Health inspection·December 10, 2021

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: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 72523. Patient Care Policies and Procedures (a) (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/26/2021, an unannounced visit was made to the facility to conduct a recertification survey and Resident 47’s care was evaluated. The facility failed to follow its policies and procedures to ensure an accident-free environment and provide necessary care and services to Resident 47, by failing to: 1. Provide supervision with toileting (how a resident uses the toilet room) to prevent Resident 47 from sustaining an unwitnessed fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) on 10/26/2021. 2. Conduct an evaluation of Resident 47 after the unwitnessed fall and document the resident’s tenderness in her hip. 3. Immediately notify Resident 47’s physician and Resident 47’s representative after the resident sustained an unwitnessed fall on 10/26/2021, which resulted in the resident experiencing severe pain, and a delay in timely treatment of 12 hours. As a result, Resident 47 sustained an unwitnessed fall requiring transfer to General Acute Care Hospital 1 (GACH 1) on 10/27/2021 at 4:40 am, where x-rays (a photographic or digital image) report indicated the resident had a comminuted (the bone breaks into several pieces) intertrochanteric fracture (breaks of the femur between the greater and the lesser trochanters [overhang toward the near end of the thighbone]). On 10/28/2021, (two days after the resident fell) the resident underwent surgery to repair the fracture. A review of Resident 47's Admission Record, indicated, the resident, an 87-year-old female, was admitted to the facility on 9/30/2020 and readmitted on 9/7/2021 with diagnoses including end stage renal disease (medical condition in which a person's kidneys cease functioning on a permanent basis), history of malignant neoplasm (cancer) of breast, need for assistance with personal care, and abnormalities of gait (manner of walking) and mobility (ability to move). A review of Resident 47’s Care Plan, dated 9/8/2021, indicated the resident was at risk for falls related to gait/balance problems. The care plan interventions included to anticipate and meet resident’s needs and to follow facility fall protocol. A review of Resident 47’s Care Plan, dated 9/9/2021, indicated the resident had a behavior problem of standing, transferring, and walking without asking for assistance. The care plan interventions included to anticipate and meet the resident's needs. A review of Resident 47's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/5/2021, indicated, Resident 47 was assessed with severely impaired cognition (ability to understand). The MDS indicated Resident 47 required limited assistance with one-person physical assist for toileting. The MDS indicated Resident 47 was assessed not steady and only able to stabilize with staff assistance moving on and off toilet and moving from seated to standing position. The MDS indicated Resident 47 was assessed as needing to use a walker and wheelchair for mobility. A review of Resident 47’s Fall Assessment, dated 10/18/2021, indicated Resident 47 was assessed as being at risk for falls due to intermittent confusion, balance problems while standing, walking, and required the use of walker/wheelchair. A review of Resident 47’s untimed Situation Background Appearance Review and notify (SBAR – a technique that provides a framework for communication between members of the health care team about a patient's condition) form, completed by Licensed Vocational Nurse 5 (LVN 5) and dated 10/27/2021 indicated the resident complained of severe pain (disabling; unable to perform daily living activities) on her left hip. Resident 47 told LVN 5 she was in pain because she fell in the resident’s restroom. LVN 5 noted the resident’s left hip was swollen and very tender to touch. LVN 5 notified the physician on 10/27/2021 and the physician ordered Resident 47 to be sent to GACH 1 Emergency Department (ED) for further evaluation and treatment. A review of Resident 47’s Physician’s Order dated 10/27/2021, timed at 4:12 am, indicated to transfer the resident to GACH 1 for further evaluation after a fall. A review of Resident 47’s Transfer form dated 10/27/2021, timed at 4:40 am, indicated the resident was transferred to GACH 1 due to uncontrolled pain (unspecified pain severity). A review of Resident 47’s GACH 1 ED Visit Summary General Assessment dated 10/27/2021 at 5:30 am, indicated Resident 47 had limited range of motion (ROM, refers to how far a person can move or stretch a part of the body, such as a joint or a muscle), of the left hip and the left lower leg was shorter than the right lower leg. A review of Resident 47’s GACH 1 ED Hip/Pelvis X-ray report, dated 10/27/2021, timed at 5:50 am, indicated Resident 47 had a left comminuted intertrochanteric fracture. A review of Resident 47’s GACH 1 History and Physical dictated on 10/27/2021 at 10:03 p.m., indicated the resident had multiple medical problems and the facility sent the resident to the GACH 1 secondary to a mechanical fall (an external force caused the resident to fall). The resident was found to have a left hip intertrochanteric fracture. A review of Resident 47’s GACH 1 Operative Report, dictated on 10/28/2021 at 3:11 pm indicated the resident had repair of left intertrochanteric femur fracture using intermediate nail device on 10/28/2021. A review of the facility’s investigation report of Resident 47's fall incident, dated 11/3/2021, indicated on 10/26/2021 at 4:30 pm, CNA 1 and Resident 47 were in the resident’s restroom. The report indicated CNA 1 stepped out of the resident’s restroom to retrieve a shower chair and upon her return, CNA 1 found Resident 47 sitting on the floor in the restroom. The report indicated CNA 1 immediately reported to the licensed nurse and the licensed nurse assessed Resident 47. The report indicated on 10/27/2021 at 4:30 am, 12 hours after the resident was found on the floor, Resident 47 complained of pain on her left hip, and had swelling and tenderness to the touch. Pain medication was administered to Resident 47. The physician and Resident 47's representative were notified. The physician ordered to transfer Resident 47 to GACH 1 for further evaluation. Resident 47 was transferred to GACH 1 and was found to have a fracture. During an