Health inspection·March 24, 2023

F689 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. This REQUIREMENT is not met as evidenced by: On 12/09/2 at 11:35 AM, an unannounced visit was conducted at the facility to investigate complaints regarding patient falls with injury. The facility failed to provide a sitter (a caregiver assigned to only one Patient or patient to ensure safety), create and revise a “Care Plan” (a plan with a goal and interventions to achieve a goal for a Patient) to prevent falls, and failed to implement interventions to prevent falls for two out of three (Patient 1, and Patient 2) Patients reviewed. The facility failed to Implement fall risk interventions for Patient 1 on the day of his admission resulting in two falls. For Patient 2 the facility failed to. I) Create a “Care Plan” to prevent falls after the 1/21/22,3/25/22, 4/18/22, 4/21/22 PM shift, 4/25/22, 4/29/22, 5/2/22, 5/3/22, 6/3/22, 6/9/22,6/10/22, 7/13/22, 8/5/22, 8/30/22 fall. II) Create a “Morse Fall Assessment” (an assessment to determine the likelihood of a Patient falling and why) after the 1/21/22, 4/21/22 PM shift (PM shifts time duration is 3:00 PM to 11:30 PM), 4/25/22, 5/3/22, 8/5/22, 9/1/22 fall. III) Create a “Post Fall Assessment” (an assessment tool to help identify injury after a fall, factors that lead to a fall, and interventions placed to prevent future falls and injury) after the 1/21/22, 4/21/22 PM shift, 4/24/22, 5/3/22, 8/5/22, 9/1/22 fall. IV) Create an “IDT Note” (the interdisciplinary team or IDT consist of care provider and the Patient or Patients Responsible party. The care providers are Physicians, social workers, case managers, nurses, administration, pharmacist any other discipline involved in a Patient’s care. This team meets and evaluate goals and interventions specific to each Patient.) after the fall on 5/3/22. V) Provide a sitter to prevent any of the 21 falls Patient 2 had in 2022. These failures resulted in the following. 1)Patient 1 having two unwitnessed falls at 2:40 PM, and 4:00 PM on 7/20/22. These falls resulted in Patient 1 sustaining a large bump and bleeding to the forehead. 2)Patient 2 falling 21 times in the year 2022. Patient 2’s fall occurrences with injury are as follows; I)1/21/22 at 8:30 PM, resulted in Patient 2 obtaining a bump on his forehead after hitting his head on the bathroom sink. II) 04/29/22 at 1036 AM Patient 2 obtained bump on forehead after an unwitnessed fall. III) 06/09/22 Patient 2 obtained injury to head, required 20 stitches to left forehead, after an unwitnessed fall. IV) 07/13/22 at 7:10 PM Patient 2 obtained Right side forehead contusion(bruising) after an unwitnessed fall. V) 08/17/22 at 1:29PM. Patient 2 obtained a right knee abrasion and right hip pain after an unwitnessed fall. VI) 08/30/22 at 0400 am. Patient 2 obtained forehead bump and a cut to the left knee after an unwitnessed fall. VII) 09/02/22 at 1:30 PM. Patient 2 obtained swelling and discoloration to his forehead after falling from the wheelchair. Findings. 1. Review of the “MDS” (Minimum Data Set, tool used for a comprehensive Patient assessment) dated 7/20/22 indicated that Patient 1 was admitted with a lumbar fracture with a history of falls, bladder cancer, and Parkinson’s disease (a disorder that includes nerve cell damage in the brain causing tremors and difficulty with movement). Review of Patient 1 “Progress Note” dated 07/20/22 at 6: 44 PM by Infection Prevention Nurse (IPN) 1 indicated that the Patient 1 arrived on 07/20/22 at 12:40 PM via ambulance. Patient 1 was confused, forgetful, and non-ambulatory (unable to walk) at the time of admission. Review of Patient 1 “Progress Note” dated 07/20/22 at 6:45 PM by IPN 1 stated that the code status was verified at 06:16 PM with the daughter and Patient 1 was a full code. During an interview with the Nurse Manager (NM)1 on 12/28/22 at 11:30 AM it was stated that on 7/20/22 before Patient 1 arrived to the facility, staff received report ( a comprehensive verbal sign off on information from one provider to another regarding a patient’s condition) that Patient 1 was a high risk for fall, had previous falls, and would most likely require a sitter. NM1 stated that Patient 1 did not have a sitter at his stay at this facility. Review of Patient 1’s “Progress Note” dated 07/20/22 at 10:10 PM by Registered Nurse (RN) 1 indicated that RN 1 received report on Patient 1 during shift change from Patient 1’s day shift primary nurse. This note indicated that the day shift primary nurse gave report that Patient 1 was a hospice patient, and at 2:40 PM fell and hit his head on the nightstand. No further information was endorsed to RN 1. RN 1 then proceeded to confirm hospice status with the admit Nurse (IPN1) and the Charge Nurse. IPN 1 and the Charge Nurse informed RN 1 that Patient 1 is not on hospice and is a full code. RN 1 informed the physician of the fall and received an order to send Patient 1 to the emergency room for a hematoma (pooled blood that collects inside a tissue, organ, or in a body space) on the head. At 4:00PM RN 1 found Patient 1 on the floor, assessed Patient 1 for injuries, and sent Patient 1 to the emergency room. This “Progress Note” indicated that RN1 informed the family of the falls, and placed fall mats (mats that are placed