Health inspection·September 27, 2024

Develop/Implement Comprehensive Care Plan CFR §483.21 (b)(1)(3) §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally-competent and trauma-informed. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure Resident 1's fall care plan interventions were updated and implemented to prevent or minimize fall-related injuries for one of 20 sampled residents (Resident 1) when Resident 1 was assessed as total dependent with activities of daily living, including repositioning when in bed. The care plan interventions did not reflect the two person physical assist required by Resident 1 when repositioning and the facility did not implement effective interventions to prevent falls after identifying Resident 1 with limited Range of Motion (ROM) on bilateral upper and lower extremities, diagnosis of Seizure Disorder (a medical condition that can cause sudden, uncontrollable movements and change in level of consciousness) and poor safety awareness due to diagnosis of Dementia (impaired ability to remember, think, or make decisions). This failure resulted in Resident 1 to have an avoidable fall from her bed during personal care by Patient Care Assistant (PCA) 1 on 1/23/24, resulting in Resident 1 sustaining a laceration of 1.5 centimeter (cm - unit of measurement) and bleeding on left forehead. Resident 1 expired two hours and ten minutes after the fall. Findings: During a review of Resident 1's "Admission Record" (AR - document containing resident demographic information and medical diagnosis), undated, the admission record indicated Resident 1 was re-admitted to the facility on 10/28/23 with diagnoses which included Seizure Disorder, Dementia, Hypertension (high blood pressure), Congestive Heart Failure (CHF, the heart cannot pump blood or fill adequately), Hypoxemia (low concentration of oxygen in the blood), Atrial Fibrillation (Afib- irregular heart rate), and Left Hip Arthroplasty (joint replacement). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated 10/4/23, Resident 1's MDS assessment indicated Resident 1's cognitive (memory) skills for daily decision making was severely impaired. The MDS mobility assessment indicated Resident 1 was dependent to staff when repositioning from lying on back to left and right side and return to lying on back on the bed. During a review of Resident 1's Schmid Fall Risk (FR, a fall risk assessment tool) assessment dated 1/6/24, Resident 1's FR assessment indicated Resident 1's fall score was "3" (a score of 3 or more means that patient is at risk for falls and fall prevention interventions should be implemented). During a review of Resident 1' s "Progress Note (PN)," dated 1/23/24, the PN indicated, " ... 8:00 p.m. Change of Condition Nursing Note ... ASSESSMENT: Resident fell from low bed to floor mat during care. Remained alert and verbal. 1.5 cm laceration with slight bleeding noted on the left forehead ... 10:10 p.m. ... On call MD (physician) was notified again after resident was observed to have stopped breathing. Resident 1 expired and pronounced at 2210 [10:10 p.m.] ..." During a review of Resident 1's "Care Plan (CP)," dated 10/28/23, the CP indicated, " ... Problem: Safety Adult - Fall ... Goal: Free from fall injury ... At risk for fall due to: poor safety awareness, cognition impaired, impaired physical function [Mechanical] lift 2 persons assist during transfer, impaired vision ... Interventions: Institute fall precautions as indicated by assessment ... 2 Person assist for all mechanical lift transfers ... Problem: ADL maintenance ... Resident is total dependent with ADLs ... Interventions: 1. Total dependent, uses [mechanical] lift for transfers with size medium of sling, 2 person assist with transfer ... Maintain environment for safety during ADL/mobility activities ..." During an interview on 2/8/24, at 2:35 p.m., with PCA 1, PCA 1 stated he was the assigned PCA to care for Resident 1 on 1/23/24. PCA 1 stated Resident 1 was dependent on staff for personal care, including feeding, transfer, and repositioning. PCA 1 stated he first saw Resident 1 at approximately 3:30 p.m. to check her disposable brief for soilage and repositioned Resident 1. PCA 1 stated at approximately 6:30 p.m., he fed Resident 1, and she consumed 50% of her dinner. PCA 1 stated one hour after dinner, he returned to Resident 1's room to change her disposable brief. PCA 1 stated he gathered the incontinent care supplies, placed on top of the bed, and he raised the bed below his waistline, approximately 27 inches in height from the floor. PCA 1 stated Resident 1 was not in any distress or agitated. PCA 1 stated he was on the right side of the bed and repositioned Resident 1 facing the left side of the bed. PCA 1 stated, "[Resident 