Health inspection·September 27, 2024

Free of Accident Hazards/Supervision/Devices 42 CFR §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: Based on interview and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) when Resident 1 was ambulating (walking) in the facility independently without any assistive devices (objects used to help stabilize someone for safer movement). This failure resulted in Resident 1 sustaining a left femoral neck fracture (a break in the long upper leg bone near where it touches the hip bone) requiring a left hemiarthroplasty (surgery necessary to replace part of the hip joint). Findings: A review of a Resident 1's Quarterly Minimum Data Set (MDS, a resident assessment tool), dated 12/29/23, indicated that Resident 1 has multiple diagnoses including Alzheimer's disease (a brain disorder that slowly impairs memory and thinking skills) and a history of a subarachnoid hemorrhage (bleeding in the space around the brain). The MDS also indicated that the staff assessment for mental status was done for Resident 1 and her "Cognitive skills [brain functions] for daily decision making" was "moderately impaired." A review of the policy titled "COACH [a person assigned to a resident for close supervision] USE FOR CLOSE OBSERVATION", last revised 10/10/23, indicated that a "coach's responsibilities include ... close monitoring of assigned resident(s) to prevent resident(s) from injury to self or injury to others." The policy also indicated that "resident behaviors that may require close observation include but are not limited to the following ... high risk for falls ... elopement risk [when someone leaves a healthcare facility against medical advice even if doing risks their own health or safety] ... intrusive behaviors [actions that are disruptive to other's space, belongings, and care]." The policy indicated that the "Coaches shall not leave residents unattended under any circumstances." The policy further indicated that the Resident Care Team (RCT, a collaborative group of people involved in a resident's care) is "responsible for the initial assessment and ongoing evaluation/need for close observation measures." A review of the policy titled "FALLS", last revised 07/09/19, indicated that "Supervision/Adequate Supervision" is defined as "an intervention and means of mitigating [decrease] the risk of an accident ... Adequacy is determined by assessing the appropriate level of and number of staff required... and the frequency of supervision needed .... The determination is based on the individual resident's assessed needs." In addition, the policy indicated that a nurse should complete the "Schmid Fall Assessment" (a specific type of scoring tool to assess someone's risk for falling) quarterly for a resident. A review of Resident 1's RCT meeting note, finalized on 09/05/23, indicated that the RCT recommended Resident 1 be provided with a "24 hour safety coach related to her medical decline/condition" until physical therapy (PT, a health care provider specialized in helping improve or maintain how bodies perform physical movements) and occupational therapy (OT, a healthcare provider who helps improve or maintain someone's ability to perform daily tasks) evaluation. During a concurrent interview and record review on 02/28/24 at 11:43 AM with Physical Therapist 1 (PT 1), PT 1's note titled, "Physical Therapy Evaluation and Care Plan", dated 09/07/23 was reviewed. The note indicated that a reason for Resident 1's PT evaluation was "consecutive falls." PT 1 stated that at time of this evaluation, Resident 1 scored a 12 out of 28 on the Tinetti Score. PT 1 stated that the Tinetti score is a "measure that tests gait [how someone walks] and balance." PT 1 stated that the resident's score of 12 out of 28 means that they are at "high risk for fall." A review of Resident 1's care plan (a health assessment tool used to determine care and services a resident receives) completed by PT 1, dated 09/07/23, indicated that "Patient [Resident 1] continues to be high falls risk and currently has a coach to assist." During a concurrent interview and record review on 02/28/24 at 11:48 AM with PT 1, PT 1's progress note titled, "Physical Therapy Discharge Summary (Short Form)", dated 09/21/23 was reviewed. The note indicated that after PT spoke to Resident 1's Patient Care Assistant (PCA, someone that helps residents with activities of daily living), the PCA "confirms patient can ambulate with assistance with hand hold assistance." PT 1 stated that hand-held assistance means that someone is "right by [Resident 1's] side" when they are walking. This progress note further indicated that Resident 1 is to be discharged from PT services with recommendations to "continue coach to assist with out of bed and daily ambulation on unit." During a concurrent interview and record review on 02/28/24 at 11:48 AM with PT 1, PT 1's progress note titled, "PHYSICAL THERAPY NON-BILLED VISIT NOTE", dated 10/05/23 was reviewed. The note indicated that PT 1 reassessed patient's ambulation after discussion with Resident 1's PCA and Registered Nurse (RN) at the time. The note indicated that "due to pt's [patient's] inability to follow instructions to use FWW [front wheel walker] safely pt should ambulate with staff vs [instead of] FWW." PT 1 stated that based on this assessment, Resident 1 should have continued with hand-held assistance while walking. A review of Resident 1's RCT meeting note, finalized on 10/10/23, indicated under recommendations that "1:1 [one to one, someone is assigned to supervise only one person] coach 4 hours day shift to monitor increased to 24 hr [hour] for a few days." A review of Resident 1's RCT meeting note, finalized on 11/16/23, indicated under recommendations that Resident 1 "continues with 1-1 [one to one, someone is assigned to supervise only one person] coach." Under an assessment of activities, the RCT note further indicated that "[Resident 1] benefits from having a coach in her daily activities to assist, keep her safe from wondering, program