Health inspection·July 22, 2021

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. F 689 §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. § 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. § 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. On 4/27/2021 an unannounced visit was made to the facility to investigate a facility reported incident received to the Department regarding quality of care / resident safety. The facility failed to ensure Resident 1 received adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistant 1 (CNA 1) did not provide Resident 1 with safe transfer from wheelchair to bed, by not using a gait belt (also known as transfer belt, is a safety device used to help someone move, such as from a bed to a chair. The belt is also used to help hold someone up while he/she walks, if too weak to walk on his/her own. The gait belt helps the caregiver provide support and prevent a fall). As a result, on 4/21/2021 at 2:15 PM Resident 1 fell onto the floor sustaining a right leg below the knee fracture, requiring transfer to General Acute Care Hospital 1 (GACH 1) where Resident 1 was diagnosed with a closed fracture (does not penetrate the skin) of the proximal end (close to the knee) of the right tibia and fibula (the fibula, along with the tibia, makes up the bones of the lower leg). A review of Resident 1's Admission Record indicated Resident 1 was 84 years old when admitted to the facility on 10/16/2010 and was readmitted on 3/2/2021 with diagnoses including dementia (loss of mental ability severe enough to interfere with normal activities of daily living) and osteoarthritis (degeneration of joint cartilage[rubber-like padding that covers the joints] and the underlying bone, causing pain and stiffness) of multiple joints with gait instability (unstable walk). A review of Resident 1's Plan of Care for Fall Risk developed 3/2/2021, indicated the goal was for the resident not to have injury related to fall. A review of Resident 1's Plan of Care for Activities of Daily Living developed on 3/2/2021, indicated the interventions to provide assistance with transfers as needed, assist with repositioning, anticipate needs prior to leaving room and keep frequently used items within close reach. According to a review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 3/12/2021, Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one person assist for transferring, bed mobility, dressing, eating, toilet use and personal hygiene. Resident 1 was not steady for surface-to-surface transfer, between bed and chair, wheelchair, and standing position. A review of Resident 1’s Interdisciplinary (IDT- healthcare professional from different disciplines participating in the care of the resident) Notes, dated 4/23/2021, indicated on 4/21/2021, at 2:15 PM, during transfer of Resident 1 from wheelchair to bed, Resident 1 was assisted by CNA 1 to stand up while the resident was holding onto the nightstand. CNA 1 moved the wheelchair away for the resident to pivot and sit on the bed. Resident 1 started saying no, no, no and started to sit back down. CNA 1 broke the fall by lowering the resident on the floor on a sitting position and reported the fall to the Registered Nurse (RN) Supervisor. RN Supervisor assessed Resident 1, did not notice injury and the resident did not complain of pain at the time. RN Supervisor and CNA 1 transferred the resident to the bed. During the 3 PM to 11 PM shift, the IDT notes indicated CNA 2 reported Resident 1 was complaining of pain and CNA 2 informed the RN Supervisor. The RN Supervisor assessed Resident 1 and Tylenol (medication used for pain control) 325 milligrams (mg) was given to Resident 1. At around 8 PM, CNA 2 reported Resident 1 was in pain and had skin discoloration and swelling of the right leg. The RN Supervisor informed the doctor and received an order for a venous doppler study (ultrasound is a diagnostic test used to check the circulation in the large veins in the legs) and x-rays (used to generate images of tissues and structures inside the body) of the right leg. A review of Resident 1's Radiology Report, dated 4/22/2021 indicated a subtle fracture of the right proximal tibia (shinbone just below the knee) could not be excluded. A review of the Resident 1’s Nursing Notes dated 4/23/2021 at 3:30 PM indicated the attending physician was made aware of the x-ray results and ordered to transfer Resident 1 to GACH 1. According to a review of GACH 1’s Emergency Department (ED) documentation, dated 4/23/2021, Resident 1 arrived at 10:10 PM complaining of right leg pain status post fall. Resident 1 was noted to have bruising and purple color to the right leg. X-rays showed nondisplaced fractures (the bone cracks but stays in place) of the proximal tibia and fibula. Resident 1 was seen by orthopedist (specialist in conditions and diseases of the bones, joints, and spine) who stated Resident 1 was not a candidate for surgery (operation) and recommended a knee immobilizer and discharged with instructions of being seen the orthopedist in two weeks. Resident 1 was given Morphine (medication used to help relieve moderate to severe pain) 4 mg for pain in the right leg. Resident 1’s diagnosis was a closed fracture of the proximal end of the right tibia and fibula. Resident 1 was sent back from the ED to the facility. On 4/27/2021 at 1:04 PM., during an interview, CNA 1 stated Resident 1 was in the wheelchair after lunch and wanted to go back to bed. During the transfer, CNA 1 removed the wheelchair and positioned herself behind the resident. Resident 1 wanted to sit down, but there was no wheelchair to sit in, CNA 1 stated she normally uses a gait belt when transferring Resident 1 but did not use one at the time of the transfer with fall. On 4/28/2021 at 3:30 PM., during an interview, the RN Supervisor stated that on 4/21/2021, at around 4:30 PM, the RN Supervisor checked on Resident 1 and Resident 1 was in pain. The RN Supervisor gave the resident Tylenol for pain control. At around 8 PM., the RN Supervisor checked on Resident 1 and noted swelling and discoloration, informed the doctor and he ordered x-ray and venous doppler. The RN Supervisor stated that gait belts were used in the facility during transfer of residents to help prevent falls. On 5/18/2021 at 2:35 PM., during an interview, the Director of Nursing (DON) stated nursing staff have been trained on using gait belts during transfer of residents. The gait belt was used to assist with weight bearing procedure. The DON stated the facility had no policy on use of a gait belt, but the CNAs were trained in the use of belts during transfers. A review of Gait Belt Training dated 7/7/2020 indicated staff were to place the belt around the patient's waist only, secure the buckle by threading the metal-tipped end through the buckle hinge, over the teeth and through the slot at the back of the buckle. The training indicated to make certain the belt fits snugly. Grasp the belt at the patient's back and the patient's right or left side. 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 received adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistant 1 (CNA 1) did not provide Resident 1 with safe transfer from wheelchair to bed, by not using a gait belt (also known as transfer belt, is a safety device used to help someone move, such as from a bed to a chair. The belt is also used to help hold someone up while he/she walks, if too weak to walk on his/her own. The gait belt helps the caregiver provide support and prevent a fall). As a result, on 4/21/2021 at 2:15 PM Resident 1 fell onto the floor sustaining a right leg below the knee fracture, requiring transfer to General Acute Care Hospital 1 (GACH 1) where Resident 1 was diagnosed with a closed fracture (does not penetrate the skin) of the proximal end (close to the knee) of the right tibia and fibula (the fibula, along with the tibia, makes up the bones of the lower leg). 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.