Other·June 25, 2021

§ 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: (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. 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. On 5/25/2017, an unannounced visit was made to the facility to investigate a complaint about quality of care. The facility failed to ensure Resident 1 did not sustain a fall with injury by not: 1. Developing a Care Plan that indicated the care to be given to by not including Resident 1 needed two staff assist with bed mobility and repositioning as assessed. 2. Reviewing, evaluating, and updating the Care Plan to include the need of two staff assist with bed mobility and repositioning in bed. 3. Implementing the facility’s policy on Fall Prevention Program which indicated assessing the resident’s fall risk and develop a plan of care to minimize risk and prevent falls. As a result, on 4/28/2017 at 8:38 p.m., when Registered Nurse 1 (RN 1) repositioned Resident 1 in bed on her own to provide wound treatment, the resident fell out of bed onto the floor requiring urgent transfer to General Acute Care Hospital 1 (GACH 1) where she was found to have a right hip fracture (break of a bone) which required surgery and hospitalization. A review of Resident 1’s Admission Record indicated the resident was an 83-year-old female re-admitted to the facility, on 2/1/2016, with diagnoses including osteoporosis (the bones become brittle and fragile) and Alzheimer's disease (degenerative brain disease that results in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood). A review of Resident 1’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 2/7/2017, indicated Resident 1 was unable to communicate needs, could not make decisions, and required two or more person physical assist with bed mobility and transfers. A review of Resident 1’s Plan of Care dated 2/12/2016, last reviewed 2//2017, developed for the resident’s risk of fractures related to osteoporosis and history of fractures, did not include in the interventions to have two staff move and reposition the resident in bed. A review of Resident 1’s Plan of Care dated 2/12/2016, last reviewed 2/2017, developed for Resident 1’s needing staff assistance with activities of daily living (ADLs – such as personal hygiene, bed mobility, transfers, etc.), did not include in the interventions having two staff to reposition the resident in bed. A review of Resident 1’s wound treatment Physician’s Order dated 4/25/2017 indicated to cleanse and apply hydrogel (to support the regeneration and healing) to a pressure sore (also known as bedsores or pressure ulcers, are damage to the skin and underlying tissues caused by staying in one position for too long. They commonly form where bones are close to the skin, such as ankles, back, elbows, and hip) on the sacrum (is a large wedge-shaped vertebra at the bottom of the spine) twice a day (during the 7 a.m. to 3p.m. shift and the 3 p.m. to 11 p.m. shift). A review of Resident 1’s Fall Risk Assessment dated 2/7/2017, indicated the resident was assessed as being at moderate risk for a fall. A review of Resident 1’s Licensed Personnel Progress Notes, dated 4/28/2017, timed at 8:38 p.m., indicated Resident 1 slipped from the bed onto the floor when RN 1 repositioned her for wound care. RN 1 informed Licensed Vocational Nurse 1 (LVN 1) Resident 1 fell on the floor and asked for assistance. According to the body assessment, RN 1 and LVN 1 saw abnormalities in the position of Resident 1's right knee and documented, "It looked weird." A review of the Physician's Order, dated 4/28/2017, at 9:20 p.m., indicated to transfer Resident 1 to GACH 1 for further evaluation due to a fall. On 5/25/2017, at 7:40 a.m., during an interview, the Director of Nursing (DON) stated that on 4/28/2017 around 8:35 p.m., RN 1 attempted to solely turn and reposition Resident 1 to render wound treatment, when Resident 1 slipped from the bed and fell face down onto the floor. DON stated RN 1 could have prevented the fall had she asked for assistance with repositioning Resident 1 by herself. A review of GACH 1’s Emergency Room documentation dated 4/28/2017, indicated Resident 1 had tenderness at the level of the midthigh (upper leg) up to pelvis (hip area) and did not tolerate rotation or movement of the right hip. A review of GACH 1’s Operation Room (OR) Surgeon note dated 4/29/2017, indicated Resident 1 had surgery for a right femur fracture and underwent a femur intramedullary rodding procedure (a specially designed metal rod inserted into the canal of the femur. Screws are placed above and below the fracture to hold the leg in correct alignment while the bone heals). On 10/27/2017, at 12:44 p.m., during a telephone interview, RN 1 stated she asked for CNA 1's assistance to reposition Resident 1 prior to providing wound care but CNA 1 did not assist her and she (RN 1) decided to reposition Resident 1 by herself. RN 1 stated she had repositioned Resident 1 by herself on 4/26/2017 (two days prior to Resident 1's fall) to render wound care. A review of the facility’s policy and procedures titled, "Fall Prevention Program," dated 2/2016, indicated it was the policy to improve or maintain the quality of life for residents by assessing fall risk based on the resident's level of functioning and current mental, physical and medical status, developing a plan of care to minimize this risk, providing timely intervention to minimize risk and being able to identify causative factors should a fall occur and then accelerate the care plan with new interventions to prevent further falls. The facility failed to ensure Resident 1 did not sustain a fall with injury by not: 1. Developing a Care Plan that indicated the care to be given to by not including Resident 1 needed two staff assist with bed mobility and repositioning as assessed. 2. Reviewing, evaluating, and updating the Care Plan to include the need of two staff assist with bed mobility and repositioning in bed. 3. Implementing the facility’s policy on Fall Prevention Program which indicated assessing the resident’s fall risk and develop a plan of care to minimize risk and prevent falls. As a result, on 4/28/2017 at 8:38 p.m., when Registered Nurse 1 (RN 1) repositioned Resident 1 in bed on her own to provide wound treatment, the resident fell out of bed onto the floor requiring urgent transfer to General Acute Care Hospital 1 (GACH 1) where she was found to have a right hip fracture (break of a bone) which required surgery and hospitalization. The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serios physical harm would result to Resident 1.