Other·January 18, 2024

F689 Title 42, Section 483.25 Free of Accident Hazards/Supervision/Devices 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. On 12/22/23 at 10:05 a.m., an unannounced visit was conducted at the facility to investigate quality of care regarding resident safety. The department determined the facility failed to supervise one resident (Resident 1) when Resident 1 was left on the toilet, fell, and hit her head. This failure led to Resident 1 sustaining a subdural hemorrhage (a severe and sudden loss of blood from a damaged blood vessel). A review of Resident 1's admission record indicated admission to the facility on 11/24/23 with diagnoses which included a displaced right femur (thigh bone) fracture after a fall, Parkinson's disease (a degenerative brain condition which results in problems with balance and movement) with dyskinesia (involuntary and erratic movement of the face, arms, and legs), difficulty in walking, and a need for assistance with personal care. A review of a fall risk assessment dated 11/24/23 at 10:11 p.m. indicated Resident 1 had a high risk for falls and was, "...Unable to independently come to a standing position... [and] Requires hands-on assistance to move from place to place..." A review of a care plan focused on Resident 1's high risk for falls, initiated on 11/24/23, indicated the staff were to implement the following interventions to prevent falls, "...Anticipate and meet the [resident]'s needs...The [resident] needs prompt response to all requests for assistance...follow facility fall protocol..." A review of a care plan focused on Resident 1's Activities of Daily Living, initiated on 11/24/23, indicated Resident 1 had a self-care performance deficit related to impaired balance, limited mobility, limited range of motion, and pain. This care plan also indicated staff were to implement the following interventions when providing assistance to Resident 1, "...TOILET USE: The [resident] requires (2) staff participation to use toilet...TRANSFER: The [resident] has requires [sic] (2) staff participation with transfers..." A review of a care plan focused on Resident 1's use of paroxetine HCl (a medication used to treat depression) initiated on 11/24/23 indicated staff were to, "...Monitor side effects of anti-depressant agent...such as...dizziness..." A review of Resident 1's Medication Administration Record (MAR), dated November 2023, indicated licensed nursing staff administered 20 mg of paroxetine HCl to Resident 1 by mouth once a day at 9 a.m. from 11/25/23 to 11/28/23. A review of Resident 1's MAR, dated November 2023, also indicated licensed nursing staff administered 40 mg (milligram, a unit of measure) of enoxaparin sodium injection solution (medication used to prevent blood clots from forming) into Resident 1's abdomen twice a day at approximately 9 a.m. and 9 p.m. from 11/25/23 to 11/28/23 to prevent a deep vein thrombosis (DVT, a blood clot). A review of Resident 1's physician's order note dated 11/25/23 at 1:15 a.m. indicated, "Enoxaparin Sodium Injection Solution...Severity: Moderate...Interaction: Coadministration of enoxaparin with antiplatelet agents... [such as] paroxetine HCl...may increase the risk of bleeding..." A review of Resident 1's progress note dated 11/25/23 at 3:30 p.m. indicated, "...Staff notified...that [resident] slid from edge of toilet seat to the ground...[resident] family member stated, '...she slid to the floor when she was trying to get up from the toilet.' Upon entering [resident] bathroom [resident] found sitting up with her bottom on ground and back against toilet and wall with left arm holding onto bathroom rail. When asking [sic] [resident] what happened, [resident] stated, 'I slid on the floor when I was finished using the bathroom.'... [resident] stated, 'No I didn't hit my head.'... [Resident] transferred...to wheelchair with 2 person assist." A review of Resident 1's History and Physical (H&P) dated 11/27/23 at 12:34 p.m., the physician indicated, "...Resident complaints since admission: had fall by bedside yesterday with no noted injuries...Delirium...daughter notes intermittent confusion during their visits." A review of Resident 1's progress note dated 11/27/23 at 8:43 p.m. indicated, "[Physician] notified of unwitnessed fall on 11/25 stated to follow facility fall protocol and inform [physician]. Order carried out..." A review of Resident 1's order summary report indicated Resident 1 received the following physician's order, "Fall precautions, and delirium precautions." A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/28/23, indicated Resident 1 had moderate memory problems. This MDS also indicated for toileting hygiene, "[was] Dependent-Helper does ALL of the