Health inspection·February 20, 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. The following citation was written as a result of an unannounced visit to the facility on 11/17/23 to investigate a facility reported incident, #CA00868807. The Department determined the facility failed to ensure a Certified Nursing Assistant (CNA 2) provided two-person physical assistance during incontinence care for Resident 1 in accordance with Resident 1's care plan, dated 9/28/2020 and the Minimum Data Set assessment (MDS, an assessment tool) dated 9/9/23. As a result of this failure, Resident 1 fell from her bed and sustained a laceration (a deep cut or tear) on her left forehead, a left midclavicular (the bone connecting the breastbone and shoulder) fracture, and a left rib fracture. A review of Resident 1's "Admission Record", indicated, Resident 1 was admitted to the facility early 2008 with multiple diagnoses that included quadriplegia (paralysis of the legs and arms) and muscle weakness (generalized). A review of the MDS dated 9/9/23, indicated Resident 1 had severe cognitive (mental processes that take place in the brain including but not limited to thinking and attention) impairment. The MDS also indicated that Resident 1 required extensive assistance from staff for activities of daily living (ADLs) and two+ person physical assist for bed mobility (how resident moves to and from lying position, turns side to side). A review of Resident 1's Care Plan, initiated 9/28/20, indicated, "The resident has ADL self-care deficit r/t [related to] Impaired mobility...Interventions...MOBILITY: The resident Is totally dependent on staff for mobility...MOBILITY: The resident requires 2 staff participation [sic] for mobility..." A review of Resident 1's "Documentation Survey Report v2" dated 10/2023, indicated, "...Bed mobility: Roll left and right (two person Assist)..." The document also indicated that Resident 1 was dependent and needed substantial/maximal assistance. A review of Resident 1's Progress Notes dated 11/3/23, indicated, "...Found the resident on the floor head is bleeding...As per the CNA [Certified Nursing Assistant] she is doing patient care, she turns patient to her right side and fell. Check the head of the resident bleeding came from the residents [sic] forehead left side. Residents [sic] sustain a deep laceration on left side of the forehead...MD recommended to transfer resident to ED [Emergency Department] via 911..." A review of Resident 1's Acute Hospital discharge summary dated, 11/15/23, indicated, "...# Mechanical fall...Reportedly was dropped at nursing facility...has left clavicle and left rib fracture. Has laceration to left head which was suture[sic]..." During an observation on 11/17/23 at 10:10 am in Resident 1's room, Resident 1 was awake lying in bed with a wound on the left forehead and a left arm sling. Resident 1 mumbled when spoken to. During an interview on 11/17/23 at 10:35 a.m., with CNA 1, she stated Resident 1 was a two person assist during incontinence care. CNA 1 further stated, two persons should be there when turning Resident 1. During a telephone interview on 11/21/23 at 3:32 p.m., with CNA 2, she stated, she was positioned at the right side of Resident 1's bed when she was changing the resident's diaper. She was almost done cleaning her when the resident started bearing down having another bowel movement and urination. CNA 2 then moved to the left side of Resident 1's bed to change her diaper and clean her again. She stated the bed was raised at her waist level because she was still giving care. The resident was in the middle of the bed in right side lying position when CNA 2 moved to the left side of the bed. CNA 2 further stated, when she was grabbing the garbage bag on the floor, Resident 1 flipped and fell on the floor. CNA 2 stated Resident 1's bed did not have siderails and she had a low air loss mattress (a special mattress used to prevent bedsores). She stated, the air loss mattress might have inflated from the side to the right side when Resident 1 fell off the bed. CNA 2 did not mention that the air loss mattress had bolsters (a raised side perimeter, helps prevent accidental patient roll-out and fall). CNA 2 stated, she was doing the incontinence care alone because Resident 1 was a one person assist. During a telephone interview on 11/22/23, at 12:16 p.m., with Licensed Nurse 1 (LN 1), LN 1 stated, CNA 2 called her to ask for help because Resident 1 had fallen. When LN 1 came to the room, Resident 1 was on the floor, facing the door in a right side lying position. Resident 1 was not moving but she was crying. LN 1 stated, CNA 2 said she was taking care of Resident 1 and she was going to pick something from the floor, then she saw Resident 1 falling and it was too fast for her to grab the resident. LN 1 further stated, according to CNA 2, Resident 1 was in the middle of the bed, however, LN 1 believed the resident was on a side lying position when she fell. LN 1 stated, the fall could have been prevented if she had not turned to pick up something but sometimes, we cannot avoid picking something up from the floor. During a telephone interview on 11/29/23 at 10:19 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated, Resident 1 required a two person assist based on her Quarterly MDS assessment dated 6/11/23 and Annual MDS assessment dated 9/9/23. The MDSN stated, Resident 1 was supposed to be a two person assist based on the care needs and in bed mobility because when they are changing her diaper during incontinent care, they are turning the resident from side to side. She further stated, for all residents that are dependent for care especially in Resident 1's case, it is safer for her to be assisted by two staff. During an interview on 11/17/23 at 12:15 p.m., with the Director of Nursing (DON), the DON stated, she expected the staff to implement fall precaution and avoid behaviors that placed a resident at risk for a fall. The goal is for residents not to have falls. A review of the facility policy titled, "Falls Management," revised 11/2012, indicated, "...Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls..." Therefore, the Department determined the facility failed to ensure CNA 2 provided two-person physical assistance during incontinent care for Resident 1 in accordance with Resident 1's care plan, dated 9/28/2020 and the Minimum Data Set assessment (MDS, an assessment tool) dated 9/9/23. This failure led to Resident 1 falling from her bed and sustaining a laceration (a deep cut or tear) on her left forehead, a left midclavicular (the bone connecting the breastbone and shoulder) fracture, and a left rib fracture.