Other·December 16, 2022

F689 § 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (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. The Department received a facility reported incident (FRI) on 6/21/2022 indicating a resident (Resident 7) was recently readmitted back to the facility from a general acute care hospital (GACH) with a diagnosis of minimally displaced fracture (broken bone) to the upper spine from an unavoidable fall on 6/11/2022, in the resident’s bathroom from a syncopal episode (fainting or passing out). The FRI indicated the facility followed up with the GACH on 6/11/2022 and was told Resident 7 would be admitted to the GACH for a urinary tract infection (UTI, infection of the bladder). On 6/24/2022, the Department conducted an unannounced investigation at the facility. The facility failed to prevent a fall for Resident 7 by failing to: 1. Provide Resident 7 with the required minimal assistance and supervision from staff when toileting per the resident’s care plans and the facility’s policies and procedures (P/P) titled, “Toileting Program” and “Falls and Fall Risk Managing”. 2. Follow Resident 7’s scheduled toileting plan and ensure the resident was assisted by staff to the toilet or offered a commode or bed pan as needed, upon waking in the morning, and before breakfast as per the facility’s P/P titled, “Toileting Program.” As a result, Resident 7 had a preventable fall that required subsequent transfer to a GACH for treatment. Resident 7 was diagnosed with a right forehead laceration (deep cut in skin) with hematoma (pool of blood collecting under the skin) and an acute minimally displaced type 3 dens (neck bone) fracture. During a record review of Resident 7's Admission Record (face sheet), the face sheet indicated Resident 7 was a 77 year-old female, who was admitted to the facility on 4/15/2021. Resident 7's diagnoses included atrial fibrillation (abnormal heartbeat), heart failure (heart muscle does not pump blood as well as it should), difficulty walking, muscle weakness, type 2 diabetes (body cannot process glucose [sugar] normally), and dementia (general term of loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/22/2022, the MDS indicated Resident 7 expressed ideas and wants, and understood verbal content. The MDS indicated Resident 7 had severely impaired cognitive skills for daily decision making (diminished ability to learn, remember, understand, and make decision). The MDS indicated Resident 7 required limited one-person physical assistance (resident is highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility and personal hygiene, and an extensive assistance with transfer, walking in the room and corridor, dressing, and toilet use. The MDS indicated Resident 7 was occasionally incontinent ([inability to control] less than seven episodes within 7 days) of bladder but continent of her bowels. According to the MDS, Resident 7 was placed in the toileting program (scheduled toileting) with decreased wetness experienced because of the program. During a record review of Resident 7’s Morse Fall Scale (used to estimate a resident's fall risk) initiated on 5/16/2022, the fall scale indicated Resident 7 was a high fall risk with a score of 80 (high risk indicates a score of 45 or more, moderate risk was between 25-44, small risk was for 0- 24) and had multiple risk factors that predisposed the resident to falls. The risk factors indicated Resident 7 had the following: 1) A history of falls. 2) Multiple medical diagnosis. 3) Used crutches, cane, or walker. 4) Weak gait (stooped but able to lift head without losing balance, steps are short and resident shuffles), and 5) A problem with overestimating or forgetting limits. During a record review of Resident 7's care plan titled, “Self-care Deficit and activities of daily living (ADLs, daily tasks involving personal care) Decline,” initiated 5/17/2022, the care plan indicated Resident 7 would be assisted with ADLs as needed. During a record review of Resident 7's care plan titled, “Risk for Fall,” initiated 5/17/2022, the care plan indicated Resident 7 would receive frequent visual monitoring, functional mobility training, bowel and bladder retraining, Occupational therapist (OT, healthcare professional assists residents to develop, recover, improve, or maintain skills needed for working and daily living) assessment and toilet program as indicated. During a record review of Resident 7’s Physical Therapy (PT, medical specialist who helps improve residents’ movements) Evaluation and Plan of Treatment dated 5/17/2022, the evaluation indicated Resident 7 exhibited impaired coordination, muscle weakness and reduced functional activity tolerance (individuals’ ability to tolerate completing their ADLs). The evaluation indicated Resident 7 was noted with decreased functional mobility and increased risk for falls. PT recommended treatment to improve functional mobility and promote safety awareness. Treatment approaches may