Other·June 24, 2021

§72311, Nursing Services – 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. On 2/2/2021, an unannounced visit was conducted at the facility to investigate a complaint about quality of care. The facility failed to ensure Resident 1’s safety, assess accident risks, and prevent a fall and injuries for Resident 1. Resident 1 required two-staff assistance for bed mobility and was lying on a low air loss (LAL) mattress (designed to prevent and treat pressure wounds, provides airflow to help keep skin dry, as well as to relieve pressure). Certified Nursing Assistant 1 (CNA 1) did not get assistance from another staff as per facility’s policy and the resident’s care plan, to reposition Resident 1 in bed and did not ensure safe use of the LAL mattress. As a result, on 1/8/2021, Resident 1 fell out of the bed onto the floor causing a laceration (a deep cut or tear in skin or flesh) above Resident 1's right eyebrow and redness to the resident’s right arm. Subsequently, Resident 1 expired six days later on 1/14/2021. A review of Resident 1's Admission Record indicated an initial admission dated 2/2/2015, and a re-admission dated 8/15/2020 with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from the lungs into blood), tracheostomy (a surgical opening into the windpipe to allow passage of air), gastrostomy tube (GT, a soft tubing inserted through the belly into the stomach to administer nutrition, hydration, and medication directly into the stomach), diabetes mellitus (abnormal elevated blood sugar), non-traumatic intracranial hemorrhage (bleeding into the brain caused by a rupture or leak of a blood vessel), and seizures (uncontrolled electrical activity between brain cells). A review of Resident 1's History and Physical (H&P) exam completed on 8/31/2020 by the attending physician, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-screening tool), dated 10/18/2020, indicated Resident 1 could not communicate needs, was totally dependent for care, and required at least two-person assistance with bed mobility and transfers. A review of Resident 1's Care Plan developed on 8/15/2020, for the resident's fall risk, had a goal to reduce the resident's risk for falls by implementing approaches or plans including maintaining a safe environment and to assist with activities of daily living (ADL, a term used to describe tasks of everyday life such as eating, dressing, getting out of bed and bathing). During an interview and concurrent record review on 5/11/2021 at 3:30 p.m. with Director of Staff Development (DSD), Resident 1's entire plan of care was reviewed. No documented evidence could be found with regards to the utilization of two-staff assistance for the totally dependent resident who required two person assist for bed mobility and transfer. DSD confirmed after also looking through Resident 1's entire plan of care that there was no documented evidence found indicating that Resident 1 required two-staff assistance. DSD stated that staff should have allocated two staff for bed mobility and transfers for Resident 1. A review of Resident 1's Physician's Order dated 9/30/2020 indicated the use of an LAL mattress for wound management and to monitor for functionality every shift. During an interview and concurrent record review on 5/11/2021 at 2:46 p.m. with Director of Nursing (DON) Resident 1's entire plan of care was reviewed. No documented evidence could be found with regards to the use of a LAL mattress. DON confirmed after also looking through Resident 1's entire plan of care that there was no documented evidence found that a plan of care was developed for Resident 1's LAL mattress. A review of Resident 1's Nursing Progress Notes dated 1/8/2021 timed at 7:15 p.m., indicated Resident 1 fell from the bed while CNA 1 was repositioning him. Charge Nurse 1 (CN 1) arrived to the room and found Resident 1 on the floor with a cut on the resident’s right eyebrow of about one centimeter (cm, unit of measure) in length and slight redness on the resident’s right arm. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a form used by the healthcare team to facilitate prompt and appropriate communication) form, dated 1/8/2021, indicated Resident 1 fell out of bed while CNA 1 was repositioning him. Resident 1 sustained a cut to his right eyebrow and slight redness on the right arm. During a phone interview on 5/26/2021, at 9:00 a.m., the DON alleged that neurological checks (a series of tests that check for disorders of the brain and spinal cord) were done for Resident 1 after the fall but was unable to locate any documented evidence of the neurological checks. DON further stated that even though it was a witnessed fall, since there was injury to the head, neurological checks are required as part of the assessment. A review of Resident 1's SBAR, dated 1/14/2021 (six days after the fall) indicated at 3:10 a.m. Resident 1's condition was declining, staff notified Resident 1's responsible party (RP), and RP refused transfer to the hospital. Paramedics came at 3:29 a.m. and Resident 1 was pronounced dead at 3:30 a.m. A review of Resident 1's death certificate indicated that Resident 1 expired on 1/14/2021 with the immediate cause of death listed as cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing, and consciousness.) and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). On 3/31/2021, at 4:45 p.m., during an interview, CN 1 stated she worked the evening of 1/8/2021, when Resident 1 slid from the resident’s bed to the floor. CN 1 stated she heard CNA 1 calling out for assistance. CN 1 arrived to the room