Other·August 29, 2022

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: Based on interview and record review, the facility failed to provide stand by assist (the presence of another person within arm's reach) during the performance of one of the "Activities of Daily Living" (ADL, the basic self-care tasks an individual does on a day to day basis), call light was not within reach and had no floor pad at bedside for one of three sampled residents (Resident 1) to prevent fall. This failure had resulted in Resident 1's unwitnessed fall on 2/18/22, sustaining a right hip fracture then hip surgery. Findings: Review of Resident 1's "Face Sheet" (FS), indicated Resident 1 was admitted on 11/27/2018 with diagnosis of dementia (memory loss), reduced mobility (ability or capacity to move), abnormalities of gait (manner of walking) and mobility, muscle weakness, osteoporosis (a condition in which bones become weak and brittle). Review of Resident 1's "Minimum Data Set" (MDS, resident assessment tool), dated 1/6/22 and 11/13/20, indicated, Resident 1 was severely cognitively impaired and required supervision (oversight/cueing) with set up help only for bed mobility, transfer, walking in room, and eating. Resident 1 also required extensive assist (resident is involved in activity; staff provide weight bearing support), with one person physical assist for dressing, toilet use and personal hygiene. Resident 1 is not steady for balance during transitions and walking, only able to stabilize with staff assistance in moving on and off toilet. MDS dated 3/13/2022, indicated a decline in functional status, Resident 1 required extensive assistance with two person assist with bed mobility, dressing, eating, toilet use and personal hygiene, walk in the room and the corridor, and locomotion on and off unit activities did not occur... Review of Resident 1's "Interdisciplinary (IDT) Meeting Note", dated 2/18/22, at 9:07 AM, indicated, Resident 1 was asymptomatic (absence of signs/symptoms) to being Covid positive and refusing to leave her room. Review of Resident 1's Nursing 24 Hour Report, dated 2/18/22, at 5:17 PM, entered by "Licensed Vocational Nurse" 1 (LVN), indicated, on 2/18/22, at 4:50 PM, Resident 1 was found lying on her right side on the floor supporting her head with right hand between the bedside drawers and bedside table. The commode was upside down, translator stated, Resident 1stated that she wanted to use commode and lost balance, gait unsteady, need extensive assist with transfer, "Range of Motion" (ROM) (the flexibility of motion around a joint) on right leg decreased and not tolerated, no bump, bruising or redness on the right side of her head, attending "Certified Nursing Assistant" (CNA) was in the next room with another resident when he heard the hard bump ... Review of Resident 1's Post Fall Assessment Notes, dated 2/18/22, at 5:16 PM, entered by LVN 1, the Post Fall notes indicated, at 4:50 PM, had unwitnessed fall in her room from moving to/from bedside commode due to urgency to void, last documented toileting prior to fall was at 4:26 PM, wearing a yellow none skid socks, no floor pad, call light not within reach, with history of prior fall on 1/28/22. Review of Resident 1's Post Skin Assessment Status Post (after) Fall, dated 2/18/22, at 5:17 PM, entered by LVN 1 indicated, at 4:50 PM, CNA called LVN 1 attention, Resident 1 lying on the floor, on her right side, supporting head with her right hand between the bed side drawer and bed side table, commode flopped down by her side, translator stated, Resident 1 wants to use the commode to urinate but lost her balance. Need extensive assist with transfer, decreased and unable to tolerate ROM on right side, holding right side of head pointing pain from right side of head to the lower leg. CNA stated, he was next to her room attending the other resident when heard a hard bump, search and noted resident on the floor, with root cause analysis of poor safety awareness. Review of Resident 1's "Morse Fall Risk Scale" (MFRS), dated 2/18/22, at 5:17 PM, entered by LVN 1, indicated total score of 90, MFRS dated 2/11/22, at 12:48 AM, entered by LVN 1, indicated total score of 90 and MFRS dated 11/11/21, at 7:29 PM, entered by LVN 1, indicated, total score of 65. Fall risk score of above 50 indicated high risk for fall. During an interview with RN 1(Registered Nurse 1), the RN 1 stated, incident happened on 2/18/22, on PM shift, Resident 1 got up from bed unassisted to use the commode then, found lying on her right side on the floor between a bedside table and nightstand. Commode was found upside down. Review of Resident 1's Care Plan Report, dated 12/28/2018, entered by LVN 2, indicated, Resident 1 was at risk for falls related to unstable gait and history of falls with intervention to have landing mat in place, place call bell/light within easy reach and remind Resident 1 importance of using call light. Review of Resident 1's Care Plan Report, dated 2/18/22, indicated, Resident 1 had unwitnessed fall inside her room, goal to maintain current level of mobility with no increase in the incidence of falls/injuries, instruct Resident 1 safety measures to reduce risk of falls. Care Plan dated 3/10/22 indicated, Resident 1 had a fall on 3/10/22 with no injury noted, related to dizziness, found lying on the floor in supine position with no injury, goal to maintain current level of mobility with no increase in incidence of falls up to 5/18/22 with a video monitor for intervention. Review of Resident 1's Occupational Therapy Plan of Care, dated 3/7/22, at 9:29 AM, entered by OT 1, indicated, prior level on initial assessment, Resident 1 not using a mechanical lift, current level is using a mechanical lift. Prior level for everyday activities with indoor mobility (ambulation), stairs, and functional cognition, Resident 1 need partial assistance from another person to complete activities, current level Resident 1 is dependent (a helper completes the activities for the resident). Prior level for eating, set-up or clean up assistance, current level is dependent (a helper does all effort). Prior level for oral hygiene, toileting, showers, dressing, and putting on/taking off footwear, supervision to substantial/ maximal assistance, current level is dependent. Review of Resident 1's Speech Therapy Plan of Care, dated 3/8/22, at 10:05 AM, entered by ST 1, indicated, Resident 1 has a diagnosis of dysphagia (difficulty or discomfort in swallowing), prior diet was regular, currently on pureed (soft, pudding-like consistency) diet. Review of Resident 1's Physical Therapy Plan of Care, dated 3/8/22, entered by PT 1, indicated, Resident 1 had status post right hip hemiarthroplasty (hip repair) on 2/19/22, now severely deconditioned (having lost fitness or muscle tone) requiring total assistance, required mechanical ventilation during Intensive Care Unit hospital stay. Initial assessment indicated, on prior level, Resident 1 required supervision with verbal cueing but no physical assist for bed mobility and transfers, with current level requiring moderate to maximum assist, prior gait distance was 150 feet and currently unable to do it. Review of Resident 1's UCSF Medical Center "Discharge Summary Notes" (DSN), dated 3/6/22, at 2:46 PM, entered by MD 1, the DSN indicated, hip fracture, displaced (bones broken into two or more pieces) fracture of right femoral neck (injury is just below the ball of the ball- and- socket hip joint), ambulates (walk, to move from place to place) with walker and stand by assist on baseline (normal/ beginning level), underwent a right hip hemiarthroplasty on 2/19/22. Review of the policy titled " Fall Prevention Program" revised 10/2021, indicated, Policy: The Jewish Home and Rehab Center ensures that the resident's environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents and mitigate injuries from falls while improving mobility and maintaining or enhancing Quality of Life. Extensiveness of supervision needed will be considered. The facility failed to provide stand by assist to Resident 1 when she was left unattended while using the toilet. This resulted in Resident 1’s unwitnessed fall on 2/18/22, sustaining a right hip fracture then hip surgery. This violation had a direct or immediate relationship to the health, safety, or security of residents.