's IDT note dated 3/15/21 at 11:56 a.m., the IDT note indicated Patient 1 had an unwitnessed fall on 3/12/21 at 3:48 p.m. "patient with sitting on the floor at the bedside. According to patient she was about to sit at the edge of her bed, but she was already sliding and could not control it, so she slowly eased herself down to the floor. No injury noted, complaint of pain 4/10 on right hip. Predisposing diseases indicated Dementia /Alzheimer's disease and other: psychosis, difficulty walking, weakness. Conditions that contributed to the fall: history of falls, cognitive deficits. IDT recommendations indicated patient is ambulatory with forward wheeled walker (FWW). Has muscle weakness and difficulty walking. Has impaired safety judgment and is impulsive. Care plan revision. Referrals to physical therapy and occupational therapy. Other intervention recommendations refer to physical therapy and occupational therapy with focus on safety. Remind patient to slow down and maintain balance prior to standing or sitting activity. During review of Patient 1's Fall Risk dated 3/12/21 at 4:08 p.m., the fall risk indicated Patient 1's level of consciousness/mental state was intermittent confusion, had three or more falls in past three months and was a high risk for falls. During review of Patient 1's fall risk care plan dated 3/12/21 and 3/15/21, the care plan indicated Patient 1 slid on the floor in her room related to impulsiveness, unable to slow down, muscle weakness pain and impaired safety judgement interventions included 1. Neuro check per facility protocol 2. Note for any pain and discomfort, offer pain medications as needed. 3. Notify MD. 4. Placed belongings and call light within reach. 5. Refer to therapy with focus on safety. 6. Remind patient to slow down, control her balance prior to standing or sitting. During review of Patient 1's fall care plan dated 3/15/21, the care plan indicated no evidence the facility addressed Patient 1's cognitive deficits, impaired safety judgement and impulsiveness as indicated in IDT note dated 3/15/21 at 11:56 a.m. and level of consciousness/mental state of intermittent confusion indicated Fall Risk dated 3/12/21 at 4:08 p.m. that increased Patient 1's risk for falls.