Other·June 6, 2024

Title 22, §72311 (a)(2) Nursing Service - General (a) Nursing service shall include, but not be limited to the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Title 22, §72523 (a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Title 22, §72637 (a)(c) General Maintenance (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff, and visitors. (c) All buildings, fixtures, equipment, and spaces shall be maintained in operable condition. Code of Federal Regulations §483.25(d)(1)(2) 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 April 23, 2024, at 10:45 a.m., an unannounced visit to the facility was made to conduct a complaint investigation. It was determined that the facility failed to ensure the safety of Patient 3, when the facility failed to repair a loose toilet seat in Patient 3's bathroom, after it was reported as needing repair on April 2, 2024. This failure resulted in Patient 3 falling off the loose toilet seat on April 3, 2024; and sustaining a hip fracture that required surgical repair at the general acute care hospital (GACH). A review of Patient 3's medical record indicated Patient 3 was initially admitted to the facility on June 21, 2023, with diagnoses which included end stage renal disease (kidneys can no longer function on their own), hypertension (high blood pressure), and stroke (loss of blood flow to a part of the brain). Patient 3's care plan dated June 21, 2023 (on initial admission), indicated Patient 3 was at risk for fall and interventions included, "... maintain safe environment..." Patient 3's Minimum Data Assessment (MDS - an assessment tool) dated February 10, 2024, indicated Patient 3's cognition (the ability to make decision and produce appropriate response) was intact, Patient 3 was independent with toilet transfer (the ability to get on and off a toilet or commode) and the patient walked independently up to 150 feet. Patient 3's "Daily Nurses Note," dated April 3, 2024, indicated Patient 3, "...was trying to use the toilet but the toiled (sic) lid (sic) was lose (sic) and when he sit (sic) the toilet the sit (sic) moved and he ended on the floor...pt complain (sic) of pain 10/10 (a score of 0 means no pain, and 10 means the worst pain)...911 (emergency telephone number) was called...pt was taking (sic) to hospital at 3:25 p.m...." A review of Patient 3's GACH notes titled, "Trauma - History and Physical," dated April 3, 2024, indicated, "...60-year-old male...presents from skilled nursing facility after ground level fall early this morning...trauma surgery consulted for left hip fracture...he notes that his toilet seat has been loose for several days and had not been fixed. He sat on the toilet seat, and it slipped, and he fell onto his left side...LLE (left lower extremity) shortened and externally rotated...ROM (range of motion- the extent or limit to which a part of the body can be moved around a joint or a fixed point) limited due to pain..." On April 23, 2024, at 12:37 p.m., a concurrent observation and interview was conducted with Patient 3. He was in his room, lying in bed, alert and conversant. He stated he fell in the restroom on April 3, 2024, at approximately 2:30 p.m. Patient 3 stated as he was sitting down to use the toilet, he placed one of his hands on the toilet seat and the toilet seat moved sideways which caused him to fall to the ground. He stated he had spoken to the Social Service Assistant (SSA) about the loose toilet seat the day before he fell (April 2, 2024). Patient 3 stated he just returned from the hospital after having left hip surgery, he was in pain, and had lost his self-respect because he now had to use a commode (portable toilet) and he needed assistance with toileting. A review of Patient 3's record indicated the patient was re-admitted to the facility on April 9, 2024, with diagnoses which included fracture of the left femoral neck (a break in the left hip bone) and status post left hemiarthroplasty (received a partial left hip replacement). A review of Patient 3's "IDT (interdisciplinary team - group of health care professionals with various areas of expertise who work together) - Incident Review," dated April 10, 2024, indicated that Patient 3 had a fall incident on April 3, 2024, at 3:00 p.m. The document indicated description of the incident, "...denies hit (sic) his head. pt states he was trying to use the toilet and the seat was lose (sic) which lid (sic) to fall..." The IDT Incident Review further indicated, "...contributing factors/root cause analysis (the process of discovering the root cause of a problem) were diagnosis/comorbidities (two or more diseases present at once) and environmental..." A review of Patient 3's "PT (Physical Therapy) Evaluation & (and) Plan of Treatment," dated April 11, 2024, indicated "...Pt has significant deficits in functional mobility due to recent L (left) hip arthroplasty (surgical reconstruction or replacement of a joint). Pt requires increased time to perform tasks due to pain and weakness...Pt is currently functioning below previous baseline and requires skilled PT intervention to restore safe functional mobility..." During an interview on April 23, 2024, at 1:12 p.m., Licensed Vocational Nurse (LVN) 1 stated on April 3, 2024, during the change of shift of 7-3 (am) and 3-11 (pm), she was making rounds with another LVN when they found Patient 3 on the restroom floor inside his room. LVN 1 stated Patient 3 stated the toilet seat went sideways when he sat down and caused him to fall. LVN 1 stated she had not received any reports from Patient 3 or any other patients about a loose toilet seat. LVN 1 stated if Patient 3 had told her about the loose toilet seat, she would have reported it to the maintenance department right away. During an interview on April 23, 2024, at 1:20 p.m., the Maintenance Assistant (MA) stated there were maintenance logs at each station where staff can record broken equipment. The MA stated he reviewed the maintenance logs every day, in the morning, to check what needed to be fixed. The MA stated he was informed about the loose toilet seat in Patient 3's restroom on April 4, 2024, the day after Patient 3's fall. A review of the facility's maintenance logs for April 2024 at Stations 1, 2, and 3 was conducted. There was no information written on the maintenance logs for April 1, 2, and 3, 2024. During an interview on April 23, 2024, at 2:06 p.m., the SSA stated if there was a broken facility equipment, she would write it on the maintenance log. The SSA stated she was not initially aware that there were maintenance logs at each nurse's station. The SSA stated Patient 3 told her about the loose toilet seat on April 2, 2024, the day before he was transferred to the hospital. The SSA stated she reported it to her supervisor, the Social Service Designee (SSD). The SSA stated the SSD told her there were maintenance logs at each nurse's station. The SSA stated she was able to locate the maintenance logs, but she did not record the loose toilet seat in Patient 3's restroom on the log. During an interview on April 23, 2024, at 3:20 p.m., the Director of Nursing (DON) stated there were maintenance logs in each nurse's station. The DON stated the staff can record on the logs what needs to be fixed, and the maintenance department would review the logs every day to identify and to address any equipment requiring repairs. In addition, the DON stated the Maintenance Director attends stand-up meeting where he would be informed of any broken equipment. The DON stated Patient 3 fell on April 3, 2024, and he (Patient 3) mentioned that the toilet seat was loose in his restroom. The DON stated she was not aware that the SSA knew about the loose toilet seat in Patient 3's restroom before the patient fell. The DON stated the SSA should have written it down on the maintenance log and should have alerted the maintenance staff verbally when she was made aware of the loose toilet seat. The DON stated a loose toilet seat was an accident hazard. During an interview on April 23, 2024, at 4:43 p.m., the Administrator (ADM) stated when staff noticed broken facility equipment or a loose toilet seat, they should record it on the maintenance log. The facility's policy and procedure titled, "Safety and Supervision of Residents" dated November 2023, was reviewed. The policy indicated, "...resident safety and supervision and assistance to prevent accidents are facility-wide priorities...employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents..." It was determined based on interview and record review, that the facility failed to repair Patient 3's loose toilet seat after it was reported as needing repair on April 2, 2024. As a result of the facility failure, Patient 3 fell off of the loose toilet seat on April 3, 2024, and fractured his hip which required surgery at the GACH. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.