on the floor to help reduce impact during a fall) on the floor for Patient 1. Review of Patient 1’s “Progress Note” and “Assessments” indicates a physician notification, a “Morse Fall Assessment”, a “Post Fall Assessment”, and immediate interventions were not done to prevent further falls for the fall that occurred at 2:40 PM on 07/20/22m by the dayshift primary nurse. During an interview with NM1 on 12/28/22 at 11:40 AM it was confirmed that a “Morse Fall Assessment”, a “Post Fall Assessment”, and immediate interventions to prevent further falls were not created after Patient 1’s fall on 7/20/22 at 2:40PM. During an interview with RN1 on 12/28/22 at 2:30 PM it was stated that when RN 1 receive report from the day shift primary nurse for Patient 1, it was confirmed by the day shift nurse that the physician and responsible party were not informed of the fall on 7/20/22 at 2:40 PM. 2. Review of Patient 2’s “MDS” dated 06/02/22 indicated Patient 2 was admitted with diagnoses including Cerebral infarction (disrupted blood flow to the brain tissue), Aphasia (disorder that affects ability to communicate), and mobility abnormality (impaired ability to move around). Review of the “MDS” indicated Patient 2 had unclear speech, was sometimes understood by others, sometimes understood others, and his vision was highly impaired without the use of corrective lens. Patient 2 had a Brief interview of Mental status (BIMS, tool used to assess cognitive function. A score of 15 means the person assessed has the highest level of cognitive function and score of zero is no cognitive function) score of three. Review of the “MDS” indicated that Patient 1 required extensive assistance with transfers and mobility to get around in bed, in the room, in the corridors, and required a wheelchair. During an Interview on 12/09/22 at 12:25 PM with Certified Nurse’s Assistant (CNA) 1, it was stated that CNA1 knew Patient 2 very well. Per CNA 1 Patient 2 would be sleeping and then would suddenly wake up and get out of bed without request for help. Patient 2 would sleep for 15 to 20 minutes then suddenly get up again and try to get out of bed. There was a mattress placed on the floor to help prevent falls and injury. Per CNA 1, Patient 2 would get up and start looking for something without warning or signs of Patient 2 needing help. Per CNA1, it was hard to communicate with Patient 2 because he did not speak. Patient 2 understood others at times, and would try to communicate via body language, squeezing hands, smiling, and showing objects. Per CNA 1 Patient 2 was very active and had lots of falls. Per CNA1 staff would try to get to Patient 2 before he could get out of bed and re-direct him or keep him in his wheelchair near the nurse’s station to keep a closer eye on him. During an interview on 12/09/22 at 12:50 PM with IPN 1, IPN 1 stated that they knew Patient 2 well and that he had frequent falls and would try to get out of bed by himself a lot. Per IPN 1 some interventions the staff placed for him were to keep the bed in a low position, floor mats on both sides of the bed, keep Patient 2 in a wheelchair near the charge nurse, and keep curtains open when Patient 2 was in bed. The IPN 1 stated that due to Patient 2’s diagnosis of cerebral infarction, he could not be educated to use the call light or ask for help verbally. IPN 1 stated that due to Patient 2’s diagnosis of Cerebral infarction Patient 2 was very impulsive and would get up or out of bed without any warning or signs that he needed help. During interview with NM1 on 12/22/22 at 09:30 AM, NM1 stated that Patient 2 did not have a sitter during his stay at the long-term care facility. NM1 stated after a Patient has a fall it is the facilities policy to complete a “Morse Fall Assessment” a “Post Fall Assessment”, a “Pain assessment”, a “Change in Condition”, and a “Care Plan” to prevent further falls and injury immediately after each fall. The IDT reviews the interventions daily after a fall (or the next business day), 72 hours after fall, and quarterly. During review of the “Progress Note” dated 1/21/22 at 9:40 PM, the “Progress Note” indicated that on 1/21/22 at 8:30 PM Patient 2 had an unwitnessed fall and acquired a bump on his forehead. The “Progress Note” indicated that the fall was most likely due to Patient 2 hitting his head on the bathroom sink, as he was found in the bathroom. This “Progress Note” indicated that the Physician (or Doctor of Medicine aka MD) was informed of the fall, although no documentation was found in the note that the Responsible Party (RP) was notified. During review of Patient 2’s “Care Plan” a “Care Plan” was not found to be revised or made to prevent falls after the 1/21/22 fall. During review of Patient 2’s “Assessments” no evidence was found that the “Morse Fall Assessment”, “Post Fall Assessment”, and “IDT Note” was completed after the fall on 1/21/22. During an interview with NM1 and the Director of Nursing (DON) on 12/28/22 at 11:30 AM, it was confirmed by NM1 that a “Morse Fall Assessment”, “Post Fall Assessment”, “Care Plan”, and “IDT Note” was not completed for the fall that occurred on 1/21/22 at 8:30 PM. During review of the nurse’s “Progress Note” dated 03/25/22 at 2:15 PM it was indicated that Patient 2 was sitting in his wheelchair before