Health inspection·May 23, 2024

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. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 4/11/24 at 12:10 PM the Department of Public Health conducted an unannounced onsite visit at the facility for a facility reported incident regarding resident safety and falls. The facility failed to: 1. Ensure Patient 1 was provided immediate care after sustaining a fall on the floor in the facility on 3/24/24. 2. Ensure Certified Nursing Assistant (CNA 1) reported to licensed nurses that Patient 1 was found on the floor in the Patient 1 ' s room, by the foot of the bed on 3/24/24 at 12AM. 3. Ensure Registered Nurse 1 (RN1) immediately conducted an assessment on Patient 1 after Patient 1 was found on the floor on 3/24/24. The facility conducted a neurocheck (an assessment tool to determine a patient's neurologic function) 10 hours after Resident 1 was found on the floor, at the foot of the bed. 4. Ensure CNA 1 Patient 1 was safely transferred to the bed after sustaining a fall. CNA1 transferred Patient 1 back to bed, alone, without licensed nurses initially assessing Patient 1 for any other injuries. 5. Ensure RN1 notified the physician and implement the facility' s fall protocols immediately after Patient 1 ' s unwitnessed fall on the floor on 3/24/24. As a result, care and services to Patient 1 was delayed for seven (7) hours after the patient was found on the floor. Patient 1 experienced pain in the left leg and upon x-ray results on 3/26/24, confirmed that Patient 1 sustained a left hip fracture that required a surgical intervention. A review of Patient 1 ' s Admission Record indicated the facility originally admitted Patient 1, a 90 year old female on 11/22/2019 and readmitted on 3/13/2024 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and displaced fracture of base of neck of left femur (a type of hip fracture [a partial or complete break in the bone]). A review of Patient 1 ' s Fall Risk Assessment, dated 3/14/2024, indicated Patient 1 was at high risk for fall. A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/18/2024, indicated Patient 1 had moderately impaired cognitive (ability to think and reasonably) impairment and memory. The MDS indicated Patient 1 was independent with oral hygiene, required supervision or touching assistance with eating, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfer, toilet transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet, and required partial/moderate assistance with shower/bathe self. A review of Patient 1 ' s MDS, dated 4/1/2024, indicated Patient 1 had severely impaired cognitive impairment and memory. The MDS indicated Patient 1 required supervision or touching assistance with eating, oral hygiene, chair/bed-to-chair transfer and toilet transfer, required partial/moderate assistance with upper body dressing, and required substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear. The MDS indicated walk 10 feet, walk 50 feet with two turns, and walk 150 feet were not attempted due to medical condition or safety concerns. A review of Patient 1’s Change of Condition (COC)/Interact Assessment Form Situation, Background, Action, and Response (SBAR), dated 3/24/2024 at 1:11 AM, indicated patient 1 was restless, removing diaper, and trying to get out of bed. The COC did not indicate CNA1 informing RN1 that patient was found seated on the floor at the foot of the bed. A review of Patient 1 ' s COC/SBAR dated 3/24/2024 at 9:00 AM, indicated at 10 AM, Patient 1 complained of pain in the left leg "with purplish discoloration on right forearm." The COC/SBAR indicated Patient 1 ' s roommate informed licensed vocational nurse (LVN) 2 that Patient 1 fell last night on 3/24/24 during the night shift (11 PM-7AM). During a review of Patient 1 ' s 72 Hours neurological assessment check (Neuro check, a routine practice by the registered nurse to assess the mental status and level of consciousness) List, dated 3/24/2024, indicated the facility initiated the 72 hours neuro-check on Patient 1 at 10 AM on 3/24/2024 (10 hours after Patient 1 ' s unwitnessed fall). A review of Patient 1 ' s Progress Notes, dated 3/26/2024, indicated Patient 1 complained of pain in the left leg during physical therapy and that the staff obtained an order for an x-ray (an imaging test that takes pictures of bones and soft tissues to help providers diagnose and treat medical conditions) to rule out a fracture. A review of Patient 1 ' s Physical Therapy Treatment Encounter Note(s), dated 3/27/2024, indicated x-ray to left leg on 3/26/2024 revealed acute left femoral neck fracture and no weight bearing to the left leg at this time. A review of Patient 1 ' s Radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) Results Report, dated 3/26/2024, indicated Patient 1 sustained an acute fracture of the neck of the