Health inspection·November 20, 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 medical record review, facility investigation review, staff interview, and review of the facility fall management guide the facility failed to ensure Resident #25 was provided adequate assistance and supervision during the provision of personal care to prevent a fall with injury. Actual harm occurred on 10/23/24 when Resident #25, who had cognitive impairment and required staff assistance for personal care including toileting sustained a fall in the bathroom after being left on the toilet unattended. The resident was assessed to have a laceration to the head (as a result of the fall) and was transported to the hospital where she was admitted and received 15 sutures to the area. The resident was hospitalized from [DATE] until 10/28/24. This affected one resident (#25) of three residents reviewed for accidents. The census was 59. Findings Include: Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including laceration to scalp, muscle weakness, hyperlipidemia, anemia, dementia, atrial fibrillation, pain, vitamin B12 deficiency, vitamin D deficiency, hypertension, history of falling (02/21/19), and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident exhibited cognitive impairment and required partial/moderate (staff) assistance for toilet use. Review of Resident #25's current care plan revealed the resident was at risk for falls and potential injuries. In addition, review of the plan of care revealed the resident had an activity of daily living (ADL) self-care deficit with an intervention to have one person assistance while using the bathroom/toilet. Review of Resident #25's progress note dated 10/23/24, revealed the nurse found Resident #25 lying on the bathroom floor with blood coming from her head. Emergency medical services (EMS) were called, and the resident was taken to the emergency room for evaluation. Review of Resident #25's progress note dated 10/28/24 revealed the resident returned from the hospital with 15 sutures to the right side of her head as a result of the fall on 10/23/24. Review of a facility self-reported incident (SRI), tracking number 253458 and facility investigation documents, dated 10/29/24, revealed Resident #25 was found in the bathroom (by herself) by Certified Nursing Assistant (CNA) #101 the evening of 10/23/24. The facility information included Resident Page 1 of 2 366155 366155 11/20/2024 New Albany Care Center 5691 Thompson Road Columbus, OH 43230

F 0689 Level of Harm - Actual harm Residents Affected - Few #25 asked for privacy while she was going to the bathroom, so CNA #101 left the room to get incontinence care items to assist Resident #25 when she was finished toileting. After leaving the room, Resident #25's roommate yelled to state Resident #25 fell in the bathroom. Staff immediately went back in and found Resident #25 on the floor with blood coming from the right side of her head. EMS were called and the resident remained in the hospital for approximately five days. Review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Interview with the Director of Nursing (DON) on 11/20/24 at 12:30 P.M. and 1:55 P.M. revealed any resident who was deemed to be confused and/or a fall risk, was not to be left alone while in the bathroom. She confirmed a resident is deemed to be confused when they have a Brief Interview for Mental Status (BIMS) score of 12 or less out of a potential total score of 15. She confirmed Resident #25's BIMS score was five, which identified the resident exhibited confusion. The DON also confirmed Resident #25 was assessed to be a fall risk, because she had a care plan for the possibility of falling. Interview with Corporate MDS Nurse #102 on 11/20/24 at 1:10 P.M. confirmed if a resident was assessed/deemed to require one person assistance for toilet use via their MDS assessment, staff should not leave the resident on the toilet alone. Interviews with CNA #103, Licensed Practical Nurse (LPN) #104, and CNA #105 on 11/20/24 at 1:25 P.M. and 1:31 P.M. confirmed if a resident was at risk for falls, staff were not to leave the room if a resident was using the bathroom. If the resident asked for privacy, they were to go outside of the bathroom door, remain in the resident's room, and leave the bathroom door cracked so they could respond immediately if there is an issue. Review of facility Fall Management Guidelines, dated 12/13/23, revealed a fall was defined as unintentionally coming to rest on the ground, floor, or other level with or without injury to the resident, but not as a result of an overwhelming force. A fall risk evaluation would be completed for residents upon admission, readmission, quarterly, and with a significant change in condition. The licensed nurse would review the resident's medical record, speak with the resident and/or their representative, and evaluate the resident to determine the resident's fall risk factor. The facility staff, with input of the attending physician, would implement a resident centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions to address the resident's modifiable fall risk factors, interventions to try to minimize the consequences of risk factors that are not modifiable, and the plan for reduction of risk and or risk for injury related to falls. This deficiency represents non-compliance investigated under Complaint Number OH00159691. 366155 Page 2 of 2