Health inspection·December 13, 2021

F 689 G §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. §72311 (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The above violation had a direct relationship to the health, safety or security of patients when the facility failed to implement the care plan for fall prevention by placement of a fall mattress (a padded floor mat) adjacent to Resident 1's bed to decrease the chance of injury from falls. This failure resulted in Resident 1 receiving emergency room treatment after he sustained a laceration (a skin cut) above his left eyebrow, bruising of his left cheek, and a broken hip prosthesis (an artificial, surgical implant replacing the original body part) after he fell from his bed onto the floor. A review of Resident 1's undated Admission Record indicated Resident 1 was admitted to the facility in 2019 with a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities) and repeated falls. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/2/21, indicated Resident 1 required extensive physical assistance from at least one person for bed mobility, transfer between surfaces, and toilet use. The MDS indicated Resident 1 used a wheelchair for locomotion and was unsteady without assistance during transfer between surfaces, with impairment of both lower extremities. A review of Resident 1's facility document Quarterly Fall Risk Assessment, dated 4/2/21, indicated, "If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." The Quarterly Fall Risk Assessment indicated Resident 1 had a score of 12, an indication of high risk of falls. A review of Resident 1's care plan with the focus of, "Potential for fall related to recent history of falls, Unsteady Gait," start date of 9/25/19, indicated an intervention, "... mattress on the floor to keep resident safe as needed." A review of Resident 1's Nurses' Notes dated 6/19/21 at 9:31 a.m., indicated Resident 1 was found on the floor at 6 a.m., with, "skin laceration top of his left eyebrow approx.[approximately] 2.5 cm. [centimeters, 2.5 cm equals 0.98 inches] long with slight bleeding and redness to left cheek." The Nurses' Notes indicated Resident 1 was lifted back into his bed with the assistance of three staff members, 9-1-1 was called, and Resident 1 went to the acute care hospital for further evaluation. During an interview on 7/26/21 at 12:45 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she was permanently assigned to care for Resident 1 on the night shift (the shift beginning at 11 p.m. and ending the next morning at 7:30 a.m.). CNA 1 stated during her last round of the shift on 6/19/21 she was changing Resident 1's adult brief when she realized she needed a new brief to replace the soiled brief. CNA 1 stated Resident 1 was in the middle of the bed, when she left the bedside and went to the sink cabinet to get another brief. CNA 1 stated when she turned around, Resident 1 was directly on the floor as there was no fall mattress on the floor. CNA 1 stated she called the charge nurse for assistance. During an interview on 7/19/21 at 1 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was called to Resident 1's room by CNA 1 on 6/19/21 at 6 a.m. LVN 2 stated when she entered the room Resident 1 was lying on his left side on the floor, as there was no fall mattress in place. LVN 2 stated she assessed Resident 1's condition, and noticed he was bleeding from a skin tear above his left eyebrow. LVN 2 stated Resident 1 then went to the acute care hospital for further evaluation. A review of Resident 1's acute care hospital, ED [Emergency Department] Provider Notes dated 6/19/21, indicated Resident 1 had a two-centimeter laceration above his eyebrow with a hematoma (a collection of blood under the skin, outside the blood vessels), which was treated with surgical skin glue to close the wound edges. The ED Provider Notes indicated, "Patient had a pelvic x-ray with concern for acute fracture." A review of Resident 1's acute care hospital document, "X-ray Pelvis AP," dated 6/19/21, indicated Resident 1 had a fractured left hip prosthesis. The ED Provider Notes indicated Resident 1 returned to the facility on 6/19/21. A review of Resident 1's care plan with the focus of, "Potential for fall related to recent history of falls, Unsteady Gait," start date of 9/25/19, indicated the last care plan review was completed 7/5/21, with the continued intervention "...mattress on the floor to keep resident safe as needed," with no changes to the care plan. During a concurrent observation and interview on 7/7/21 at 10:10 a.m., with Licensed Vocation Nurse 1 (LVN 1), in Resident 1's room, there was no fall mattress on the floor at Resident 1's bedside. LVN 1 stated Resident 1's care plan indicated Resident 1 should have a fall mattress as part of his fall prevention interventions. Therefore, the facility failed to implement the care plan for fall prevention by placement of a fall mattress adjacent to Resident 1's bed to decrease the chance of injury from falls. This failure resulted in Resident 1 receiving emergency room treatment after he sustained a laceration above his left eyebrow, bruising of his left cheek, and a broken hip prosthesis after he fell from his bed onto the floor.