Other·June 9, 2023

F689 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES §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. On 3/16/23 at 9:35 a.m., an unannounced visit was conducted at the facility for an abbreviated survey. The facility failed to ensure residents were free of accidents and hazards for one of three sampled residents (Resident 1) when: 1. Admission Assessment for Fall Risk for Resident 1 was not accurately assessed by the Interdisciplinary team (IDT, a coordinated group of experts from several different fields who work together toward a common business goal). 2. Staff did not develop and/or implement individualized interventions to prevent falls; and 3. Staff did not assist Resident 1 during toileting and left Resident 1 unsupervised inside the resident restroom. These failures resulted in Resident 1's unwitnessed fall with left femoral neck fracture (broken hip bone). Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on 1/24/23 and had diagnoses including left humerus fracture (broken upper arm bone), unspecified altered mental status, muscle weakness, difficulty in walking, abnormalities of gait and mobility, lack of coordination, reduced mobility, and repeated falls. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/26/23, indicated a brief interview for mental status (BIMS, a structured cognitive test) was not conducted because the resident was rarely/never understood. Resident 1 required extensive assistance (staff provide weight-bearing support) with one-person physical assist for bed mobility, transfer, and toileting. The MDS also indicated Resident 1 was not steady and was only able to stabilize with staff assistance for moving from seated to standing position, moving on and off toilet, and surface to surface transfers. Resident 1 had a fall with fracture prior to admission to the facility. Review of Resident 1's Fall Risk Assessment, dated 1/24/23, indicated Morse Fall (an assessment tool of fall risk) Score of 25 (Moderate Risk). The assessment had a section that asked, "Does the resident have more than one diagnosis on the chart? " The answer "No" was marked in response to this question. The question that asked, "What type of gait does the resident exhibit? " The answer "Normal" was marked in response to this question. The question that asked, "Does the resident's response to the above indicated they know the limits of their abilities to ambulate (walk) safely? " The answer "Knows own limits" was marked in response to this question. The IDT Admission Assessment dated 1/25/23, indicated "Review for past 100 days: Fall related injury" and "Resident is: Fall risk" were not marked. Review of Resident 1's Admission Note from the physician, dated 1/24/23, indicated "She was admitted to the hospital status post fall with left humerus fracture. Resident is high risk of fall." Review of Resident 1's Occupational therapy progress report, dated 2/21/23, indicated, "Resident will safely perform toileting tasks ... with stand by assist (SBA, being there to help when help needed) and occasional tactile cues (a physical touch to guide) for clothing management ... " The report included "impairments: body awareness deficits, decreased functional capacity, decreased safety awareness, and deficits in judgment." Review of Resident 1's fall risk care plan, dated 1/25/23, indicated she was at risk for falls and injuries related to pain, weakness, advanced age, reduced mobility, history of falling, repeated fall and dizziness. Some interventions on the care plan included keeping the resident's call light within reach, encouraging the resident to use the call light, and instructing the resident to avoid sudden position changes. Review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation)-Fall Report of Incident, "Effective Date: 2/22/23," indicated "Patient has unwitnessed fall in the bathroom ... patient was brought into the bathroom and sat on the toilet. Certified Nursing Assistant A (CNA A) went to arrange the bed. CNA A found the resident on the floor." According to the SBAR, Resident 1 was assessed with extremity (a limb of body, like a leg or arm) deformity or misalignment, external head injury, she complained of pain, and she was transferred to the emergency department (ED) for evaluation. Review of Resident 1's Pelvis X-ray report, dated 2/23/23, indicated "Findings demonstrate acute left femoral neck fracture. " Review of Resident 1's IDT Post Fall Follow Up, with a signed date of 3/06/23, indicated "CNA assisted this resident to the toilet and left the resident for privacy. The CNA was in the resident's room arranging the bed sheets. When CNA heard the noise in the toilet, opened the door, resident was on the floor..." The IDT Post Fall Follow Up indicated "Reassess Fall Risk" was marked for potential interventions evaluation. During an interview with the director of staff development (DSD) on 3/16/23 at 11:30 a.m., the DSD stated one-person physical assistance meant staff should have stayed with the resident and provided assistance during toileting. The DSD further stated staff should not leave residents with one-person physical assist alone to do another task during toileting. During an interview and record review with the director of nursing (DON) on 3/16/23 at 11:45 a.m., the DON confirmed Resident 1 was not accurately assessed for the Fall Risk Assessment, dated 1/24/23 and the IDT Admission Assessment, dated 1/25/23. The DON acknowledged the intervention on the fall risk care plan of providing reminders to Resident 1 was not an appropriate intervention because Resident 1 would not remember. The DON stated staff should not leave the resident alone during toileting because the resident required one-person physical assist for her toileting. During a phone interview with CNA A on 3/16/23 at 1:38 p.m., CNA A stated he brought Resident 1 into the bathroom, told her to use a call device for assistance, and left her alone to fix her bed. CNA A stated he heard a noise and found the resident on the bathroom floor. CNA A further stated he did not stay with Resident 1 in the bathroom and the resident did not ask for privacy. During Resident 1's room tour with the DON on 3/16/23 at 1:50 p.m., the toilet in the resident bathroom with an opened door was not visible from the resident bed. The DON confirmed the observation. During a phone interview with LVN B on 3/16/23 at 1:57 p.m., LVN B confirmed she completed Resident 1's Fall Risk Assessment dated 1/24/23. LVN B stated Resident 1 had more than one diagnosis, her gait was not normal, and the resident "didn't know her limits to ambulate safely." LVN B acknowledged Resident 1 was not accurately assessed for the Fall Risk Assessment. LVN B further stated she made mistakes. During an interview and record review with physical therapist C (PT C) on 3/16/23 at 2:56 p.m., she stated Resident 1 required a standby assist during toileting. PT C further stated Resident 1 had decreased safety awareness and impulsiveness. During an interview and record review with registered nurse D (RN D) on 3/16/23 at 3:45 p.m., she stated CNA A brought Resident 1 into the bathroom on 2/22/23, left to arrange her bed, and the resident was found on the floor. RN D stated Resident 1's hip was deformed, and she was transferred to ED. RN D stated Resident 1 was alert to person only and forgetful. RN D stated when she reminded Resident 1 to use her call device, she would not remember to do so. RN D stated providing reminders to Resident 1 was not an appropriate intervention because she would not remember. RN D further stated staff should have stayed with the resident or stayed next to the bathroom door to provide one-person physical assist during toileting. Review of facility policy "Fall Management" dated 8/2014, indicated "Purpose, to evaluate risk factors and provide interventions to minimize risk, injury, and occurrences. Assessment guidelines, may include fall risk factors/ fall history ..." Review of facility policy "Care Plan, Comprehensive" dated 2008, indicated "The care plan is individualized by identified resident problems, unique characteristics, strengths, and individual needs. The care plan becomes a comprehensive tool for the IDT to utilize as a reference for resident specific problems and approaches to establish guidance on meeting the individual needs of the resident. " The facility failed to ensure residents were free of accidents and hazards for one of three sampled residents (Resident 1) when: 1. Admission Assessment for Fall Risk for Resident 1 was not accurately assessed by the Interdisciplinary team (IDT, a coordinated group of experts from several different fields who work together toward a common business goal); 2. Staff did not develop and/or implement individualized interventions to prevent falls; and 3. Staff did not assist Resident 1 during toileting and left Resident 1 unsupervised inside the resident restroom. These failures resulted in Resident 1's unwitnessed fall with left femoral neck fracture (broken hip bone). This failure had direct relationship or immediate relationship to the health, safety, and security of the resident.