Health inspection·December 3, 2021

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The Department of Public Health (Department) received a facility reported incident (FRI) on 5/13/2021 indicating a resident (Resident 1) was found on the floor with an injury to her lower left arm. The left open arm injury was the only injury noted. On 5/25/2021, an unannounced investigation was conducted at the facility. The facility failed to: 1. Implement the physician’s orders for a sitter to be bedside to prevent falls and injuries for Resident 1, who was confused and would constantly attempt to climb out of bed. 2. Implement Resident 1’s plan of care to provide adequate supervision for Resident 1. As a result, Resident 1 did not have a sitter on 5/10/2021 during the night shift and fell out of bed, sustaining a left wrist fracture (broken bone) with pain and requiring a transfer to a general acute care hospital (GACH). At the GACH, the resident underwent an open reduction and internal fixation ([ORIF] a surgical repair of a broken bone) of the left wrist and required a four-day hospital stay. During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1, an 84 year-old female, was admitted to the facility on 3/1/2021 and last readmitted on 5/14/2021. Resident 1's diagnoses included intracerebral hemorrhage (bleeding in tissues of the brain), dementia (condition characterized by memory loss and impairment judgement) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave). During a review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 3/5/2021, the MDS indicated Resident 1 was severely impaired in cognition (ability to learn, reason, remember, understand, and make decisions), exhibited continuous behavior of inattention (inability to pay attention to something), disorganized thinking (failure to "think straight;" thoughts may come and go rapidly), required extensive assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living (ADL) including bed mobility, transfers, walking, dressing, eating and personal hygiene. The MDS indicated Resident 1 was not steady for moving from seated to standing position, walking, turning around, and transfers, and was only able to stabilize with staff assistance. During a review of Resident 1's Care plan titled, "Needs Companion at Bedside," dated 3/12/2021, the care plan indicated Resident 1 needed a companion at the bedside to minimize the resident from falling. The staff interventions included providing a companion at the bedside to ensure a safe environment. During a review of Resident 1's Fall Risk Assessment (FRA), dated 5/1/2021, the FRA indicated Resident 1 had a high risk for falls. During a review of Resident 1's telephone physician's order, dated 5/1/2021, the physician's order indicated Resident 1 may have a companion until further orders. During a review of Resident 1's Licensed Progress Note (LPN), dated 5/5/2021, the LPN indicated Resident 1 had a previous fall on 4/30/2021 and the Interdisciplinary Care Team ([IDT] team members from different disciplines working collaboratively with a common purpose for the residents]) indicated Resident 1 was supposed to have a 1:1 companion (type of care/continuous observation provided to ensure safety) until further notice. During a review of Resident 1's LPN, dated 5/11/2021 and timed at 7:35 a.m., the LPN indicated the nurse noticed movement in Resident 1's room and went to see what was happening and saw Resident 1 on the floor scooting (slide in a sitting position) on her back. The LPN indicated Resident 1's left lower arm was disfigured with flesh (the soft substance consisting of muscle and fat, found between the skin and bones of an animal or a human) and bone exposed with minimal bleeding. The RN was notified and assessed the resident, 911 (emergency service) was called, the left arm was immobilized (restrained), and pain medication (Tylenol [mild pain reliever] 325 milligrams [mg] two tablets) was given as the resident was grimacing (a facial expression usually of disgust, disapproval, or pain) in pain. During a review of the GACH emergency room (ER) note, dated 5/11/2021, the ER note indicated Resident 1, who has dementia presented to the ER via ambulance from a skilled nursing facility with a broken left forearm after falling on her arm. During a review of Resident 1's GACH History and Physical (H/P) record, dated 5/11/2021, the H/P record indicated Resident 1 was reportedly agitated with a history of restlessness at a nursing facility and was later found on the floor with a "left forearm bone broken and exposed." Resident 1 underwent an ORIF of the left wrist on 5/11/2021. During a review of Resident 1's Operative Report, dated 5/11/2021, the Operative Report indicated the resident needed surgery for emergency surgical treatment of a severely open injury with widely displaced open fracture (break in skin near the site of broken bone, bone breaks into two or more places and moves out of alignment) of the left wrist. During a review of Resident 1's GACH Discharge Summary, dated 5/14/2021, Resident 1 was discharged back to the facility with a diagnosis of an acute left forearm fracture secondary to a mechanical fall (any fall caused by gravity or by something other than a medical reason) after ORIF procedure. The plan was to continue post-op care and pain management. During an interview on 6/14/2021 at 7:04 p.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 1 was confused and did not use the call light for assistance. CNA 1 stated on 5/11/2021, Resident 1 was awake and lying-in bed at approximately 6:30 a.m. without a companion at the bedside. CNA 1 stated he left Resident 1's room and within minutes Resident 1 had fallen onto the floor. During an interview on 6/15/2021 at 3:06 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 5/10/2021 during the evening shift (time not specified), Resident 1 was restless and frequently attempting to get out of bed. LVN 1 stated medication was given to calm Resident 1 down and decrease the restlessness, as other interventions were not working. LVN 1 stated Resident 1 was confused, weak, and would jump out of bed. LVN 1 stated Resident 1 required a companion for safety. During an interview on 6/22/2021 at 2:08 p.m., the Director of Nursing (DON) stated Resident 1 had a companion at the bedside every day and on all shifts since 5/1/2021. The DON stated the physician's order for a companion was not complied with for Resident 1 on 5/10/2021, and the resident did not have a companion during the night shift. The DON stated, "The IDT has not met since implementing the companion for the resident and the doctor was not notified prior to holding or discontinuing the companion at the bedside." During a review of the facility's undated Policy and Procedure (P/P) titled, "Policy Interpretation and Implementation" related to sitter use, the P/P indicated a sitter was a caregiver who provides companionship and observation to residents for as long as the physician determines that the companionship and observation is needed. According to the P/P, the resident and/or representative will be informed of the plan to discontinue a sitter as ordered by the physician. The facility failed to: 1. Implement the physician’s orders for a sitter to be at the bedside to prevent falls and injuries for Resident 1, who was confused and would constantly attempt to climb out of the bed. 2. Implement Resident 1’s plan of care to provide adequate supervision for Resident 1. As a result, Resident 1 did not have a sitter on 5/10/2021 on the night shift and fell out of the bed, sustaining a left wrist fracture with pain and requiring a transfer to a GACH. At the GACH, the resident underwent an ORIF of the left wrist and required a four-day hospital stay. 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 to Resident 1.