Health inspection·July 16, 2021

F689 §483.25 (d) Accidents. The facility must ensure that- §483.25 (d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25 (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The Department received a complaint on 4/23/2021 alleging a resident (Resident 1) was treated horribly which included Resident 1 having three falls and sustaining injuries. The first fall the resident an sustained injury to her hip; the second fall the resident sustained a large bump on the head and the third fall the resident was left alone in the bathroom and fell and split her head open. On 4/26/2021, an unannounced complaint investigation was conducted at the facility. The facility failed to: 1. Ensure Resident 1, who had confusion and a high fall risk, was supervised and not out of the line of sight with the door closed during toileting. 2. Ensure staff provided Resident 1’s level of assistance needed when caring for the resident, as she was a high fall risk. As a result, Resident 1 fell and sustained a hematoma (collection of blood outside the vessels) to the back of the head with complaint of 4 out of 10 pain (pain scale 0-10 [10 being the worse pain]) to the back of the head. Resident 1 required a transfer to a general acute care hospital (GACH). During a review of Resident 1’s admission record (Face Sheet), the Face Sheet indicated Resident 1, a 90 year-old female, was admitted to the facility on 11/10/2020. Resident 1’s diagnosis included lack of coordination, abnormalities of gait (pattern of walking) and mobility, hypertension (high blood pressure), dementia (group of thinking and social disorders that interfere with daily functioning), and atherosclerotic heart disease (a buildup of fats inside artery walls). During a review of Resident 1’s Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 11/12/2020, the MDS indicated Resident 1 had severe cognitive (thought process) impairment. The MDS indicated Resident 1 required an extensive assistance and staff to provide weight-bearing support while using the toilet, transferring on and off the toilet, and assistance with clean up after elimination. The MDS indicated Resident 1 was unsteady on her feet and was only able to stabilize herself with staff assistance when moving from a seated to a standing position. According to the MDS, Resident 1 had impairment to both lower extremities that interfered with daily functions and placed her at risk for injury. During a review of Resident 1’s Medication Administration Record (MAR) for the month of November 2020, the MAR indicated Resident 1 was being monitored for orthostatic hypotension (form of low blood pressure that happens when you stand up from a sitting or lying down and can make one dizzy or even faint [a sudden loss of consciousness]) every shift due to Resident 1 receiving Mirtazapine (medication used to treat depression and may cause orthostatic hypotension). The MAR indicated Resident 1 was being monitored for signs and symptoms of bleeding and bruising due to taking Clopidogrel ([Plavix] a medication used to prevent blood clots (gel-like clumps of blood) which can cause bleeding and bruising]) 75 milligrams (mg [unit of measurement]) one (1) tablet (tab) by mouth in the mornings to prevent Cerebral Vascular Accident (CVA [stroke, a sudden death of some brain cells due to lack of oxygen when the blood flow to the brain]). During a review of Resident 1’s “Fall Risk Assessment (FRA), “dated 11/10/2020, and timed at 6:15 p.m., the FRA assessment indicated Resident 1 had a high fall risk, was intermittently confused, and had one to two falls in the past three months. The assessment indicated Resident 1 had balance problems while standing and walking due to decreased muscular coordination. During a review of Resident 1’s care plan titled, “Risk for Falls,” initiated on 11/11/2020, the plan of care goal indicated Resident 1 will be free of falls and will not sustain any serious injury from a fall. The staff’s interventions included to encourage Resident 1 to use the call light for assistance, wear appropriate footwear, and to monitor Resident 1 every two hours. During a review of Resident 1’s Physician orders, dated 11/14/2020 and timed at 12:34 p.m., the orders indicated to hold Lovenox and Plavix status-post ([S/P] when someone has had a significant procedure/ event happen]) fall. At 12:42 p.m. on 11/11/2020, the orders indicated to apply an ice pack to Resident 1’s back of the head every two hours for 20 minutes for pain management and at 12:45 p.m., the same day, the orders indicated to transfer Resident 1 to the GACH for further evaluation S/P fall. During a review of a situation, Background, Assessment, Recommendation ([SBAR] an internal communication), dated 11/14/2020 and timed at 1:15 p.m., the SBAR indicated Resident 1 had an unwitnessed