§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.
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Observations:
Based on review of clinical records, interviews with staff, facility documentation and policy, it was determined that the facility failed to implement fall interventions for one of two residents reviewed for falls. (Resident CL1)
Findings include:
Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on January 5, 2025, with diagnoses including cerebral palsy (group of neurological disorders that affect movement), muscle weakness, need for assistance with personal care, and abnormalities of gait and mobility. Resident CL1 had a Brief Interview for Mental Status score of 15, indicating intact cognitive function.
Review of Resident CL1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening), dated April 13, 2025, indicated that the resident had an upper extremity impairment on one side, and lower extremity impairment on both sides. The resident utilized wheelchair for mobility and required substantial/maximal assistance with showers; and extensive assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed.)
Review of Resident CL1's current care plan revealed a care plan for falls related to deconditioning, date-initiated January 5, 2025. Interventions included "low bed in lowest position at all times, except during care."
Continued review of Resident CL1's clinical records revealed a nursing note dated April 28, 2025, which indicated, "resident fell at 10:15 p.m." and complained of pain on the head. The resident hit her face on the nightstand.
Review of facility fall investigation dated April 28, 2025, revealed that the resident fell at 10:15 p.m. and hit her head on the nightstand. Review of resident statement revealed, "I slid off the bed while on my side."
Interview with the Director of Nursing, conducted on May 5, 2025, at 10:52 a.m. revealed, "the aid was bathing the resident on the air mattress. The resident was on her side, on the bed and lying on the middle of the bed. The Nurse Assistant, Employee E5, noted redness on her bottom and went to the door to ask for some cream and the resident had fallen."
Interview with the Nurse Assistant, Employee E5, conducted on May 5, 2025, at 12:10 p.m. revealed that the resident "was positioned in the middle of the bed, on her right side facing the door; and the bed was in the average position at the hips when I went up to the door to ask for cream." Further interview confirmed that Employee E5 had not placed the bed in the lowest position and on the back side, prior to leaving the resident unattended.
Follow-up interview with the Director of Nursing, conducted on May 5, 2025, at approximately 1:30 p.m. confirmed that the resident's bed should have been lowered before the Nurse aide, Employee E5 walked away from the resident to request the cream because she was no longer providing direct care.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12 (d)(5) Nursing services
| | Plan of Correction - To be completed: 05/27/2025
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report.
Resident CL1's fall interventions were reviewed for appropriateness and to ensure that the fall interventions in place were being implemented.
House-wide audit performed of all residents' fall interventions to ensure they are being implemented.
Nursing staff will be in-serviced on ensuring that fall interventions are being implemented per the residents' care plan.
The Director of Nursing/Designee will conduct a random audit of five resident's fall interventions to ensure those interventions are being implemented in accordance with the fall care plan weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
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