Health inspection·January 28, 2025

F689 §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient 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. The facility failed to provide adequate supervision to Patient 1 after the facility assessed Patient 1 was at risk for falls, and leaving Patient 1 unattended in Patient 1’s wheelchair on 1/3/25. As a result, Patient 1 sustained a fall, and was found lying on the ground, outside of the facility building on 1/3/25 at 1:45 PM. Patient 1 was observed by facility staff holding his left arm. Patient 1 sustained a laceration (a deep cut or tear in the skin) on the patient’s left eyebrow measuring one (1) centimeter (cm- unit of measurement). Patient 1 was transferred to the General Acute Care Hospital (GACH) on 1/3/2025 at around 2:12 PM, by the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital). At the GACH, Patient 1 was found to have an acute (sudden) displaced fracture (a broken bone where the pieces have moved out of alignment, creating a gap between them) deformity in the left neck of the humerus (the short, narrow area that connects the head to the body of the upper arm bone). An unannounced visit was conducted at the facility on 1/7/25 at 1:07 PM for a facility reported incident regarding quality of care and treatment. A review of Patient 1’s Admission Record, indicated an 84 year old male Patient was initially admitted to the facility on 11/22/2023 and readmitted on 8/6/2024 with diagnoses that included unspecified dislocation of left hip (when the ball portion of the hip joint is dislodged from its socket), unspecified dementia (a progressive state of decline in mental abilities), and history of falling. A review of Patient 1’s Minimum Data Set (MDS- a patient assessment tool), dated 11/13/2024, the MDS indicated Patient 1 was assessed having severely impaired (never/rarely made decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Patient 1 was assessed to require partial/moderate assistance (helper does less than half the effort) with sit to stand, sit to lying, and lying to sitting on side of bed. The MDS indicated, Patient 1 was assessed to be dependent (helper does all of the effort) with walking 10 feet (ft- unit of measurement) and that the patient used a manual wheelchair and required partial/moderate assistance with wheeling 50 ft with two turns and substantial/maximal assistance (helper does more than half the effort) with wheeling 150 ft. Patient 1 was assessed having fall incident with no injury since admission/entry or prior assessment. A review of Patient 1’s Fall Risk (Morse) Assessment (a widely used assessment tool that helps healthcare professionals predict a patient’s risk of falling in healthcare settings like hospitals and long-term care facilities), dated 9/23/2024, the Fall Risk Assessment indicated Patient 1 was high risk for falls. A review of Patient 1’s Care Plan, dated 9/23/2024, the Care Plan indicated Patient 1 had an actual fall with no injury due to impaired sensory perception, confusion, impaired safety awareness, and muscle weakness initiated on 9/23/2024. The care plan indicated intervention to keep patient up in wheelchair in a supervised area and to provide frequent visual checks several times per shift. A review of Patient 1’s PT Evaluation and Treatment Plan, with a certification period of 10/7/2024 to 11/17/2024, the PT Evaluation and Treatment Plan’s Functional/Mobility Assessment indicated Patient 1 required substantial/maximal assistance with sit to stand. The Functional/Mobility Assessment further indicated walking 10 feet was not attempted due to medical conditions or safety concerns. A review of Patient 1’s Progress Note, dated 1/3/2025, at 1:50 PM, the Progress Note indicated, Patient 1 was found on the floor with a 1 cm laceration on left eyebrow and the patient complained of unable to move left arm. The progress note indicated medical doctor (MD) ordered to transfer the patient to GACH by paramedic. A review of Patient 1’s Pain Assessment, dated 1/3/2025, the Pain Assessment indicated Patient 1 complained of breakthrough pain rated at 3 out of 10 on his left eyebrow laceration site. Patient 1 received Tylenol (a medication used for pain) 325 milligrams (mg- unit of measurement) 2 tablets by mouth. A review of Patient 1’s Skin Observation Check, dated 1/3/2025, the Skin Observation Check indicated Patient 1 had a laceration measuring 1 cm by 0.1 cm on his left eyebrow. A review of Patient 1’s GACH X-ray (pictures of the inside of the body) of the left shoulder, dated 1/3/2025 entered time at 8:16 PM, the X-ray result indicated an acute displaced fracture deformity in the left neck of the humerus. A of Patient 1’s Progress Note, dated 1/5/2025 entered at 6:38 AM, the Progress Note indicated, Patient 1 was monitored for unwitnessed fall and readmission (date and time not specified). A review of Patient 1’s Multidisciplinary Progress Record signed by Patient 1’s MD, dated 1/6/2025, the Multidisciplinary Progress Record indicated Patient 1 had a left humerus fracture after the fall on 1/3/2025. A review of GACH’s Orthopedic (relating to the branch of medicine dealing with