Health inspection·May 12, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and review of the facility policy, the facility failed to ensure staff completed appropriate neurological checks for a resident with an unwitnessed fall. This affected one resident (#73) of three residents reviewed for falls. The facility census was 72. Residents Affected - Few Findings include: Review of the closed medical record for Resident #73 revealed an admission date of 03/31/23 with diagnoses including chronic respiratory failure with hypoxia, moderate protein calorie malnutrition, major depressive disorder, gastroparesis, anxiety disorder, anemia, history of infrarenal abdominal aortic aneurysm, atherosclerotic heart disease, Barrett's esophagus, hypertension (HTN), and a discharge date of 04/25/23. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #73 dated 04/13/23 revealed the resident was cognitively intact and required extensive assistance of one staff member with activities of daily living (ADLs.) Review of nurse progress notes for Resident #73 dated 04/24/23 timed at 4:12 P.M., revealed the resident was assessed following a fall from the bed and had no injuries. Staff assisted resident back to bed and initiated neurological checks per protocol. Review of the facility fall investigation for Resident #73 dated 04/24/23, revealed the resident had an unwitnessed fall from bed on 04/24/23 at approximately 3:00 P.M. The resident was found on the floor next to her bed and staff reported the resident was on the floor because it was cooler on the floor. Review of the facility document titled Neurological Check Worksheet for Resident #73 revealed the staff completed checks per protocol which included the following information: level of consciousness, pupil response, strength of hand grasps, motor function of extremities, blood pressure, pulse, respirations, temperature. Further review of the worksheet initiated on 04/24/23 revealed an incomplete neurological (neuro) check was conducted at 10:00 P.M. on 04/24/23 which did not include pupil response or motor function. A neurological check was due to be completed on 04/25/23 at 3:00 A.M.; however, there was no documented evidence the neuro check for Resident #73 was completed. Interview on 05/12/23 at 12:33 P.M. with the Director of Nursing (DON) confirmed the neuro checks for Resident #73 were not fully completed after the resident had a recorded fall on 04/24/23. DON confirmed the neuro check due at 10:00 P.M on 04/24/23 was not completed and the neuro check due on 04/25/23 at 3:00 A.M. was not completed. Page 1 of 4 365515 365515 05/12/2023 Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Neurological Checks dated 10/18/21 revealed neurological checks should be completed after each fall in which there could have been a head injury. The checks should be done at the following intervals following the fall: every 15 minutes times four, every 30 minutes times four, every one-hour times four, every four hours times four, then every eight hours times four. Residents Affected - Few 365515 Page 2 of 4 365515 05/12/2023 Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, resident's representative interview, staff interview, and review of the facility policy, the facility failed to ensure assistive devices were in place per physician's orders and a resident's care plan to prevent falls. This affected one resident (#60) of three residents reviewed for falls. The facility census was 72. Findings include: Review of the medical record for Resident #60 revealed an admission date 05/02/23 with diagnoses including fracture of femur, end stage renal disease (ESRD), congestive heart failure (CHF), and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #60 dated 05/09/23 revealed resident was cognitively impaired and required extensive assistance of two staff with bed mobility and was totally dependent on the assistance of staff with transfers. Review of the care plan for Resident #60 dated 05/03/23 revealed resident was at risk for falls due to right fracture, reduced mobility, cognitive impairment, obesity, noncompliance with care, and history of falls. Interventions included the following: bed in lowest position, encourage and remind to ask for assistance, have commonly used articles within easy reach, maintain clear pathway, bilateral assistance (assist)/grab bars to assist in bed mobility. Review of the fall risk assessment for Resident #60 dated 05/06/23 revealed the resident was at risk for falls. Review of the admitting physician's orders for Resident #60 revealed an order dated 05/02/23 for the resident to have bilateral assist/grab bars to enhance bed mobility. Review of nurse progress note for Resident #60 dated 05/05/23 revealed the resident was found in his room laying on his left side parallel to the bed. The resident reported he was trying to retrieve something from the bedside table and rolled onto the floor. There was a knot visible over resident's right eyebrow and right side of his head. Resident was sent to the hospital for evaluation. Review of the hospital notes for Resident #60 dated 05/05/23 revealed the resident presented with a large hematoma in right orbital and supraorbital area. The X-ray and Computerized Tomography (CT) scan of the resident's head and face were negative for any fractures. Review of nurse progress note for Resident #60 dated 05/06/23 revealed the resident returned from the hospital with no new orders. His right eye remained swollen from the fall. Review of the facility's fall investigation for Resident #60's fall dated 05/05/23 revealed the resident fell out of the bed while trying to retrieve items from the bedside table next to the bed. The investigation did not include any documentation regarding the presence or absence of bilateral assist/grab bars. Observation on 05/12/23 at 12:20 P.M. revealed Resident #60 was in his room with his 365515 Page 3 of 4 365515 05/12/2023 Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few representative. The resident was seated in wheelchair with a large knot on the right side of his forehead. Observation revealed the resident's bed had an assist/grab bar on the left side but there was no assist/grab bar on the right side of the bed. Interview on 05/12/23 at 12:20 P.M. with Resident #60 and the resident's representative confirmed resident fell out of bed on 05/05/23 and sustained a hematoma to his right forehead and had to go to the hospital to be checked out. Resident #60 confirmed he fell out of the right side of the bed and onto the floor while reaching for an item on his nightstand. Resident #60 confirmed the assist/grab bar was not on his bed at the time of the fall, and resident's representative confirmed she believed the absence of a right assist/grab bar contributed to resident's fall. Interview on 05/12/23 at 12:33 P.M. with the Director of Nursing (DON) confirmed Resident #60 was admitted on [DATE] with orders for bilateral assist/grab bars to his bed. DON confirmed she was unaware there was no assist/grab bar on the right side of resident's bed, and he was supposed to have assist/grab bars on both sides to assist with mobility. DON confirmed the facility's fall investigation did not address the presence or absence of the assist/grab bars at the time of the fall. DON confirmed the absence of a right-side assist/grab bar could have been a contributing factor to resident's fall with injury on 05/05/23. Observation on 05/12/23 at 1:19 P.M. with the DON of Resident #60's room revealed resident and representative were in room with resident still seated upright in a wheelchair, but there were now assist/grab bars to both sides of the bed. Interview on 05/12/23 at 1:19 P.M. with Resident #60 and his representative confirmed staff had installed an assist/grab bar to the right side of resident's bed at about fifteen minutes prior to this observation. Interview on 05/12/23 at 1:38 P.M. with Licensed Practical Nurse (LPN) #105 confirmed she noticed there was no assist/grab bar to the right side of Resident #60's bed, so she installed one in accordance with the physician's order and resident's care plan. Review of the facility policy titled Falls Management dated 10/17/16 revealed each resident would be assessed for fall risk and an interdisciplinary care plan would be developed, implemented, reviewed, and updated to reflect the resident's current safety needs and fall reduction interventions. This deficiency represents non-compliance investigated under Complaint Number OH00142772. 365515 Page 4 of 4