interview on 10/27/2021 at 8:50 am, Registered Nurse 1 (RN 1) stated Resident 47 fell inside the resident’s restroom on 10/26/2021 at 4:30 pm and was transferred to GACH 1 on 10/27/2021 at 4:40 am for an evaluation. During an interview on 10/28/2021 at 1 pm, the facility’s DON stated CNA 1 reported Resident 47's fall to LVN 1 on 10/26/2021 at 4:30 pm, but LVN 1 did not document the fall incident in Resident 47's clinical record. During a phone interview on 10/28/2021 at 1:45 pm, LVN 1 stated on 10/26/21 at approximately 4:30 pm, CNA 1 asked him and LVN 2 to accompany her to Resident 47's room and they found Resident 47 sitting on the floor in the resident’s restroom. LVN 1 stated he and LVN 2 assisted Resident 47 from the floor to the shower chair. LVN 1 stated CNA 1 wheeled Resident 47 to the shower room and showered the resident. LVN 1 stated Resident 47's fall was unwitnessed, and the resident was by herself in the restroom when she fell. LVN 1 stated he was responsible for Resident 47's care and was supposed to document Resident 47's unwitnessed fall on 10/26/2021. LVN 1 stated he failed to notify the physician of Resident 47's unwitnessed fall. LVN 1 stated he failed to notify Resident 47's family representative after the unwitnessed fall on 10/26/2021. LVN 1 stated he failed to notify the Administrator or the DON of Resident 47's unwitnessed fall on 10/26/2021 as soon as the fall was discovered. During an interview on 10/28/2021 at 4:20 pm, the DON stated according to CNA 1's statement, CNA 1 left Resident 47 sitting on the toilet by herself to get the shower chair. The DON stated it was not safe for CNA 1 to leave Resident 47 on the toilet by herself because the resident had episodes of confusion and occasionally got up by herself without assistance. The DON stated LVN 1 who was assigned to Resident 47 was supposed to assess the resident after the resident fell on 10/26/2021 at 4:30 pm, complete an incident report, document the fall incident in the resident's clinical record, and notify the physician and the resident's family representative about the fall. During an interview on 10/28/2021 at 4:32 pm, LVN 2 stated on 10/26/2021, CNA 1 called him and LVN 1 to accompany her to Resident 47's room and they found Resident 47 sitting on the floor in the resident’s restroom with the resident’s back against the wall. LVN 2 stated he helped LVN 1 pick-up Resident 47 off the floor and put her into the shower chair. LVN 2 stated Resident 47 was unsteady and had a history of getting out of her wheelchair without assistance. LVN 2 stated after a fall incident, licensed nurses (in general) needed to call the RN Supervisor to assess the resident, and to notify the physician and the resident's representative about a fall. LVN 2 stated licensed nurses should notify the Administrator and the DON regarding the resident's fall and document the fall incident in the resident's clinical record. On 10/28/2021 at 2 pm and at 3:15 pm, the Surveyor attempted contacting CNA 1 by telephone, but CNA 1 did not answer the calls. A review of the facility’s Policy and Procedure titled “Accident and Incident Prevention”, dated 5/24/2021, indicated the facility will prevent accidents and incidents and eliminate preventable occurrences, practices, or systems, which negatively impact residents and/or resident care and environment hazards over which the facility has control over. Any fall risk factor identified will be addressed with interventions that will be documented on the resident’s plan of care. A review of the facility's Policy and Procedure titled" Fall Risk Assessment", revised 3/2018, indicated staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. A review of the facility’s Policy and Procedure on “Assessing Falls and Their Causes”, revised 3/2018, indicated the following: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. 5. Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. b. When a fall does not result in significant injury or a condition change, notify the practitioner routinely (e.g., by fax or by phone the next office day). Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing. The same policy indicated “Identifying Causes of a Fall or Fall Risk” were the following: 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident, refer to resident specific evidence including medical history, known functional impairments, etc. 2. Evaluate chains of events or circumstances preceding a recent fall, including: a. Time of day of the fall. b. Time of the last meal. c. What the resident was doing. d. Whether the resident was standing, walking, reaching, or transferring from one position to another. e. Whether the resident was among other persons or alone. f. Whether the resident was trying to get to the toilet. g. Whether any environmental risk factors were involved. h. Whether there is a pattern of falls for this resident. 3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that cause cannot be found. 4. Consult with the attending physician or medical director to confirm specific causes from among multiple possibilities, when possible, document the basis for identifying specific factors as the cause, 5. If the cause is unknown but no additional evaluation is done, the physician or nursing staff should note why (e.g., workup already done, finding a cause would not change the approach, etc.). The process for “Performing a Post-Fall Evaluation” was the following: After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results of this effort. A review of the facility's Policy and Procedure titled, "Accidents and Incidents-Investigating and Reporting", revised 4/2016, indicated that regardless of how minor an accident or incident may be, it must be reported to the DON and Administrator as soon as an accident or incident is discovered or when information of an accident/incident is learned. The physician and the resident representative will be notified as soon as possible. The licensed nurse shall examine the resident and document the findings on the Incident/Accident Report form; conduct a neurological assessment of resident who had an unwitnessed fall. The licensed nurse will document information regarding the accident or incident in the licensed nurse's progress notes. A review of the facility's Policy and Procedure titled, "Change in a Resident's Condition or Status", revised 1/2012, indicated the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge n