Other·August 26, 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. §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. On 6/2/2021, an unannounced visit was made to the facility to investigate a complaint regarding quality of care. The facility failed to ensure Resident 1, who was diagnosed with dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), was a high fall risk, and severe cognition impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), received adequate supervision and assistance devices to prevent accidents. The facility failed to: 1. Notify the physician of Resident 1’s behavior of crawling out of bed as indicated in the resident’s care plan for Seroquel (anti-psychotic medication). 2. Ensure the resident’s call light was within reach as indicated in the resident’s fall care plan. 3. Implement the facility’s fall prevention program to provide Resident 1 a floor mat as indicated in the facility’s policy on falling star program. 4. Implement the facility’s fall prevention program to place the falling star emblem at Resident 1’s head of bed, outside the room on the name sign, or the wristband. As a result, on June 2, 2021, at 2:12 PM, Resident 1 fell on the floor, in the doorway of her room, sustaining a laceration to the right eyebrow which measured 0.6 centimeters (cm) in length by 0.6 cm. in width and required daily skin treatment for 14 days. A review of Resident 1's Admission Record indicated the resident was a 97-year-old female, admitted to the facility on May 5, 2021 with diagnoses including history of falling, dementia and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). A review of Resident 1’s Fall Risk Assessment dated May 5, 2021 indicated Resident 1 had a score of 75, which was a high risk for falls (score of above 45 indicates score of high risk). The fall risk assessment included Resident 1’s mental status indicating resident forgets limits or overestimates ability to ambulate safely. A review of the Fall Care Plan dated May 6, 2021 indicated Resident 1 had a problem related to status post (previous) right hip fracture. The care plan interventions indicated to anticipate and meet the resident’s needs, be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The interventions indicated Resident 1 needed prompt response to all requests for assistance and to follow facility fall protocol. According to a review of the Physician’s Orders dated May 6. 2021, Resident 1 received Seroquel (an anti-psychotic drug) 25 milligrams (mg) by mouth two times a day for psychosis (a condition that affects the way your brain processes information, causes you to lose touch with reality), manifested by unknown behavior. A review of Resident 1's Minimum Data Set (MDS – a standardized assessment and care screening tool), dated May 8, 2021, indicated Resident 1 had severe cognitive impairment and required extensive assistance for bed mobility, personal hygiene, total dependence for toilet use and was only able to stabilize with staff assistance. The MDS indicated Resident 1 had a history of a fall within the last month. The functional status section indicated Resident 1 was not steady moving from seated to standing position, was impaired on both sides of lower extremities, and did not use a mobility device (cane or walker). A review of Resident 1’s Seroquel Care Plan, dated May 14, 2021, indicated Resident 1 would be free of psychotropic drug complications. The care plan interventions indicated to monitor behavior every shift (did not include specific behavior), discuss with the physician Resident 1’s behaviors and document adverse reactions such as frequent falls and behavior symptoms not usual to the person. During an observation on June 2, 2021 at 2:12 PM, the surveyor found Resident 1 sitting on the floor in the doorway of her room. Resident 1 stated, "All day she no come. I go home." Upon inspection of Resident 1's room, the call light was out of the resident's reach, hung above the bed over the overhead light. There was no floor mat or bed alarm in place. During an observation on June 2, 2021 at 2:20 PM, Treatment Nurse/Licensed Vocational Nurse 2 (LVN 2) arrived to Resident 1’s room and called for help. LVN 2 noted the small laceration on Resident 1's right eyebrow, measuring 0.6 cm in length by 0.6 cm in width, with purple discoloration. LVN 2 stated, "This is new." LVN 2 then stated and confirmed the call light was hung over the overhead light and should be within Resident 1’s reach. During the observation, LVN 2 administered first aid to Resident 1’s laceration to the right eyebrow. A review of the Post Fall Assessment, dated June 2, 2021, indicated the physician ordered for Resident 