Other·April 23, 2024

F689 483.25 (d)(2) (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §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 Based on observation, interview, and record review, the facility failed to protect the safety of one of three sampled residents (Resident 1), who were reviewed for falls and injuries, from a significant avoidable injury when Resident 1 had been evaluated to benefit from bed rails (rails attached to the bed to help with turning over in bed), and Resident 1 had requested bed rails that were never put on her bed. Certified Nursing Assistant (CNA) B told Resident 1 to roll over in bed so that she could change Resident 1 ' s brief (an adult protective underwear for loss of bowel and bladder control). Resident 1 told CNA B that she did not have enough room to turn over and was going to fall off of the bed, and CNA B told her to roll over anyway. This failure to protect Resident 1, resulted in Resident 1 rolling off of her bed onto the floor where she landed on her face and broke her nose in two places and had the potential to put residents who required rolling over in bed to be changed, at risk for falls and serious injuries. Findings: The facility ' s policy titled, "Fall Management Program," revised 3/13/2021, was reviewed and indicated the purpose was to provide residents a safe environment that minimizes complications associated with falls. The facility ' s policy titled, "Bed Rails," revised 12/4/2020, was reviewed and indicated, "A bed rail is an assistive device ..."The licensed nurse will complete the Bed Rail Risk Screen upon admission. The Facility ' s maintenance team is responsible for installing bed rails." The facility ' s Fact Sheet titled, "A Guide to Bed Safety," revised 4/2010, was reviewed and indicated, "The benefits and risks of bed rails are aiding in turning and repositioning within the bed, providing a feeling of comfort and security and reducing the risk of patients falling out of bed when being transported." The facility ' s CNA job specific competencies titled, "Repositioning Competency," revised 3/2021, was reviewed and indicated, "Aligns resident safely in the center of bed, away from the edge and encourages resident to use bed rails to assist during the repositioning process." Resident 1 ' s medical record was reviewed. Resident 1 was admitted to the facility on 12/13/23 with diagnoses that included epilepsy (seizures-uncontrolled body jerking or shaking), depression, weakness and difficulty in walking. Resident 1 ' s Admission Minimum Data Set (MDS, a complete clinical assessment), dated 12/20/23, was reviewed. Resident 1 ' s Brief Interview for Mental Status (BIMS, an evaluation of memory and understanding) score was 15 (ranges from 1-15, with 15 indicating intact cognition). Section GG of the MDS indicated Resident 1 required partial assistance (minimal assistance from staff) for turning in bed, and was dependent (required full assistance from staff) for toileting (the ability to wipe, clean self, adjust clothes before and after going to the bathroom, or changing brief). Section H of the MDS indicated Resident 1 was frequently incontinent (lack of control) of urine and always incontinent of bowel. Resident 1 ' s Interdisciplinary Team (IDT, a group of facility management staff from all departments who work together to determine a residents needs), note dated 3/1/24 at 9:51 am, written by Licensed Nurse (LN) F was reviewed. LN F documented that Resident 1 had rolled out of bed [on 2/29/24] and was found by a CNA lying on the floor by her bed. Interventions documented by LN F were to have the RNA (Restorative Nursing Assistant, a CNA that provides physical assistance to help residents improve strength). LN F documented there were no new physician's orders following the fall. Resident 1 ' s IDT note dated 3/14/24 at 2:43 pm, was reviewed and indicated that Resident 1 had rolled out of bed again on 3/13/24, when CNA B was changing her brief, "Resident ' s bed was raised up at this time to allow staff to assist her. Resident fell out of bed on her left side while hitting her face and nose at the same time. EMS [Emergency Medical Services] was called, and [Resident 1] was sent to the hospital for evaluation and treatment. Root cause: poor body position in bed while being assisted with ADL [activities of daily living], B&B [bowel and bladder] needs. New interventions: half rails [short bed rails] placed on bilateral [both] sides of bed for bed mobility, DSD [Director of Staff Development] will give 1:1 education to involved staff related to bedside safety." A review of Resident 1's CT scan report (computerized tomography scan, type of x-ray), that was done at the acute care hospital dated 3/13/24, reflected that Resident 1 had a broken nose on both sides that was comminuted (a bone that is broken in at least two places), and displaced (out of alignment). During an Interview on 3/15/24 at 10:58 am, the DSD stated that on 3/13/24, "[CNA B] was in the middle of doing cares [changing Resident 1 ' s brief] when she rolled her [Resident 1] away from her and she fell off the bed. [CNA B] should have had her hand on the resident, and she did not. You should never take your hand off your resident." During a concurrent observation and interview on 3/15/24 at 12:15 pm, in Resident 1 ' s room, Resident 1 was observed lying in bed with bed rails on the upper half of both sides of her bed. Resident 1 had black and blue coloring below her eyes, on her cheeks and on her nose. Her