Health inspection·July 5, 2022

Citation "A" 72311 Nursing Service- General (a) (1) (C) (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition. 72523 Patient Care Policies and Procedures (a) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. CFR 42 483.25 (d) Accidents. The facility must ensure that – (d) (1) the resident environment remains as free of accidents hazards as is possible; and (d) (2) each resident receives adequate supervision and assistance devices to prevent accidents. It was determined that the facility failed to ensure the care plans were reviewed and revised to address the episodes of fall on August 3, and September 30, 2019, for one of one patient reviewed for fall (Patient 158). In addition, the facility failed to conduct post fall risk assessment after the fall incidents on July 15, August 3, and September 30, 2019, in accordance to the facility policy and procedure. These failures resulted in Patient 158 to fall for the fifth time since admission to the facility. Patient 158 sustained non-displaced vertical fracture (break in the continuity of bone) of the right proximal tibial shaft (lower leg) and fracture of the lower back. On January 7, 2020, at 1:19 p.m., during the recertification survey, Patient 158’s representative was interviewed. The representative stated Patient 158 had a fall last December 2019, and sustained a broken back. The representative stated the patient had multiple falls while at the facility, resulting in multiple injuries. A review of Patient 158’s record indicated that the patient was admitted to the facility on January 20, 2019, with diagnoses which included fracture of the neck, fracture of unspecified thoracic vertebra (spine), muscle weakness, difficulty in walking, and dementia (loss of thinking, remembering and reasoning skills). Patient 158’s Minimum Data Set (MDS- an assessment tool) dated February 3, 2019, indicated that the patient had a BIMS (Brief interview on mental status- an assessment of cognition level) score of 13 (meant cognitively intact). A review of Patient 158's nursing progress notes indicated the following: a. On March 20, 2019, at 19:00 (7 p.m.) (First fall), "...Resident (Patient 158) was found by CNA (Certified Nursing Assistant) while assisting another - resident to the bathroom, she was laying on her left side - by bed C. resident's bed (sic). She claimed she was trying to get back to her bed & slipped upon assessment there were no injury noted. Assisted with help of CNA to wheelchair. Vitals were taken wnl (within normal limits) ...” ; b. On March 21, 2019, at 12:00 p.m., "...Taken via EMS (emergency medical services) to (name of acute care hospital) for x-ray (test which produces images of structures in the body) left hip r/t (related to) c/o (complaint of) pain..." At 14:02 (2:02 p.m.) "...resident had a fracture to left hip area. (Family member's name) was called & notified of the result per radiology, they were taking her in thru the ER at (name of acute care hospital) ..."; c. On July 15, 2019, at 12:55 p.m., (Second fall) "...Resident had a non injury fall during shower and CNA was trying to get clothes & resident stood up & slide to ground - an assessment was completed. No injuries to report @ (at) present..."; d. On August 3, 2019, at 00:20 (12:20 a.m.) (Third fall) "...Resident (Patient 158) was found on the floor at foot of the bed with a large amount of blood covering her shirt face, and arms. Due to patient's position and complaint of head & neck pain we did not move patient. 911 was called immediately. Upon waiting for (name of transport) resident remained awake, and notified us that she fell in the restroom. (Excessive amount of blood found in the restroom.) Resident was alert and normal to usual behavior. (Name of transport) arrived and took pt. (patient) to ER (emergency room) for further evaluation..."; e. On August 3, 2019, at 17:30 (5:30 p.m.) "...Resident returned back from (name of acute care hospital) ER. Resident arrived back to facility...with discharge Dx (diagnosis) of UTI (Urinary Tract Infection). However, resident sustained a fall at facility in bathroom area...and obtained a laceration (tear) to right forehead area. ER reports show a nondisplaced fracture of the fourth proximal phalanx (finger) may be present to right hand, her hand also has a skin tear to top of wrist...shows bruising & swelling to area of fingers. Reports also show limited R (right) tibia/fibula (lower leg) trauma - with a nondisplaced vertical fracture of the proximal tibial shaft (broken lower leg) ..." ; f. On September 30, 2019, at 20:00 (8 p.m.) (Fourth fall) "...Resident (Patient 158) was observed to have gotten out of bed and was walking by her closet door attempting to reach the restroom & slipped on to ground. She hit the side of her R (right) head on closet wall. Was found in a sitting position..."; g. On December 8, 2019, at 7:40 a.m., (Fifth fall) "...Pt (patient) found on floor in front of toilet. States she leaned forward to wipe and chair tilted forward. Denies pain. Body assessment no s/s (signs and symptoms) of injury noticed. B/P (blood pressure) 130/76 (normal range 120/80 - 140/80) R-18 (respirations - normal range 16-20) P-76 (pulse - normal range 60-100) T-98.2 (temperature - normal range 96.8 - 99.9) Will cont. (continue) to monitor." h. On December 8, 2019, at 12:30 p.m., "New order r/t (related to) fall this am, Resident was in pain on L (left) side. Sent to (name of acute care hospital) for further eval (evaluation)..." Patient 158's care plan titled, "At risk for fall/injury," dated January 20, 2019, indicated, "...Goal...Be free of injury r/t (related to) falls...Interventions...Keep bed in low position. Assist with transfers. Educate resident how to call for assist and keep call bell within reach. Non slip footwear/shoes." Patient 158's care plan regarding fall incident dated March 20, 2019, indicated "...Assess and address injuries PRN (as needed). Notify MD and Family promptly. Attempt to determine reason for fall. Post falling star to alert continued fall risk. Add to toileting schedule PRN. Assess for possible pain. Teach resident and family regarding falls and safety. Monitor and document any skin tears, abrasions, lacerations, bruising, or c/o pain for 72 hours and evaluate for need to follow up. Fall Mat at bed side when in bed. Other: X-ray L (left) hip r/t c/o of pain. A review of the care plan for Patient 158's fall incident while at the shower on July 15, 2019, indicated the same goal and interventions as the care plan on March 20, 2019. There was no documented evidence that the care plan for fall was reevaluated and revised to address the fall incident which occurred at the shower room while with the CNA on July 15, 2019. On January 8, 2020, at 4:11 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON verified there was no documented evidence Patient 158's plan of care was revised or updated after Patient 158's fall incident on August 3, 2019 and September 30, 2019. The DON stated there was no documented evidence an Interdisciplinary Team (IDT) meeting was conducted after the patient (Patient 158) fell on August 3, 2019, and September 30, 2019. On January 8, 2020, at 10:32 a.m., CNA 1 was interviewed. CNA 1 stated Patient 158 likes to get up every hour, and would not let the staff know if she wanted to use the bathroom. CNA 1 stated Patient 158 would grab the call light and throw it on her dresser. On January 8, 2020, at 10:39 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Patient 158 has confusion. LVN 1 stated the patient would get out of bed and would forget to use the call light. On January 8, 2020, at 3:26 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated Patient 158 has dementia. She stated the patient would not listen and would not remember to call for help. On January 9, 2020, at 2:42 p.m., the DON was interviewed. The DON stated when a patient falls, the licensed nurse should initiate an incident report and should update the patient's plan of care. A concurrent record review was conducted with the DON. The DON verified there was no documented evidence an incident report was conducted when Patient 158 fell on August 3, 2019 and September 30, 2019. The DON verified there was no documented evidence the facility staff completed a fall risk assessment or evaluation for Patient 158 after the fall incidents on July 15, 2019, August 3, 2019, and September 30, 2019. In addition, the DON stated the licensed nurse should have made an incident report and updated the care plans for Patient 158. A review of Patient 158's nursing progress notes dated December 8, 2019, indicated Patient 158 had a fall and was sent to the acute care hospital. (This was Patient 158's fifth fall since she was admitted at the facility on January 20, 2019.) A review of the x-ray result from the acute care hospital dated December 8, 2019, indicated, "...L1 vertebral infrapedical/lower endplate acute compression fracture (broken lower back) ..." A review of the undated facility policy titled, "Falls: Post Assessment," indicated, "...All residents are assessed post fall in order to identify any physical problems, medications or environmental issues related to the fall. A Post Fall Assessment and Fall Incident Report will be completed on all residents who have fallen...Document...Plan of Care accelerated/approaches updated..." The undated facility policy titled, "Falls and Fall Risk, Managing," indicated, "...Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling...If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant...If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified..." Therefore, the facility failed to ensure the care plans were reviewed and revised to address the episodes of fall on August 3, and September 30, 2019, Patient 158. In addition, the facility failed to conduct post fall risk assessment after the fall incidents on July 15, August 3, and September 30, 2019, in accordance to the facility policy and procedure. These failures resulted in Patient 158 to fall for the fifth time since admission, while at the facility. Patient 158 sustained non-displaced vertical fracture (break in the continuity of bone) of the right proximal tibial shaft (lower leg) and fracture of the lower back. This failure had a direct or immediate relation to patient's health, safety, or security.