Health inspection·February 23, 2024

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 record review, interview, and policy review, the facility failed to provide adequate resident supervision and assistance resulting in a fall with major injury. Actual Harm occurred on 01/19/24 when Resident #1, who was identified at risk for falls, assessed to have cognitive impairment, and required supervision while smoking, exited the facility through two sets of locked doors, to the facility's outdoor smoking area with a cigarette and the intention of helping Receptionist #100 shovel snow due to inclement weather. Once Receptionist #100 discovered the resident was outside, the resident was instructed to return to her room. The resident entered the facility while wearing wet footwear (from snow) and subsequently slipped on the tile floor. The resident sustained a right distal radius and ulnar fracture. The resident was transported to the emergency room for evaluation/splinting and later followed with orthopedic surgery for cast application. This affected one resident (Resident #1) of three residents reviewed for falls. The facility census was 72. Findings include: Review of the Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease, heart disease, chronic kidney disease, chronic pain, and acquired absence of right leg, below the knee (Resident #1 used a right leg prosthesis). Review of the care plan, initiated on 10/31/22, revealed Resident #1 as at risk for falls related gait/balance problems, right lower leg prosthesis, and a history of falls. Interventions included to assess for falls on admission, quarterly, and as needed, to ensure the resident was wearing appropriate non-skid footwear, to ensure the resident's room was free of accidents/hazards, fall mat next to bed, ensure bed locks engaged, and to place the call bell within reach and to remind the resident to call for assistance. Review of the fall risk assessment, dated 12/01/23, revealed Resident #1 was identified as a potential risk for falls. Further review revealed the assessment was inaccurate as it indicated there were no predisposing conditions (the form specified loss of limbs as an example of a predisposing condition). The resident had a right leg below the knee amputation and required the use of a prosthetic leg. Review of the 5-Day Minimum Data Set (MDS) 3.0 assessment, dated 12/27/23, revealed the resident had a diagnosis of dementia and was not able to report the correct month or day of the year. The Page 1 of 4 365686 365686 02/23/2024 Columbus Healthcare Center 4301 Clime Road North Columbus, OH 43228

F 0689 Level of Harm - Actual harm Residents Affected - Few resident had a prosthetic, and had lower extremity impairment on one side. The resident received scheduled opioid pain medication. The assessment indicated there had been no falls since the last assessment. Review of a nursing progress note, dated 01/20/24 at 1:54 P.M., revealed Resident #1 said she had a fall yesterday on 01/19/24 in the smoking area but did not hurt herself. The resident said she didn't mention it because she wasn't hurt and did not hit her hand. The resident's right wrist is swollen. The Physician was notified. Review of a nursing progress note, dated 01/20/24 at 3:36 P.M., revealed an x-ray was ordered of the right wrist. A head-to-toe assessment was completed. The right wrist was swollen with minimal movement. The resident denied wrist pain. The resident was educated on the smoking policy and when she is allowed outside, supervised during smoking time. Review of Receptionist #100's written statement dated 01/20/24, revealed on 01/19/24, while he was in the smoke area shoveling snow and putting down salt, Resident #1 came outside and tried to help him. Receptionist #100 told the resident no and that she needed to go back inside. Upon turning around, he observed a cigarette in her hand trying to smoke. Receptionist #100 told Resident #1 that it wasn't smoke time and she needed to go back in. At this time, Resident #1 turned and started walking toward the door and she slipped and fell. Receptionist #100 asked the resident if she was okay, and she stated that she was fine and got up and walked away. On 01/20/24, the resident's risk for falls care plan was updated to include the following interventions: educate the resident on the smoking policy regarding supervision and smoking times was initiated. Further review of the care plan, initiated on 01/30/24, revealed the resident is a smoker and will be free from injury while smoking with interventions including to complete a smoking evaluation, to educate the resident on the smoking policy and designated smoking area, and to provide safe smoking devices, and to provide supervision during designated smoke times. Review of the x-ray report of the right wrist, date of service 01/21/24, revealed an acute fracture of the distal radius and ulna. Review of a telehealth notification, dated 01/21/24 at 10:58 A.M., revealed the resident had an acute fracture of the right distal radius and ulna. The fall was on Friday (01/19/24) and the resident continues to have pain. Non-emergent transport to the emergency department (ED) for splinting. Review of a nursing progress note, dated 01/21/24 at 1:04 P.M., revealed the nurse practitioner (NP) was notified of the x-ray results indicating a right wrist fracture. A new order was given to send the resident to the emergency room stat. Review of a post hospital encounter Nurse Practitioner (NP) progress note, dated 01/22/24, revealed the resident was seen post fall which occurred on 01/19/24. X-rays were obtained on 01/20/24 and indicated a right wrist fracture. The resident was sent to the ED on 01/21/24 and returned that evening with a right arm splint. According to the resident, she was walking in from the outside and slipped on tile. She caught herself with her hand and had ongoing wrist pain since. X-rays were obtained and showed a radius and ulnar fracture. In the ED, the arm was splinted and a follow-up with orthopedic surgery was recommended. The follow-up was scheduled for 01/24/24. Continue pain control and continue to monitor. Acute chronic pain with Tramadol prescribed and Percocet added and to be administered as needed. 365686 Page 2 of 4 365686 02/23/2024 Columbus Healthcare Center 4301 Clime Road North Columbus, OH 43228

