Other·June 22, 2022

Title 22 § 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. This REQUIREMENT is not met as evidenced by: The facility failed to ensure Resident 1 was supervised by the facility's staff member at all times, to prevent accidents during a family member's visit, in accordance with the facility's policy and procedure. Resident 1 was left unsupervised by staff in the activity room with a family member and fell on the floor from her (Resident 1) wheelchair, after leaning forward to take a photo, on 3/24/22. As a result Resident 1 fell out of the resident's wheelchair and on to the floor during family visitation. Resident 1 sustained a laceration (cut) on her left arm and a non-displaced hairline fracture (one in which the bone cracks or breaks but retains its proper alignment) in the lateral (from the side) segment of the left 10th rib (bones surrounding the lungs). A review of Resident 1's Face Sheet (document which contains personal information of the resident) indicated that Resident 1 was admitted to the facility on 11/27/21. A review of Resident 1's History and Physical (H&P), dated 12/1/21, the H&P indicated, Resident 1 was admitted with chronic obstructive pulmonary disease exacerbation (worsening of a breathing condition), ventilatory-dependent respiratory failure (a medical condition wherein a person's lungs are dependent on a medical equipment to perform breathing functions), status-post tracheostomy (a procedure of creating an opening through the front of the neck into the windpipe), hypertension (elevated blood pressure), and anxiety (a feeling of worry, nervousness, or unease). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/1/21, indicated Resident 1 was able to make herself understood and was able to understand others. Resident 1 required total dependence with 2-person physical assist with bed mobility, transfer, and dressing. Resident 1 required 2-persons physical assist when transferring to or from bed to wheelchair. Resident 1 has posture control while sitting on the wheelchair. During an interview on 4/7/22, at 11:10 a.m., the Director of Nursing (DON) stated Resident 1 had a visit with her (Resident 1) mother in the facility's activity room, on 3/24/22. During the visit, Resident 1 repositioned herself (Resident 1) in her (Resident 1) wheelchair and leaned forward to take a photo, Resident 1 fell onto the floor. DON stated the incident (Resident 1's fall) was unwitnessed. DON said, Resident 1's mother reported to a facility staff who was outside the activity room. DON stated, Resident 1 sustained a laceration (cut) on her left arm from the fall. DON stated, Resident 1 complained of left upper abdominal (stomach area) pain on 3/25/22 and an X-ray (a photographic/digital image of the body's internal composition) revealed a hairline fracture on the 10th rib. During an interview on 4/22/22, at 11:57 a.m., Director of Nursing (DON) stated, the Restorative Nursing Assistant (RNA, a person with special training in restorative care which entails helping to attain and implementing strategies to increase strength capacity) left the activity room during visitation to assist a certified nursing assistant with providing bath to another resident. DON stated, this was against protocol as one staff must always monitor visitation to ensure safety practices including infection control and social distancing. RNA was responsible in supervising Resident 1 while Resident 1 was in a wheelchair in the activity room with the visitor. During an interview on 5/2/22, at 10:45 a.m., with nurse manager (NM), NM stated, RNA was aware of the facility's visitation guideline that staff must remain with residents to ensure safety. NM stated, upon interview with RNA, RNA said he (RNA) left the room during visitation because "She's (Resident 1) alert." NM said, upon counseling, RNA stated, "I accept. It's my fault." A review of Resident 1's "Fall Risk Assessment," dated 11/27/21, revised on 2/28/22, the "Fall Risk Assessment" indicated, Resident 1 scored 10 and 14, which placed her (Resident 1) at high risk for fall due to her (Resident 1) ambulation (ability to walk) status, gait (walk) balance, and number of medications. A review of Resident 1's "Risk for Fall" (Care Plan), dated 11/27/21, the "Care Plan" indicated, Resident 1 was "At risk for fall, injuries r/t B&B (bowel and bladder) incontinence, unsteady gait, chronic/acute condition makes unstable". The "Care Plan" indicated, "Approach Plan, Assess resident for propensity of falls." A review of Resident 1's Physician's Orders, dated 3/24/22, indicated, "Left lower arm laceration. Cleanse with NS (normal saline, solution used for cleaning wounds), pat dry, paint with betadine (antiseptic liquid solution) and cover with foam dressing q (every) shift times (x) 14 days." Resident 1 to be monitored for 72 hours (hrs.) neuro check (neurological check, assessment of reflexes to determine impairment after a fall (S/P Fall). A review of Resident 1's Nursing Progress Notes, dated 3/24/22, indicated, Resident 1 was found on the floor sitting during visitation. Body check done to left lower arm noted with laceration/cut, slight bleeding. A review of Resident 1's Nursing Progress Notes, dated 3/25/22, indicated, Resident 1 felt a little pain on the left side under her (Resident 1)'s breast. A review of Resident 1's Physician's Orders, dated 3/25/22, indicated, an order for stat (immediate) X-ray (a photographic/digital image of the body's internal composition) of the left (L) rib (S/P Fall). A review of Resident 1's Radiology Report, dated 3/25/22, indicated, "Nondisplaced hairline fracture in the lateral segment of the left 10th rib." A review of the facility's policy and procedure (P&P) titled, "Visitation Policy During COVID-19 Pandemic", revised 3/15/21, indicated, "Visitation will be supervised at all times by a staff member." The facility failed to ensure Resident 1 was supervised by the facility's staff member at all times, to prevent accidents during a family member's visit, in accordance with the facility's policy and procedure. Resident 1 was left unsupervised by staff in the activity room with a family member and fell on the floor from her (Resident 1) wheelchair, after leaning forward to take a photo, on 3/24/22. As a result Resident 1 fell out of the resident's wheelchair and on to the floor during family visitation. Resident 1 sustained a laceration (cut) on her left arm and a non-displaced hairline fracture (one in which the bone cracks or breaks but retains its proper alignment) in the lateral (from the side) segment of the left 10th rib (bones surrounding the lungs). The above violation had a direct relationship to the health, safety, or security of Resident 1.