and found Resident 1 on the floor. CN 1 stated CNAs should have more than one staff for repositioning dependent residents. CN 1 stated she does not know why CNA 1 was repositioning Resident 1 by herself. On 3/30/2021, at 10:30 a.m., during an interview with DON and a concurrent record review, DON stated Resident 1 required the assistance of at least two persons for bed mobility and could not explain why CNA 1 was repositioning Resident 1 without assistance. On 3/30/2021, at 11:15 a.m., during an interview, the DSD stated if the MDS indicated two or more persons were needed for bed mobility, at least two persons should have assisted the resident with repositioning. The DSD stated it is the facility's practice that residents requiring total care, should always have two staff assist with repositioning. On 3/31/2021, at 4:00 p.m., during an interview, CNA 1 stated on 1/8/2021 at 7:15 p.m., she was repositioning Resident 1 and the resident began to slide off the bed. CNA 1 tried to prevent him from falling, but the resident was too heavy for her, so she assisted him to the floor. CNA 1 stated she was not aware of the LAL mattress setting or did not remember that if the LAL mattress was too firm that would contribute to the resident sliding off the mattress. CNA 1 stated she had put the bed brakes on but felt that the bed was moving while repositioning the resident. CNA 1 stated she always repositioned dependent residents by herself without another staff for assistance. CNA 1 stated the bed was at the regular height (not a low bed). On 5/11/2021, at 1 p.m., during an interview with DON and concurrent review of Resident 1's Inventory List (record of belongings residents bring to the facility), the DON stated Resident 1's RP brought the LAL mattress but there was no record of the model and type of LAL mattress. DON stated Resident 1's family did not provide the LAL mattress manufacturer's manual to determine how to use it and the needed setting of the mattress firmness. DON further stated the nursing staff were not trained on the use of the LAL mattress brought by the resident’s family. DON was unable to provide documentation the LAL mattress was safe to use, if it fitted safely on the bed frame, and if its height was above or below the height of the bed side rails. DON stated there was no policy and procedures for the safe use of outside equipment or devices. On 5/11/2021, at 2:46 p.m., DON stated there was no documentation or a plan of care for the use of an outside purchased LAL mattress. DON stated the family took the LAL mattress two days after the resident expired. On 5/11/2021, at 2:37 p.m., during an interview with DSD and concurrent review of an in-service training titled, "How to Monitor LAL" dated 10/9/2020, DSD stated she gave the training and CNA 1 did not attend. The training content included: "Air loss mattress and ensuring proper setting". A LAL mattress typically utilizes two methods to aid in the prevention of pressure injuries. It is the responsibility of the charge nurse and CNAs to ensure proper setting. DSD stated that they could not provide evidence CNA 1 was trained on the use of LAL mattress. On 5/11/2021, at 3:40 p.m., during an interview with DSD and concurrent review of the ADL Flow sheet, DSD verified that during the months of 11/2020, 12/2020, and 1/2021 one staff assisted Resident 1 with bed mobility during the evening and night shifts. DSD stated Resident 1 required the assistance of two staff members to eliminate or minimize injuries for staff and accidents for Resident 1. A review of facility's policy and procedures titled, "Safety and Supervision of Residents," revised 12/2007 indicated the facility strives to make the environment as free from accident hazards as possible. Resident's safety, supervision, and assistance to prevent accidents are facility-wide priorities. Approach 1: "Facility-Oriented Approach to Safety - safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting processes. Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents." Approach 2: "Resident-Oriented Approach to Safety - Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility or carrying out interventions, providing training as necessary, ensuring that interventions are implemented and documenting interventions ..." Approach 3: Systems approach to Safety - ...Resident Risks and Environment Hazards were identified as: "Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include bed safety, safe lifting and movement of residents, falls ..." A review of the facility's policy and procedure titled "Activities of Daily Living (ADL), Supporting", dated 3/2018 indicated that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. A review of facility's policy and procedure titled, "Falls-Clinical Protocol," revised 3/2018 indicated under Assessment and Recognition that the nurse shall assess and document and report the Neurological Status. The facility failed to ensure Resident 1’s safety, assess accident risks, and prevent a fall and injuries for Resident 1. Resident 1 required two staff for bed mobility and was lying on a LAL mattress. CNA 1 did not get assistance from another staff as per facility’s policy and care plan, to reposition Resident 1 in bed and did not ensure safe use of the LAL mattress. As a result, Resident 1 fell out of the bed onto the floor causing a laceration above Resident 1's right eyebrow and redness to the resident’s right arm. Subsequently, Resident 1 expired six days later on 1/14/2021. The above violations, jointly or separately, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.