Other·December 22, 2022

§483.25(d) Accidents. The facility must ensure that - §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 8/3/22, at 1:20 PM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a resident fall. Resident 1 was an elderly and confused resident in a long term care facility who was assigned to have a one-to-one monitor[BA1] stay with her to supervise her actions and protect her from harm. The monitor left the resident alone, which enabled the resident to walk down a hallway without supervision, where she fell and fractured multiple bones in her face, suffered a laceration (a tear to her skin that required stitches), and a subdural hematoma, (a dangerous, potentially life threatening, bleed into her brain tissue), decreased mobility, and pain. The facility failed to ensure the monitor assigned to monitor Resident 1 on a one-to-one basis stayed at her post, which resulted in Resident 1 falling and suffering significant injuries. Resident 1 was an 82-year-old female admitted to the facility on 11/3/21, with diagnoses that included dementia and Alzheimer's Disease (mental disorders that affect memory, mood, and judgement). During a review of the Physician's Orders for Resident 1, an order dated 12/14/21, indicated Resident 1 was to have "1:1 resident monitoring daily as needed." During a review of a statement written and signed by Monitor 1, dated, 7/24/22, the statement indicated, "I was monitoring [Resident 1] when the lunch meals arrived. I left her eating her lunch, while sitting on her bed. I volunteered to feed another patient while she [Resident 1] was eating, because she [Resident 1] typically stays seated for a long time, until she [Resident 1] finishes her meals. I checked on her [Resident 1] twice before heading into Room 131 to assist another patient. Less than 5 minutes later I heard another female patient yell three[BA2] times "[Resident 1] fell," I headed out and saw [Resident 1] laying on the floor on her left side, immobile. I went to see her [Resident 1], but the nurse, [Licensed Vocational Nurse, or LVN, 9] was able to arrive to her first. [Resident 1] was bleeding from the left side of the head thus another nurse, [LVN 8] applied a towel and pressure to the wound. Someone called for the Gurney [a portable stretcher with wheels, used to transport patients] to be brought. Then several people assisted [Resident 1] on to the Gurney. She [Resident 1] was then transported to the ER [Emergency Room, which was located in another part of the same facility where the fall took place] where she was treated. I then stayed with [Resident 1] in the ER until she was released back into the [Skilled Nursing Facility]." During a review of the Progress Notes, for Resident 1, dated 7/24/22, at 6:42 PM, the Progress Notes indicated, "resident was found on floor in hall three, when nurse approached resident, she was lying on her left side bleeding from her eyebrow area. Large laceration to her left eyebrow area was observed, pressure applied to area. Resident was conscious and moaning upon arrival of nurse. It was determined that resident needed to go to ER right away." The Progress Note was written by LVN 9. During a review of the Progress Notes, for Resident 1, undated, the Progress Notes indicated, "Resident returned from ER [after] fall with injury at 7:20 PM, via wheelchair, accompanied by [Monitor 1/ one-to-one staff]. Resident had blood on her forehead and to the left of her left eye, and some blood also in her hair and left ear Resident has bruising to the left of her eye wrapping down under the eye across the top of the cheek bone, it is a dark blue in color. Resident has 11 sutures to the forehead and left of her eye that must be removed in 8 days. Resident states her eye only hurts when she blinks. Resident came back with new order for Norco [Norco is a combination of two medicines (acetaminophen and hydrocodone bitartrate) used to treat moderate to severe pain. Hydrocodone is an opioid pain medication, commonly referred to as a narcotic. Acetaminophen is a less potent pain reliever that increases the effect of hydrocodone]." The Progress Note was written by LVN 7. During a review of the Care Plan, for Resident 1, dated 7/25/22, the Care Plan indicated, Resident 1 was at risk for increased pain due to multiple facial fractures, and, that there was also a tear to the skin that required stitches and bruising near the eye. During a review of "Physician Orders," for Resident 1, a physician order dated 7/24/22, indicated, Resident 1 was prescribed Norco with the purpose of controlling "acute