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.
Based on clinical record review and review of incident reports, it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent falls for one of four sampled residents who were at risk for falls. (Resident 36)
Clinical record review revealed that Resident 36 was admitted to the facility on February 25, 2022, and had diagnoses that included dementia, insomnia, and spinal stenosis. The Minimum Data Set assessment dated February 28, 2022, indicated that the resident had memory impairment, and required a one person assist for transfers The assessment further indicated that she was not steady moving from a seated to a standing position, she was not steady walking and had a history of falls. Review of the current care plan identified the resident was at risk for falls. Review of a fall risk evaluation dated March 31, 2022, revealed that the resident had a history of falls, she was disoriented, occasionally incontinent and had poor safety awareness due to taking risks. Review of a second fall risk evaluation dated June 23, 2022, revealed that the resident was disoriented, was frequently incontinent, lacked safety awareness, and had problems walking even with a device.
Review of nursing documentation and incident reports revealed that Resident 36 had fallen 13 times between February 26, 2022, through June 29, 2022. Most of the falls occurred in her room. Six of the falls were between 5:00 p.m., and 11:00 p.m., four of the falls were between 12:00 a.m., and 2:00 a.m.
On February 26, 2022, a nurse noted that the resident was extremely confused and had gotten out of bed several times. Review of an incident report dated February 26, 2022, at 8:00 p.m., revealed that the resident had been found on the floor in her room. On April 15, 2022, a nurse noted that the resident had gotten up repeatedly from her bed and was combative with staff. Review of incident reports dated April 16, 2022, and April 26, 2022, revealed that the resident had additional falls. A nurse noted on April 26, 2022, that the resident had been exit seeking, was confused and had been pacing the hallway. Review of incident reports revealed that the resident fell again on May 24, 2022, and May 29, 2022. On June 8, 2022, a nurse noted that the resident gets up unassisted in her room. Review of incident reports dated June 8, 11, 13, 23, and 24, 2022, revealed that the resident had fallen five more times. Review of an incident report dated June 29, 2022, revealed that at 12:30 a.m., the resident had an unwitnessed fall in her room requiring a hospital evaluation.
There was no documented evidence that the facility had evaluated the need for increased supervision in order to prevent falls.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| ||Plan of Correction - To be completed: 08/15/2022|
- Resident 36 was assessed and has no more residual effects from the fall. The fall interventions for the resident will be reviewed and amended to include options for varying levels of increased monitoring.
- The Resident Safety Committee shall review the interventions implemented for residents with recent falls for appropriateness and the consideration of increased Supervision/monitoring.
- The Falls and Falls Rick, Managing Policy shall be reviewed for the inclusion of supervision/monitoring considerations and updated as necessary. The nurses will be educated on the Policy. Audits will be conducted to verify the staff understanding and compliance.
- The Resident Safety Committee will audit incidents reports for appropriate interventions weekly x 4 and then monthly x2. Results will be reported to the Quality Assurance Committee. Compliance will be evaluated and the process revised if necessary.
- Completion date: August 15, 2022.