F 0689 Level of Harm - Actual harm The Fall Investigation was unavailable at the time of the on-site survey. During interview on 02/23/24 at 2:17 P.M. the DON revealed Unit Manger/Registered Nurse (RN) #204 had completed the fall investigation and it was in RN #204's office. The DON shared she went into RN #204's office but was unable to locate the fall investigation and RN #204 was off work and unable to be contacted. \ Residents Affected - Few Review of the physician orders revealed the resident had an order to follow-up with orthopedics on 01/24/24 (orthopedics applied a cast to the resident's right wrist/forearm) and a follow-up appointment is scheduled for 02/26/24. The facility continues with the circulation checks each shift as ordered with the initial injury and splint. Observation and interview on 02/23/24 at 11:22 A.M. revealed Resident #1 sitting on the side of her bed. A cast was observed to the right forearm/wrist area. Resident #1 stated a couple of weeks ago, after it snowed, she wanted to go out to the smoking area to help the receptionist shovel snow and apply salt. The resident stated that the receptionist agreed and knew she was going to help and she followed him through two doors, and out into the smoking area. The resident stated after she helped with the salt, she went back into the facility. The resident further stated that after she entered through the exterior door and back inside the facility, she slipped on the wet tile floor and then fell. The resident didn't think she was hurt or injured at the time of the fall and didn't report the fall to the nurse. The resident stated the next day her arm started hurting but she didn't ask for any pain medication because she already gets scheduled pain medicine for other pain. Interview and observation on 02/23/24 at 1:32 P.M. with the Assistant Director of Nursing (ADON) revealed to her knowledge, Resident #1 followed the receptionist out of the doors to the smoking area when he was shoveling snow. The ADON stated the receptionist re-directed the resident and told her it wasn't time to smoke. The resident went back in through the door and slipped on the tile. The resident denied injury at that time to the receptionist. Observation revealed a locked door located on the hallway that opened into a room with a tile floor. A second locked door exited into the designated, outside smoking area. Both door locks had to be unlocked with a key. The ADON confirmed the keys are kept at the nursing station. During interview on 02/23/24 at 1:45 P.M., Receptionist #100 stated he was shoveling snow and putting salt down in the smoking area when Resident #1 followed him out and wanted to help. Receptionist #100 stated that he told her no, and that he was ok. Receptionist #100 stated he saw that the resident had a cigarette and told her it wasn't smoke time and she needed to go back to her room. Receptionist #100 did not know how the resident obtained the cigarette. Receptionist #100 stated, I opened the door for her to go back into the facility and after she entered through the door, she slipped and fell on her knees. I asked her if she was ok, and she said she was ok. I don't know how she got out of the locked doors to the smoking area, she must have followed me out. She is really fast and can get around. Receptionist #100 confirmed that he did not report the fall to anyone because the resident said she was not hurt, however, he has since been educated to report any fall or accident to nursing staff. During a follow-up interview on 02/23/24 at 2:06 P.M., Resident #1 confirmed she did not ask any nursing staff if she could go outside to the smoking area the day she fell. The resident stated she does not recall if the two doors were locked that lead out to the smoking area and could not recall if she immediately followed the receptionist through the doors or if he was already outside in the smoking area. During interview on 02/23/24 at 2:17 P.M., the DON stated it was reported that Resident #1 had a 365686 Page 3 of 4 365686 02/23/2024 Columbus Healthcare Center 4301 Clime Road North Columbus, OH 43228

F 0689 Level of Harm - Actual harm Residents Affected - Few fall in the smoke area after it had snowed. The DON stated she believed the resident came outside and tried to help the receptionist and was also trying to smoke when he told her she couldn't smoke and to go back inside. The DON stated the resident reported pain and swelling the next day. The DON stated, I'm honestly not sure if the door wasn't locked initially or if she just followed him out. The DON confirmed she was not sure how the resident obtained the cigarette because smoking supplies are secured by the nursing staff. The DON confirmed Resident #1 required smoking supervision and was not properly supervised as she should not have been able to exit through the two locked doors and should not have had a cigarette in her possession outside of supervised smoking times. The DON further stated she determined the root cause of the fall was because the resident wasn't properly supervised and should not have been able to get outside to the smoking area. The RN verified the resident should not have been outside, with her smoking item and she should have been assisted back into the facility due to the inclement weather. The DON also verified the receptionist should have reported the fall to the nursing staff. Review of the facility's policy titled, Fall Prevention and Management, revision date of 06/01/22, revealed it is the policy of this facility to provide resident centered care that meets the psychological, physical, and emotional needs and concerns of the residents. Fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage a resident's care if a fall occurs. Process after a fall: Assessment, the resident should not be moved until assessed by a licensed nurse. Review of the facility's policy titled, Resident/Patient Smoking, revision date of 03/24/2016, revealed it is the policy of this facility to promote resident centered care by promoting a safe smoking area for resident/patients that request to smoke and are capable of safe smoking behaviors either independently or with supervision unless the facility is a designated non-smoking facility. A supervised smoker is a resident that is unable to demonstrate safe smoking habits including smoking materials management, lighting, controlling cigarette ash and extinguishing smoking materials and requires staff supervision when smoking. This deficiency represents non-compliance investigated under Complaint Number OH00150837. 365686 Page 4 of 4