Health inspection·March 8, 2022

WINDSOR POST Acute Intake #: CA00699096 CITATION - CLASS B 483.25(d) [1] ACCIDENTS The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. (F689) The facility failed to provide adequate supervision for one of three sampled residents, Resident 1 (R1), when R1 did not receive one-on-one supervision on 7/29/20 in accordance with the assessed need and care plan and the facility policy and procedure on smoking. These failures resulted in R1 being permitted to smoke outside unsupervised, falling from her wheelchair onto her right arm and shoulder; having to be transported to an acute care hospital (ACH) for evaluation with fracture to the right humerus (largest bone of the upper arm) and greater tuberosity (the prominent area of bone at the top of the humerus and is the attachment for the two large powerful rotator cuff muscle), treatment for pain and splint/cast (a device used to support and immobilize a broken bone) for the fracture. R1 was transported back to the skilled nursing facility (SNF) and had decreased mobility of the right arm. An onsite investigation of Facility Reported Incident (FRI) CA00699096 was conducted on 8/12/20. R1 was admitted to the facility on 1/06/20, with diagnoses which included cerebral infarction (a portion of the brain that has restricted blood supply or stroke), aphasia (is a language disorder that affects the ability to communicate, it's most often caused by a stroke), and generalized muscle weakness. R1's "Minimum Data Set" (MDS- an assessment of healthcare and functional needs) assessment, dated 6/30/20, Resident 1's Brief Interview for Mental Status (BIMS- assessment of cognitive status) scored 5 of 15 points which indicated R1 had severe cognitive impairment. The MDS section G (assessment of functional status) indicated "...locomotion on unit ... Supervision- oversight ... locomotion off unit Supervision- oversight ... Mobility device ...Wheelchair ..." Resident 1's "Care Plan", dated 4/7/20, indicated, R1 needed assistance with smoking ... The Care Plan, dated 1/13/20 indicated "The Resident [R1] is at risk for falls and injuries due to the following risk factors: decline in functional status, impaired mobility ..." During an observation on 8/13/20 at 2:39 p.m., R1 was in her room, laid in bed with her eyes closed. R1 had a splint on her right arm. During an interview on 8/13/20 at 4 p.m., with License Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse assigned to Resident 1 on 7/29/20, when Resident 1 had a fall from her wheelchair outside the facility in the smoking area. LVN 1 stated Resident 1 was anxious to go outside and smoke on that day. LVN 1 stated the certified nursing assistant (CNA) assigned to supervise Resident 1 smoking was caring for another resident and was not available to accompany R1 to the smoking area. LVN 1 stated she gave the cigarette and lighter to R1 and R1 wheeled herself outside the facility to smoke. LVN 1 stated R1 was not safe to smoke outside unsupervised. LVN 1 stated she should not have given R1 her cigarette and lighter. LVN 1 stated she should have waited for the CNA to supervise R1 smoking instead of permitting R1 to go outside to smoke unsupervised. During a review of R1's "Progress Notes", dated 7/29/20 at 8:20 a.m., R1's Progress Notes indicated, "Resident [R1] wanted to go out to smoke for the scheduled smoke break. Resident became very anxious and refused to wait for staff to supervise the smoke break. Resident wheeled herself out of the unit ... resident fell out of wheelchair..." Progress notes dated 7/29/20 at 8:47 a.m., indicated, "She fell because she refused to wait for staff to go out for her smoke break... she complained of right shoulder pain... she was sent to the ER [emergency room] for eval [evaluation]..." During a review of R1's [name of acute hospital] "Diagnostic Radiology", dated 7/29/20, indicated " ...XR [xray - specialized equipment to take an image of the inside structures of the body] Shoulder Complete Minimum 2 views right ... Clinical Information: Injury and pain ... Findings: Acute comminuted fracture (broken bone into 3 or more places) of the right humeral neck and head [upper right arm and shoulder] ..." During a review of R1's [name of acute hospital] "Patient Education & Visit Summary" (hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team) dated 7/29/20, indicated " ...Presenting Complaint: BIBA [brought in by ambulance] from [name of skilled nursing facility], with right arm pain ... Patient Diagnosis: Fall from wheelchair; Fracture of surgical neck humerus ... Humerus Fracture treated with Immobilization ... Printed Prescription hydrocodone bitartrate and acetaminophen ..." During a concurrent interview and record review, on 8/13/20 at 4:43 p.m., with the Director of Nursing (DON), the "Smoking Policy", dated 10/24/17. indicated, "To respect resident choice to smoke and to maintain a safe and healthy environment for both smokers and non-smokers ... Resident smoking is only allowed during scheduled times ... All smoking sessions will be supervised by Facility Staff members only ... Residents are not permitted