pain" for 12 doses. During a review of the "CT Scan [Computerized Tomography, a type of advanced x-ray] of Head" for Resident 1, dated 7/26/22, it indicated Resident 1 had a "2 - 3-millimeter subdural hematoma." During a review of the "CT Scan of Facial Bones" for Resident 1, dated 7/24/22, it indicated Resident 1 had multiple fractures of the facial bones, a laceration and bruise near her eye. During a review of "Physician Orders," for Resident 1, a physician order dated 7/29/22, indicated, Resident 1 received a new order for Norco, to be given for "facial [fracture] pain." During a review of the Progress Notes written by Registered Nurse (RN) 1 for Resident 1, dated 7/30/22, at 6:11 PM, the Progress Notes indicated, "Nursing will continue to monitor sutures and bruises. The resident monitor stated that [Resident 1] started holding the right side of head during dinner and lost her appetite saying her head hurt. Norco was given with good results." During an interview on 8/3/22, at 2 PM, with Monitor 2, Monitor 2 stated, the Monitor's role is to supervise Resident 1 because she is a wanderer [wandering is the act of moving from place to place with or without a specified course or known direction] and a fall risk. Monitor 2 stated, Resident 1 has been assigned Monitors to supervise her since March 2022 and is very familiar with Resident 1's needs. Monitor 2 stated, Resident 1 has memory issues and can easily get confused and needs to be reminded to use her cane before she tries to walk. Monitor 2 stated, Resident 1 can walk on her own if she used her own cane and had someone to supervise her, because she is unsteady. Monitor 2 stated, Resident 1 now requires a wheelchair for mobility after the fall on 7/24/22 due to weakness. During an interview on 8/3/22, at 2:30 PM, with LVN 9, LVN 9 stated, that after lunch on 7/24/22, a staff member notified LVN 9 that Resident 1 had fallen onto the floor in hallway 3. LVN 9 stated, that she observed Resident 1 bleeding from a facial wound while on the floor. LVN 9 stated, that Resident 1 was transferred to a local emergency department for treatment. LVN 9 stated, a CT scan was performed, and Resident 1 had multiple facial fractures and required stitches to close the open wound. During a review of video surveillance of Hallway 3, occurring on 7/24/22, the video indicated, Resident 1 ambulating in hallway 3 at 12:16 PM. The surveillance video indicated, Resident 1 walked down hallway 3 without her cane, with an unsteady step, shuffling from side to side. Resident 1 then turned around and fell onto the floor. No staff were observed in hallway 3 at time of fall at 12:16 PM. The video was viewed with the Director of Nursing (DON), on 8/3/22, who identified Resident 1. During an interview on 8/3/22, at 1:40 PM, with DON, DON stated, on 7/24/22, Monitor 1 was assigned as the one-to-one staff for Resident 1 at the time of the fall. DON stated Monitor 1 should have been monitoring Resident 1 continuously but Monitor 1 voluntarily left Resident 1 alone in their room during lunch. DON stated, Resident 1 then wandered into the hall, without her walker, unsupervised, and fell onto the floor in hallway 3. During an interview on 8/3/22, at 2:40 PM, with DON, DON stated, Resident 1 was placed on one-to-one monitoring due to wandering and confusion. DON stated, the role of the monitor is to redirect the patient and make sure she is using her walker when attempting to walk. DON stated, "I think the fall could have been prevented if the Monitor was there, they could have helped [Resident 1] eat her lunch and coax her into using their walker." DON stated, "with 100% certainty the fall was preventable" had the one-to-one Monitor not left Resident 1 alone. During an interview with LVN 6, on 9/14/22, at 11:34 AM, LVN 6 stated, Resident 1 is not ambulating the same as before [the fall on 7/24/22] and becomes short of breath and fatigued easily, often requiring use of a wheelchair. LVN 6 stated that since the resident's fall, Resident 1 now complains of headaches and back pain for which she has been prescribed Norco. In violation of the above cited standards, the facility failed to ensure Resident 1 received the necessary supervision from the Resident Monitor to prevent a fall which resulted in serious injury. This violation presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and is a Class "A" citation. [BA1]If there is a preferred term (sitter or monitor), okay to use it in both places, but be consistent [BA2]I moved the location of "three times", because the transcript looks like she fell three times