he fell. Patient 2 stood up quickly from a sitting position and tried to walk and fell. In this note it was indicated that Patient 2 is unable to verbalize what he wants, and therefore staff is unable to determine the cause of the fall. Review of the “Post Fall Assessment” note dated 03/25/22 at 2:15 PM indicated that the interventions placed post fall were to involve Patient 2 in activities, place bilateral floor mats, keep Patient 2 closer to the nurse’s station, and apply hip padding (to protect the Patient from injury in case of future falls) for Patient 2. Review of the “IDT Note” dated 03/25/22 at 12:53 PM and review of the interventions from the “Progress Note” dated 3/15/22 at 2:15 PM indicated to continue to monitor Patient 2, and no new interventions were suggested. Review of Patient 2’s “Care Plan” dated on 03/25/22 indicated a “Care Plan” was created so Patient 2 “will not have an ill effect through the next review date”, and a “Care Plan” for fall prevention was not created after the 3/25/22 fall. During an interview with the NM1 and the DON on 12/28/22 at 11:30 AM it was stated by the DON that the goal for Patient 2 was to minimize and prevent injury, not to prevent future falls. The DON and the NM indicated that to prevent falls for Patient 2 was impossible, as he required continuous monitoring and a sitter for safety. During this interview it was confirmed by NM1 and the DON that Patient 2 did not have a sitter during his stay at this facility. During this interview NM1 confirmed that a “Care Plan” to prevent falls was not created for Patient 1 after the 03/25/22 fall. During review of the nurse’s “Progress Note” dated 4/18/22 at 02:27 AM it was indicated that Patient 2 had a witnessed fall on 04/18/22 at 12:50 AM. This “Progress Note” indicated that staff found Patient 2 out of bed, tried to assist Patient 2 to the bathroom, and Patient 2 tried to sit in the air and fell. In this note it was assessed that Patient 2 needed to go the bathroom as he had an episode of incontinence. In this “Progress Note” the new immediate interventions to be placed were hourly monitoring for safety and whereabouts. Review of the “IDT Note” on 4/18/22 at 10:45 AM added new interventions to always anticipate Patient’s needs, provide assistance when toileting, do not leave unattended while toileting, and confirmed hourly monitoring. Review of Patient 2’s “Care Plan” showed no documentation of a “Care Plan” was created to prevent falls after the 4/18/22 fall. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a “Care Plan” was not created to prevent falls after the fall on 4/18/22 at 12:50 AM. During review of the “Progress Note” dated 04/21/22 at 7:36 AM indicated that Patient 2 had an unwitnessed fall on 4/21/22 at 04:20 AM. This “Progress Note” indicated that the nurse attempted to determine the cause of the fall but Patient 2 was unable to verbalize or communicate his needs. Review if this “Progress Note” indicated that new immediate interventions placed after the fall were to implement a bowel and bladder program and use a wander guard (alarm sounds if a Patient changes position or tries to get out of bed). No “IDT Note” was found for the fall on 04/21/22 at 04:30 am. Review of Patients 2 “Care Plan” on 04/21/22 for falls indicated the goal for Patient 2 was to “not have ill effect due to the recent fall”, not to prevent future falls. Review of Patient 2’s “Care Plan” indicated that a “Care Plan” to prevent future falls was not created after the fall on 4/21/22. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a “Care Plan” was not created to prevent falls after the fall on 4/21/22 at 4:20 AM. Review of Patient 2’s “Progress Note” dated 4/21/22 at 10:23 PM indicated that Patient 2 had an unwitnessed fall sometime during the PM shift as Patient 2 was trying to get up on his own. Review of Patient 2’s “Progress Notes”, “Care plan”, and “Assessments” indicated that a “Morse Fall Assessment”, a “Post Fall Assessment”, immediate interventions, a “IDT Note”, and a “Care Plan” was not created after the fall on 04/21/22 on the PM shift. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was stated by NM1 that a “Care Plan” to prevent falls, “Morse Fall Assessment”, “Post Fall Assessment” was not created after the fall on 4/21/22 on PM shift. During this interview NM1 stated that the fall on 4/21/22 at 04:20 AM was so close to the fall on 4/21/22 PM shift that the interventions from the previous “IDT Note” had not taken effect, and therefore a new one was not made. During Review of Patient 2’s “IDT Note” dated 04/25/22 at 12:21 PM it was indicated that the Charge Nurse heard a loud sound and found Patient 2 laying on his right side on the floor. This note indicated that staff was unable to determine the cause of the fall because Patient 2 cannot verbalize his needs. Review of this “IDT Note” implemented new interventions of having things close by to prevent falls. Review of the “Assessment” and “Care Plan” indicated that a “Morse Fall Assessment”, “Post Fall Assessment”, and a “Care Plan” was not created to prevent further falls after the fall on 4/25/22. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a “Care Plan”, “Morse Fall Assessment”, and a “Post Fall Assessment” was not created after the fall on 4/25