Other·February 11, 2021

F 689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) §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 that Resident 1, who had suffered a fall from bed on 03/17/20, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. As a result, Resident 1 suffered a fall from bed with major injury (broken hip) on 04/25/20, which required hospitalization and surgery for Resident 1. On 08/18/20, an onsite investigation was conducted at the facility to investigate an incident regarding a resident's fall. Resident 1, a 68-year-old female, was admitted to the facility on 10/07/19 with Medical Diagnoses including Hemiplegia (Paralysis on one side of the body) and Hemiparesis (Weakness on one side of the body), according to the facility's Admission Record. Resident 1's MDS (Minimum Data Set - a clinical assessment), dated 08/05/20, indicated her BIMS (Brief Interview for Mental Status - a structured evaluation aimed at evaluating aspects of cognition) score was 5, which indicated her cognition was severely impaired. Resident 1's MDS also indicated she required extensive assistance with bed mobility and total dependence on staff for toilet use. A nursing care plan for falls initiated on 10/08/19 included the following intervention, "[Resident 1] has low bed with mat at side." A fall risk assessment dated 10/07/19 (day of facility admission), indicated Resident 1 was at high risk for falls. First Fall: An undated facility document titled, "Facility-reported Event Follow-Up," indicated Resident 1 had an unwitnessed fall from bed on 03/17/20. The document indicated, "It was reported at 1415 (2:15 p.m.), resident [Resident 1] was found on the floor next to her bed. Resident was screaming and crying for help and complaining of pain to her back...Intervention: d/c (Discontinue) air mattress, replace with regular foam mattress, fall mats at bedside and f/u (follow up) investigation." Resident 1's care plans for falls was updated after the fall on 03/17/20, but only one (1) new intervention was added. The new intervention, initiated on 03/18/20 indicated, "Place fall mat at bedside when [Resident 1] is in bed." This intervention had already been in place since 10/08/19 and had not been effective in reducing the incidence of falls. Replacing the air mattress with a regular foam mattress was not documented in the revised care plan. This was confirmed by the Director of Nursing (DON) during a phone interview on 09/15/20 at 2:30 p.m. The Nursing Care Plan did not mention increased supervision for Resident 1. The facility provided a delivery ticket dated 04/28/20 at 10:29 a.m., which indicated the facility received a foam mattress for Resident 1 on 04/28/20, 42 days after the fall on 03/17/20, and after Resident 1 had suffered a subsequent fall from bed that resulted in injury. During a phone interview with the DON on 09/15/20 at 2:30 p.m., she was asked how floor mats prevented incidents of bed falls. The DON confirmed floor mats did not reduce incidents of falls but could prevent injuries. A fall risk assessment dated 04/10/20 (performed 24 days after Resident 1's fall on 03/17/20) indicated Resident 1 was at high risk for falls. Second Fall: A facility's document titled, "Resident Incident Report" dated 04/25/20, indicated, "Pt (patient [Resident 1]) heard yelling that she fell out of bed. Was found on floor mat c/o (complaint) L (left) Hip + (and) pelvic pain." According to this document, the incident occurred on 04/25/20 at 1:30 a.m. An undated facility document titled, "Facility-reported Event Follow-Up," indicated, "Resident [Resident 1] yelled out that she had fallen out of bed. CNA (Certified Nursing Assistant) found her on the floor on the left side fall mat next to her bed. Resident MD (Medical Doctor) and RP (Responsible party) notified. Resident sent to [Acute Care Facility] ER (emergency room) per MD order for evaluation for possible hip fracture. Hospital report indicated resident sustained L hip fracture; she is now s/p (status post) L hip hemiarthroplastly (a surgical procedure that involves replacing half of the hip joint). Resident 1's care plan for falls was revised after the fall on 04/25/20, but only one (1) new intervention was added. The new intervention, initiated on 05/15/20 (20 days after Resident 1's fall) indicated, "[Resident 1] has low bed with mat at side." This intervention had been in place since 10/20/19 and had not been effective in preventing falls for Resident 1. During a phone interview with the DON on 09/15/20 2:30 p.m., she was asked how low beds prevented incidents of bed falls. The DON stated low beds did not reduce incidents of falls. The DON was asked if supervision had been increased for Resident 1 after the falls. The DON stated she did not know if Resident 1 received increased supervision after the falls. During a phone interview on 09/14/20 at 8:45 a.m., Unlicensed Staff A (Nursing assistant who found Resident 1 on the floor on 04/25/20) stated she was not the assigned nursing assistant for Resident 1 the night of the fall, but heard Resident 1 yelling loudly and went to check on her. Unlicensed Staff A stated she found Resident 1 on the floor right next to her bed. Unlicensed Staff A stated Resident 1's bed was "3 to 4 feet high." During a phone interview on 09/14/20 at 1:49 p.m., Unlicensed Staff B (Resident 1's assigned nursing assistant the night of the fall) confirmed Resident 1's bed was a little high the night of her fall, and higher than previous shifts. When asked the reason for leaving the bed in that position, Unlicensed Staff B stated she did not think Resident 1 would fall that night but confirmed Resident 1 could move slightly in bed and may have slid. Unlicensed Staff A stated being unaware Resident 1 had suffered a fall from bed on 03/17/20, or that Resident 1 was at high risk for falls. Unlicensed Staff B was asked if she remembered what time she checked Resident 1 prior to the fall on 04/25/20. Unlicensed Staff B stated she did not remember the last time she checked on her. Unlicensed Staff B was asked if she had access to the residents' nursing care plans. Unlicensed Staff B stated not knowing if she had access to residents' nursing care plans. During an interview on 09/15/20 at 2:30 p.m., the DON confirmed nursing assistants did not have access to nursing care plans, and indicated they could only see the interventions in the nursing care plans if those interventions were present in the Residents' Kardex (a medical-patient information system). The DON was asked if, based on her judgment, Resident 1's care plan for falls was appropriate, and had resident centered interventions to prevent further falls. The DON stated, "No, it is not." Resident 1's Kardex, dated 10/07/19 and active on 04/25/20, the day of the second fall, did not indicate Resident 1's bed needed to be in low position; therefore, nursing assistants would not have access to that information, since they did not have access to Resident 1's Nursing Care Plans. The facility policy titled, "Care Plans, Comprehensive Person-Centered," last revised in December of 2016 indicated, "Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making...Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change." The facility policy titled, "Falls-Clinical Protocol" last revised in March of 2018, indicated, "For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall...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...If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The facility failed to ensure that Resident 1, who had suffered a fall from bed on 03/17/20, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. As a result, Resident 1 suffered a fall from bed with major injury (broken hip) on 04/25/20, which required hospitalization and surgery for Resident 1. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.