Health inspection·February 2, 2023

Representing the Department, HFEN 32717 State Citation A was written. Free of Accident Hazards/Supervision/Devices §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. §72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility ogjectives are achieved. On 7/21/21, an unannounced visit was conducted at the facility to investigate a Facility-Reported Incident regarding Resident l's unwitnessed fall and injury. The facility failed to: 1. Update Resident 1's care plan to minimize the risk for fall accidents and provide the level of supervision needed when Resident 1 was a high fall risk, as required by the care plan and policies and procedures. 2. Accurately calculate Resident's 1 risk for falls and develop new interventions for fall accident prevention after Resident 1 suffered six unwitnessed falls over a month. These failures resulted in Resident 1 suffering a laceration on his face above the eye after being found at the end of his bed in the early hours of the morning on 6/30/21. Resident 1 was transferred to a general acute care hospital (GACH). Upon being transferred back to the facility Resident 1 continued to suffer several more falls without the care plan being updated. Resident 1 was 73 years old and admitted to the facility on 6/14/21 with diagnoses that included repeated falls, difficulty walking and muscle weakness, laceration on the head, dementia (memory loss and impaired decision-making capacity), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), major depressive disorder (persistently depressed mood and loss of pleasure and interest in life), and psychotic disorder (mental illness). Resident 1 was not steady, and only able to stabilize with staff assistance for transfers and activities of daily living. The facility failed to provide Resident 1, known to be a high risk for falls, the level of supervision that could be implemented, for example, a sitter­ (assigned to render constant supervision) to prevent further falls and injury. Resident 1 sustained multiple falls (eight falls over 28 days). On 6/30/21, Resident 1 had an unwitnessed fall and sustained a facial laceration (cut) on the forehead. Resident 1 was sent to the hospital and was diagnosed with a subdural hematoma (when a pool of blood develops between the brain and its covering, usually from head trauma) and was hospitalized for nine days. Review of Resident l's History & Physical by the Attending Physician dated 6/15/21 indicated Resident 1 was a fall risk who had a prior intracerebral hemorrhage (bleeding within the brain) and recurrent falls. Review of Resident l's "Care Plan for Fall- High Risk" dated 6/14/21 indicated Resident 1 was considered a high risk for falls due to a history of falls, use of psychoactive (group of drugs that include stimulants, depressants, narcotics that causes changes in mood awareness, thoughts, feelings, or behavior) drugs, use of cardiovascular (body's circulatory system) medications, poor safety awareness, dementia, decline in functional status, unsteady gait, impaired balance and wandering. The approaches to minimize recurrence of falls included to assess the cause, pattern of falls, and activities; evaluate possible medical, physical, cognitive, and psychiatric (mental health disorder) conditions. However, the care plan did not initiate the cause and effect after each fall incident with new nursing approaches for fall prevention or consider a sitter for direct supervision for protecting Resident 1. During an interview and concurrent review of Resident l's Fall Risk dated 6/14/21, with Registered Nurse (RN) 1 on 7/21/21 at 11: 55 a.m., showed Resident 1's fall risk was incorrectly totaled as "8" and should have been "12" (10 and above represented a high fall risk). RN 1 stated she had not reviewed Resident 1's fall history in the last three months and did not consider that Resident 1 took four medications that would affect Resident 1's fall risk score. RN 1 further stated the medications should have changed Resident 1 score to "4" and not "2." Resident 1's Fall Risk Assessment had a total of 4 missed points that were not calculated in the fall risk assessment to accurately total 12 that represented a high fall risk. Review of Resident l's Departmental Notes indicated eight unwitnessed fall episodes from 6/18/21 through 7/15/21, and staff were to implement cueing/supervision as needed. There were no revised care plans to include new interventions or approaches to protect Resident 1 from repeated falls. During an interview with the Nursing Supervisor (NS) on 7/21/21 at 1:40 p.m., NS stated, during the Interdisciplinary Team (IDT, a group of individuals representing different departments) meeting on 6/23/21, Resident 1 was moved to Room A, two rooms closer to the nurse's station for supervision. Although it was closer in proximity to the nurse's station, staff still did not have a clear view and visual line of sight of Resident 1 inside the room from the nurse's station. During a telephone interview with LVN 4 on 7/26/21 at 11:33 a.m., LVN 4 stated, on 6/30/21 at 4:25 a.m., CNA 1 notified LVN 4 that Resident 1 was found on the floor and had a cut on the head with a "lot of blood." LVN 4 stated, a sitter could have provided 24/7 supervision to help reduce the falls and was not implemented. Review of Resident 1's Departmental Notes indicated Resident 1 had an unwitnessed fall on 6/30/21 at 2:45 a.m. and was on the floor near the foot of the bed. Resident 1 sustained a two-centimeter laceration (cut) above the right eyebrow that was bleeding. Resident 1 was transferred to the hospital on 6/30/21 at 5 a.m. Review of Resident 1's Neurosurgery (brain or spinal cord surgery) Consultation Note dated 6/30/21 showed, Resident 1 had abrasions (scrapes) on the right side of the face. Resident l's Computed Tomography (CT- detailed images of the body) scan showed a small, acute right-sided subdural hematoma that required serial head CT's (repeat scans taken in intervals) to establish clinical stability. Resident 1 was admitted to the Neuro Intensive Care Unit (specialty unit for those with immediately life­ threatening neurological problems). Review of Resident l's Face Sheet indicated Resident 1 was discharged from the hospital and re-admitted to the facility on 7/8/21. Review of Resident 1's Departmental Notes indicated Resident 1 continued to have unwitnessed falls after being readmitted to the facility from the hospital. On 7/10/21 at approximately 11 a.m., the housekeeper found Resident 1 head-first on the ground with a raised red bump on the left side of the forehead measuring one inch. No fall care plan was created until 7/10/21 and had the same interventions from the care plan dated 6/18/21. Resident 1 had two more unwitnessed falls on 7/11/21 at 9:22 p.m., and 7/15/21 at 7:56 p.m. without injuries and no changes to the care plan. During an interview and concurrent review of Resident l's fall care plan with the Licensed Vocational Nurse 2 (LVN 2), on 7/21/21 at 12:05 p.m., LVN 2 stated, the fall care plan interventions were not reviewed, updated, or evaluated if they were effective after multiple unwitnessed falls. During an interview with NS on 7/21/21 at 1:05 p.m. and review of the Departmental Notes, NS stated NS and the Interdisciplinary Team (staff from different departments) had a meeting on 6/23/21 to discuss Resident l's fall incident on 6/18/21 but was not aware of the fall incident on 6/19/21. NS stated, IDT was aware of Resident l's fall incident on 6/20/21 but did not discuss the incident. The facility's policy and procedure, "Fall Prevention Program" revised 3/4/14, indicated ... " all residents will receive adequate supervision.... If a resident triggers a risk for falls, the IDT will further assess the fall risk actors utilizing RAP (resident assessment protocol) guidelines and will discuss at the initial care plan meeting. The IDT, if indicated, will further update care plan to minimize the risk of falls." During a telephone interview with the Assistant Administrator (AA) on 7/21/21 at 4:22 p.m., AA stated that providing a sitter for supervision could have been considered. In violation of the above cited standards, the facility failed to provide Resident 1, known to be a high risk for falls, according to §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 update Resident 1's care plan to minimize the risk for fall accidents and provide the level of supervision needed for fall accident prevention as required by the care plan, policies, and procedures, Furthermore, to accurately calculate Resident's 1 risk for falls and develop new interventions for fall accident prevention. Resident 1 suffered six unwitnessed falls over a month and was hospitalized with a subdural hematoma for nine days.