§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 observation, closed clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to to provide the services necessary to prevent accidents resulting in multiple sustained fractures for one of five residents reviewed resulting in actual harm (Resident CR1).
Findings include:
Closed clinical record review for Resident CR1 revealed a nursing note dated May 14, 2024, at 9:09 PM noting the resident was being turned by a nurse aide and rolled off the bed onto the floor. It was noted the resident had a left dorsal head bump and complaints of severe left hip pain.
A follow up nursing note for Resident CR1 dated May 14, 2024, at 9:23 PM indicated the physician had provided a verbal order to send the resident to the emergency room due to the severe left hip pain.
Nursing documentation dated May 14, 2024, at 11:34 PM summarized the incident that occurred prior to being transferred to the hospital. The writer noted they heard a loud thump outside of Resident CR1's room and entered the room to find Resident CR1 on the floor between the resident's bed and the first bed in the room. It was noted a hematoma (bruise) was observed on the back of the resident's head on the left side, and the resident had complaints of hip pain. A nurse aide in the room was questioned as to how the incident occurred and what side the resident landed on. The nurse aide in the room replied with, "I don't know." The nurse aide was halfway between the resident's bed and bathroom when the writer entered. The writer indicated that based on experience, the resident is unable to roll independently and will continue to roll if she is rolled by the nurse aide and let go. The writer noted the resident left the facility at 9:35 PM to go to the emergency room.
A review of Resident CR1's documents from the emergency room visit revealed the resident received several tests in the emergency room dated May 14, 2024, to include x-rays of her bilateral hips, chest, and left shoulder as well as CT scans of her cervical spine, head/brain, chest/abdomen, and pelvis. Review of the resident's emergency department provider summary of the visit revealed the resident was diagnosed with a scalp hematoma (bruise), right hip fracture, multiple left-sided rib fractures, and a left scapular (shoulder blade) fracture. It was noted the residents responsible party declined surgery for the resident's hip fracture.
A nursing note dated May 15, 2024, at 5:55 AM for Resident CR1 indicated the resident returned to the facility from the emergency department at 5:00 AM and staff were not able to complete a full skin assessment due to the resident being in too much pain. Nursing staff administered Morphine (an opioid medication used to treat severe pain).
Continued review of Resident CR1's nursing notes after her return to the facility revealed multiple entries of the resident being in pain and requiring increased doses of Morphine. A referral for hospice services to assist with pain management was noted on May 17, 2024, at 8:01 AM.
Nursing documentation dated May 17, 2024, at 11:39 AM noted Resident CR1 had a significant decline, noting the resident was unable to eat breakfast, intermittently crying out in pain, presenting cognitive decline, and unable to swallow pills safely. The resident's pain regimen was changed, and the resident was placed on hospice care as of May 17, 2024, at 12:31 PM.
Resident CR1 continued to have noted decline, and expired at the facility on May 20, 2024, at 10:23 AM.
Closed record review for Resident CR1 revealed the resident was listed in care tasks as requiring maximum assistance of two and a bed rail to the left side for bed mobility since December 1, 2023, and at the time of the incident noted above.
A review of Resident CR1's plan of care for ADL deficits (activities of daily living) initiated April 18, 2017, identified an intervention added to the care plan dated April 8, 2019, that the resident required maximum assistance and a bedrail to the left side of the bed for bed mobility.
A quarterly MDS (minimum data set, an assessment completed at periodic intervals of time to determine resident care needs) for Resident CR1 dated May 2, 2024, revealed facility staff assessed the resident as requiring extensive assistance of two people physical assist for bed mobility.
Review of a statement dated May 14, 2024, obtained from Employee 1, nurse aide, who was identified as the nurse aide in the room at the time of the incident with Resident CR1 on May 14, 2024, indicated Employee 1 was dressing and cleaning the resident, turned the resident to her side to clean her bottom and fix the pad underneath the resident, and the resident kept yelling about her bottom hurting and kept trying to turn off her side. Employee 1 asked the resident to stop rocking. Employee 1 indicated she got the pad under the resident and when she went to roll the resident towards her the resident said "no," and ended up turning toward the nurse aide and fell off the bed noting she tried to catch the resident but was not able to hold onto her. Employee 1 did not indicate any staff were assisting her with providing care to the resident in bed as the resident required.
Interview with the Nursing Home Administrator on June 4, 2024, at 10:45 AM revealed that Employee 1 was staffed from a nursing agency and had first worked at the facility on Saturday, May 11, 2024, again on May 13, and May 14, 2024, the day of the incident with Resident CR1.
