Other·December 24, 2021

F689 §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 fall management and interventions were evaluated and implemented to prevent further falls for four patients (Patients 36, 52, 54 and 283) when: 1. For Patient 36, neuro-checks (an evaluation to sensory and motor responses, reflexes to determine if the nervous system is impaired) were incomplete, interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) did not discussed falls, OT evaluation was not implemented, no new interventions were implemented after a fall, there was no physician order for the use of soft padded helmet, postural hypotension was not monitored. 2. For Patient 52, medication regimen review (MRR, process of comparing medication), no fall risk assessment, and no evidence an IDT was done after a fall. 3. For Patient 54, failed to follow care plan and physician order for the use of floor mat. 4. For Patient 283, failed to provide assistance to two falls, fall care plan interventions was not specific for Patient 283's condition, did not have an IDT and rehabilitation therapy recommendation was not implemented after the second fall, and Fall Risk Assessment was not coded correctly. These failures resulted in repeated falls and had the potential to cause decline in the resident's physical function. Review of Patient 36's clinical record indicated, she was admitted to the facility on 6/18/19 with diagnoses including dementia (memory loss) and repeated falls and history of falling. Review of Patient 36's Post-Fall Review dated 1/6/21, indicated Patient 36 was observed on the floor in her room. She stated she hit her head. Review of Patient 36's progress notes dated 1/6/21, indicated Patient 36 had an unwitnessed fall and large bump at the back of her head was noted and neuro check was initiated. Patient 36's clinical record did not indicate her fall on 1/6/21 was discussed by the IDT and there was no documentation neuro check was initiated. Review of Patient 36's Post-Fall Review dated 1/23/21, indicated she had an unwitnessed fall in the facility's lobby. Review of Patient 36's clinical record did not indicate her fall on 1/23/21 was discussed by the IDT and there were no documented neuro checks. During an interview with the minimum data set nurse (MDSN) on 12/9/21 at 1:56 p.m., the MDSN confirmed the fall on 1/6/21 and 1/23/21 were not discussed by the IDT. The MDSN further stated the fall should had been discussed within 72 hours by the IDT. During an interview with the MDSN on 12/10/21 at 1:49 p.m., the MDSN confirmed there were no neuro checks initiated for both falls on 1/6/21 and 1/23/21. Review of Patient 36's Post-Fall Review dated 1/24/21, indicated she had an unwitnessed fall in her room. Review of Patient 36's IDT notes dated 1/25/21 indicated resident was observed lying on the floor in her room. "Resident (Patient) was assessed and found a lump on the back of her head, skin appeared to have a laceration with small amount of bleeding noted." Patient 36 was transferred to a community hospital per family request. The IDT recommended an occupational therapy evaluation (OT, health care area that deals with rehabilitation through performing activities of daily living). Review of Patient 36's clinical record did not indicate an OT evaluation was done. During an interview on 12/9/21 at 4:44 p.m., the MDSN confirmed the OT evaluation was not done. Review of Patient 36's minimum data set (MDS, an assessment tool) dated 6/26/21 indicated Patient 36 had a fall without injury. Further review of Patient 36's clinical record did not indicate a post fall risk assessment was done. There was no change of condition notes and no post fall review or progress notes done. Review of Patient 36's IDT notes dated 4/27/21 indicated, she had an unwitnessed fall in the hallway. IDT recommended to continue neuro checks. Additional review of Patient 36's clinical record did not indicate a neuro check was done. During an interview with the MDSN on 12/9/21 at 2:56 p.m., the MDSN confirmed there were no post fall review, no progress notes and no change of condition notes for the fall in April 2021. Review of Patient 36's Post-Fall Review dated 7/26/21, indicated she had a witnessed fall in front of station AA. Review of Patient 36's neurological assessment flowsheet dated 7/26/21, indicated the assessments were incomplete. During a concurrent interview and record review with the MDSN on 12/10/21 at 9:47 a.m., the MDSN reviewed the above neurological flowsheet and confirmed it was incomplete. Review of Patient 36's Post-Fall Review dated 8/28/21, indicated she had a witnessed fall by station BB. Review of Patient 36's IDT notes dated 8/30/21, indicated the IDT recommended a soft padded helmet. During an observation in Patient 36's room on 12/8/21 at 8:10 a.m., there was a white helmet hanging at the front wheeled walker. Review of Patient 36's clinical record indicated there was no physician order for the use of the soft padded helmet. During a concurrent interview and record review with the MDSN on 12/9/21 at 2:16 