Health inspection·February 1, 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, fall investigation review, staff interview, and policy review, the facility failed to ensure staff members exercised care and caution around residents following a fall incident and failed to ensure fall incidents were thoroughly and accurately investigated. This affected one (#1) of three residents reviewed for falls. The facility census was 69. Findings Included: Review of Resident #1's medical record revealed an admission date of 10/26/23. Diagnoses included cellulitis of the left lower limb, sepsis with septic shock, non-pressure chronic ulcer of the left calf with fat layer exposed, contusion of left lower limb, acute kidney failure, coronary artery disease and respiratory failure. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with intact cognition, required a substantial/maximum assist for all transfers, and required oxygen therapy at all times. Review of Resident #1's most recent care plan revealed the resident was at risk for injury related to falls due to deconditioning, gait/balance problems, and psychoactive drug use. Interventions included to assist with toileting and transfers, ensure the call light was within reach, and encourage her to use it before attempting to transfer. Resident #1 was at risk for skin breakdown due to a history of chronic non-pressure ulcer on left calf and immobility. Review of Resident #1's nursing progress note dated 11/12/23 at 2:19 A.M. revealed the resident was found by a nursing assistant lying on her left side. The resident indicated she was trying to get up and walk. Agency Nurse #4 began to obtain Resident #1's vital signs when the nurse tripped over the resident's oxygen tubing. When the nurse fell, the nurse stepped on Resident #1's leg causing a 20 centimeter (cm) long by 3.0 cm skin tear on the resident's right lower leg. Resident #1 then sat up and vital signs were taken which were stable. The resident's right lower leg was cleansed, wrapped with an absorbent bandage, and wrapped with kerlix and a compression bandage. The on-call hospice nurse was contacted and was sent to the facility to assess the resident. Review of the fall investigation dated 11/12/24 revealed the investigation contained no information regarding Agency Nurse #4 tripping over Resident #1's oxygen tubing and falling onto the resident causing a skin tear. Review of Resident #1's skin assessment dated [DATE] revealed an impaired skin condition was noted Page 1 of 2 366279 366279 02/01/2024 Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to the front of the resident's right lower leg. The skin impairment was noted to be a a skin tear measuring 20 cm long by 3.0 cm wide by 0.1 cm deep and had moderate bloody drainage. Wound closure strips were applied and treatment orders were given to cleanse the wound with with normal saline, pat dry, apply gauze, an absorbent dressing, and wrap with kerlix and was to be changed daily. Interview with the Director of Nursing (DON) on 02/01/24 at 10:49 A.M. revealed Resident #1's sustained a fall on night shift on 11/12/23. The DON further stated the nurse was going in to assess Resident #1 after the fall and tripped on the oxygen tubing which resulted in the skin tear to Resident #1's right leg. The DON confirmed hospice and Resident #1's family were notified, and the resident received treatment in the facility. Review of a facility policy titled, Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed all accidents or incidents involving residents occurring on the facility' premises shall be investigated and reported to the administrator. Applicable data from the accident or incident shall be included on the Report of Incident/Accident form and should include, among other items, the date and time the incident or accident took place, the nature of the injury or illness, the circumstances surrounding the accident or incident, and the name(s) of witnesses and their accounts of the accident or incident. This deficiency represents an incidental finding discovered during investigation of Complaint Number OH00149866. 366279 Page 2 of 2