Other·June 5, 2024

F689 Free of Accident Hazards/Supervision/Devices 483.25 Section 483.25(d) Accidents. The facility must ensure that - Section 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and Section 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. The following citation was written as a result of an unannounced visit to the facility on 4/24/2024 for the investigation of complaint #CA00896540. As a result of the investigation, the Department determined the facility failed to ensure one resident (Resident 2) was provided with adequate supervision and safe environment to prevent accidents. This failure resulted in Resident 2's falling from a 4-inch ledge in her wheelchair and injuring her head before being transferred to the acute care hospital for further evaluation. Resident 2 sustained multiple fractures (break) to the bones of the neck requiring surgical intervention. A review of the "ADMISSION RECORD" Record indicated Resident 2 was admitted with diagnoses including hemiplegia and hemiparesis (weakness on one side of the body) following cerebral infarction (disruption of blood flow to the brain) affecting right dominant side, schizoaffective disorder, bipolar type (episode of mood swings ranging from depression [loss of interest in activities] to mania [extreme changes in mood or emotions]). The Minimum Data Set (MDS, an assessment tool) dated 3/21/24, indicated, Resident 2 was cognitively impaired and required moderate assistance (the staff does less than half of the effort) once in a wheelchair to wheel at least 50 feet and make 2 turns. Further review of Resident 2's clinical records indicated the following: -Care plan dated 5/6/23 indicated Resident 2 was at risk for alteration in Activities of Daily Living (ADL, self-care activities performed daily such as grooming, dressing, and personal hygiene) related to hemiplegia, history of CVA (stroke) and cognitive impairment. The interventions included staff supervision with mobility and self-propelling while in wheelchair; -Care plan dated 5/6/23 indicated Resident 2 was at risk for repeat fall related to history of fall, hemiplegia and cognitive impairment. The intervention included to provide resident with safe environment such as even floors; -Care plan dated 4/13/23 indicated Resident 2 was at risk for fall or injury due to poor fall safety awareness. The interventions included to keep close observation during activities to minimize potential for falls and to keep environment free of hazards; and a -Fall Risk Assessment dated 2/27/24 indicated Resident 2 was at high risk for falls with a score of 26 (16-42 is considered high risk for falls). A review of Resident 2's "Nurse's Not"' dated 4/20/24 at 14:30 [2:30 p.m.] indicated, "I was told the [Resident 2] fell outside on the smoking area at 1345 p.m., [1:45 p.m.] she was on her wheelchair heading to the smoking area and she fell because the wheelchair was pulled to the edge of the slightly uneven surface. we [sic] assisted her back to the wheelchair. on [sic] assessment I noticed the bruise and minimal bleeding on her right side of the head. i [sic] asked her if she hit her head and she said yes. she [sic] said it hurts my head and my back...paramedics [responds to emergency calls and transports patients to acute care hospitals] ...picked her... and left the facility ..." A review of Resident 2's physician notes from the Emergency Department (ED) on 4/20/24 indicated, "... [brought in by ambulance] to the ED [status post] witnessed mechanical GLF [ground level fall] today at SNF [Skilled Nursing Facility]." A review of Resident 2's "TRAUMA ADMISSION HISTORY AND PHYSICAL NOTE", dated 4/20/24, indicated, Resident 2 was admitted to the Surgical Intensive Care Unit [ICU, provides critical care and life support for the acutely ill or injured]. The assessment and plan included a neurosurgeon, NSG (neurosurgeon, NSG, specializing in surgery of the brain and spine or backbone) was consulted due to multiple cervical fractures (break in the bones of the neck) including a Cervical 6 ( one of the bones in the neck, controls the muscles of the wrist and the large muscle on the front of the upper arm between the shoulder and elbow) left floating lateral mass fracture and C5 to C7 (C5- controls the large muscles of the shoulders and front of the upper arm, C7- controls the large muscle on the back part of the upper arm and wrist muscles) left lateral mass fractures. A review of Resident 2's "DEPARTMENT OF NEUROLOGICAL [branch of medicine that deals with problems affecting the brain, spinal cord, and complex network of nerves] SURGERY SPINE CONSULTATION" dated 4/20/24, indicated, "...fell at SNF and was found to have multiple cervical injuries...consider trauma consultation for full trauma workup given significance of cervical injuries." A review of Resident 2' s "INPATIENT OPERATION RECORD" indicated an operation date of 4/22/24. Resident 2 had pre and post operative diagnosis of closed fracture of cervical vertebra, unspecified cervical vertebral level (there are 7 bones of the neck, from C1 to C7). The procedure performed included: Anterior interbody fusion (a major surgery performed to fuse 2 or more bones to restore stability), with discectomy (surgical removal of abnormal disc material that presses on a nerve root) and decompression (helps return bulging discs to their correct locations), of the C5 to C7. During an observation conducted on 4/24/24 at 8:05 a.m., there was an uneven curved pavement on the right side of the building leading to the smoking area. The dirt area had yellow plastic caution sign around supported by 5 sticks and 4 cones along the side. During an interview on 4/24/24 at 8:09 a.m. with Resident 6 in the smoking area, Resident 6 stated he knew Resident 2 and she was in the hospital. Resident 6 stated, 5 to 6 days ago at the scheduled smoke break at 1:30 p.m., Resident 2 was impatient, and she went out without assistance. Resident 2 pushed herself out and started rolling. Resident 2's wheelchair tipped sideways, and she hit her head on the wall. The Certified Nursing Assistant (CNA) told Resident 2 to stay there (inside), she led herself out and she fell. Resident 6 stated the caution sign was there at the time of the fall and the cones were