Health inspection·August 13, 2024

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 medical record review, staff interview, and policy review, the facility failed to ensure fall interventions were implemented to address the root cause of resident's falls. This affected one (#7) of three residents reviewed for falls. The census was 57. Findings included: Medical record review for Resident #7 revealed an admission date of 05/01/23. Diagnoses included stroke, aphasic, non-Alzheimer's dementia, hemiplegia, and seizure disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was rarely or never understood. His functional status was a setup or clean-up assistance for eating, partial/moderate assistance for toileting and transfers, and the resident was independent for bed mobility. Review of the care plan updated 07/01/24 for Resident #7 revealed an intervention dated 05/23/23 to review information on past falls and attempt to determine the root cause of the falls. Review of an unwitnessed fall note on 07/25/24 at 5:46 A.M. revealed Resident #7 was attempting to self-toilet at the time of the fall. The note revealed the reason for the fall was evident. A new intervention was implemented to encourage the resident to change positions slowly. Review of an unwitnessed post fall note on 07/26/24 at 3:41 P.M. revealed Resident #7 was found in his room with feces around him on the floor and no non-skid socks on. The new intervention was to wear non-skid socks in the room and initiate neurological checks. Review of an unwitnessed fall note dated 07/31/24 at 7:00 A.M. revealed a fall occurred in the bathroom. Resident #7 was attempting to self-toilet in bare feet at time of the fall. The resident could not communicate what happened but pointed at the toilet. The resident was re-educated on the use of his call light for assistance, provided a non-skid sock, and staff transferred him to his recliner. Interview with the Assistant Director of Nursing (ADON) on 08/13/24 at 1:30 P.M. confirmed the fall interventions implemented for Resident #7's falls on 07/25/24, 07/26/24, and 0731/24 did not address the root cause of the resident's falls involving the resident attempting to self-toilet. Review of the policy titled, Falls Policy, dated 02/01/22, revealed it is the policy of the facility to identify residents at risk of falls and to implement a fall prevention approach to reduce the risk of falls and possible injury. Page 1 of 2 365813 365813 08/13/2024 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0689 This deficiency represents non-compliance investigated under Complaint Number OH00155954. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365813 Page 2 of 2