to keep smoking materials such as lighters, matches or any other related items in their possession ...R1's "Smoking Assessment (an assessment tool used to evaluate resident safety during smoking)" dated 7/9/20, was reviewed. R1's smoking assessment indicated, R1 needed one-on-one assistance for safety The DON stated the fall could have been prevented if supervision and assistance was provided and the license nurse did not give R1 her cigarettes until the CNA assigned to supervise smoking was ready to accompany R1. During an interview on 8/18/20, at 12:30 p.m., with CNA 1, CNA 1 stated she was assigned to supervise R1 during smoking on 7/29/20. CNA 1 stated she was providing care to another resident and was not ready to supervise R1 on 7/29/20 at the time R1 requested to go out and smoke. CNA 1 stated she heard staff members yelling and when she stepped outside the facility, she saw R1 on the ground. CNA 1 stated the fall could have been prevented if the license nurse waited for her to provide supervision to R1 before giving the cigarettes and the lighter. During an interview on 8/18/20, at 6:30 p.m., with LVN 2, LVN 2 stated she was outside the Red Zone unit (area in the facility dedicated to care for residents with the Coronavirus [COVID-19- a contagious serious respiratory infection transmitted from person to person]). LVN 2 stated she was performing hand washing inside the tent (area in the facility where staff washed their hands before entering and exiting the Red Zone). LVN 2 stated she saw R1 on her wheelchair coming out of the Red Zone unsupervised. LVN 2 stated she told R1 to wait for a staff member to supervise her smoking. LVN 2 stated R1 did not listen to her and just passed by her. LVN 2 stated she heard a loud noise and when she stepped outside the tent, she saw R1 on the ground. LVN 2 stated she could not stop R1 from going out the facility unsupervised because she was in the middle of washing her hands. LVN 2 stated R1 was assessed as a high fall risk and it was not safe for her to smoke outside unsupervised. During a concurrent interview and record review on 8/25/20, at 2:09 p.m., with the Assistant Director of Nursing (ADON), Resident 1's "Smoking Assessment" dated 7/9/20, indicated Resident 1 needed one-on-one assistance during smoking sessions for safety. R1's "Fall Risk Assessment" dated 3/29/20, indicated Resident 1 was assessed as a Moderate risk for falls. ADON stated it was not safe for Resident 1 to smoke outside the facility unsupervised based on the smoking assessment and fall assessment. During a review of the facility's policy and procedure titled, "Fall Management", dated 11/2012 indicated, "It is the policy of this facility that our physical environment remains as free of accident hazards as possible. Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls ... Residents, who have sustained a fall, will be placed on the facility's heightened awareness program... outlined on the care plan ..." During a review of the professional reference titled, "Nursing home resident smoking policies" dated 2008, https://pubmed.ncbi.nlm.nih.gov/19343890/ indicated ..."Objective: To identify nursing home standards related to resident smoking through a nationwide survey of directors of nursing. Methods: A national survey was distributed online and was completed by 248 directors of nursing. The directors of nurses answered questions concerning resident smoking including the criteria utilized to determine an unsafe resident smoker. For those residents identified as unsafe, the questions asked were specifically related to monitoring, staff involvement, safety precautions and policy. Results: The results of the survey demonstrated a consistent policy practiced among facilities across the United States. The monitoring of nursing home residents is based on a resident's mental acuity, physical restrictions and equipment requirements. Once a resident was identified as a smoker at risk of harm to self or others, staff involvement ranged from distributing cigarettes to direct supervision. Conclusion: Monitoring policies of nursing home residents who smoke starts with identifying those residents at risk based on an assessment of mental acuity, physical restrictions and equipment requirements. Those that are identified as being at risk smokers have their cigarettes controlled and distributed by nursing staff and are supervised by facility staff when smoking. This policy is implemented through written policy as well as staff education ..." The facility failed to provide 1:1 supervision to R1 during smoking time in accordance with the assessed need and care plan and the facility's policy and procedure on smoking. The facility provided R1 with a cigarette and permitted R1 to smoke outside without supervision. R1 fell from her wheelchair onto the ground and sustained fractures to her right upper arm requiring treatment and immobilization of the fracture at the hospital. R1 experienced pain and decreased mobility of the right arm. This violation had a direct relationship to the health, safety and security of Resident 1 and therefore constitute a class "B" citation.