put up 2 days after Resident 2 fell. In a concurrent observation and interview on 4/24/24 at 8:23 a.m., Resident 6 pointed to the area where Resident 2 fell. Resident 6 stated Resident 2 fell in the middle of the dirt area. Upon further inspection of the location of the fall, the unpaved area on the side of the building had approximately 4-5 inches of elevation from the ground to the cemented area. A review of the clinical records indicated Resident 6 was admitted with diagnoses including acute and chronic respiratory failure (lungs have a hard time loading the blood with oxygen). Resident 6's MDS dated 2/23/24 indicated he was cognitively intact. During an interview on 4/24/24 at 8:24 a.m., the Activities Director (AD) stated there was a big palm tree that was removed on the side of the building. The AD further stated she heard about Resident 2's fall. In an interview on 4/24/24 at 8:30 a.m., the Director of Nursing (DON) stated she received a text message from the Social Services Director (SSD) on 4/20/24 regarding Resident 2. The DON further stated Resident 2 had a fall after, one of the wheels of her wheelchair got caught on the uneven pavement. In an interview on 4/24/24 starting at 11:07 a.m., the SSD stated she was the Manager of the Day on 4/20/24 when Resident 2 fell. The SSD was in the hallway, while CNA 2 was outside by the patio door. The SSD stated Resident 2 was going outside slowly, using her hand to propel her wheelchair when the wheelchair got close to the cement and the front wheel on the right tipped over. The SSD saw Resident 2 lying on her side and her head was against the wall. The SSD stated the area was curved and Resident 2 went straight. The SSD further stated before the CNA 2 could turn around, Resident 2's wheelchair tipped off the ledge. The yellow tape was there with the sticks, no cones. Resident 2 was picked up by nurses from the ground back to her wheelchair. The SSD stated the fall could have been prevented if CNA 2 pushed the residents in their wheelchairs one at a time. The SSD described there was approximately 5 inches difference from the cemented area to the ground. The SSD stated a tree was taken out and the elevation from the cemented area to the ground was something new. In a follow-up interview on 4/24/24 starting at 12:01 p.m., the DON stated she could not tell if Resident 2's fall was preventable or not. In an interview on 4/24/24 at 1:17 p.m., the Administrator (ADM) stated a huge palm tree was taken out since the roots were going underneath the foundation of the building. The ADM added the facility put the caution sign when the tree was taken out. The ADM was unable to state if Resident 2's fall was preventable or not. During a telephone interview on 4/24/24 starting at 2:51 p.m., Licensed Nurse (LN) 2 stated the SSD was the one who informed him of Resident 2's fall. When LN 2 went to check on Resident 2, she was in the soil area, lying on her right side and her wheelchair was tipped. The LN 2 saw a little bruise on the right side of her head. The LN 2 stated they did a manual transfer because resident was in the soil and there was an uneven surface between the cement and the soil. The LN 2 stated the safest way should be to leave Resident 2 on the ground. The LN 2 further stated Resident 2 was transferred manually with 3 people (including LN 2) from the ground back to her wheelchair because resident was screaming, and she insisted on getting up. The LN 2 stated Resident 2 complained of pain on her head and on her back after she was transferred. LN 2 further stated, the fall was preventable, and the surface should be even. In a telephone interview on 4/25/24 at 12:15 p.m., the AD stated the safest way to assist Resident 2 while going outside the patio was for another staff to push her wheelchair when she was not agitated. If Resident 2 was agitated she will immediately notify the nurse or CNA to assist her and make them aware of her behavior. The AD described there was a huge palm tree with the roots that had lifted. The AD added there was no way a wheelchair would flip due to the area being "pretty high." In a telephone interview on 4/25/24 at 12:38 p.m., the Maintenance Supervisor (MS) stated there was 4 inches of elevation between the concrete and the dirt. In a telephone interview on 4/25/24 starting at 3:12 p.m., CNA 2 stated she was assigned to supervise the residents for the smoking break on 4/20/24. The CNA 2 further stated Resident 2 was in the wheelchair and she was going out with other residents to the smoking area. CNA 2 was in the middle of helping a male resident when Resident 2 had a fall. CNA 2 further stated her back was facing Resident 2 and she was not able to see how she fell. CNA 2 saw Resident 2 on the ground lying on her right side in the wheelchair and her head was touching the wall. CNA 2 stated she could have prevented the fall if she had the chance, but it was too late. CNA 2 further stated Resident 2 fell on the dirt and she could not have fallen if the area was all cemented. CNA 2 stated the yellow sign did not prevent Resident 2's wheelchair from tipping over the side. In a follow-up telephone interview on 4/26/24 at 10:06 a.m., the MS stated the 30-foot palm tree was taken out on 4/16/24. The MS further stated the contractor worked on the site for 2 days, they removed 150 feet of gravel, and it was 4 inches deep. The MS agreed the area was unpaved when the tree and the stump was removed. A review of the facility's policy revised July 2017 and titled, "Safety and Supervision of Residents" indicated, "Our 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... Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment... The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) ..." Therefore, the Department determined the facility failed to ensure one resident (Resident 2) was provided with adequate supervision and a safe environment to prevent accidents. This failure resulted in Resident 2 falling from a 4-inch ledge in her wheelchair and injuring her head before being transferred to the acute care hospital for further evaluation. Resident 2 sustained multiple fractures to the bones of the neck requiring surgical intervention. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result to Resident 2.