p.m., the MDSN reviewed Patient 36's clinical record and confirmed there was no physician's order for the use of soft padded helmet. Review of Patient 36's Post-Fall Review dated 10/2/21, indicated she had an unwitnessed fall and was found on the floor in her room. Review of Patient 36's IDT notes dated 10/4/21 indicated "IDT believes that given residents hx (history) of falls and impulsive behavior, dementia the event was unavoidable. IDT will continue to monitor resident and evaluate for new interventions if required." Review of Patient 36's neurological assessment flowsheet dated 10/2/21, indicated the assessments were incomplete. During a concurrent interview and record review with the MDSN on 12/10/21 at 9:47 a.m., the MDSN confirmed the neuro check assessment flowsheet was incomplete. Review of Patient 36's Post-Fall Review dated 10/8/21, indicated she had a witnessed fall in the dining room. Further review of Patient 36's clinical record did not indicate an IDT was done to address the fall. During a concurrent interview and record review with the MDSN on 12/9/21 at 2:27 p.m., the MDSN reviewed Patient 36's clinical record and confirmed there was no IDT done for the fall on 10/8/21. Review of Patient 36's Post-Fall Review dated 10/16/21, indicated she had an unwitnessed fall and was found on the floor in the hallway next to station AA. Review of Patient 36's IDT notes dated 10/18/21, indicated "IDT has used all interventions, exhausted all possibilities. Will continue to monitor." During a concurrent interview and record review with the MDSN on 12/9/21 at 2:32 p.m., the MDSN reviewed the IDT notes dated 10/18/21 and stated there was no new intervention. Review of Patient 36's eInteract Change in Condition Evaluation V4.2 dated 10/24/21, indicated she was found on the floormat in a resident's room. Review of Patient 36's clinical record did not indicate a post fall review and a post fall risk assessment were done on the above fall. During an interview with the MDSN on 12/10/21 at 1:45 p.m., the MDSN confirmed there was no post fall risk assessment and no post fall review done for Patient 36's fall on 10/24/21. Review of Patient 36's Post-Fall Review dated 10/26/21, indicated she was found on her floormat inside her room. During a concurrent interview and record review with the MDSN on 12/9/21 at 1:46 p.m., the MDSN reviewed Patient 36's physician order dated 10/28/21, indicating to monitor orthostatic hypotension (low blood pressure when standing up, sitting, or lying down). On 12/9/21 at 4:46 p.m., the MDSN stated she could not find the orthostatic hypotension monitoring. Review of Consultant Pharmacist's Medication Regimen Review (MRR) dated 10/27/21, indicated the MRR was done after a fall, the report further indicated "Please consider screen for postural hypotension at lying and standing position." Review of Patient 36's Post-Fall Review dated 11/24/21 indicated she had a witnessed fall in the dining room. Review of Patient 36's Post-Fall Review dated 12/2/21, indicated she had a witnessed fall. Review of Patient 52's clinical record indicated she was admitted to the facility on 7/6/21, with diagnoses including repeated falls, unspecified dementia with behavioral disturbance. During a concurrent interview and record review on 12/10/21 at 10:12 a.m., with the MDSN, the MDSN reviewed Patient 52's clinical record and confirmed she had an unwitnessed fall on 7/6/21, witnessed fall on 7/12/21, an assisted fall on 7/13/21, an unwitnessed fall on 8/6/21 and a witnessed fall on 8/24/21. Review of Patient 52's eInteract change of condition dated 11/19/21, indicated she had an unwitnessed fall. During a concurrent interview and record review with the MDSN on 12/10/21 at 1:52 p.m., the MDSN reviewed Patient 52's clinical record and confirmed the resident had a fall on 11/19/21 and there was no post-fall review, no fall assessment after the fall and there was no IDT done. Review of Consultant Pharmacist's Medication Regimen Review dated 7/9/21, indicated the MRR was done due to Patient 52's falls. The MRR further indicated "Please screen for postural hypotension at lying and standing positions." During an interview with the MDSN on 12/10/21 at 2:00 p.m., the MDSN reviewed Patient 52's clinical record and confirmed there was no order for postural hypotension and there was no postural hypotension monitoring done. During an interview with the consultant pharmacist (CP) on 12/10/21 at 2:44 p.m., the CP stated if the resident was ambulating and prone to falls, his expectations was for the facility to check postural hypotension. Review of the facility's policy, "Change in a Resident's (Patient's)Condition or Status" dated 2/2021, indicated "A significant change" of condition is a major decline or improvement in the resident's status that requires interdisciplinary review and/or revision to the care plan". Review of the facility's policy, "Fall Risk Assessment" dated 3/2018, indicated "The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The attending physician and nursing staff will evaluate the