Health inspection·May 24, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of a facility incident report, review of the facility investigation, policy review, and review of hospital records, the facility failed to ensure fall preventions were implemented. This resulted in Actual Harm on 05/08/23 when Resident #50, who was cognitively impaired and required extensive assistance from two staff for bed mobility, was left by staff laying in bed in the high position after care was provided. Subsequently, Resident #50 fell from the high positioned bed sustained multiple injuries resulting in hospitalization. This affected one Resident (#50) of three residents reviewed for falls. The facility census was 31. Findings Include: Review of the medical record revealed Resident #50 was admitted on [DATE] with diagnoses including Parkinson's disease, Alzheimer's, disorders of bone density and structure, osteoarthritis, age-related osteoporosis without current pathological fracture, history of falling and anxiety. Review of Resident #50's plan of care, last updated 02/10/23 revealed the resident was at risk for falls due to weakness, difficulty in walking, lack of coordination, pain, and dementia. Fall interventions included putting pillows to the side of bed, to assist elder to not pull self to side of bed. Two people assist with incontinence care, enabler bars per family request, and Resident #50's bed should always be in the low position. Review of Resident #50's fall risk assessment dated [DATE] revealed the resident was high risk for falls. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility and used a mechanical lift for transfers. Review of Resident #50's physician's orders dated 04/24/23 to 05/24/23 revealed orders for enabler bars with padding per family request, a low bed, and the use of a mechanical lift for transfers. Review of Resident #50's nursing progress notes revealed on 05/08/23 at 6:50 A.M. State Tested Nursing Assistant (STNA) #130 called Licensed Practical Nurse (LPN) #120 to Resident #50's room. Upon arrival Resident #50 was on her back lying on the floor, with skin tears, abrasions and swelling to her head. STNA #130 reported he dressed Resident #50, left the room to get the mechanical lift, and Page 1 of 3 365416 365416 05/24/2023 Ohio Living Westminster-Thurber 717 Neil Avenue Columbus, OH 43215

F 0689 when the STNA returned to the room Resident #50 was on the floor. At 7:00 A.M. the hospice nurse evaluated the resident obtained an order to send Resident #50 out to the hospital for sutures. Level of Harm - Actual harm Residents Affected - Few Review of the incident report dated 05/08/23 at 5:50 A.M. revealed STNA #130 called LPN #120 to Resident #50's room after finding the resident on the floor. The family representative, the guardian and the hospice provider were notified. STNA #130 revealed he got the resident up and dressed, laid her back in the bed, left the room, helped two other residents, and came back to Resident #50's room with the mechanical lift and found the resident lying on the floor. The bed was in a high position. Review of the fall investigation initiated by the Director of Nursing (DON) revealed on 05/08/23 at 4:12 P.M. an interview with STNA #130 revealed he got Resident #50 dressed for the day; he placed the resident back in the bed in a laying position. He left the room and took care of two other residents on the unit. He came back to the room with the mechanical lift and found Resident #50 on the floor. He called for the nurse, LPN #120 who witnessed Resident #50 on the floor. Review of LPN #120's statement in the fall investigation report revealed on 05/08/23 at 6:50 A.M. STNA #130 called LPN #120 to Resident #50's room. Upon arrival the resident was laying on her back on the floor, with skin tears, abrasions and swelling on the back of her head. The area was red and moist with a small amount of sanguineous drainage noted. STNA #130 reported he dressed the resident, went to get the mechanical lift, came back to the room and Resident #50 was on the floor. Neurological checks were initiated due to the unwitnessed fall and notifications were made. Review of the hospital record dated 05/08/23 for Resident #50 revealed an [AGE] year-old female with history of dementia presented to the emergency department for evaluation status post fall with a small area of active bleeding several hours and clotting. Various bruising noted throughout the body. No midline tenderness appreciated on exam. Resident #50 was admitted to the hospital trauma unit with a closed non-displaced fracture of the seventh cervical vertebra, unspecified fracture morphology, traumatic cephalohematoma, fall, and multiple contusions. Interview on 05/24/23 at 9:30 A.M., with the DON revealed a fall investigation was implemented as soon as the fall was reported. She interviewed LPN #120 and STNA #130. The investigation determined Resident #50 was left lying in a bed (not in a low position) while STNA #130 left the room, which resulted in Resident #50 falling on the floor sustaining injuries. Telephone interview on 05/24/23 at 2:25 P.M., LPN #120 revealed on 05/08/23 he was called to the room by STNA #130 when he arrived at the room Resident #50 was on the floor. He could not recall if the pillows were placed beside the resident in the bed. He verified the bed was not in a low position. The bed was higher than a normal positioned bed. A follow-up interview on 05/24/23 at 3:00 P.M., with the DON verified per her investigation Resident #50's bed was not in a low position when she fell. Telephone interview on 05/24/23 at 4:12 P.M., with STNA #130 revealed he went into Resident #50's room and dressed her for the day. The STNA indicated it was too early to get her out of bed, so he went and helped two other residents. He came back with the mechanical lift and found Resident #50 on the floor. He noticed Resident #50 was bleeding and called for the nurse. He verified the bed was in a high position, but stated it was not the highest position. Review of the policy titled Fall Prevention and Management, dated 09/13/22 revealed fall risk 365416 Page 2 of 3 365416 05/24/2023 Ohio Living Westminster-Thurber 717 Neil Avenue Columbus, OH 43215

F 0689 Level of Harm - Actual harm screening will be completed on admission and quarterly thereafter, interventions will be put into place based on risk factors for example falls from bed require the resident to have a low bed, customized activities, etc. Residents Affected - Few This deficiency represents noncompliance discovered in Complaint Number OH00142774. 365416 Page 3 of 3