include therapeutic activities and exercises, and gait training therapy. During a review of Resident 7's OT Evaluation dated 5/17/2022, the evaluation indicated Resident 7 needed minimal assist (resident requires small amount of help to accomplish activity and requires no more help than touching and expends 75 percent or more of the effort) with toileting. During a record review of Resident 7's Certified Nurse Assistant (CNA) ADL flow sheet, regarding toilet use, the flow sheet, for the month of June 2022, indicated CNA did not provide a one-person physical help and minimum assistance to Resident 7 for the following dates: a. From 6/1/2022 to 6/6/2022 and 6/10/2022. CNA guided the resident with no physical assist b. On 6/11/2022 (date of Resident 7’s fall), no documented evidence of any type of CNA assistance noted. During a record review of Resident 7's Bowel and Bladder Assessment (tool used to determine how the facility needs to address a resident’s toileting needs) dated 5/17/2022, the assessment indicated Resident 7 scored a 16, (score of 0 to 15 meant candidate for bowel and bladder training, 16 to 19 meant the resident should be on a scheduled toileting plan, 20 or above the resident was not a candidate for toileting program nor bowel and bladder training) which indicated Resident 7 should be on a scheduled toileting plan. The assessment indicated Resident 7 was identified as having the following triggers: 1. Frequently incontinent for one or more years. 2.Occasionally incontinent with bowels. 3. Confused. 4. Diagnosed with an old stroke (blood flow to brain is stopped and can cause numbness or weakness or confusion or loss of balance) or debilitating disease (disease that affects physical abilities that affect brain function and impair thought process). 5. Uncooperative. 6. Requiring one person assist with transfer and ambulation with or without assistive devices. 7. High risk for dehydration (condition when person use or lose more fluids than the person takes in). During a record review of Resident 7’s Scheduled Toileting Plan for the month of June 2022, there was no documented evidence Resident 7 was assisted to the toilet or offered a urinal, commode, or bed pan as scheduled on 6/10/2022 and 6/11/2022 (day of the fall) on the night and day shifts. During an interview with Licensed Vocational Nurse (LVN) 1 on 6/24/2022 at 10:59 a.m., LVN 1 stated he was doing a medication pass on 6/11/2022 at approximately 8:40 a.m., when LVN 1 responded to Registered Nurse (RN) 1's call for assistance in Resident 7's restroom. LVN 1 stated upon entry to Resident 7’s restroom, Resident 7 was observed sitting upright on the floor of the restroom. LVN 1 stated there was blood observed on the floor and on Resident 7’s head. LVN 1 stated Resident 7 reported she was trying to use the restroom and fell. LVN 1 stated Resident 7 did not use the call light. LVN 1 stated he assessed Resident 7, applied pressure to the resident’s head, rendered first aid, and called 911. LVN 1 stated Resident 7 was transferred to a GACH for further evaluation. During a concurrent interview and record review on 6/24/2022 at 11:05 a.m. with RN 1, Resident 7’s Morse Fall scale dated 6/11/2022, was reviewed. RN 1 stated from 5/17/2022 to 6/11/2022, Resident 7 walked to the restroom unassisted and independently. RN 1 stated Resident 7 would hold on to things or furniture to keep her balance. Resident 7’s Morse fall scale dated 6/11/2022 indicated Resident 7 used furniture for support, she was weak and had a history of falling. The document further indicated that Resident 7 overestimates and forgets her limits. RN 1 stated Resident 7 needed a one-person physical assist. RN 1 stated she was doing morning rounds on 6/11/2022, at approximately 8:30 a.m. she noticed Resident 7 was not in her bed. RN 1 stated she went to Resident 7's restroom at approximately 8:40 a.m. and observed Resident 7 sitting on the restroom floor. RN 1 stated she called for help. During a telephone interview with CNA 2 on 7/15/2022 at 2:58 p.m., CNA 2 stated on the morning of 6/11/2022, before the breakfast trays came out, CNA 2 assisted Resident 7 up out of bed and onto her wheelchair. CNA 2 stated she did not assist Resident 7 to the restroom when Resident 7 woke up nor before breakfast. CNA 2 stated by the time she returned to Resident 7’s room at approximately 8:30 a.m., the nurses were in the room and Resident 7 was observed on the restroom floor. During a telephone interview with CNA 3 on 7/15/2022 at 4 p.m., CNA 3 stated she knew Resident 7 urinated a lot. CNA 3 stated Resident 7's functional ability for toileting varied. CNA 3 stated sometimes staff would supervise, and sometimes staff would provide limited to extensive assistance to Resident 7. During a concurrent interview and record review on 7/18/2022 at 12:10 p.m. with LVN 3, Resident 7's scheduled toileting plan for the month of June 2022 was reviewed. LVN 3 stated from 5/17/2022 to 6/11/2022, Resident 7 