Based on clinical record review, facility documentation review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent accidents to the resident causing actual harm, when the resident fell and sustained a nasal fracture, to one of three residents reviewed (Resident R1).
Review of Resident R1's diagnosis sheet revealed a diagnosis of a stroke resulting in left sided hemiparesis and hemiparalysis (weakness and inability to move one side of the body).
Review of Resident R1's Quarterly Minimum Data Set assessment (MDS- periodic assessments of resident needs), dated December 17, 2018, revealed that Resident R1 required extensive assistance of two people to transfer and toilet.
Review of Resident R1's Rehab Discharge Program for Occupational Therapy dated September 29, 2018, revealed the resident was impulsive and had impaired balance with sitting and standing, and required supervision while seated on the toilet and in the wheelchair or on the edge of bed.
Review of Resident R1's revealed a care plan for falls with interventions to encourage the resident to be in the common areas when in the wheelchair for increased supervision and to keep the resident in the living area when in the wheelchair and not supervised in the room.
Review of resident R1's progress notes revealed an entry on January 27, 2019, at 2:17 p.m. stating "the resident was found in her room laying on her stomach on the floor. Her nose was bleeding. Resident states that she dropped her candy on the floor and leaned forward and try to pick it up and fell to the floor."
Review of the facility investigation of the incident revealed that Resident R1 was "in the east lounge and self-propelled herself in her wheelchair back to her room following another resident toward the dining room and stopped in her room for candy. A CNA (nurse aide) saw resident in the room with candy in her hand, resident states that she wanted to eat her candy before going to the dining room for supper. The CNA (nurse aide) went to answer a call bell and when she came back 5 minutes later resident was on the floor. Resident states that she dropped her bag of candy on the floor and she leaned forward to try to pick it up and fell out of her wheelchair."
Review of documentation submitted by the facility dated February 5, 2019, revealed that the resident had an x-ray of the nose on January 28, 2019, which showed a fracture of the nasal bone.
Interview with the Director of Nursing at approximately 2:00 p.m. on February 14, 2019, confirmed that the facility staff failed to follow Resident R1's care plan intervention of not being left unsupervised in the room in the wheelchair which resulted in the resident falling out of the chair and sustaining a fracture.
The facility failed to provide supervision to the resident as care planned to prevent falls which resulted in Resident R1 falling and causing a nasal fracture.
Free of Accident Hazards/Supervision/Devices
CFR(s): 483.25(d)(1)(2) - Previously cited 11/09/18
28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/09/18
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 11/09/18
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 11/09/18
| ||Plan of Correction - To be completed: 03/13/2019|
1. Resident R1's careplan and Kardex were reviewed and updated to ensure individualized careplan interventions (which also feed into the Kardex) are appropriate and relevant to the resident's current status. The updated Kardex and careplan are being reviewed and signed off on by RN's, LPN's and aides who work with resident R1.
2. All residents:
a. Are reviewed for risk of falls with admission, quarterly and with significant changes along with any falls that occur, per fall prevention program policy (policy updated to include significant changes).
i. Individualized risk factors are identified with the fall risk evaluation/ assessment, and based on identified risk factors, individualized interventions are determined.
ii. A one-time report identifying high risk residents with 2 or more falls in the past 3 months was created. Careplans and Kardexes were reviewed by the nursing team for currency and appropriateness and any necessary changes were made to the careplans and Kardexes for the residents identified on the report.
iii. All resident fall situations are evaluated for factors including staff factors that may have been a factor affecting a resident fall.
iv. Further, deviations from care plans when noted are addressed according to facility disciplinary policy and procedures regardless of whether such deviations result in injury.
b. To address current residents at risk for being impacted by the deficiency, additionally to the steps above high risk for fall residents (as determined by 2 or more falls in the past 3 months) will have their careplans and Kardexes reviewed for currency and appropriateness and will be signed off on by RN's, LPN's and aides who routinely care for these residents.
3. To reduce the risk of a recurrence the facility has:
a. Amended its electronic health record alert charting bundle which is completed with admissions, quarterly and with significant changes to include a sign off section by the charge nurse verifying for each shift that the nursing care plans have been reviewed for currency and appropriateness and that if necessary, changes have been made to the nursing careplans.
b. Amended its falls evaluation form that is reviewed by the interdisciplinary team (IDT) when reviewing falls during weekly/ semi-weekly meetings to include a line verifying the fall careplan in its entirety was reviewed for currency and appropriateness when a fall happens, as well as lines for input from the aide team regarding the circumstances of the fall or other concerns around resident falls and safety.
c. Amend the Abuse and Neglect Mandatory Power Point reviewed by staff in Relias semi-annually ongoing
d. Will include in mandatory staff meetings "culture of safety" slides for licensed staff on 3/5/2019 and nurse aide staff 3/13/2019.
4. As part of the QAPI program the facility will audit for 3 months residents that come up for care conference:
a. to determine if they have had 2 falls within the past rolling quarter
i. If so, has their alert charting bundle been completed including the newly created sections requiring signoff for each shift nursing careplan review?
ii. Have their post fall analyses include the newly revised IDT form?
iii. Have any deviations from standards been addressed by facility disciplinary processes when applicable?
b. The facility will continue to evaluate ways of promoting a culture of safety through use of its safety committee and use of the QAPI process and evaluation of best practice guidelines such as those available from sources like AHRQ.gov.
5. Elements as noted above will be in place as of completion of 3/13/2019 staff meeting.