effort. [Resident] does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the [resident] to complete the activity." A review of a Situation, Background, Appearance, and Review (SBAR) Communication Form dated 11/29/23 indicated, "... [Resident 1] struck head on floor of bathroom, skin intact. Bump present on posterior scalp measuring 2 in. [inches, a unit of measurement] x 3.1 in. x 1.7 in. redness noted in center. Pain and warmth upon touch... [Resident 1] had an unwitnessed fall in the bathroom attempting to self-transfer [sic] from toilet to [wheelchair]... [Resident 1] was found in supine position with head in between the wall near the door and wheelchair, feet facing opposing door into next room, wheelchair [sic] is locked and facing the toilet. [Resident] states that she hit her head on the floor and feels increasing aching pain on the back of head that does not radiate [travel] anywhere." A review of Resident 1's order summary report, printed 12/22/23 at 1:13 p.m., indicated Resident 1 received the following physician's order, "[Resident] has limited capacity to make medical decision (brought forward from [physician's name] H&P...)...Order Date 11/29/23." A review of Resident 1's computed tomography scan conducted at the hospital on 11/29/23 at 9:10 a.m. indicated, "Impression...Subdural hemorrhage along the falx [a strong, crescent-shaped sheet which lies between the two hemispheres of the brain] measuring 4 mm [millimeters, a unit of measurement] in thickness...Left parietal scalp [the main side bone of the skull] hematoma [an injury which results in a collection of blood to pool under the skin]..." A review of an Interdisciplinary Team (IDT, a team made up of various disciplines who work in collaboration to address a resident's needs) progress note dated 11/30/23 at 2:22 p.m. indicated, "IDT met to discuss [Resident 1's] fall on 11/29/23. [Resident] had a fall in the bathroom. [Resident 1] attempted to stand up unassisted lost her balance and fell...[Resident 1] was sent out to [Emergency Room] for further eval...[Resident 1] has capacity to make medical decisions and has a BIM [Brief Interview for Mental Status, a screening tool used to assess a person's mental processing ability] score of 9 (moderate impairment)...Upon further investigation the CNA [Certified Nurse Assistant] instructed the [Resident 1] to push the call light when she is finished and then the CNA stepped out and left the door ajar. Rehab came in they found the [Resident 1] on the bathroom floor. [Resident 1] had not used the call light and attempted to stand up and transfer self-off of the toilet..." In an interview on 12/27/23 at 4:52 p.m., the CNA 3 stated he would maintain a close distance to the resident's bathroom if a resident asked for assistance to the toilet and privacy. The CNA 3 also stated he would knock on the bathroom door to follow-up with the resident if he had not heard from the resident after some time had passed. In an interview on 12/29/23 at 9:10 a.m., the CNA 1 confirmed she had been assigned to Resident 1 on the day Resident 1 fell in the bathroom and hit her head. The CNA 1 stated she had assisted Resident 1 to the toilet and Resident 1 asked her to give her privacy. The CNA 1 stated she closed the door to the restroom and while Resident 1 was in the restroom, the CNA 1 left Resident 1's room to return Resident 1's used meal tray to the tray cart in the hallway. While CNA 1 was placing Resident 1's tray to the cart, another CNA asked for assistance with another resident. The CNA 1 stated she went to assist her coworker with care for another resident in the same hallway, a couple of rooms down from Resident 1. When CNA 1 returned to Resident1's room, she found out Resident 1 had fallen and had been found by another CNA. A review of the facility's policy and procedure titled "Falls- Clinical Protocol", revised March 2018, indicated, "...The physician will identify medical conditions affecting fall risk...and the risk for significant complications for falls (for example...increased risk of bleeding in someone taking an anticoagulant)...Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling...Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling...Frail elderly individuals are often at greater risk for serious adverse consequences of falls...Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented." Therefore, the department determined the facility failed to supervise Resident 1 when Resident 1 was left on the toilet, fell, and hit her head. This failure led to Resident 1 sustaining a subdural hemorrhage (a severe and sudden loss of blood from a damaged blood vessel). This violation had a direct or immediate relationship to the health, safety, or security of residents or residents.