ground level fall while getting up from the toilet without assistance in the bathroom and was transferred to a GACH. The SBAR indicated at about 12:30 p.m., on 11/14/2020, the resident was assisted to the bathroom, instructed to press the call light when done using the bathroom and she verbalized understanding. The SBAR indicated while staff waiting outside the door Licensed Vocational Nurse 2 (LVN2) heard a noise inside the bathroom. Upon opening the door, Resident 1 was standing up at the door, and while approaching the resident, the resident loss her balance and fell on the floor. LVN 2 was unable to catch the resident at that time. Resident 1 did not lose consciousness but did hit her head on the floor. The SBAR indicated Registered Nurse (RN) 1 was notified and an assessment was performed. The SBAR indicated Resident 1 was noted to have a 2 x 3-inch ([in.] unit of measurement) area of swelling on the back of her head. The SBAR indicated Resident 1 complained of 4 out of 10 dull pain on the back of her head and Acetaminophen ([Tylenol] a mild pain medication) 650 mg was administered to Resident 1 for pain. The SBAR indicated Resident 1 was transferred to the GACH via 911 (emergency call for transportation) due to the resident being on blood thinners and developing a hematoma. During a review of Resident 1’s Nurse Progress Notes (NPN), dated 11/14/2020 and timed at 2:16 p.m., the NPN indicated RN 1 was called by LVN 2 for assistance. RN 1 observed Resident 1 sitting on the floor outside of the bathroom, responsive, with her hand touching the back of her head. The NPN indicated per LVN 2, Resident 1 was assisted onto the toilet. Resident 1 got up quickly from the toilet and pushed the door open. LVN 2 was unable to catch the resident, she lost her balance, and fell into the hallway. The resident hit her head on the floor and did not lose consciousness. The NPN indicated a 3.5- inch hematoma formed on the upper occipital (back of the head) skull, neuro checks (assessment to assess brain function). An ice pack for the back of Resident 1’s head was ordered, and blood thinner medications were placed on hold. The NPN indicated Resident 1 was transferred to GACH via 911. During a review of the emergency medical service (EMS) report, dated 11/14/2020 and timed at 1:39 p.m., the EMS report indicated Resident 1’s chief complaint was blunt head injury and the mechanism of injury was a ground level fall. The report also indicated Resident 1 sustained a left occipital hematoma measuring 2 x 3 inches diameter post- trip and fall and Resident 1 was taking Plavix. During a review of Resident 1’s GACH discharge summary, dated 11/14/20 and timed at 9:10 p.m., the discharge summary indicated Resident 1’s diagnosis was a head injury. The GACH’s physician documentation indicated Resident 1 was admitted with a history of dementia, receiving Plavix and had a ground level fall with left occipital (back of the head) hematoma. Resident 1’s GACH computed tomography ([CT] computerized cross-section images of the body) indicated Resident 1 sustained a left occipital scalp hematoma without any fractures (broken bones). During an interview on 4/26/2021 at 1:25 p.m., the Director of Nursing (DON) stated, “It was the Resident’s (Resident 1) first fall in the bathroom. The DON stated the nurse closed the door while the resident was in the bathroom and he heard a noise, went in, and saw the resident (Resident 1) on the floor. The staff should keep the door ajar (slightly open) and stay there to watch the residents.” The DON stated Resident 1’s door was closed all the way for privacy on 11/14/2020. The DON stated LVN 2 took the resident to the bathroom and closed the door. He (LVN 2) heard a noise, opened the door, and saw the resident standing up, the resident lost her balance and LVN 2 was unable to catch the resident before she fell. The DON stated LVN 2 was standing outside of the bathroom door located in the hallway. During an interview on 4/27/2021 at 12:25 p.m., the DON stated Resident 1 was at high risk for falls and had dementia. The DON stated LVN 2 should have had the door “cracked a little at least to be able to see the resident. “Safety first then privacy.” During an interview on 4/27/2021 at 1:00 p.m., the Director of Rehabilitation (DOR) stated Resident 1 needed close supervision, 1:1 close contact guard [touch contact], a lot of cueing (instructions), and redirection. The DOR acknowledged Resident 1 could lose her balance posteriorly (fall backwards). The DOR stated the staff try to give residents privacy, but the door should be open for supervision and to provide assistance, especially for Resident 1, who has the tendency to fall backwards when she tries to stand on her own. The DOR stated, “We (the rehabilitation [the action of restoring health or normal life through training) try