correction of deformities of bones or muscles) Notes dated on 1/7/2025, it indicated, Patient 1 had a fall from the patient’s wheelchair on 1/3/2025 and fractured his left arm and family opted not to do surgery (branch of medicine treats injuries, diseases, and deformities by the physical removal, repair or readjustment of organs, bones and tissues often involving cutting into the body). The orthopedic notes also indicated, Patient 1 reported sharp pain with level of seven (7) out of 10 (pain level of 10 is the most painful). During an observation in Patient 1’s room on 1/8/2025 at 9:09 AM, Patient 1 was observed lying in bed with left arm in a sling (a device used to limit movement of the shoulder or elbow while it heals). Patient 1 had a dry scab (a dry, rough protective crust that forms over a cut or wound during healing) on the patient’s left elbow. Patient 1 stated he fell but did not remember when, how or why he fell. During an interview with Licensed Vocational Nurse 3 (LVN 3), on 1/8/2025, at 9:50 AM, LVN 3 stated Patient 1 is unable to stand without assistance. LVN 3 stated Patient 1 uses the wheelchair and can wheel his wheelchair in the hallway. LVN 3 stated on 1/3/2025 at around 1 PM, Patient 1 was sitting on his wheelchair in the dining room while CNA 1 was feeding another patient (not sure if in the dining room or into another patient’s room). LVN 3 stated on 1/3/2025 Speech Therapist 1 (SPT 1) found Patient 1 on the ground outside Building 1’s back door (unknown how the patient was able to get outside). LVN 3 stated SPT1 found patient lying on the patient’s right side with blood coming from the patient’s left eyebrow. LVN 3 stated Patient 1 complained of left shoulder pain after the fall. LVN 3 stated 911 (a phone number used to contact emergency services) was called and Patient 1 was transferred to GACH. LVN 3 stated Patient 1 should not have been left unsupervised in the dining room. During an interview with CNA 1 on 1/8/2025, at 10:21 AM, CNA 1 stated she was assigned to care for Patient 1 on 1/3/2025. CNA 1 stated Patient 1 ate his meal in the dining room while sitting on his wheelchair. CNA 1 stated Patient 1 was able to wheel around in his wheelchair. CNA 1 stated on 1/3/2025, Patient 1 was sitting in the dining room when CNA 1 left the dining room to feed another patient. CNA 1 stated not remembering if there were other facility staff in the dining area to supervise the patients. CNA 1 stated she did not notify other staff that she was leaving Patient 1 in the dining room on 1/3/2025 and that she did not ask another staff to supervise Patient 1 before leaving the dining room to attend to another patient. During an interview with SPT 1, on 1/8/2025 at 10:57 AM, SPT 1 stated he was in another building when he heard someone crying outside. SPT 1 stated he went outside and saw Patient 1 on the ground, lying on his right side next to the patient’s wheelchair outside Building 1’s back door. SPT 1 stated Patient 1 was asking for help, and no staff was present when SPT 1 found the patient on the floor. SPT 1 stated Patient 1 was bleeding from his left eyebrow. During an interview and record review with LVN 2, on 1/8/2025, at 12:33 PM, Patient 1’s Care Plan for fall dated 9/23/2024, was reviewed. The Care Plan indicated intervention to keep the patient in a supervised area. LVN 2 also stated Patient 1 fell outside Building 1 on 1/3/2025 and that the Care Plan intervention to keep Patient 1 in a supervised area was not followed. LVN 2 stated Patient 1’s fall could have been prevented if the Care Plan was followed and a facility staff stayed in the dining room to supervise Patient 1. LVN 2 stated CNA 1 should have informed another staff that she was leaving the dining room so that Patient 1 can be supervised by another staff. LVN 2 stated the facility’s policy to prevent falls and to provide a safe environment for patients was not followed. A review of the facility’s policy and procedure (P&P), titled, “Fall Management Program,” revised on 6/1/2017, the P&P indicated the facility will prevent patient falls and minimize complications associated with falls. The P&P further indicated, it is the policy of this facility to provide the highest quality of care in the safest environment for the patients residing in the facility and to prevent patient falls through meaningful assessments, interventions, education, and reevaluation. The facility failed to provide adequate supervision to Patient 1 after the facility assessed Patient 1 was at risk for falls, and leaving Patient 1 unattended in Patient 1’s wheelchair on 1/3/25. As a result, Patient 1 sustained a fall, and was found lying on the ground, outside of the facility building on 1/3/25 at 1:45 PM. Patient 1 was observed by facility staff holding his left arm. Patient 1 sustained a laceration (a deep cut or tear in the skin) on the patient’s left eyebrow measuring 1 cm. Patient 1 was transferred to the GACH on 1/3/2025 at around 2:12 PM, by the. At the GACH, Patient 1 was found to have an acute displaced fracture deformity in the left neck of the humerus. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and Patient 2.