Health inspection·June 14, 2021

F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; T22 72311. Nursing Service- General. (a) Nursing service shall include, but not be limited to the following: (2) Implementing each patient’s care plan according to the methods indicted. Each patient’s care shall be based on this plan. On 2/24/2020, an unannounced visit was made to investigate a facility reported incident regarding quality of care and resident safety. The facility failed to implement the intervention of one-on-one supervision to prevent Resident 1 from falling on the floor while out of bed in the therapeutic recliner chair, as indicated in the resident's care plan. Resident 1, who was at high risk for falls, was left unattended in the dining room on 2/15/2020, at 12:05 a.m., Resident 1 stood up and fell face down on the ground. This failure resulted in Resident 1 sustaining a bilateral frontal lobe subarachnoid hemorrhage (bleeding in the brain), 5 millimeter thick hemorrhage along the anterior falx (bleeding on the back of the eye), nasal bone fractures (broken nose), opacified left maxillary sinus, and left frontal scalp swelling and hematoma (swelling and bruises in the nose area). Resident 1 required a transfer to the general acute care hospital (GACH) where Resident 1 was admitted to the intensive care unit (ICU, a department of a hospital in which patients who are dangerously ill are kept under constant observation). A review of Resident 1's Admission Record indicated the facility admitted Resident 1, an 89 year-old female, on 10/23/19, and readmitted to the facility on 2/21/2020 with diagnoses that included traumatic (relating to physical injury) subdural hemorrhage (a collection of blood in the brain as a result of a severe head injury), bilateral glaucoma (abnormal pressure in the eye that can cause blindness), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), vascular dementia (a type of dementia caused by brain damage with symptoms that included memory loss and difficulties with thinking, problem-solving or language), unsteadiness, and history of falls. A review of a handwritten care plan initiated on 12/22/19, indicated that Resident 1 constantly yelled and screamed for the resident's deceased mother and for people that were not there and disturbed other residents. The care plan interventions included to get Resident 1 up in the wheelchair and place the resident by the nursing station or the dining room with supervision and attempt a "one-on-one" with the resident. A review of Resident 1's record titled, "Fall Risk Assessment", dated 12/23/19, indicated Resident 1 scored 14 (a score of 10 or greater indicated Resident 1 was a higher risk for potential falls) indicating Resident 1 was a high risk for fall. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 12/29/19, indicated Resident 1 had severe impairment in cognitive skills (ability to make decisions of daily living), required extensive (staff providing weight-bearing support) two-persons plus physical assistance with transfer and walking in between locations within a room. The MDS indicated Resident 1 had impaired functional limitation in range of motion (the full movement potential of a joint, usually its range of flexion and extension) to both lower extremities (hips, knees, ankles, and feet). The MDS indicated Resident 1's balance during transitions (shifts) and walking required staff assistance for stability. A review of Resident 1's record titled, "Licensed Nurses Progress Notes" dated 2/15/2020 timed at 4 a.m., indicated at around 11:05 p.m. (2/14/2020) CNA 1 attempted to put Resident 1 in bed and Resident 1 became very agitated and was yelling and screaming for her deceased mother, waking up Resident 1's roommate. The progress notes indicated Resident 1 was transferred to a therapeutic recliner chair and placed at the nursing station for close supervision to prevent her from disturbing other residents. The progress notes indicated Resident 1 continued to yell at the nursing station, so CNA 1 moved Resident 1 to the dining room where CNA 1 stayed with the resident. The Licensed Nurse Progress Notes dated 2/15/2020 and timed at 4 a.m., indicated that on the same date (2/15/2020) at around 12:05 a.m., CNA 1 called Licensed Vocational Nurse (LVN) 1 to the dining room and LVN 1 found Resident 1 lying on the floor next to the recliner chair. The progress notes indicated Resident 1's recliner chair was reclined with the foot part elevated. The progress notes indicated CNA 1 had left Resident 1 while asleep on the recliner chair to get a blanket and throw out the trash. The progress notes indicated CNA 1 witnessed (from approximately 10 feet away) Resident 1 get up and fall next to the reclining chair when CNA 1 was coming back to the dining room. The progress notes indicated Resident 1 sustained a laceration (tearing of soft body tissue) on the left temporal (side of the head) area with swelling to the left eye and a bloody nose. The progress notes indicated another charge nurse (unknown) called 9-1-1 emergency services and Resident 1 was transferred to the GACH. A review of Resident 1's GACH records titled "History and Physical" (H and P) dated 2/15/2020 and timed at 11:27 a.m., indicated Resident 1 had a witnessed fall while standing without assistance and landed on the resident’s left