Health inspection·November 2, 2023

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 and staff interview, the facility failed to provide adequate supervision and assistance by staff when rolling Resident #75 in bed to provide incontinence care which resulted in Resident #75 falling out of the bed sustaining injuries to his face and upper extremities. This affected one resident (#75) of three residents reviewed for falls. The facility census was 70. Findings include: 1. Record review was conducted for Resident #75 who was admitted to the facility on [DATE] with diagnoses including monoplegia of upper limb following a stroke affecting right dominant side, aphasia, dysphagia, dysarthria, unspecified dementia, malignant neoplasm of bronchus and lung, secondary malignant neoplasm of bladder, obesity, need for assistance of personal care and gastrostomy. Review of Resident #75's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/14/23, revealed the resident had unclear speech and never made himself understood by others. Resident #75 had short-term and long-term memory impairment, severely impaired cognition, no known display of any behaviors nor known to reject care. Resident #75 required the extensive assistance of two staff for bed mobility and toilet use, required limited assistance of one staff for locomotion on unit in wheelchair and dressing. A review of Resident #75's care plans, dated initiated 04/13/23, revealed he was at risk for falls due to cognitive impairment, stroke, debility and required maximum assistance by staff for mobility and transfers. A fall intervention dated 04/13/23 indicated to assist with with mobility as needed. On 10/09/23 a fall intervention was added for two-person assistance with ADL care and mobility. On 10/09/23 an intervention was added for a perimeter defined mattress. A review a progress note written on 10/08/23 by Registered Nurse Supervisor (RNS) # 393 about Resident #75 revealed she was notified by the State Tested Nurse Aid ( STNA) #454 that while STNA #454 was turning Resident #75 to change him, Resident #75 had fallen out of bed. Resident #75 was lying on his side/stomach between the bed and wall. Resident #75 was lifted with a maxi ( Hoyer) lift and placed back in bed. Resident #75 had a hematoma and bruising to the left eyebrow, hematoma to the left hand, abrasion to the upper lip, and scrapes to the bilateral elbows. Vial signs were taken, neurological checks were initiated and the family and physician were made aware. Resident #75 was ordered an intervention of two staff with all hands-on care. Further review of the medical record revealed Resident #75 did not require hospitalization after the fall. Review of a progress note by the Nurse Practitioner (NP) dated 10/09/23 revealed he was seen Page 1 of 3 365783 365783 11/02/2023 Aventura at Assumption Village 9800 Market Street North Lima, OH 44452

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and examined in his room with his wife at the bedside. There was noted ecchymosis (skin discoloration) and small laceration to the left eyebrow after a fall. The NP noted baseline mental status was disoriented and he required total care for all ADLs. Review of the facility investigation revealed a witness statement given to the Director of Nursing (DON) via telephone dated 10/12/23 and provided by STNA #454. STNA #454 stated she went into the room of Resident #75 on 10/08/23, moved the bed away from the wall, stood on the side of the bed and rolled him onto his left side with her left hand holding his shoulder while she used her right hand to wipe his buttocks. Resident #75's feet began to move towards the edge of the bed and he began falling off the bed. STNA #454 tried to catch him but he fell and landed on his left side. STNA #454 moved the bed to roll him onto his back, went and got the nurse who completed an assessment then they both put him back into bed using hoyer lift. The witness statement noted STNA #454 was from a staffing agency. An observation was conducted on 11/01/23 at 10:54 A.M. of Resident #75 sitting in his wheelchair in a common area with Licensed Practical Nurse (LPN) #380 present in the area. Resident #75 was alert, nonverbal and unable to communicate any wants or needs to the surveyor when asked simple questions. LPN #380 verified Resident #75 had healing bruises on the left side of his face. An interview was conducted on 11/01/23 at 10:55 A.M. with LPN #302 who revealed Resident #75 prior to the fall on 10/08/23 was a two person assist for all care and bed mobility for checking and changing incontinence care. LPN #302 stated the STNA should have had another STNA help with Resident #75's care. LPN #380 was also interviewed at this time and revealed no STNA should work with Resident #75 alone because Resident #75 needed two people to assist with checking and changing briefs. An interview was conducted on 11/01/23 at 2:47 P.M. with the DON and Administrator who revealed the STNA rolled Resident #75 by herself to check and change the resident's brief. The DON explained most residents will reach out to assist staff by grabbing the bed bar and for any agency staff or new STNA's care needs were communicated via a document labeled Transfer Bed Mobility Instruction sheet kept in all resident's closets for reference by staff. The DON stated not all Transfer Bed Mobility Instruction sheets are automatically updated when the care plan is updated. The DON and Administrator verified the Transfer Bed Mobility Instruction Sheet for Resident #75, dated 07/11/23, was in Resident #75's room on 10/08/23. The DON and Administrator also verified bed mobility status for Resident #75 was not checked off on the document for communication to new staff, and the form did indicate Resident #75 required a two people transfer with the Maxi (mechanical lift). Interview on 11/01/23 at 3:00 P.M. with RNS #393 revealed she was the nurse who assessed Resident #75 on 10/08/23 after the fall out of bed. RNS #393 stated she did not witness the fall but did witness Resident #75 on the floor between the bed and the wall and verified his injuries sustained from the fall. RNS #393 stated the bed was pulled away from the wall. RNS #393 stated Resident #75 required full care because he needed everything done for him. Interview on 11/01/23 at 4:09 P.M. with Physical Therapist ( PT) #350 revealed it was possible for one STNA to roll a resident for bed mobility if the resident had adequate trunk control, but Resident #75 did not have adequate trunk control. PT #350 verified the last PT assessment dated [DATE] revealed Resident #75 was a total dependence for care and Resident #75 did not attempt or initiate trunk control. Interview on 11/01/23 at 4:41 P.M. with STNA #324 revealed Resident #75 was a two person assist to 365783 Page 2 of 3 365783 11/02/2023 Aventura at Assumption Village 9800 Market Street North Lima, OH 44452

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roll because Resident #75 did not understand to grab the bar on the bed and would not have been able to help or stabilize himself when the STNA rolled him in the bed for incontinence care on 10/08/23. Interview on 11/01/23 at 4:43 P.M. revealed STNA #340 used two person assist to check and change Resident #75 because he was a bigger man, and Resident #75 could not move from side to side or understand to grip the grab bar for safe rolling. STNA #340 verified Resident #75 had healing bruising on his face caused by a fall. Interview on 11/01/23 at 5:25 P.M. with LPN #452 revealed two staff members were needed to change Resident #75's brief because of Resident #75's weight and Resident #75 had no trunk control. Review of facility education titled Mastering Bedside Care revealed staff were to verify if a resident was a two person assist, if so, be sure to have a second staff member present. This deficiency represents non-compliance investigated under Complaint Number OH00147407 365783 Page 3 of 3