Other·October 14, 2022

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. On 6/27/2022, the Department received a facility reported incident (FRI) reporting a resident (Resident 1) had a witnessed fall while being assisted to his bed from the restroom by a certified nursing assistant 1 (CNA 1). Resident 1 hit his head on the wall as he was helped to the ground and sustained a laceration (deep cut). On 6/28/2022, an unannounced investigation was conducted at the facility. The facility failed to: 1. Provide Resident 1 with a 2 person assist during toilet use as recommended by the Director of Physical Therapy (DPT) and the Minimum Data Set ([MDS] a standardized assessment and care screening tool). 2. Ensure Resident 1’s care plan was updated to address the need for a two-person assist with transfers and mobility as indicated in the MDS and the Physical Therapy (PT) Evaluation and Plan of Treatment. CNA 1 assisted Resident 1 to the toilet without help of other staff and Resident 1 fell and hit his head on the wall. Resident 1, who was at high risk for fall was not assisted by two or more staff during toilet use. As a result, Resident 1 sustained a right forehead laceration (deep cut) and was transferred to a general acute care hospital (GACH) via 911 (emergency medical services) and required staples (used to close incisions) to the laceration on the forehead on 6/23/2022. During a review of Resident 1’s Admission Record (Face sheet), dated 6/28/2022, the face sheet indicated Resident 1, was an 81 year-old male, who was admitted to the facility on 6/17/2022 with diagnoses which included encephalopathy (disease that damages the brain), benign prostatic hyperplasia ([BPH] age-associated prostate gland enlargement that can cause urination difficulty), difficulty walking and generalized muscle weakness. During a review of Resident 1’s MDS, dated 6/21/2022, the MDS indicated Resident 1's cognitive (the ability to understand or to be understood by others) skills for daily decision making was severely impaired, and required extensive assistance with two or more-person physical assist for toilet use and bed mobility. The MDS indicated Resident 1’s balance during transitions and walking was not steady, only able to stabilize with staff assistance, and was frequently incontinent with urinary and bladder (7 or more episodes of incontinence, but at least one episode of continent voiding or bowel movement). The MDS also indicated Resident 1 had at least one episode of a fall with injury since admission. During a review of Resident 1’s Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall), dated 6/18/2022, the fall risk assessment indicated Resident 1 was at high risk for falls due to disoriented mental status, 1 to 2 histories of falls in the past 3 months, required use of assistive device, and balance problems while standing and walking. During a review of Resident 1’s undated care plan titled, “At Risk for Fall/Injury,” the care plan indicated Resident 1 had an unsteady gait, confusion, generalized weakness, and poor safety awareness. The goal indicated Resident 1 would be free or have minimized fall incidents and would not have injury from fall. The care plan did not address Resident 1’s need for 2-person assistance during toilet use. During a review of Resident 1’s Physical Therapy Evaluation and Plan of Treatment, dated 6/20/2022, the record indicated Resident 1’s Elderly Mobility Scale, (diagnostic tool used to help assess the mobility of seniors, with score below 10 indicated a high level of dependence and required help with mobility and activities of daily living) indicated the resident had score of 2 out of 20 and needed help from 2 or more people for sitting to standing position. During a review of Interdisciplinary Team [(IDT), a team of professionals from various disciplines who work in collaboration to address the resident’s care] incident review note, dated 6/22/2022, the IDT note indicated Resident 1 had a history of witnessed fall on 6/18/22 at 8:55 a.m. The IDT note indicated Resident 1 lost his balance and fell forward landing on top of the bed mattress and did not sustain any injury. During an observation on 6/29/2022, at 2:40 p.m., in the Resident 1’s room, Resident 1 was observed sleeping in the bed. Resident 1 was observed to have two staples on the right top forehead, open to air with no drainage, bruises or swelling noted. During a telephone interview on 6/30/22, at 2:30 p.m., with CNA 1, CNA 1 stated on 6/23/2022, she assisted Resident 1 from bed to the toilet by herself, from sitting on the toilet bowl to standing position, and held the resident's left arm to walk