femur, with mild displacement. A review of Patient 1 ' History and Physical (H&P) from the general acute care hospital (GACH), dated 3/27/2024, indicated Patient1 sustained a left hip fracture and was admitted to the GACH for pain management and possible surgical repair of the fractured left hip. A review of Patient ' s Progress Note of Surgery Orthopedics from the GACH, dated 3/28/2024, indicated Patient 1 and family did not want to proceed with surgery, During a telephone interview on 4/10/2024 at 1:14 PM with CNA 1, CNA 1 stated he was conducting his rounds when he found Patient 1 sitting on the floor mat on the floor. CNA1 stated Patient 1 was at the foot of the right side of her bed between the times of 12:00 and 1:00 AM on 3/24/2024. CNA 1 stated assisting Patient 1 back to bed, by carrying Patient 1 by himself. CNA1 stated Patient 1 was smacking the bedside rail with her arm and moaning. CNA 1 stated he informed RN 1 regarding finding patient 1 , "at the foot of her bed,” and that Patient 1 was agitated. CNA 1 stated Patient 1 continued to act restlessly for the rest of the night, and that Patient 1 was very agitated. CNA1 stated not informing RN1 that Patient 1 was found on the floor, at the foot of the bed. During an observation on 4/10/2024 at 1:35 PM in Patient 1 ' s room, Patient 1 was observed lying in bed with a blue abduction wedge pillow (designed to separate the legs of a patient. It is often used after hip surgery to prevent the new hip from "popping out") Patient 1 had a bruise at left upper inner thigh. During an interview on 4/10/2024 at 2:04 PM with Patient 2, Patient 2 stated she was the roommate of Patient 1. Patient 2 stated she was awaken up by a loud thud sound around 1AM on 3/24/24. Patient 2 stated she saw Patient 1 seated on the floor by the foot of Patient 1 ' s bed. Patient 2 stated she did not see how Patient 1 fell out of the bed and no staff was present when the fall happened. Patient 2 stated the staff came in after the fall and found Patient 1 was on the floor. A review of Patient 2 ' s Admission Record indicated Patient 2 was admitted to the facility on 3/15/24 with a diagnoses of malignant neoplasm of the pancreas (cancer of the pancreas), urinary tract infection(UTI, bladder infection) , and diabetes (high blood sugar). A review of Patient 2 ' s History and Physical dated 3/17/2024 indicated Patient 2 had the capacity to understand and make decisions. A review of Patient 2 ' s MDS, dated 3/21/24, indicated Patient 2 had no cognitive impairment. During a telephone interview on 4/10/2024 at 2:29 PM with Registered Nurse 1, RN 1 stated CNA 1 approached her and told her that Patient 1 was restless and if Patient 1 had any medication for restlessness at 12:00 AM on 3/24/2024. RN 1 stated CNA 1 did not tell her that he found Patient 1 sitting on the floor by the foot of the bed and or that Patient 1 fell out of bed. RN 1 stated when she went to assess Patient 1, Patient 1 was restless on the bed, but did not see any visible injuries on patient 1. RN1 stated Patient 1 did not complain of any pain at that time, but RN 1 stated unawareness of Patient 1 falling out of bed. RN 1 stated she did not ask questions to clarify if Patient 1 had a fall when CNA 1 told her Patient 1 was at the foot of her bed. RN 1 stated she did not conduct a post fall assessment and did not report to other staff and the physician that Patient 1 sustained a fall during her shift from 11:00 PM on 3/23/2024 to 7:00 AM on 3/24/2024 because she was not aware of the fall. RN 1 stated she was informed about Patient 1's fall when she returned to work at 11:00 PM on 3/24/2024. RN 1 stated it was around 9:00 AM on 3/24/2024, the morning shift CNA 1 found Patient 1 with a bruise on the right arm and reported to the morning shift LVN. RN1 stated the morning shift LVN went to check on Patient 1 and Patient 2 reported to the morning shift LVN that Patient 1 fell out of the bed the night before. RN 1 stated the morning shift LVN initiated the fall protocol on Patient 1 at 10AM on 3/24/2024. RN 1 stated CNA 1 should have reported Patient 1's fall to RN1 and CNA1 to prevent a delay in treatment, and that CNA1 should not move Patient 1 back to the bed by himself before any licensed nurses assessed Patient 1, to prevent further injury to Patient 1. During a telephone interview on 4/10/2024 at 2:49 PM with CNA 1, CNA 1 stated he informed RN 1 that "She (Patient 1) was at the foot of her bed." CNA 1 stated he did not report to RN1 that Patient 1 was found seated on the floor, at the foot of the bed, or that Patient 1 had a fall. During a telephone interview on 4/10/2024 at 3:51 PM with the Physical Therapist (PT), the PT stated Patient 1 was at high risk for fall prior to her recent fall on 3/24/24. The PT stated conducting a fall assessment on Patient 1 after being notified that Patient 1 fell. The