usually went to the toilet by herself. LVN 3 stated Resident 7 was occasionally supervised meaning staff just supervised the resident and no physical assistance was involved. LVN 3 confirmed there was no documented evidence that Resident 7 was taken to the restroom before breakfast on 6/10/2022 and 6/11/2022; and as needed upon waking during the night shift (11p.m. to 7 a.m.) on 6/11/2022. LVN 3 stated Resident 7's toileting plan for the month of June 2022 indicated the night shift for eight (8) hours on 6/11/2022, and approximately one (1) hour during the days shift before breakfast on the day she fell, Resident 7 was not assisted to the toilet or offered a commode or bed pan as scheduled. LVN 3 stated since Resident 7 was on a toileting schedule plan, the CNAs should have taken the resident to the restroom when she woke up, before breakfast, and as needed on 6/11/2022. LVN 3 stated not taking Resident 7 to the restroom as scheduled increased the risk of incontinence and increased the risk that Resident 7 would attempt to go to the bathroom by herself. LVN 3 stated it was not safe because Resident 7 did not call for help and she was a high risk for falls. During an interview with the Director of Nursing (DON) on 7/18/2022 at 12:27 p.m., the DON stated staff should have assisted Resident 7 to the restroom as indicated in the OT assessments and MDS assessments. The DON stated CNAs should have also taken Resident 7 to the bathroom before breakfast and when she woke up on 6/11/2022 AM shift. The DON stated doing so might have prevented Resident 7 from walking to the restroom herself and falling. During a record review of Resident 7’s GACH History and Physical (H/P) dated 6/11/2022, the H/P indicated Resident 7 reported going to the restroom three times but did not remember the fall. The H/P indicated Resident 7 complained she had been urinating a lot and reported the dysuria (discomfort or burning urination) to staff. Resident 7's right eyebrow laceration was repaired with sutures (sterile surgical threads used to repair cuts) and Resident 7 was admitted to the hospital for continued evaluation. During a record review of Resident 7's Computed Tomography (CT, diagnostic imaging that produces images of the inside of the body showing bones, muscles, fats, organs, and blood vessels) of the head without contrast (a dye or other substance that helps show abnormal areas inside the body) completed on 6/11/2022 at 11:17 a.m., the CT findings indicated right fontal scalp (right forehead area) laceration and hematoma. During a record review of Resident 7's CT of the Spine Cervical (back and neck) without contrast dated 6/11/2022 at 11:32 a.m., the CT findings indicated an acute minimally displaced type 3 dens (neck bone) fracture (break in the bone) with broken bone through the cervical 2 vertebrae (also called the axis or the neck bone, part that enables head rotation). During a record review of Resident 7's Neurosurgery (specializing in injury or disorders of brain, spinal cord and spinal column, and peripheral nerves) Consult Note dated 6/18/2022 at 8:03 a.m., the note indicated no surgical intervention at the present time but Resident 7 needed to wear a cervical collar (medical device used to always support a person’s neck) and follow up in the Neurosurgery Clinic in 6 weeks. During a record review of facility’s undated P/P titled, “Toileting Program,” the P/P indicated the toileting program was to promote continence with bladder function and attempt to decrease episodes of incontinence in residents. The P/P indicated the resident will be assisted to the toilet, commode or offered a bed pan or urinal upon awakening, after meals, after naps and before bed. Toileting will be offered every three to four hours during waking hours and at least two times during sleeping hours. The P/P indicated the toileting will be documented in the plan of care. During a record review of the facility’s P/P titled, “Falls and Fall Risk Managing,” revised 10/2020, the P/P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input and interdisciplinary team, will identify appropriate interventions to reduce the risk of falls. The facility failed to prevent a fall for Resident 7 by failing to:1. Provide Resident 7 with the required minimal assistance and supervision from staff when toileting per the resident’s care plans and the facility’s P/Ps titled, “Toileting Program” and “Falls and Fall Risk Managing”. 2. Follow Resident 7’s scheduled toileting plan and ensure the resident was assisted by staff to the toilet or offered a commode or bed pan as needed, upon waking in the morning, and before breakfast as per the facility’s P/P titled, “Toileting Program.” As a result, Resident 7 had a preventable fall the required subsequent transfer to a GACH for treatment. Resident 7 was diagnosed with a right forehead laceration with hematoma and an acute minimally displaced type 3 dens fracture. 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.