side. The H and P indicated Resident 1 was admitted for further care in the GACH's ICU. A review of Resident 1's GACH record indicated the result of the computed tomography (CT, a combination of X-rays and a computer to create pictures of your organs, bones, and other tissues) of the head dated 2/15/2020, indicated Resident 1 had small bilateral frontal lobe subarachnoid hemorrhages, a 5 millimeter thick hemorrhage along the anterior falx, nasal bone fractures, opacified left maxillary sinus, and left frontal scalp swelling and hematoma. During an interview, on 2/24/2020 at 1 p.m., the Director of Nursing (DON) stated that on 2/14/2020 at 11 p.m., Resident 1 was yelling and screaming in her room and in the hallway upsetting other residents. The DON stated CNA 1 left the resident unsupervised in the dining room to get a blanket when Resident 1 fell asleep. The DON stated that when CNA 1 returned to the dining room, Resident 1 was out of the recliner chair, stood up, and fell on the floor. The DON stated CNA 1 should have asked another staff member to get the blanket, to ensure a staff member always remained with Resident 1 while in the dining room. During a telephone interview, on 7/17/2020 at 6:25 a.m., LVN 1 stated Resident 1 was yelling during the night shift (11 p.m. to 7 a.m.) on 2/14/2020. LVN 1 stated the resident was placed at the nursing station. LVN 1 stated CNA 1 moved Resident 1 to the facility's dining room because Resident 1 continued to yell and scream. LVN 1 stated Resident 1 eventually fell asleep after all the lights were turned off. LVN 1 stated CNA 1 left Resident 1 in the dining room unsupervised, to throw something out and get a blanket. LVN 1 stated when CNA 1 returned to the dining room, CNA 1 saw Resident 1 standing up, tried to walk, and then fell. LVN 1 stated Resident 1 had a laceration (cut) to the left side of the forehead. LVN 1 stated Resident 1 needed to be "watched (monitored) because she might get up." During a telephone interview, on 7/17/2020 at 6:30 a.m., CNA 1 stated that on 2/14/2020 at 11 p.m., Resident 1 was restless, screaming and yelling. CNA 1 stated that CNA 1 and an unnamed coworker tried to place Resident 1 back in bed, but Resident 1 continued to scream and yell. CNA 1 stated other residents complained about Resident 1's screaming and yelling. CNA 1 stated she took Resident 1 to the Nursing Station. CNA 1 stated Resident 1 denied pain, feeling hungry or feeling thirsty. CNA 1 stated Resident 1 was transferred to the dining room when she started to scream and yell again. CNA 1 stated she remained with Resident 1 until the resident fell asleep and then left Resident 1's side to throw something out and get a blanket. CNA 1 stated that upon her return to the dining room, Resident 1 was getting up from the recliner chair. CNA 1 stated she witnessed Resident 1 start to walk and fall on the floor face down. CNA 1 stated she did not call for another staff member before leaving Resident 1 in the dining room because she did not want to wait until another staff member was available. CNA 1 stated the linen closet was down the hall. During a telephone interview with the DON on 4/6/2021 at 4 p.m., when asked about Resident 1's care plan (to address the resident’s yelling and screaming) dated 12/22/19, the DON stated that a "one-on-one" with the resident indicated "a person managing the resident at all times, like a sitter." The DON stated that when Resident 1 fell from the reclining chair on 2/15/2020, Resident 1 had a sitter (CNA 1). The DON stated the sitter left Resident 1 to go to the linen closet which was not too far away from Resident 1. The DON stated there were no other witnesses to Resident 1's fall incident on 2/15/2020. A review of the facility's policy and procedure titled, "Fall Prevention Program", dated 12/2016, indicated if a resident is at risk for falls, it would be identified in the care plan. All precautions would be implemented to protect the resident according to the fall prevention program. The policy indicated the care plan interventions should include the treatment prescribed by the physician and interdisciplinary recommendations, if any. The care plan should also include the following interventions but not limited to "close observation and increase supervision." The facility failed to ensure nursing service shall include, but not be limited to the following: Implementing each patient’s care plan according to the methods indicted. Each patient’s care shall be based on this plan, including but not limited to: The facility failed to implement intervention of one-on-one supervision to prevent Resident 1 from falling on the floor while out of bed in the therapeutic recliner chair, as indicated in the resident's care plan. Resident 1, who was at high risk for falls, was left unattended in the dining room on 2/15/2020, at 12:05 a.m., and Resident 1 stood up and fell face down on the ground. This failure resulted in Resident 1 sustained bilateral frontal lobe subarachnoid hemorrhages, a 5 millimeter thick hemorrhage along the anterior falx, nasal bone fractures, opacified left maxillary sinus, and left frontal scalp swelling and hematoma. Resident 1 required a transfer to the GACH where Resident 1 was admitted to the ICU. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious physical harm would result to Resident 1.