out of the bathroom without assistance from another staff. CNA 1 stated Resident 1 verbalized he was not feeling good, his legs gave out and Resident 1 fell and hit his right side of the face against the wall near the bathroom. CNA 1 stated she called the charge nurse for help after Resident 1 had fallen to the floor. During a review of the IDT Incident Review note, dated 6/23/22, the IDT note indicated CNA 1 took Resident 1 to the bathroom and helped cleaned the resident. Resident 1 got up from the toilet and CNA 1 held Resident 1 on his left arm to help steady the resident’s gait (manner or style of walking) and while walking back to his bed, Resident 1 stated he did not feel good and lost his balance. CNA 1 tried to ease the resident down to the floor, but the resident's legs gave out and the resident fell hitting his head on the wall. CNA 1 noticed the resident bleeding from the right forehead, yelled for help and the charge nurse came to help. The charge nurse applied pressure to the site to stop the bleeding. The note indicated Resident 1’s diagnoses of impaired mobility, cognitive impairment and history of falls contributed as risk factors to the fall. The IDT incident review did not address Resident 1's need for assistance by two or more staff during toilet use as indicated in the MDS and PT Evaluation and Plan of Treatment. During a telephone interview with Licensed Vocational Nurse (LVN) 1 on 7/13/2022 at 4:56 p.m., LVN 1 stated she was notified by CNA 1 that Resident 1 fell (6/18/2022). LVN 1 stated she immediately assessed Resident 1 and observed a laceration on the right side of the forehead. LVN 1 stated she notified Resident 1's physician and received an order to immediately transfer Resident 1 to the GACH emergency department (ED) on the same day. LVN 1 stated Resident 1 required two people to assist him to the bathroom and CNA 1 should have asked another staff to assist Resident 1 to ensure Resident 1’s safety. During a review of Resident 1’s Licensed Nurse Progress note, dated 6/23/2022, at 2:17 a.m., the progress note indicated on 6/23/2022 at 2 a.m., Resident 1 fell and sustained a laceration on the right side of the forehead. On 6/23/2022 at 2:15 a.m., LVN 1 notified Resident 1's physician of the resident's worsening condition and vitals signs and received an order to transfer Resident 1 to the GACH’s Emergency Department at 2:30 a.m., via 911 for further evaluation. During a review of Resident 1’s GACH’s Computed Tomography (CT, procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) scan of the head report, dated 6/23/2022 at 3:44 a.m., the CT report indicated Resident 1 sustained a right frontal scalp laceration without visible calvarial (top part of the skull) fracture. During a review of Resident 1’s Physician's order dated 6/23/2022, the order indicated to cleanse Resident 1's right forehead laceration with Normal Saline ([NS] medical solution used to cleanse wounds), pat dry then apply bacitracin ointment (topical medication used to prevent minor skin infections caused by small cuts, scrapes, or burns) every day for 21 days. During a telephone interview on 7/12/2022 at 3:42 p.m., with Director of Physical Therapy (DPT), the DPT stated a recommendation was made during Resident 1's Physical Therapy Evaluation on 6/20/2022 for Resident 1 to have two people assist him to the restroom and it would be unsafe for Resident 1 to have only one person assisting him. During a telephone interview on 7/12/2022, at 3:27 p.m., with the Director of Nursing (DON), the DON stated CNA 1 should have asked for assistance from other staff if a two-person assistance was required for Resident 1 during toilet use. During a review of the facility’s policy and procedure (P/P) titled, “Falls-Clinical Protocol,” revised March 2018, the P/P indicated the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling. The facility failed to: 1. Provide Resident 1 with a 2 person assist during toilet use as recommended by the DPT and MDS. 2. Ensure Resident 1’s care plan was updated to address the need for a two-person assist with transfers and mobility as indicated in the MDS and the PT Evaluation and Plan of Treatment. CNA 1 assisted Resident 1 to the toilet without help of other staff and Resident 1 fell and hit his head on the wall. Resident 1, who was at high risk for fall was not assisted by two or more staff during toilet use. As a result, Resident 1 sustained a right forehead laceration and was transferred to a GACH via 911 and required staples to the laceration on the forehead on 6/23/2022. These violations jointly, separately, or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.