1 to receive a daily 14-day skin treatment to the right eyebrow. During an observation on June 2, 2021 at 2:30 PM, Resident 1 was noted with no falling star emblem on a blue wrist band nor a star next to Resident 1’s name sign outside the room. During this same observation, LVN 3 arrived at Resident 1's room, assisted the resident to standing with a front wheel walker (FWW), and walked with Resident 1 back to her bed with standby assistance. During a concurrent interview, when asked about a floor mat or bed alarm for the resident, LVN 3 stated there was no floor mat or bed alarm in place and left Resident 1's room. During an observation on June 2, 2021 at 2:35 PM, Resident 1 was observed crawling out of bed, through the FWW and out to the hallway. A review of the Un-witnessed Fall report, dated June 2, 2021, indicated Resident 1 had a small skin abrasion on the side of the right eyebrow which measured 0.6 cm x 0.6 cm) noted with scant bleeding. Resident 1 complained of a little pain on skin area and refused to take pain medication. During an interview on June 2, 2021 at 2:48 PM, LVN 3 stated Resident 1’s behavior of crawling out of bed had been going on for a couple days. LVN 3 stated and verified there was no documentation the physician was notified regarding Resident 1’s behavior of crawling out of bed and sitting in the hallway. During an interview on June 2, 2021 at 3:20 PM, the social services staff stated she noticed Resident 1 constantly verbalizing wanting to go home and crawling out to the hallway. The social services staff further stated Resident 1 was not safe to go home. When asked if the behavior was documented or reported to the family or physician, the SSW stated she did not document Resident 1's behavior and did not notify the family or physician. During an interview with the Director of Staff Development (DSD) on July 20, 2021 at 9:27 AM, the DSD stated staff did not notify physicians or resident’s responsible party and use Changes in Condition form on the computer to document adverse reactions such as frequent falls and behavior symptoms not usual to the person. On July 26, 2021 at 4:11 PM, during an interview, when asked about the falling star emblem not observed for Resident 1, the DSD stated Resident 1 was not a high fall risk upon admission. A review of the facility's policy titled, "Fall Prevention Program," dated December 2016, indicated if on admission, a risk for fall was identified, initiate use of fall prevention and reduction program according to fall risk score. All precautions on the falls care plan should be implemented to protect the resident. Care plans should include treatment prescribed by the physician and interventions, such as, monitoring medication review and alarms should be implemented. This same policy indicated the Falling star program: The falling star emblem will be placed and/or located at: Head of bed, assistive devices such as wheelchairs, walkers, etc.; outside the resident's room on the name sign; wristband; bed and/or chair alarms; non-skid floor mat. Environment: Bed height, Support and Mattresses: landing mattress may be use for fall prevention next to bed to decrease injuries. Bed Alarm systems: These are designed to warn nursing staff that patients or residents who should not attempt to leave their bed unassisted are doing so. Evaluate and choose alarm systems based on such features as loudness, built-in time delays, ease of use, etc. The facility failed to ensure Resident 1, who was diagnosed with dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), was a high fall risk, and severe cognition impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), received adequate supervision and assistance devices to prevent accidents. The facility failed to: 1. Notify the physician of Resident 1’s behavior of crawling out of bed as indicated in the resident’s care plan for Seroquel (anti-psychotic medication) 2. Ensure the resident’s call light was within reach as indicated in the resident’s fall care plan. 3. Implement the facility’s fall prevention program to provide Resident 1 a floor mat as indicated in the facility’s policy on falling star program. 4. Implement the facility’s fall prevention program to place the falling star emblem at Resident 1’s head of bed, outside the room on the name sign, or the wristband. As a result, on June 2, 2021, at 2:12 PM, Resident 1 fell on the floor, in the doorway of her room, sustaining a laceration to the right eyebrow which measured 0.6 cm in length by 0.6 cm. in width and required daily skin treatment for 14 days. The above violation had a direct or immediate relationship to the health, safety, and security of Resident 1.