Other·July 28, 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. § 72311(a)(2) 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. The Department received a facility reported incident on 7/10/2020 indicating a resident (Resident 1) fell and sustained an acute displaced distal femoral supracondylar fracture (when the thigh bone, or femur, is broken at the knee) while ambulating (walking) to the bathroom with a certified nursing assistant (CNA). On 7/24/21, an unannounced investigation was conducted at the facility. The facility failed to: 1. Ensure the use of a gait belt (device use for residents who have mobility problems to assist in stabilization and fall prevention by caregivers prior to moving residents) and/or use of Close Guard Assist ([CGA] to assist a resident and have one or two hands on the resident's body) while ambulating. 2. Implement Resident 1’s care plan by ensuring close supervision was provided to Resident 1 while ambulating (walking). 3. Follow policy on the use of gait belt during transfer for the prevention of injury. As a result, Resident 1, who had a recent fracture (broken bone), weakness, and risks for falling, was allowed to walk to the restroom without the assistance of the staff, use of a gait belt or CGA, felt dizzy and fell to the floor. Resident 1 reinjured a previous fracture to the right lower leg tibia (inner and larger bone) and fibula (outer and narrower bone) and sustained a new right distal femur (thighbone) fracture requiring a transfer to a general acute care hospital (GACH) and underwent an open reduction internal fixation ([ORIF] type of surgery used to stabilize and heal a broken bone) to the right leg. During a review of Resident 1's Admission Face sheet, the face sheet indicated Resident 1, was a 51 year-old female, who was admitted to the facility on 2/14/2020. Resident 1's diagnoses included generalized muscle weakness, displaced (out of alignment) pilon fracture (break that occurs at the bottom of the tibia [shinbone] and involves the weight-bearing surface of the ankle joint) of right tibia and difficulty walking. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 5/18/2020, the MDS indicated Resident 1 had the ability to understand other and made herself understood. The MDS indicated Resident 1 required extensive assistance of a one-person physical assist for transferring (moving between surfaces including to or from: bed, chair, wheelchair, standing position) and toilet use. The MDS indicated Resident 1 was not steady for moving on and off toilet unless stabilized by staff assistance and had impairment on one side (not indicated) of the lower extremities (everything between the hip to the toes). During a review of Resident 1's care plan titled, "ADL (activities of daily living) self-care Performance Deficit Related to Non-Weight Bearing ([NWB] no weight/pressure) to Right Leg," revised on 6/2/2020, the care plan indicated Resident 1 would safely perform toilet transfer with CGA. The staffs' interventions included to assist Resident 1 with a one-person physical assist for transfers on and off the toilet. During a review of Resident 1's Fall Risk Evaluation, dated 6/9/2020, the evaluation indicated Resident 1 was at medium risk for fall with a score of 10. According to the Fall Risk Evaluation Grid 0-5=low risk, 6-10=medium risk and 11-35=high risk. During a review of Resident 1's History and Physical (H/P), dated 7/7/2020 and timed at 2:40 p.m., the H/P indicated Resident 1 was seen by the Nurse Practitioner ([NP] an advanced practice registered nurse) and indicated Resident 1 required CGA for transfers. During a review of Resident 1's Change in Condition (COC) evaluation, dated 7/7/2020, the COC indicated on 7/7/2020 at 10:10 p.m. CNA 1 caught Resident 1 while the resident was falling when ambulating (walking) by herself to the restroom. Resident 1 cried in pain and was yelling, "I think I broke my leg again." The COC indicated Resident 1 had declined in her abilities in ambulation (walking), mobility and transferring. The COC also indicated Resident 1 was noted with bruising (discoloration), swelling and pain on her right knee, front side of the right lower leg, and outer side of the right ankle. According to the COC, was notified and gave orders for a STAT (immediate) x-ray of the right leg. During a review of Resident 1's Fall Committee Interdisciplinary Team (IDT- group of health care professionals with various areas of expertise who work together toward the goals of the residents) notes, dated 7/8/2020 and timed at 10:14 a.m., the IDT note indicated upon ambulating to the restroom, Resident 1 had a fall. The IDT note indicated on 7/7/2020 at 10:10 p.m., Resident 1 was asking for help, but the staff was not able to understand the resident because of a language barrier. During a review of Resident 1's x-ray results of the right leg done on 7/8/2020 and timed at 11:33 a.m., the results indicated a right knee acute displaced distal (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) femoral supracondylar (thigh bone break at the knee) fracture and acute displaced fractures of the right distal tibia (inner and larger bone) and fibula (outer and narrower bone). During a review of Resident 1's nurses Progress Note (NPN), dated 7/8/2020 and timed at 8:46 p.m., the NPN indicated an untimed late entry for 7/7/2020 written by Licensed Vocational Nurse 1 (LVN 1), which indicated LVN 1 ran into Resident 1's room after hearing CNA 1 yelling out for help. The NPN indicated upon LVN 1 entering the room Resident 1 was leaning forward holding on to her walker and CNA 1 behind the resident. The NPN indicated Resident 1's right leg was noted in an irregular position during assessment and was then transferred by LVN 1, and CNAs 1 and 2 to a raised shower chair located near the resident. During a review of the facility's internal investigation interview report, dated 7/8/2020, the investigation report indicated Resident 1 stated she asked