Health inspection·May 11, 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 and interviews the facility failed to provide adequate and appropriate quality of care and services when transferring Resident #22 into bed after a fall incident. This affected one resident (Resident #22) of four residents reviewed for assistance with transfers. The facility census was 116. Residents Affected - Few Findings include: Review of the medical record for Resident #22 revealed an admission date of 09/10/20. Diagnoses included Alzheimer's disease, dementia with behavior disorder, left shoulder pain, hyperlipidemia, aphasia, anxiety, major depressive disorder (MDD), and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/05/23, revealed the resident had severely impaired cognition. Resident #22 required extensive assist by one staff member for for bed mobility, wheelchair mobility, dressing, and eating and was totally dependent on two staff members for transfers, toileting, and personal hygiene. Review of the plan of care dated 09/10/20 revealed the resident was at risk for falls due to dementia, Alzheimer's disease, anxiety, MDD, and decreased mobility. Interventions included bed in lowest position, clutter free pathways, call light within reach, defined perimeter mattress (DPM) to bed at all times, body pillow to bed at all times, large touch pad with in reach, and a bed alarm to alert staff for safety. Review of physician orders for May 2023 identified orders for Resident #22's bed to be in the lowest position, clutter free pathways, call light with in reach, defined perimeter mattress (DPM) to bed at all times, body pillow to bed at all times, large touch pad with in reach, and a bed alarm to alert staff for safety. Review of the nurses notes dated 03/27/23 at 8:00 P.M. Licensed Piratical Nurse (LPN) #814 documented Resident #22 was found on the floor next to right side of bed. She documented injuries to residents mouth, bruising to right side of face and bruising with swelling to right hand including her second digit. The physician was contacted and gave orders to send resident to the local emergency room (ER) for evaluation and treatment. Resident #22's family was updated about the fall and new orders to send the resident to the ER. Nurse to nurse was called to the local ER. Review of nurses noted dated 03/27/23 at 11:32 P.M. Resident #22 returned from the ER with no new orders, all scans completed at the hospital including x-rays, and Computed Tomography scans revealed no fractures. Resident #22 had bruising to right side of face and to her right hand including her second digit. Page 1 of 2 365574 365574 05/11/2023 Crandall Nursing Home 800 S 15th St Sebring, OH 44672

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the fall investigation dated 03/27/23 revealed all ordered fall interventions were in place, alarm was sounding when nurse entered room and found Resident #22 on the floor next to her bed. Staff witness statements revealed State Tested Nursing Assistant (STNA) #804 and STNA #805 assisted Resident #22 to bed prior to her fall by using a two person transfer per her plan of care, then left the room together. LPN #814 entered Resident #22's room to give the resident her medicine and heard the alarm sounding and found the resident on the floor. LPN #814's statement included she ensured the resident was safe and did a quick assessment. LPN #814 noted bruising and swelling to resident right side of face, bleeding from her mouth and bruising and swelling to right hand including her second digit. LPN #814 yelled for help, found there was no one present in the hall way, so she ran to the nurses station to get help to assist the resident back to bed. Upon returning to Resident #22's room she found STNA #805 alone in the room with Resident #22, STNA #805 was standing next to the residents bed and Resident #22 was already in bed. LPN #814 questioned STNA #805 how the resident got back in bed and he stated he did not know, he found her in the bed with blood on her mouth. LPN #814 cleaned the residents face and notified the physician, the residents family, gave nurse to nurse to receiving hospital and obtained statements from all staff working at at the time of the fall. Interviews completed throughout the survey on 05/09/23 through 05/11/23 with the Administrator and Director of Nursing revealed on 03/28/23 via phone interview with STNA #805, STNA #805 told them he transferred Resident #22 off of the floor by himself even though he knew the resident was a two person transfer per her plan of care. He stated he lied the night before when she fell because he did not want to get in trouble for her falling. At the time of the phone interview STNA #805 was terminated due to his actions. Interview on 05/10/23 at 3:10 P.M. with LPN #814 verified she found Resident #22 on the floor next to her bed laying on her right side. LPN #814 noted bruising and swelling to right side of face, bleeding from her mouth, and bruising and swelling to her right hand including her second digit. LPN #814 yelled for help there was no one present in the hall way, so she ran to the nurses station to get help to assist the resident back to bed. Upon returning to Resident #22's room she found STNA #805 standing next to the residents bed. LPN #814 questioned STNA #805 how the resident got back in bed and he stated he did not know, he found her in the bed with blood on her mouth. LPN #814 cleaned the residents face and notified the physician, the residents family, gave nurse to nurse to receiving hospital and obtained statements from all staff working at time of the fall. This deficiency represents non-compliance investigated under Complaint Number OH000141625. 365574 Page 2 of 2