PT stated while conducting the fall assessment, Patient 1 was in "a lot of pain" so the PT notified the physician to obtain x-ray order. The PT stated the results of the Xray indicated Patient 1 had a left hip fracture. During an interview on 4/10/2024 at 4:20 PM with Licensed vocational nurse (LVN) 1, LVN 1 stated if a patient was found on the floor for an unwitnessed fall, CNAs should report to licensed nurses immediately and not to move the patient. LVN 1 stated licensed nurses should assess the patient for injury, change of level of consciousness (LOC), vital signs, skin integrity, and neuro-check, then, notify the physician and responsible party. LVN 1 stated CNAs should not move the patient until the licensed nurse assess the patient for possible fracture and head injury. LVN1 stated it was not until after an assessment was conducted and the patient was cleared to be moved, should the CNA safely move a patient after being found on the floor. During an interview on 4/11/2024 at 10:59 AM with CNA 2, CNA 2 stated when as patient was found on the floor, CNAs must report to the charge nurse and the RN supervisor immediately by stating what where and what position the patient was found. CNA 2 stated CNAs should not move or touch the patient until the licensed nurses assessed the patient and gave instruction to move the patient because moving the patient without proper assessment could cause more injury to the patient. During an interview on 4/11/2024 at 11:09 AM with RN 2, RN 2 stated Patient 1 was at high risk for fall. RN 2 stated when a patient had a fall either a witnessed or unwitnessed fall, the licensed nurse should follow the fall protocol immediately, which included assessing the patient for pain and injury RN 1 stated CNAs should report to the licensed nurse immediately when a patient was found on the floor. RN 1 stated the patient should not be moved or touched the patient until the licensed nurse completed the assessment and determined it was safe to move the patient to prevent further injury. During an interview on 4/11/2024 at 1:18 PM with the Director of Nursing (DON), the DON stated according to the facility ' s fall protocol and the standards of practice, CNA 1 should report to RN 1 that Patient 1 was found sitting on the floor at the foot of the bed. The DON stated CNA 1 should not move Patient 1 back to the bed by himself without an assessment conducted from the licensed nurses. The DON stated by moving Patient 1 without the proper assessment from the licensed nurse could cause more injury to the patient. The DON stated Patient 1 was restless on 3/24/2024 after the fall. The DON stated 1 did not know that Patient 1 had fall during her shift and did not start the fall protocol on Patient 1 until 10:00 AM on 3/24/2024 when Patient 2 informed the staff. The DON stated Patient 1 ' s 72 hours neurological assessment, which could determine any change of LOC, was not started immediately after Patient 1 ' s fall. The DON stated it was not until 10 AM (10 hours after Patient 1 ' s fall) on 3/24/24 was the neurocheck initiated. The DON stated the nurse documented Patient 1 had pain at her left leg on 3/24/2024, but the facility did not obtain an x-ray for Patient 1 ' s left leg until the PT noticed Patient 1 had a lot of pain to her left leg and called the doctor for an order for an x-ray of left leg on 3/26/2024. The DON stated the x-ray results on 3/26/24 of Patient 1 ' s left leg indicated Patient 1 sustained a hip fracture and Patient 1 was transferred to an acute hospital on 3/27/2024. The DON stated Patient 1's family member refused any surgical intervention and Patient 1 returned to the facility on 3/30/2024. The DON stated after a fall, the licensed nurse should immediately follow the fall protocol by conducting post fall assessment, neuro-check assessment and fall risk assessment, and notifying the doctor immediately to provide appropriate interventions and prevent any delay of treatment. During a telephone interview on 4/11/2024 at 3:13 PM with CNA 1, CNA 1 stated he saw Patient 1 was sitting on the floor at the foot of her bed and he tried to help her by assisting her back to her bed, but he did not know that he should not move or touch Patient 1 until the licensed nurses assessed the patient. CNA 1 stated he worked for a registry company, and he did not receive regular in-service training at the facility as other facility ' s permanent staff. During a review of the updated facility ' s P&P titled, "Incidents/Accidents," the P&P indicated incidents/accidents will be reported to the charge nurse. During a review of the updated facility ' s P&P titled, "Fall," the P&P indicated "MD and responsible party will be notified as soon as possible after the incident occurred, and of any significant change noted." The P&P indicated as soon as an incident of fall occurs, the