Health inspection·June 21, 2021

42 CFR § 483.25(d) - Free of Accident Hazards/Supervision/Devices (d)The facility must- (1) The residents environment remains as free of accident hazards as is possible. (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Findings: Resident A was an 81-year-old male who had been admitted to the memory care unit on 6/28/2019, with a history of difficulty walking, and dementia (a disorder that affects memory, judgment, and the ability to communicate). The facility failed to properly supervise Resident A who, when toileting, had his attendant leave his immediate area resulting in a fall on 2/3/2020, with a resultant fractured left ninth rib. Resident A's Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) dated 1/2/2020, indicated a Brief Interview for Mental Status (an assessment of cognitive status) score of seven points out of fifteen which indicated Resident A had severe cognitive impairment. MDS indicated Resident A required supervision, oversight, encouragement, or cueing, and for self-performance support, one-person physical assist for toilet use. On 2/25/2020 at 9:55 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated she assisted Resident A to the toilet on 2/3/20 and left the room to go pass breakfast trays. CNA 1 stated Resident A required assistance to bathroom and CNA's were supposed to stay with Resident A while he was on the toilet. CNA 1 stated Resident A would refuse to use his call light. A review of Resident A's clinical record titled, "Interdisciplinary Resident Fall Investigation and Intervention" dated 2/3/2020 indicated, "Analysis of fall ...At approximately 0745 CNA [CNA 1] assisted resident [Resident A] to the toilet and placed wheelchair in front of him [Resident A] ...while CNA [CNA 1] was passing breakfast trays ...Floor nurse went to give medications to the resident [Resident A] and noticed resident [Resident A] was sitting on the floor between the toilet and wheelchair ..." On 3/3/2020 at 10:37 a.m., during an interview, Supervisor Registered Nurse (SRN) stated his [Resident A's] first fall was on 1/23/20. Resident A was in the bathroom and refused CNA assistance and fell while staff was on standby in his [Resident A's] room. Resident [Resident A] had an unwitnessed fall 2/3/2020 during breakfast while staff was busy passing out breakfast trays. This was Resident A's second fall and the nurse found him on the floor. SRN stated staff should have stayed with him [Resident A] till done toileting, it might have prevented the fall. During a review of Resident A's clinical record titled, "Interdisciplinary Resident Fall Investigation and Intervention" dated 1/24/20 indicated, "Analysis of Fall 1...At approximately 2340 on 1/23/20 CNA was assisting resident [Resident A] from the bathroom to bed resident [Resident A] refused help and wheelchair ...as resident [Resident A] stepped out of the bathroom door way he stumbled sat down on the floor then laid on his back ..." On 3/03/2020 at 11:09 a.m., during an interview, CNA 2 stated Resident A was not stable to walk or transfer without assistance. CNA 2 stated Resident A does not use the wheelchair or call light because Resident A does not remember. A review of Resident A's clinical record titled "Radiology Report" dated 2/3/2020, indicated, " ...Conclusion ...Fracture left ninth rib." A review of Resident A's clinical record titled "Plan of Care" dated 1/28/2020, indicated, "[Resident A] is a high risk for falls R/T [Related to] Dementia ...HX [history]of falls, unsteady gait, poor judgment, poor coordination and balance ...place w/c [wheelchair] within resident's reach, remind, encourage and assist resident with use of w/c and walker ...[Resident A] is resistant with call light for assistance, attempts to transfer self without assistance ...Assist resident with his toileting needs ..." A review of Resident A's clinical record titled "Plan of care" dated 2/2/2020 indicated, " ...Provide assistance with mobility and transfers and toileting ..." The facility's failure to provide adequate supervision for Resident A led to Resident A's fall and the corresponding fracture of the left ninth rib. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of the residents thus constitute a Class B violation.