Health inspection·January 11, 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 record review, review of facility policy, and staff interview the facility failed to ensure care was not delayed and a fall was properly assessed for one resident, Resident #1, out of three residents reviewed for falls. The current census is 46. Findings include: Record review of Resident #1 revealed the resident was admitted to the facility on [DATE] and discharged to another facility on 01/05/24. Diagnoses for Resident #1 included displaced fracture of the femur, chronic obstructive pulmonary disease, malnutrition, and heart disease. Review of Resident #1's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was a fall risk. Review of Resident #1's care plans dated 12/2023 revealed a focus for falls. Interventions included non-skid footwear, keeping path free of clutter, and call light within reach at all times. Review of the fall assessment dated [DATE] at 1:30 P.M. revealed the nurse documented her progress note regarding the assessment completed on Resident #1 in the medical records as the time of the fall. Per the fall assessment the resident rated her pain at a level 2 out of 10, (10 being highest level of pain). Per the assessment the nurse documented no injuries due to fall. The fall assessment was unsigned and not a part of the electronic medical record. Review of written physician orders, undated, revealed a written order for x-ray of left hip with two to three views was signed by Certified Nurse Practioner (CNP) #400 and dated 11/28/24. No nurse signature, date, or time was noted on the physician's written order. Review of the radiology report from the radiology provider revealed the order for Resident #1's x-ray was ordered priority STAT and the date of service was 11/28/23 at 11:43 A.M. and reported to the facility on [DATE] at 11:59 A.M Further review of Resident #1's electronic records revealed on 11/27/23 there were no vital signs documented. No nursing assessments were dated 11/27/23 and no fall assessments were documented on 11/27/23. Review of Resident #1's progress notes dated 11/28/23 at 9:03 A.M. Licensed Practical Nurse (LPN) #100 charted her assessment of Resident #1's fall on 11/27/23. On 11/28/23 at 1:18 P.M. the nurse documented the resident was transferred to the hospital at 1:18 P.M. due to the x-ray results showing a Page 1 of 2 365953 365953 01/11/2024 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0689 hip fracture. Level of Harm - Minimal harm or potential for actual harm Interview on 01/11/24 at 1:20 P.M. with the Director of Nursing (DON) verified there was no electronic order for the x-ray entered into Resident #1's electronic record. The DON verified the written order did not have a nurse's name and was not a part of Resident #1's electronic records. The DON verified there was no order date on the x-ray order but it was signed by CNP #400 on 11/28/23. The DON stated the x-ray was completed on 11/27/23 but the final results were not in the system until 11/28/23. The DON verified there was no fall risk assessment by LPN #100 in the electronic record and the fall investigation had been completed on 11/28/23 by the nurse. The DON verified LPN #100 had not documented on the day of the fall and entered a late entry in the progress notes. Residents Affected - Few Interview on 01/11/24 at 1:45 P.M. with LPN #100 verified after the fall she assessed Resident #1 but the nurse stated she could not remember notifying the family or CNP #400 after the fall. LPN #100 verified she did not follow fall protocols after the fall and did not document the fall assessments or any orders for the x-ray in the record. LPN #100 stated she could not recall talking with CNP #400 after the fall and stated she believed the nurse for the second shift finished the fall protocols on the day after the fall. Interview on 01/11/24 at 2:23 P.M. with CNP #400 stated she was in the facility and assessed Resident #1 on 11/28/23 the day after the fall. Per CNP #400 she could not recall when she was notified of the resident's fall but stated she did fill out the order for the x-ray on 11/28/23 and stated the x-ray was taken on 11/28/23. CNP #400 stated when she assessed Resident #1 the resident's pain level was around two or three, on a scale of 1-10, and the CNP stated she ordered the resident to be sent out after she was given the results of the x-ray. Review of the facility's fall policy titled, Falls Management, dated 12/03/19, revealed in the event of a fall the nurse will document a fall assessment into the electronic medical record, documentation in the medical record's progress note should be a complete assessment and record of the fall and the nurse is to notify the physician and family immediately after the assessment of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00149285 365953 Page 2 of 2