face and nose were swollen. There was a skin tear (scrape), on the right side of her nose with some dried blood around her nose and on the bed sheets. Resident 1 was asked about her most recent fall that occurred on 3/13/24, and she stated, "I was being changed by a girl and she said to roll over and I said I ' m too close and she said it ' s all right, I am right here so don ' t worry, the next thing I knew I took a header. She was not there." Resident 1 indicated that the bed rails, "were not put on until yesterday." Resident 1 indicated that she had asked for bed rails to help her turn and keep her from falling out of bed after she fell out of bed, "two weeks ago" on 2/29/24. Resident 1 stated staff told her at that time, "they would put them on, but they never did until yesterday." Resident 1 stated, "I could have held on to the rail and stopped myself from falling if the rails were on." During an interview on 3/15/24 at 12:20 pm, LN A indicated that Resident 1 was asleep when she rolled out of bed the first time on 2/29/24, and confirmed that bed rails would have prevented Resident 1 from falling out of bed. During a concurrent interview and record review on 3/19/24 at 9:30 am, with MDS LN E, Resident 1 ' s admission document titled, "Bed Rail Assessment" dated 12/19/23, was reviewed. Section 1 identified that Resident 1 was at risk for falls, displayed poor bed mobility, and had difficulty with balance or poor trunk (middle of the body), control. The Bed Rail Assessment identified that Resident 1 had expressed a desire to have bed rails for safety and/or comfort and bilateral bed rails were recommended for both sides of her bed. The Bed Rail Assessment was signed by Nursing Supervisor (NS). MDS LN E indicated that she was unsure of how the facility implemented their interventions based on the Bed Rail Assessment. MDS LN E confirmed that bed rails had not been put on Resident 1's bed as her Bed Rail Assessment recommended on 12/19/23, and they should have been. During an interview on 3/19/24 at 10 am, CNA C indicated that he had cared for Resident 1 many times. CNA C stated that Resident 1 could assist with turning in bed, "But you never knew how hard she would kick her leg over. She would take her leg and swing it right over. She was heavy on the lower end and had extra weight in her legs. She tended to roll with enthusiasm and could easily fall off the bed. I always rolled her toward me when changing her brief." During an interview on 3/19/24 at 10:10 am, CNA D indicated that she had cared for Resident 1. CNA D indicated that she always rolled Resident 1 toward her, and never away from her, when changing her brief because that was how she was trained. During a concurrent interview and record review on 3/19/24 at 10:20 am, with the NS, Resident 1 ' s admission Bed Rail Assessment, dated 12/19/23, was reviewed. NS confirmed that the Bed Rail Assessment indicated Resident 1 expressed a desire to have bed rails for safety and/or comfort and that there was a recommendation for placement of bilateral bed rails. NS confirmed that this was not followed up on, and the bed rails were not put on Resident 1's bed and they should have been. During an interview on 3/19/24 at 10:30 am, the DSD stated that CNA B, "should have rolled [Resident 1] towards her and kept a hand on her, but she did not do this." During an interview on 3/19/24 at 10:40 am, CNA B confirmed she had asked Resident 1 to roll away from her while changing Resident 1 ' s brief on 3/13/24. CNA B indicated Resident 1 was in her bed and confirmed that there were no bed rails on her bed. CNA B confirmed that she told Resident 1, "I got you." CNA B indicated that Resident 1 swung her top leg over and then she fell off the bed. CNA B stated, "I should have rolled her toward me and that would have been safer." CNA B confirmed that bed rails would have helped in this situation because Resident 1 would have been able to hold on to them, but they were not on the bed. CNA B indicated that Resident 1 should have had bed rails placed after her first fall on 2/29/24, and that she had discussed this with, "the nurses" but nothing was done. A record review of Resident 1 ' s, "Falls Care Plan" initiated on 12/14/24, identified Resident 1 to be at risk for falls. The intervention for bilateral bed rails had not been added until 3/14/24, three months after Resident 1's Bed Rail Assessment indicated that Resident 1 had requested and could have benefited from bed rails. Therefore, the facility's failure to implement the findings of their Bed Rail Assessment for Resident 1 that was conducted on 12/19/23 by a nurse supervisor, who indicated that Resident 1 not only requested bed rails, but was evaluated to have needed bed rails for safety and repositioning herself. This resulted in Resident 1 falling out of bed on 2/29/24, and bed rails were not put on her bed at that time. The facility's Certified Nursing Assistant failed to ensure Resident 1's safety and follow facility safe practices as she had been trained to do, when she asked Resident 1 to roll over in bed to be changed, even though Resident 1 expressed to her that she did not think she had enough room. This resulted in Resident 1 falling out of bed again on 3/13/24 and required a transfer to the Emergency Room of the local hospital. Subsequently, Resident 1 sustained a broken nose, in 2 places, a scrape on her face, black eyes and a swollen face. This violation had a direct affect on the health, safety and welfare of the resident.