Health inspection·January 12, 2022

T22 § 72311. Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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. 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. The facility failed to implement its policy and procedure to prevent Patient 1 from falling and sustaining injuries who was high risk for falls, had behaviors of getting up unassisted, and required personal safety devices when up in the wheelchair by: 1. Ensuring Licensed Vocational Nurse (LVN) 2 informed Certified Nurse Assistant (CNA) 1 that Patient 1 should not be left alone and be left unsupervised. Patient 1 required the use of a personal safety alarm (alerting devices intended to monitor a patient’s movement; the devices emit an audible signal when the patient moves in a certain way), and self-release seat belt (a flexible band or strap, typically made of leather, plastic, or heavy cloth, worn around the natural waist or near it, meant to protect the person who is seated in the wheelchair to prevent fall) when up in the wheelchair as indicated in the facility’s “Fall Prevention-Falling Star Policy” to prevent or decrease the risk of injury from falls. 2. Failing to implement interventions indicated in Patient 1’s care plan dated 10/31/2020, to place a personal safety alarm on the patient and to wear a self- release seat belt when patient is in wheelchair to decrease the risk of fall. CNA 1 and LVN 2 left Patient 1 in the Nursing Station, unsupervised and without a personal safety alarm and self- release safety belt in place while the patient was left sitting in the wheelchair. These deficient practices resulted in Patient 1 wheeling himself outside the facility’s patio and falling onto his left side after standing up from the wheelchair on 12/5/2020. On 12/8/21, three days after the patient fell, Patient 1 complained of left hip pain and sustained a fracture (complete or partial break in a bone) to the left hip. Patient 1 was transferred to the General Acute Hospital (GACH) on 12/9/2020 at 2:58 AM where the patient underwent surgery to fix the fracture on the left hip. An unannounced visit to the facility was conducted on 12/23/2020 to investigate a facility reported incident about Patient 1 sustained a fracture after a fall. A review of Patient 1’s Admission Record dated 10/30/2020, indicated the patient is an 86- year-old male patient, who was admitted to the facility with diagnoses that included left side hemiplegia (paralysis) and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). A review of Patient 1's Fall Risk Data Collection dated 10/30/2020, indicated the patient was at high risk for falls with a score of 20 (10 or above represents high risk). A review of Patient 1's Care Plan (CP) with start date on 10/31/2020, indicated the patient had increased susceptibility to fall due to dementia and trying to get out of bed and chair unassisted. The CP indicated the approach to prevent fall, to start on 10/31/2020, was to place patient’s personal safety alarm while in wheelchair. The CP indicated another approach to start on 11/14/2020 was for the patient to have a self-release seat belt while the patient was in the wheelchair to prevent the patient from sliding down due to lower extremity (part of the body that includes the leg, ankle, and foot) spasticity (condition in which there was an abnormal increase in muscle tone or stiffness of muscle, which might interfere with movement). A review of Patient 1's History and Physical (H & P) dated 11/2/2020, indicated the patient did not have the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, standardized assessment and care-screening tool) dated 11/6/2020, indicated the patient had a moderately impaired cognition (process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance (the patient was involved in activity; staff provide weight bearing support) from two staff with transferring to and from bed, chair, wheelchair, and standing position. A review of Patient 1's Physician Order Report dated 11/13/2020, indicated an order for the patient to have a self-release seat belt while in wheelchair every shift to prevent from sliding down from the wheelchair. A review of Patient 1's Progress Note dated 12/5/2020 entered at 4:30 PM, indicated Patient 1 was found lying on the floor near the fountain (by the patio) on his left side. The Progress Note indicated the patient got out of his wheelchair which caused the fall. The Progress Note indicated the patient complained of slight discomfort on his left knee. A review of Patient 1's Situation Background Assessment and Recommendation (SBAR, a communication tool between members of the health care team about the patient’s condition) form, dated 12/05/2020 entered at 5:51 PM, indicated the patient had an unwitnessed fall at 4:30 PM. The SBAR form indicated the patient was found lying on the floor near a fountain (by the patio) and was very confused. The SBAR form indicated, Patient 1 complained