1] was using an air loss mattress ( is a mattress designed to prevent and treat pressure wounds) for pressure ulcer (are localized skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body, typically bony prominences) prevention and her bed does not have side rails. She used to have it before, but it was removed. I pulled [Resident 1] closer to me before turning her body facing the window [left side of the bed]. She was almost in the middle of the bed. I placed [Resident 1]'s right hand under her body and her left hand on top of her body. She was wearing a gown. While performing peri care to [Resident 1], her entire body rolled to the left side of the bed, falling out of the bed, and hit the floor mattress. I don't know what part of her body hit the floor mattress first. I immediately went to the left side of the bed and found her face down and was bleeding on her left forehead. I called the [Charge Nurse, CN 1]. She was assessed by [CN 1] then the two of us carried [Resident 1] back to her bed. Other staff came later, including the doctor." PCA 1 stated the current care plan requires two person assist and one person assist during personal care. PCA 1 stated the unassisted fall will not happen if another staff was helping him during Resident 1's personal care. During an interview on 2/8/24, at 2:50 p.m., with PCA 1, PCA 1 stated he was not instructed by the CN to obtain Resident 1's vital signs after the fall. PCA 1 stated he was not instructed by the CN to conduct Resident 1's follow-up neuro assessment (an assessment tool to determine a patient's neurologic function) after the fall. PCA 1 stated he was not asked to write a statement about the incident. PCA 1 stated Resident 1 died at 10:10 p.m. and he provided the post-mortem care together with another male CNA (Certified Nursing Assistant). PCA 1 stated he worked and completed his shift and clocked out at 11:30 p.m. During a telephone interview and record review on 2/8/24, at 8:13 p.m., with Charge Nurse/Registered Nurse (CN) 1, Resident 1's "Nursing Note (NN)," dated 1/23/24 was reviewed. The NN indicated, " ... At around 2000 [8:00 p.m.], PCA reported that resident fell from low bed to floor mattress during care. Neuro check and post fall assessment initiated. On assessment, resident was noted to have a 1.5 [cm] laceration on the left forehead ... Notified MD (physician) again after resident was noted to have irregular breathing. Instructed to increase O2 (oxygen) to 5L (Liters, unit of measurement) and administer Acetaminophen (use as pain reliever/fever reducer) and albuterol (use to prevent and treat wheezing and shortness of breath). On call MD was notified again after resident was observed to have stopped breathing. Resident expired and pronounced at 2210 [10:10 p.m.] ..." CN 1 stated, while at the nurses' station on 1/4/24 at approximately 8:00 p.m., PCA 1 informed him that Resident 1 fell from the bed to the floor mattress during personal care. CN 1 stated she went to Resident' s 1 room immediately and found her on the floor, on the left side of the bed, with her face down. CN 1 stated he saw [PCA 1] holding a cloth towel on Resident 1's forehead. CN 1 stated, "I saw blood on the cloth towel but don't recall the approximate amount of blood saturation on the towel. I noted a 1.5 cm laceration on Resident 1's left forehead. It was bleeding." CN 1 stated he initiated a post-fall neuro check and post-fall assessment, then notified the on-call physician. CN 1 stated, "[PCA 1] and I transferred [Resident 1] back to her bed. She was nonverbal. She was comfortable in bed." CN 1 stated he noted blood on the floor mat where the patient fell, approximately the size of 4x4 gauze. CN 1 stated, "Resident 1 has a bedside drawer next to the head of the bed and her head probably hit the bedside drawer during the fall that resulted to the 1.5 cm laceration on her left forehead." CN 1 stated there was no documentation stating that he informed the on-call physician on the amount of the blood on the floor and the bedside drawer as the possible reason for the laceration on Resident 1's forehead. During a telephone interview and record review on 2/8/24, at 8:22 p.m., with CN 1, the facility's policy and procedure (P&P) titled, "Falls," dated 7/2019 was reviewed. The P&P indicated, " ... Purpose: 1. Provide a safe environment for residents ... An on-going evaluation of interventions shall be documented to ensure their proper implementation and efficacy and modified or replaced as necessary ... 