A review of Employee 1's "Quick Start" orientation packet for the facility, which included information on abuse and reporting, resident rights, proper body mechanics, and incidents and accidents, was dated May 13, 2024, the employee's second day of work at the facility. The orientation packet did not include any information on how to access the Point of Care system or how to find a resident Kardex in the electronic system to determine resident care needs, which indicate a resident's needed level of assistance for tasks such as bed mobility, eating, transferring, bathing, and ambulation.
Interview with the Nursing Home Administrator on June 4, 2024, at 1:20 PM revealed that Employee 1 did not complete the orientation packet until May 13 due to the first day of work (May 11th) being a Saturday and confirmed the orientation packet had no information as to where to find or determine a resident's care needs prior to providing care to residents.
Review of information submitted by the facility on May 21, 2024, for the above incident regarding Resident CR1 and Employee 1, indicated Employee 1, nurse aide, was providing care to Resident CR1 at the time of the above incident, and while providing care the resident rolled out of bed and sustained multiple fractures. The report indicated Employee 1 was immediately suspended at the time of the incident to complete an investigation, and the facility substantiated neglect had occurred as Employee 1 provided care to the resident independently without the resident's required assistance of two people, despite the fact that the facility failed to provide this information to Employee 1. The facility noted Employee 1 was placed on "do not return" status with the agency. As further intervention, the facility indicated nurse aides had been educated regarding care on the resident Kardex in Point of Care (system location to find resident care needs) and the agency orientation packet that agency staff complete when starting at the facility would have a bed mobility and transfer status section added to it to identify resident care needs.
An observation in the facility on June 4, 2024, at 11:30 AM revealed Employee 2, nurse aide, providing care to residents on the upper level of the facility. In a concurrent interview with Employee 2 she indicated she was agency staff who was called into the facility and arrived at the facility around 8:40 AM. Employee 2 indicated it was the first time she had worked at the facility. Employee 2 stated she was not provided nor completed any orientation packet upon arrival to the facility or prior to providing care to residents in the facility. Employee 2 indicated she was provided a user log in for the Point of Care system but had not logged into it yet, and only knew how to obtain a resident Kardex due to using the same system in another facility she had worked at. Employee 2 was able to demonstrate to the surveyor after multiple attempts to log in to the electronic system how to find a resident Kardex and that it was like another place she had worked.
Further review of the facility's follow up to the above incident and interventions facility staff indicated would be implemented in the information submitted revealed the facility did not complete nurse aide and licensed practical nurse education until May 16, 2024, on utilizing the resident's Kardex on the Point of Care system. The facility's current "Quick Start" orientation packet agency staff are to complete when starting at the facility remained unchanged from the packet Employee 1 signed off as completing on May 13, 2024.
Interview with the Nursing Home Administrator on June 4, 2024, at 2:52 PM confirmed no changes had yet been made to the packet to include the information regarding the resident Kardex and Point of Care system to determine resident care needs. The Administrator was made aware agency staff were actively working in the facility and Employee 2 was permitted to start working with residents in the facility without completing an agency orientation packet or any competency that the employee could access information to determine resident care needs prior to her start of work with residents in the facility. The Administrator also confirmed Employee 1 had no record of education or competency on identifying resident care needs prior to the incident, which caused harm to Resident CR1.
483.25 (d) Free from accident hazards
Previously Cited 11/17/23
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a) Resident rights
| | Plan of Correction - To be completed: 06/24/2024
Step 1: The facility DNR'd the agency CNA who neglected Resident CR1, her agency was notified, as well as her registry number reported.
Step 2: THe NHA/Designee will look at all current residents to ensure transfer status, bed mobility status, and ADL status is located and accurate in Kardex on POC system. Agency orientation packet will be updated with location of Kardex in POC.
Step 3: Affinity Services will provide directed in-service for direct care staff on F689 Free of accident hazards/supervision/devices on 6/20/2024. The facility will educate direct care staff on location of bed mobility, transfer status, and ADL care on Kardex system within POC system. The NHA/Designee will ensure all agency direct care staff entering facility are oriented to the facility via updated agency orientation packet.
Step 4: The NHA/Designee will monitor bi-weekly for two months to ensure agency staff are completing agency orientation packets prior to the start of their first shift within the facility. With substantial compliance, NHA/Designee will monitor monthly for three months, bringing results to quality assurance committee.
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