of discomfort on his left knee and Physician 1 (PH 1) was notified. A review of Patient 1’s Activities of Daily Living Administration History (AH) dated from 12/1/2021 to 12/30/2020, indicated the order for personal safety alarm while in wheelchair was started on 12/7/2021 (one month and four days after the CP for increased susceptibility to fall due to dementia and trying to get out of bed and chair unassisted). A review of Patient 1’s Progress Notes dated 12/8/2020 entered at 12:30 PM (three days after the patient fell), indicated the patient was performing active range of motion (moving part of the body using muscles) with the Physical Therapist (PT) when the patient complained of left hip pain. PH 1 ordered an x-ray (an imaging device that creates pictures of the inside of the body) of Patient 1’s left hip. A review of Patient 1's radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) report dated 12/8/2020 at 6:41 PM, indicated a left hip x-ray was performed and the result showed an acute (sudden) left hip intertrochanteric (bony protrusions on the femur [thighbone] and the points where the muscles of the thigh and hip were attached) fracture. A review of Patient 1’s Progress Notes dated 12/9/2020 entered at 12:58 AM, indicated Patient 1 had an abnormal x-ray result and PH 1 ordered to send the patient to GACH for further evaluation and treatment. The Progress Notes indicated Patient 1 was transferred to GACH at 2:58 AM via ambulance. A review of Patient 1's Discharge Summary from GACH dated 12/12/2020, indicated that on 12/10/2021, Patient 1 underwent an open (cutting of skin and tissues so that the surgeon has a full view of the structures or organs involved) reduction internal fixation (operation that involved the surgical implementation of implants such as rods, screws or nails for the purpose of repairing a bone) of the left intertrochanteric fracture. On 2/25/2021 at 11:15 AM, interview with the Director of Nursing (DON) and review of Patient 1’s Fall Risk Data Collection dated 10/30/2020, the DON stated Patient 1's admission fall assessment scored a 20 which made Patient 1 a very high risk for falls. The DON stated the facility should have placed Patient 1 in the facility’s “Falling Star” Fall Prevention Program to alert the staff that Patient 1 was identified as a high risk for falls. On 2/25/2021 at 11:35 AM, the DON stated she could not find documented evidence that Patient 1 was included in the facility’s “Falling Star” Fall Prevention Fall Program prior to the fall on 12/5/2020. The DON stated the facility’s “Falling Star” Fall Prevention Fall Program included interventions such as alerting the facility staff of patients who were assessed as high risk for falls and implementing care plan interventions such as putting a self-release seat belt and personal safety alarm when in the wheelchair. The DON stated Patient 1 did not have a physician’s order to use a personal safety alarm while in the wheelchair as indicated in the Patient 1’s care plan on 10/31/2020. The DON stated that it was important to have a physician’s order for Patient 1 to use the personal safety alarm for all facility staff to be aware and implement the safety intervention. On 2/25/2021 at 11:35 AM, the DON stated if Patient 1 had the personal safety alarm been in place in the wheelchair on 12/5/2020, staff would have heard the personal safety alarm when Patient 1 tried to stand up on his own from the wheelchair and staff would have gone to Patient 1’s location immediately and could have prevented the fall. The DON stated she could not find documented evidence of Patient 1’s personal safety alarm being placed in the wheelchair and the failure to implement this intervention led to Patient 1’s fall. On 2/25/2021 at 4:50 PM, CNA 1 stated she cared for Patient 1 on the date and time of his fall on 12/5/2021 (at 4:30 PM). CNA 1 stated she clearly remembered the events leading up to Patient 1's fall incident. CNA 1 stated she placed Patient 1 in the wheelchair between 4:30 PM and 5 PM as requested by LVN 2. CNA 1 stated Patient 1 did not have a personal safety alarm and a self-release seat belt in place when she sat Patient 1 in his wheelchair. CNA 1 stated she did not see the personal safety alarm device and the self-release seat belt in the patient's room. CNA 1 stated she did not receive a report or update from LVN 2 or from the outgoing CNAs on 12/5/2020 that Patient 1 was a high risk for falls and required the use of a personal safety alarm and self-release seat belt when up in the wheelchair. On 2/25/2021 at 4:50 PM, CNA 1 stated Patient 1 was very confused. CNA 1 stated she left Patient 1, sitting in the wheelchair, at the Nurse’s Station to go to another patient’s room. CNA stated that a short while after, she heard a facility staff calling for her (CNA 1) because Patient 1 was found on the floor, by the facility patio. CNA 1 stated if she had received report, she would know what Patient 1 needed and would help