3. After a fall: a. The RN assess the resident for signs of injury and for changes in condition: i. if a serious injury is suspected do not attempt to move the resident. Notify the physician immediately ... b. After the initial assessment ... Do not lift the resident by the arms or legs ... always use a minimum of 2 person assist. Whenever necessary, use a mechanical lifting device ... i. Begin neuro checks if the resident hit their head or if the fall was unwitnessed ... ii. Check vital signs ..." CN 1 stated he conducted an initial neurological assessment and no further follow-up assessment. CN 1 stated he did not obtain the vital signs or instructed the PCA to collect vital signs after the fall. CN 1 stated Resident 1 was on Palliative Care (is specialized medical care for people living with a serious illness) and with a physician order of no vital signs. CN 1 stated he did not clarify with the physician the frequency of the neurological assessment and if vital signs was needed after the fall. CN 1 stated Resident 1 was not lifted from the floor using a mechanical lift. CN 1 stated Resident 1's nursing care plan indicated two person assist during transfer and the use of mechanical lift. CN 1 stated he failed to follow the facility's falls policy and the nursing care plan. CN 1 stated Resident 1's unassisted fall could have been prevented if another staff was present and assisted PCA 1 during Resident 1's personal care. CN 1 stated the number of direct care staff on his unit when the fall incident happened was less than usual. CN 1 stated Resident expired two hours after the unassisted fall. During an interview on 2/9/24, at 12:20 p.m., with PCA 2, PCA 2 stated she was the assigned PCA to care for Resident 1 on 1/23/24, from 7 :00 am to 3:00 p.m. PCA 2 stated Resident 1 was dependent on staff for personal care, including feeding, transfer, and repositioning. PCA 2 stated Resident 1 was at her baseline, sleepy but arousable during her shift. PCA 1 stated she assisted Resident 1 with her meals for breakfast and lunch. PCA 1 stated Resident 1 ate 100% of her breakfast and 25% of her lunch. PCA 2 stated Resident 1 was transferred from her bed to her geri-chair using a hoyer lift with two person assist. PCA 2 stated Resident 1 stayed in her geri-chair from 11 a.m. to 2:00 p.m., then returned to her bed using a hoyer lift with two persons during transfer. PCA 2 stated Resident 1's nursing care plan indicated two-person assist during transfer and the use of mechanical lift. PCA 2 stated she gave a change of shift report to [PCA 1] around 3:00 p.m., including Resident 1's activities and meal intake for breakfast and lunch. During an interview and record review on 2/9/24, at 3:24 p.m., with Nursing Supervisor (NS) 1, the facility's P&P titled, "Falls," dated 7/2019 was reviewed. The P&P indicated, " ... Purpose: 1. Provide a safe environment for residents ... An on-going evaluation of interventions shall be documented to ensure their proper implementation and efficacy and modified or replaced as necessary ... 3. After a fall: a. The RN assess the resident for signs of injury and for changes in condition: i. if a serious injury is suspected do not attempt to move the resident. Notify the physician immediately ... b. After the initial assessment ... Do not lift the resident by the arms or legs ... always use a minimum of 2 person assist. Whenever necessary, use a mechanical lifting device ... i. Begin neuro checks if the resident hit their head or if the fall was unwitnessed ... ii. Check vital signs ..." NS 1 stated Resident 1's unassisted fall with injury was considered a change in condition. NS 1 stated the staff failed to follow the falls policy. NS 1 stated, "If we have two person assisting during Resident 1's personal care, the fall could have been prevented." NS 1 stated, "I will defer to the physician's assessment on the cause of her [Resident 1] death." During an interview and record review on 2/9/24, at 3:48 p.m., with Nursing Manager (NM) 1, the facility's P&P titled, "Falls," dated 7/2019 was reviewed. The P&P indicated, " ... Purpose: 1. Provide a safe environment for residents ... An on-going evaluation of interventions shall be documented to ensure their proper implementation and efficacy and modified or replaced as necessary ... 3. After a fall: a. The RN assess the resident for signs of injury and for changes in condition: i. if a serious injury is suspected do not attempt to move the resident. Notify the physician immediately ... b. After the initial assessment ... Do not lift the resident by the arms or legs ... always use a minimum of 2 person assist. Whenever necessary, use a mechanical lifting device ... i. Begin neuro checks if the resident hit their head or if the fall was unwitnessed ... ii. Check vital signs ..." NM 1 stated Resident 1's unassisted fall with injury was a change in condition. NM 1 stated she can't find any documentation in Resident 1's record clarifying the physician's order of no vi