Observations:
Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for one of seven residents (Resident R1).
Findings include:
The facility policy " Fall protocols" dated 2/12/19, indicated that residents would be assessed for fall risk upon admission, re-admission, quarterly and with a significant change in medical condition. In the event of an actual fall, an attempt would be made to eliminate causal factors and prevent further falls. Once a resident has had a fall, they are considered to be at high risk for falls. Resident determined to be at high risk for falls will have the following interventions including that the care plan will be revised for any new fall prevention interventions and documentation of any educational interventions for prevention.
Review of the Quarterly Minimum Data Set (MDS- periodic assessment of care needs) dated 7/17/19, indicated that Resident R1 had diagnoses that included Alzheimer's disease, dementia, high blood pressure, osteoporosis (thinning of bones), osteoarthritis and seizure disorder. The MDS indicated that Resident R1 had moderate cognitive impairment, required extensive assist of two persons for transfer and did not ambulate.
Review of facility documentation indicated that Resident R1 had fallen without sustaining injury on 3/16/19, 3/26/19, 6/23/19 and 8/17/19.
Review of the Progress Note dated 8/4/19, indicated that Resident R1 had bed and chair alarms (device to prevent falls by alerting staff to resident movement) but "she often removes alarms from her bed and chair, she is educated on this almost daily."
Review of the Progress Note dated 8/11/19, indicated that Resident R1 "is sometimes non-compliant with her alarms, she shuts them off and each time is educated on the importance of them."
Review of a Fall Report dated 8/17/19, indicated that Resident R1 was found on the floor, disconnects bed alarm. Interventions included offering toileting if awake during rounds.
Review of the Progress Note dated 9/1/19, indicated that Resident R1 "turned off her alarm and was seen self-transferring to her w/c (wheelchair). Education provided about the risks of falls, she did not reply that she understood, so I repeated it. She still did not reply."
Review of a Fall Investigation statement from Nurse Aide Employee E1 dated 9/24/19, indicated that Resident R1 was not compliant with use of her call bell and would self-transfer into her wheelchair.
Review of a Fall Report dated 9/24/19, at 2:30 a.m. indicated that Resident R1 was heard yelling for help and was found on the floor in front of the toilet with wheelchair in the bathroom, possible injury and transfer to the hospital.
Review of the current Care Plan for Resident R1 last updated on 5/29/19, indicated a risk for falls was identified as a problem and included interventions of bed sensor alarms.
During an interview on 9/30/19, at 2:40 p.m. the Director of Nursing confirmed that Resident R1 was known to be non-compliant with call bell use, frequently turned off bed and chair alarms and was known to self transfer. The DON confirmed that Resident R1 was at high risk for falls and the facility failed to provide adequate supervision to prevent the fall on 9/24/19.
28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 5/3/19.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
Previously cited 5/3/19.
28 Pa. Code 211.10(d) Resident care policies.
Previously cited 5/3/19.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 10/17/2019
The Facility will provide adequate supervision to prevent falls for residents. The facility cannot retroactively correct the concern identified for resident R1, this resident was discharged from the facility.
The Regional Clinical Consultant or Designee will review residents who had a fall in the last 30 days to validate that a fall assessment has been completed and that care plan interventions are in place, and adequate supervision is provided to assist in prevention of further falls.
The Director of Nursing or Designee will re-educate licensed staff on the facility fall protocol to include fall risk assessment upon admission/re-admission quarterly/ and with significant change in medical status, and updating the care plan
to include appropriate interventions to prevent further falls, and providing
adequate supervision for resident safety.
The Director of Nursing or/designee will complete an audit weekly times four
weeks then monthly times three months to validate that a fall assessment has been completed and care plan interventions are in place to assist in prevention of further falls for residents.
The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
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