her provide better care and prevent such accidents. On 3/5/2021 at 2:12 PM, LVN 1 stated it was the facility’s policy to use personal safety alarms for patients at high risk for falls when in their wheelchair. On 11/3/2021 at 3:19 PM in a telephone interview, LVN 2 stated she remembered the day Patient 1 fell on 12/5/2020 (at 4:30 PM), when she asked CNA 1 to help Patient 1 to transfer in the wheelchair. LVN 2 stated CNA 1 wheeled Patient 1 to the Nurse’s Station so we (licensed nurses) could monitor (supervise) Patient 1 since he tends to stand up on his own and forgets to call for assistance. LVN 2 stated she left the Nurse’s Station to continue with her rounds and CNA 1 remained with Patient 1. LVN 2 stated while she was doing her rounds, that’s when another nurse (cannot recall who) told her patient was found on the floor by the patio, near the fountain. LVN 2 stated that CNA 1 left Patient 1 unsupervised, at the Nurse’s Station to go to another patient’s room. LVN 2 stated no one was left at the Nurse’s Station to monitor Patient 1 and the patient could have wheeled himself to the patio. On 11/3/2021 at 3:25 pm, during a concurrent telephone interview with LVN 2 and review of Patient 1’s AH dated 12/1/2020 to 12/30/20201, the AH indicated LVN 2 signed the AH (on 12/5/2021) to indicate the self- release seat belt was applied while Patient 1 was up in wheelchair. LVN 2 stated, she only assumed that CNA 1 placed Patient 1’s self- release seat belt while the patient was up in wheelchair, so she signed the AH form on 12/5/2021. LVN 2 stated she did not personally check if the self- release seat belt was used, so she was not sure if Patient 1’s self-release seat belt was use on 12/5/2021. LVN 2 stated, she did not instruct CNA 1 and she assumed CNA 1 knew that Patient 1 needed to have the personal safety alarm, self-release seat belt while up in his wheelchair, and needed to be supervised because he was a high risk for falls. A review of the facility's Fall Prevention- Falling Star (FP) Policy dated 12/01/2005, the FP Policy indicated the program was developed to provide each patient with adequate supervision and assistive devices to prevent or decrease the risk of injury from falls. The purpose of the Falling Star Program was to alert all staff about patients who were at risk for falls. A review of the facility’s Field Guide: Falls Policy dated 5/2017, the policy indicated one of the strategies was the use of assistive devices and engage front-line staff members (staff who had direct patient care such as the licensed nurses and CNAs) by doing safety huddles (short briefing to the licensed nurses and CNAs at usually at the start of their shift or held at a predictable time and place, and focused on the patients most at risk) and bedside hands-off (the transfer of patient information and knowledge, along with authority and responsibility, from one nurse to another nurse or team of clinicians during transitions of care during change of shift). The facility failed to implement its policy and procedure to prevent Patient 1 from falling and sustaining injuries who was high risk for falls, had behaviors of getting up unassisted, and required personal safety devices when up in the wheelchair by: 1. Ensuring Licensed Vocational Nurse (LVN) 2 informed Certified Nurse Assistant (CNA) 1 that Patient 1 should not be left alone and be left unsupervised. Patient 1 required the use of a personal safety alarm (alerting devices intended to monitor a patient’s movement; the devices emit an audible signal when the patient moves in a certain way), and self-release seat belt (a flexible band or strap, typically made of leather, plastic, or heavy cloth, worn around the natural waist or near it, meant to protect the person who is seated in the wheelchair to prevent fall) when up in the wheelchair as indicated in the facility’s “Fall Prevention-Falling Star Policy” to prevent or decrease the risk of injury from falls. 2. Failing to implement interventions indicated in Patient 1’s care plan dated 10/31/2020, to place a personal safety alarm on the patient and to wear a self- release seat belt when patient is in wheelchair to decrease the risk of fall. CNA 1 and LVN 2 left Patient 1 in the Nursing Station, unsupervised and without a personal safety alarm and self- release safety belt in place while the patient was left sitting in the wheelchair. These deficient practices resulted in Patient 1 wheeling himself outside the facility’s patio and falling onto his left side after standing up from the wheelchair on 12/5/2020. On 12/8/21, three days after the patient fell, Patient 1 complained of left hip pain and sustained a fracture (complete or partial break in a bone) to the left hip. Patient 1 was transferred to the General Acute Hospital (GACH) on 12/9/2020 at 2:58 AM where the patient underwent surgery to fix the fracture on the left hip. This violation had a direct or immediate relationship to the health and safety of Patient 1.