Health inspection·July 23, 2021

42 CFR § 483.25(d) - Free of Accident Hazards/Supervision/Devices (d) Accidents. The facility must ensure that - (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Findings: The facility failed to provide adequate supervision at night to prevent accidents for one of three sampled residents (Resident 1), when Resident 1 was not provided staff supervision for toileting. As a result of this failure, Resident 1 fell and sustained a laceration to the back of the head. A review of Resident 1's clinical record titled, "Admission Face Sheet", indicated Resident 1 was 95 years old. Resident 1 had multiple diagnoses which included syncope (temporary loss of consciousness caused by fall in blood pressure), wandering and Alzheimer's disease (a disorder that affects memory, judgement, and the ability to communicate). A review of Resident 1's Minimum Data Set (MDS-a resident's assessment tool used to identify care needs) dated 7/10/2020, indicated a brief interview for mental status (BIMS-an assessment of cognitive status) score of five points out of fifteen which indicated Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 required two-person physical assist for toilet use. A review of "Fall Risk Assessment" dated 8/26/2020 indicated a score of 24, "...if a score is 10 or greater, the resident should be considered at HIGH RISK for potential falls..." A review of "Post Fall/Nursing Note" dated 8/26/2020, indicated "Probable Cause of Fall" indicated, "...staff not able to respond on time while helping other residents and unable to hear alarm..." A review of "Post Fall/Nursing Note" dated 7/29/2020, indicated "1st Responders Detailed Description of Incident" indicated, "CNA responded to bed alarm and found resident on the floor...when he ambulated to the toilet unassisted...resident fell near the toilet..." During an interview, with Certified Nursing Aide (CNA 1), on 10/6/2020 at 10:20 a.m., she stated Resident 1 would get up without assistance and will not use the call light. During an interview with CNA 2, on 10/7/2020 at 7:23 a.m., she stated on 8/26/2020 she had been in another resident's room and when she came out she had heard Resident 1's bed alarm (a device that alarms when it detects a reduction of pressure when a patient gets out of bed). She entered into Resident 1's room at 5:17 a.m. and saw Resident 1 exit the bathroom and witnessed him fall backward. She stated Resident 1 hit his head on the bathroom doorframe. CNA 2 stated she was assisting another Resident and no other staff was present to respond to Resident 1's alarm. CNA 2 stated Resident 1 was a high risk for falls and got up frequently without assistance. During an interview with Registered Nurse (RN), on 10/7/2020, at 7:30 a.m., she stated Resident 1's fall could have been prevented had more staff been present on the unit. She stated the nurses were covering multiple stations and the CNA covers fifteen residents, each station had at least two residents with a high-risk for falls. She stated the staff was running to answer call lights and trying to prevent falls. During an interview with Supervisor Registered Nurse (SRN), on 10/8/2020, at 1:19 p.m., he stated Resident 1 had a history of falls associated with getting up without staff assistance. The facility policy and procedure titled, "Call Light System" dated 2/10/2020, indicated "D. Residents unable to use the call light system due to physical or mental condition will have alternate safety monitoring...Care staff will be notified of Residents inability to use the call light system and will be monitored more frequently." The facility policy and procedure titled, "Fall Prevention and Intervention Program" dated 7/24/20 indicated, "A. Based upon the fall risk assessment, if the resident is assessed as high risk (score of 10 or higher), RN will: 1. Develop and implement a plan of care based upon the identified risks defined by fall risk assessment, individual deficits, medications, history of falls and any other needs that will affect the plan of care." These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents thus constitute a Class B violation.