to communicate to the Certified Nursing Assistants (CNA) and LVNs through interdisciplinary team meeting ([IDT] team of professionals including representatives of different disciplines who coordinate residents; care) and huddles (impromptu [unplanned] staff meeting) of the residents’ level of assistance needed, because they (facility staff) should all know the amount of assistance the residents required. During a telephone interview on 4/28/2021 at 8:37 a.m., Registered Nurse 1 (RN 1) stated Resident 1 was placed in the bathroom and LVN 2 stepped out to give the resident privacy. RN 1 stated LVN 2 heard a noise and opened the door to assist the resident but he was not able to catch the resident in time. RN 1 stated, “I know the resident (Resident 1) and she has a high risk for falls. I believe someone should have been in the bathroom with the resident or had the door open. Safety is always first.” During a telephone interview on 4/28/2021 at 8:46 a.m., CNA 1 stated “When I took Resident 1 to the bathroom one time, I left the door cracked so I could hear. It would be a good idea to see her. I would not close the door all the way. I would make sure she didn’t fall. Safety is more important than privacy.” During a telephone interview on 4/28/2021 at 9:16 a.m., CNA 2, stated Resident 1 was a high risk for falls and had limited mobility. CNA 2 stated Resident 1 was confused and would try to get up without assistance. CNA 2 stated they learn about their residents’ level of care in the huddle.” CNA 2 stated with residents like Resident 1, she would stand in the bathroom to prevent the resident from falling. CNA 2 stated if she was outside the door, she could not reach the resident in time, so she needed to keep her eyes on the resident. CNA 2 stated it was dangerous to shut the door because if you leave for a minute, the resident could fall, because Resident 1 was very confused. During an interview on 4/28/2021 at 10 a.m., the Director of Staff Development (DSD) stated, “For high risk falls we do in-service and training. If residents want privacy, we teach the staff to leave the door cracked and peek in as much as possible and to never close the door all the way and always have a line of sight on the resident.” The DSD stated, Resident 1 was confused and really unsteady. The DSD stated, “The resident (Resident 1) should not be in the bathroom with the door closed.” During an interview on 4/28/2021 at 10:51 a.m., a Licensed Vocational Nurse 1 (LVN 1) stated, “The resident (Resident 1) is a high fall risk. I would not let the resident use the bathroom without seeing her, because she is unsteady and had a history of falls.” During a telephone interview on 4/28/2021 at 2:25 p.m., LVN 2 stated “Resident 1 was alert with periods of forgetfulness. She (Resident 1) usually stands with assistance, because she’s (Resident 1) not stable. When she (Resident 1) stands on her own, she loses her balance. She had a fall in the hallway bathroom, after I assisted her to the bathroom. She told me she wanted privacy. I gave her the string to pull when she was done. I had the door kind of open and I could still see her feet. I heard a noise and I went into the bathroom, but it was too late. She was standing and falling when I got there. They gave me an in service on how it’s important not to leave the residents alone. I was looking for someone to help me when the resident asked me for privacy, but I couldn’t find anyone.” LVN 2 acknowledged he had an in-service after the incident, educating him on not closing the door completely when residents were in the bathroom. LVN 2 stated he does not remember if he completely closed the door while Resident 1 was using the bathroom on 11/14/2020. LVN 2 stated, “The supervisor was upset with me and told me the number one rule is to not leave the resident alone.” LVN 2 acknowledged he could not directly see Resident 1 the entire time in the bathroom at the time of the fall. During a review of the facility’s policy and procedure (P/P) titled, “Falls Clinical Protocol” and revised in April 2013, the P/P indicated risk factors for falls included lightheadedness, dizziness, multiple medications, gait and balance disorders, cognitive impairment, weakness, and confusion. The facility failed to: 1. Ensure Resident 1, who had confusion and a high fall risk, was supervised and not out of the line of sight with the door closed during toileting. 2. Ensure staff provided Resident 1’s level of assistance needed when caring for the resident, as she was a high fall risk. As a result, Resident 1 fell and sustained a hematoma to the back of the head with complaint of 4 out of 10 pain to the back of the head as a result of the fall. Resident 1 required a transfer to a GACH. These violations, jointly or separately, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result.