encouragement, supervision and redirection as needed." During a concurrent interview and record review on 02/28/24 at 11:54 AM with PT 1, a physical therapist progress note titled, "Quarterly Rehab Screen Form/PHYSICAL THERAPY NON-BILLED VISIT NOTE", dated 11/21/23, was reviewed. The screening indicated that there was no decrease in Resident 1's ability to walk with or without an assistive device. PT 1 stated that since Resident 1 was discharged from PT services, this screening tool would help assess if there was a change in function since the last full PT assessment. PT 1 stated that there is "not a change from baseline" walking ability according to the screening and she would therefore refer to the previous PT assessment she completed with Resident 1 on 10/05/23 which indicated that Resident 1 should have continued with hand-held assistance while walking. PT 1 verified that at the time of this screening, the resident would continue to need hand-held assistance while walking. During a concurrent interview and record review on 02/28/24 at 3:40 PM with the Director of Regulatory Affairs (DRA), an RN, Resident 1's fall risk assessment, dated 12/05/23, was reviewed. The fall risk assessment indicated a Schmid Fall score of three. DRA stated that this score means that Resident 1 is at risk for fall. During a concurrent interview and record review on 02/28/24 at 10:09 AM with the Charge Nurse (RN 1), Resident 1's nursing weekly summary (a snapshot of the resident's assessment and care plan), dated 12/08/23, was reviewed. The nursing weekly summary indicated that Resident 1 needed one-person "Supervision" assistance during "Locomotion [walking] on Unit." RN 1 stated that "Supervision" assistance means that someone is watching the resident and "keeping an eye on [Resident 1]" while walking on the unit. During a concurrent interview and record review on 02/28/24 at 10:27 AM, with Nursing Supervisor 1 (RNS 1), a nursing note, dated 12/13/23, was reviewed. The note indicated that Resident 1 continues "with 1:1 coach for poor safety awareness, risk for injury, and high risk for fall." RNS 1 stated that Resident 1's coach is for safety and that safety is an umbrella term that covers many types of risks and behaviors. RNS 1 further stated that "we don't coach for falls [using a coach to prevent a fall]." During a concurrent interview and record review on 02/28/24 at 10:23 AM with RN 1, a nursing note dated 12/13/23 was reviewed. The nursing note indicated that "RCT decided to DC [discontinue] resident's coach. Resident has a slow medical decline and has been noted to be less intrusive lately." RN 1 stated that this note means the RCT met and agreed that Resident 1 no longer needed a coach. A review of Resident 1's care plan addendum (update or correction to a care plan), dated 12/13/23, indicated a problem of "Safety Adult - Fall" with a goal of "[Resident 1] will remain safe despite discontinuation of her coach." During a concurrent interview and record review on 02/28/24 at 10:09 AM with RN 1, Resident 1's nursing weekly summary, dated 12/15/23, was reviewed. The nursing weekly summary indicated that Resident 1 needed one-person "extensive" assistance during "Locomotion on Unit." RN 1 stated that "extensive" assistance means that someone is walking right beside the resident. A review of Resident 1's nursing weekly summary, dated 12/15/23, indicated that there were multiple active care plans with interventions related to the use of a coach. Regarding the goal of "Skin integrity is maintained or improved", a listed intervention was that Resident 1 "continues 24 hrs [hours] coach to monitor/safety." In addition, regarding the goal of "Patient will be free from physical and verbal abusive behavior", a listed intervention was that Resident 1 is "with coach for safety r/t [related to] intrusive behavior, wandering around the unit and into other resident's rooms, continue with 24 hours coach to keep free from injury." During a concurrent interview and record review on 02/28/24 at 12:24 PM with the DRA, Resident 1's mobility flowsheet (a document summarizing assessments and routine care tasks over time), dated 12/17/23 at 12:20 AM, was reviewed. The mobility flowsheet indicated that Resident 1 needed "extensive assistance" with mobility. The DRA stated that extensive means that someone is "right next to" Resident 1 when walking. A review of a Change of Condition nursing note for Resident 1, dated 12/17/23, indicated that at "15:07 (3:07 PM)," Resident 1 was "walking towards great room [large gathering space where meetings, activities, or meals can occur] from her room while walking patient lost her balance and landed on the floor and hit her head on the floor." The note further indicated that this was a "witnessed fall." During an interview on 02/27/24 at 3:28 PM with RN 2, RN 2 stated that she had witnessed Resident 1's fall on 12/17/23. RN 2 stated that Resident 1 was walking independently in the great room and was not using any assistive devices before Resident 1 fell. A review of Resident 1's abdominal and hip Computerized Tomography scan (CT Scan, a specialized machine used to take detailed pictures inside someone's body to help determine injury), dated 12/17/23, indicated that Resident 1 had a "minimally impacted left femoral neck fracture." A review of Resident 1's history and physical (a formal and complete assessment of someone done by a medical provider), dated 12/21/23, indicated that Resident 1 obtained a "left hemiarthroplasty of the hip: Post [after] mechanical fall on 12/17/23." During a concurrent interview and record review on 02/28/24 at 12:17 PM with the DRA, Resident 1's nursing weekly summary, dated 02/23/24, was reviewed. The nursing weekly summary indicated that Resident 1 is now totally dependent with locomotion on unit. The DRA stated that total dependence means that the Resident 1 is unable to help and will need staff to move around the unit. This violation had a direct or immediate relationship to the health, safety, or security of residents.