CNA 1 to walk behind her as the other CNAs does. The report indicated the day of the fall on 7/7/2020, CNA 1 walked in front of Resident 1 and the resident fell. During an interview on 9/18/2020 at 1:57 p.m., Resident 1 stated on 7/7/2020 she asked CNA 1 to assist her to the restroom. Resident 1 stated she asked CNA 1 to walk behind her as the other nurses did, but CNA 1 refused and walked in front of her. Resident 1 stated CNA 1 was not able to assist her while inside the restroom when she asked for help after she felt dizzy. Resident 1 stated CNA 1 moved her head side-to-side saying "No Spanish," and then shortly after remembered hearing a "pop" sound and her weight shifting to the right as she was falling to the ground. During a concurrent interview and review on 9/18/2020 at 3:06 p.m., of the physical therapy ([PT] the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) assessments, Occupational Therapist ([OT] health care professionals who promote independence, meaningful occupations, and residents' functional ability to fulfill their daily routines and roles) indicated Resident 1 required one-person physical assist to transfer from wheelchair (w/c) to toilet and back to w/c. The OT stated Resident 1 was assessed as a non-weight bearing as tolerated to the right lower leg due to an external fixator (surgical treatment wherein rods are screwed into bone and exit the body to be attached to a stabilizing structure on the outside of the body). The OT stated on 6/22/2020, the order for NWB as tolerated (by the resident) was given by the orthopedic doctor (specialized in care and treatment of bones, joints, ligaments, nerves, and tendons [the tissue that connects bones and joints]) and meant weight bearing as tolerated by Resident 1. During a concurrent interview and record review on 9/28/2020 at 4:02 p.m., of all Resident 1's care plans and interview statement, and in the presence of the Administrator (ADM), Interim Director of Nursing (IDON) stated during the investigation Resident 1 stated CNA 1 was walking in-front of her when the resident fell to the ground. The IDON stated and confirmed a care plan created on 2/17/2020 indicated Resident 1 required a one-person physical assist to transfer onto toilet. The IDON stated the staff had received in-service on how to transfer residents with fractures and utilizing a gait belt. During an interview on 9/29/2020 at 3:30 p.m., CNA 1 stated on 7/7/2020 at approximately at 11 p.m. she got Resident 1 up from bed utilizing the walker and walking resident to the restroom. CNA 1 stated she did not utilize a gait belt to assist Resident 1 during ambulation or transfer to the toilet, instead she was holding Resident 1 from the back of her gown while ambulating and walking the resident. CNA 1 stated she was in-serviced on the use of a gait belt when ambulating residents but did not utilize the gait belt on the night Resident 1 fell. CNA 1 stated she left Resident 1 in the restroom and allowed her privacy, but Resident 1 slid leaning backwards and CNA 1 able to hold her and prevent her from falling [sic]. CNA 1 stated she was sorry or what happened to Resident 1 and for her not utilizing a gait belt to assist the resident. During an interview on 9/29/2020 at 7:39 p.m., CNA 3 stated being in-serviced on the use of a gait belt when transferring or ambulating a resident. CNA 3 stated gait belts are helpful during transfers and help prevent falls when ambulating a resident. During an interview on 9/29/2020 at 7:47 p.m., Director of Staff Development (DSD) stated staff was in-serviced on the use of a gait belt when ambulating or transferring a resident and each carries their own gait belt. During an interview on 9/30/2020 at 11:41 a.m., Resident 2 stated not witnessing how Resident 1 fell but does remember hearing Resident 1 yelling out for help. Resident 2 stated she did not see any staff CNA assisting Resident 1 to the toilet or walking behind her. Resident 1 stated from her bed, she was only able to see Resident 1's hands holding on to the walker. During a review of Resident 2's MDS, dated 7/16/2020, the MDS indicated Resident 2 was able to understand and understood others. During an interview on 10/6/2020 at 11:40 a.m., the Physical Therapist Aide ([PTA] aides perform nonmedical tasks, such as setting up and cleaning treatment rooms and transporting patients to different areas of a health care facility) stated gait belts are used depending on the status of each resident. The PTA stated it was always recommended to use a gait belt when transferring or ambulating residents. During a review of the facility's undated policy and procedures (P/P) titled, "Gait Belt/Transfer," the P/P indicated it was the policy of the facility to prevent injuries to employees and residents (back strain or potential for chronic disability, resident falls or fractures) by the use of the gait belt allowing the resident and aide to feel more secure during a transfer. The P/P indicated for staff to place gait belt around resident's waist, grasp from the back and walk on resident's weakside and a little to the back. The P/P indicated to place gait belt around a resident's waist for a one-person transfer and a resident that can bear weight. The facility failed to: 1. Ensure the use of a gait belt and/or use of CGA while ambulating. 2. Implement Resident 1’s care plan by ensuring close supervision was provided to Resident 1 while ambulating. 3. Follow policy on the use of gait belt during transfer for the prevention of injury. As a result, Resident 1, who had a recent fracture, weakness, and risks for falling, was allowed to walk to the restroom without the assistance of the staff, use of a gait belt or CGA, felt dizzy and fell to the floor. Resident 1 reinjured a previous fracture to the right lower leg tibia and fibula and a new right distal femur fracture requiring a transfer to a GACH and underwent an ORIF to the right leg. 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.