Health inspection·June 20, 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, staff interview, resident interview, and review of the facility policy, the facility failed to provide adequate supervision and assistance during resident care, resulting in the resident falling out of bed. This affected one (Resident #87) of three residents reviewed for falls. The facility census was 112. Findings include: Review of the medical record for Resident #87 revealed an admission date of 11/13/23. Diagnoses included quadriplegia and left lower leg amputation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intake and dependent on staff for all care. The resident suffered impairment to bilateral sides of his upper and lower body. Review of Resident #87's most recent care plan revealed the resident was at risk for falls due to quadriplegia. Review of Resident #87's Fall Risk Evaluation dated 06/01/24 revealed he was at a high risk for falls. Review of the nurse's note dated 06/01/24 revealed Resident #87 fell out of bed and hit his head. He had a raised area to the forehead and skin tear to the right upper arm. The resident complained of a headache and raised area was noted on his forehead. The physician was notified and ordered the resident be transferred to a local hospital. The wife, clinical director and the Director of Nursing (DON) were notified. State Tested Nursing Aide (STNA) #229 stated she left the resident on his side and went into the bathroom. When she returned, Resident #87 was on the floor. Review of Resident #87's emergency room report dated 06/01/24 revealed he was a bed-bound male, left above the knee amputation, indwelling catheter, chronic sacral decubitus ulcers, residing in the nursing home over over one year. He was status post fall from his bed while getting changed and onto the floor. He felt diffusely achy but nothing tender, but wife stated he had diminished sensation globally. X-rays and testing found no new fractures or further injuries. Review of Resident #87's Fall Review/Investigation dated 06/01/24 revealed during morning care while in bed, Resident #87 requested STNA #229 to roll him on his left side to facilitate a bowel movement. STNA #229 stepped away from the bed to retrieve items from the bathroom and the resident Page 1 of 2 366305 366305 06/20/2024 Kingston Care Center of Sylvania 4121 King Road Sylvania, OH 43560

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few apparently had rolled off the side of the bed onto the floor. Resident #87's perception of how the incident happened revealed he fell out of the bed. The conclusion was loss of trunk control. Interview and observation with Resident #87 on 06/20/24 at 11:02 A.M. revealed on 06/01/24, STNA #229 had positioned him on his left side and stepped away and he rolled off bed. The resident verified there were no injuries. Resident #87 was sitting in his wheelchair in the book lounge. The resident revealed he had no control or use of his body from the chest down. Resident #87 was able to use his left hand to control his motorized wheelchair, but there was no movement in the lower extremities nor trunk. The resident's left lower extremity was amputated above the knee. Interview with STNA #229 on 06/20/24 at 11:14 A.M. revealed Resident #87 was in bed and she asked him if he would like to receive morning care and he shook his head yes. The resident was unsure if he had had a bowel movement and asked to get placed on his side. The STNA positioned the resident on his side so he could complete his bowel movement and went into the bathroom to retrieve towels. When she returned, he had rolled off of the bed and onto the floor. She stated the bed rail had been in the up position. STNA #229 immediately called for assistance. Review of the facility policy titled Managing Fall and Fall Risks, dated June 2023, revealed based on assessments, previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency represents non-compliance investigated under Complaint Number OH00154549. 366305 Page 2 of 2