resident's (patient's) vital signs." Review of the facility's policy, "Falls and Fall Risk, Managing" dated 3/2018, indicated "If the resident (patient) continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions." Review of the facility's policy, "Charting and Documentation" dated 7/2017, indicated "All services provided to the resident (patient), progress toward the care plan goals, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care." Review of Patient 54 's admission record indicated he was admitted to the facility with a diagnosis including quadriplegia (paralysis that results in the loss of movement and sensation in all four limbs) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Review of Patient 54's order summary report dated 8/21/19, indicated single floor mat r/t (related) poor safety awareness. Review of Patient 54's care plan dated 8/21/19, indicated Resident 54 was high risk for fall and his interventions included single floor mat r/t (related) poor safety awareness. Review of Patient 54's post fall review dated 6/11/21, indicated he had an unwitnessed fall in his room trying to get out of bed. Review of Patient 54's Inter Disciplinary Team (IDT) review notes dated 6/14/21, indicated Patient 54 had skin tear to left forearm, left lateral ankle and lifted his great toe nails. During an observation on 12/7/21 at 9:36 a.m., 12/8/21 at 8:45 a.m. and 12/9/21 at 9:10 a.m., Patient 54 was in lying in bed and there was no floor mat. During an interview with CNA B on 12/9/21 at 9:10 a.m., CNA B confirmed Patient 54 did not have a floor mat and he had previous falls. During an interview and concurrent record review with the NS on 12/9/21 at 2:12 p.m., the NS reviewed Patient 54's IDT and it did not indicate Patient 54 had a floor mat in place during the fall. The NS acknowledged Patient 54's physician order and care plan were not implemented. Review of Patient 283's admission record indicated he was admitted on 11/5/21, with a diagnosis including Parkinson's disease (a movement disorder that causes tremors, stiffness, and slow movement), need assistance with personal care, dementia, repeated falls and history of falling. Review of Patient 283's admission/readmission data tool dated 11/5/21, indicated he was alert, needed two-person physical assistance and complete assistance or mechanical assistance (e.g. Hoyer Lift) and under fall risk assessment, he was identified as at risk for falls. Review of Patient 283's MDS dated 11/10/21, indicated he has a BIMS of 7 (meaning cognitively impaired). He needed extensive assistance with two or more-person physical assistance during bed mobility and transfer; extensive assistance with one-person physical assistance during toilet use. His balance during transition and walking was not steady and only able to stabilize with staff assistance. Review of Patient 283's Fall Risk Assessment dated 11/5/21, indicated he had multiple falls within the last six months, his medication use did not identify he was taking anti Parkinson's medication, and he was identified as at risk for falls. Review of Patient 283's order summary report dated 11/ 5/ 21, indicated Carbidopa- Levodopa (a type of anti-Parkinson's medication) tab 25-100 mg one tablet p.o. (by mouth) at bedtime related to Parkinson's disease and give 2 tablets by mouth before meals related to Parkinson's disease. Review of Patient 283's care plan dated 11/6/21, indicated Patient 283 was at risk for falls r/t Parkinson's and Parkinson's Dementia with hallucinations. His interventions initiated on 11/6/21, indicated "Implement facility fall prevention protocol " and notify MD (physician) if increase in falls. The fall care plan did not specify what type of fall prevention protocol needed to be in place. Review of Patient 283's Post Fall Review dated 11/5/21, indicated he had a fall on 11/5/21 at 5:20 p.m., seen falling on the floor in his room, ambulating and no slide/gripper socks. He was alert and oriented to person. Review of Patient 283's progress notes dated 11/5/21, indicated after multiple reminders to wait for a CNA within a five-minute window, Patient 283 fell on the way to the bathroom. Patient fell while a CNA was entering room to assist. During an interview with CNA L on 12/9/21 at 2:52 p.m., he stated he was not the assigned nurse for Patient 283 when he answered Patient 283's roommate call light. CNA L stated Patient 283 said he needed to go to the bathroom. Since Patient was not trying to climb out of bed, CNA L exited the room to get some help because Patient 283 was "pretty big." CNA L stated he was away between 3-5 minutes looking for help and when he returned, he saw Patient 283 on the floor. CNA L stated he did not know Patient 283's cognitive and functional level. Review of Patient 283's care plan dated 11/16/21, indicated Patient 283 placed himself of the floor from the wheelchair. His interventions included to request therapy to reevaluate wheelchair and wheelchair cushion. Review of Patient 283's physical therapy and occupational therapy treatment notes provided by the NS,