Health inspection·January 30, 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. Based on medical record review, resident interview, staff interview, review of facility accident logs, and review of the facility policy, the facility failed to ensure falls were documented and investigated with follow-up interventions implemented as needed. This affected one (Resident #42) of three residents reviewed for activities of daily living (ADLs.) The facility census was 61. Findings include: Review of the medical record for Resident #42 revealed an admission date of 12/29/23 with diagnoses including spondylosis without myelopathy or radiculopathy to the lumbar region, muscle weakness, difficulty in walking, and arthrodesis. Review of the fall risk assessment for Resident #42 dated 12/29/23 revealed the resident required an assistive device for mobility and assistance with bed mobility, transfers, and ambulation. Further review of the assessment revealed Resident #42 was at a moderate risk for falls. Review of the physician orders for Resident #42 revealed an order dated 12/29/23 to keep call light within reach at all times. Review of the care plan for Resident #42 dated 01/02/24 revealed the resident required assistance with ADLs due to weakness, impaired balance, limited mobility and was at risk for falls. Interventions included staff would provide assistance with ADLs and keep the resident's call light in reach. Review of the care plan for Resident #42 dated 01/02/24 revealed the resident was at risk for falls due to multiple risk factors including impaired balance, impaired mobility, pain, unsteady gait, debility, and psychotropic medication use. Interventions included the following: be sure call light is within reach and encourage use for assistance as needed, prompt response to all requests for assistance, ensure environment is free of clutter, evaluate effectiveness and side effects of psychotropic drugs with physician for possible decrease in dosage/elimination of medication, gait belt for all ambulation, gait belt for all transfers, have commonly used articles within easy reach, nonslip footwear Review of the physician orders for Resident #42 revealed an order dated 01/02/24 for mobility per plan of care. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 01/05/24 revealed the resident was cognitively intact and was dependent on staff assistance with ADLs. Page 1 of 2 366272 366272 01/30/2024 O'Neill Healthcare North Olmsted 4800 Clague Road North Olmsted, OH 44070

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/29/24 at 10:59 A.M. with Resident #42 confirmed she had a fall approximately a week ago in her bathroom, and she waited for 15 minutes before staff checked on her. Resident #42 was unable to identify the exact date of the fall. Interview on 01/29/24 at 11:19 A.M. with Licensed Practical Nurse (LPN) #853 confirmed Resident #42 had a fall the previous week in her bathroom. LPN #853 confirmed she found Resident #42 on the floor of her room in front of her recliner, and the resident reported she had fallen in the bathroom and moved herself into the room. LPN #853 confirmed she did not document the fall in the resident's medical record and did not complete any type of post-fall investigation. Interview on 01/29/24 at 4:35 P.M. with the Administrator confirmed the facility staff had not documented the fall for Resident #42 and had not completed a follow up investigation regarding the resident's fall and to determine if the fall could have been prevented. Review of the late entry progress note for Resident #42 created on 01/29/24 at 4:55 P.M. but dated for 01/25/24 at 7:15 A.M. revealed the resident had an unwitnessed fall in her bathroom and was found on the floor on her buttocks in front of her recliner chair. Resident #42 stated she was dizzy and after falling, scooted herself into her room. Review of the facility incident log dated 10/29/23 to 01/29/24 revealed there no documented falls for Resident #42. Review of the facility document titled Falls Prevention and Management dated January 2013, revealed the facility would identify residents at risk for falls and would plan appropriate care and interventions to maintain the resident's safety. If a resident fell the charge nurse would conduct and complete a review of the fall and based on the investigation the nurse and the staff involved would reevaluate the resident's specific care plan in place with interventions individualized based on the root cause analysis of the fall. Changes to the care plan would then be reviewed with all staff on the unit. The fall information and preliminary investigation would be reviewed the next business day by the Interdisciplinary Team (IDT) to determine if the interventions were appropriate, and the care plan would be adjusted as necessary. 366272 Page 2 of 2