§483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally-competent and trauma-informed.
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Observations:
Based on review of clinical records, facility policy, facility investigative reports, and interview with staff, it was determined the facility failed to ensure hospice staff implemented care-planned interventions for one of 34 residents reviewed, who was identified as a fall risk. This failure resulted in actual harm to Resident R24 who sustained a fall out of bed during care, required transfer to the hospital via emergency medical services and sustained four sutures to left forehead/eyebrow and back of the head. (Resident R24)
Findings include:
Review of facility policy titled, "Fall Prevention and Management" revised January 1, 2023, revealed the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Review of subsection titled, "Procedure" revealed 1. Assess and review resident risk factors for falls and injuries upon admission, re-admission, quarterly, annually a significant change and/or after a fall. Review the completed Fall Risk Assessment/ Evaluation. Review other interdisciplinary Team (IDT) assessments as they related to fall risks. 2. Implement goals and interventions with input from resident/family if able for inclusion in Interdisciplinary Plan of Care based on individual needs after attempting to determine possible causes. 3. Communicate interventions to the care giving teams and family responsible party.
Review of facility policy titled, "Incident Reporting and Investigation of Accident Hazards, Supervision, Assistive Devices," revised October 30, 2024, revealed "assistance Devices" or "Assistive Device" refers to any item (e.g. fixtures such as handrails, grab bars, and mechanical devices/equipment such as stand- alone or overhead transfer lifts, cane, wheelchairs, and walkers) that is used by, or in the care of a resident to promote, supplement, or enhance the resident's function or safety... "Environment" refers to any environment in the facility that is frequent by or accessible to resident including (but not limited to) the resident 's rooms, bathrooms, hallway, dining areas, lobby, outdoor patios, therapy areas and activity areas.
Review of facility policy titled "Care Planning Process and Care Conference," revised March 19, 2025, revealed the purpose of policy is to "assure that all services, as outlined by the comprehensive care plan being provided, meet professional standards of quality," including "activities of daily living (ADL's), falls, skin tears, risk for skin breakdown, nutritional status, behaviors..."
Review of Resident R24's clinical record revealed the resident's diagnoses of Dementia (progressive decline in mental ability), Parkinson's disease (disorder of central nervous system that affects movement), and Anxiety (mental health condition characterized by excessive fear or anxiety that interferes with daily activities)
Review of R24's quarterly Minimum Data Set (MDS- assessment of resident's care needs) completed on August 14, 2024, revealed BIMS score of 2 which indicated the resident had severe cognitive impairment. Continued review of the MDS assessment revealed the resident was determined to require extensive assistance of one person physical assist for bed mobility.
Review of Resident R24's physician orders revealed an order initiated April 16, 2024, for side rail enablers to bed bilaterally to assist with bed mobility and increase functional independence.
Review of Resident R24's care plan initiated November 18, 2024, revealed the care plan included the use of 1/4 siderail enablers to bed bilaterally to assist with bed mobility and increase functional dependance. Intervention listed "ensure enablers are up at all times while resident is in bed."
Review of information dated September 3, 2024 submitted by the facility to the Department of Health revealed, "On 9/3/2024 while performing personal care, the aide from [hospice provider] turned [resident] toward her in the bed to assist (resident) with pulling up (his/her) pants. The aide was attempting to walk to the other side of the bed to finish up, and did not realize that [resident] was holding on to her (aide) pocket. [Resident R24] fell from the bed to the floor. [Resident R24] sustained a laceration to (his/her) left eyebrow and the left back side of (his/her) head. First aid was applied to the area and 911 was called. [Resident R24]'s daughter was notified regarding the fall. [Resident] was taken to [area hospital] where (he/she) received 4 sutures to (his/her) left eyebrow and 4 staples to the left back side of (his/her) head. [Resident] returned to the facility around 2028. Care plan reviewed and updated. New intervention noted for 2-person assist with bed mobility noted."
Review of nursing documentation dated September 3, 2024, at 11:45 a.m. revealed the hospice nurse aide called nurse on duty for help, upon arrival resident was on the floor in supine (lying on one's back with face upward) position. Resident had two lacerations on the head, one above (his/her) left eyebrow and the left side of the head. "Injury site was cleansed with normal saline, gaze applied, Bright blood noted pressure applied to the area... on O2 (oxygen) @ 2L (liters). 911 (emergency medical services) called to transfer resident to [local hospital]."
Continued review of nursing notes dated September 4, 2024, revealed "Resident did return with 4 sutures in left forehead/eyebrow, 4 stapes left side of head."
Review of facility investigation report, completed on September 4, 2024, revealed on September 3, 2024, while receiving care from hospice nurse aide, Employee E3, at approximately 11:45 a.m., Resident R24 had a "witnessed fall that resulted in a transfer to hospital where [he/she] received four sutures to [his/her] left eyebrow and four staples to the left back side of [his/her] head."
Further review of same report revealed the hospice nurse aide, Employee E3 turned Resident R24 toward her in bed to assist him/her with pulling up his/her pants; the aide was attempting to walk to the other side of the bed to finish up, and did not realize Resident R24 was holding onto aide's pocket. Resident R24 fell from bed to the floor. The resident sustained two lacerations on the head.
Further review of Resident R24's fall incident/accident investigation report, completed on September 3, 2024, at 11:45 a.m., revealed one of the question on the report was "were proper tools/equipment being used?" for which the answer was marked as "no," without further description.
Review of hospice nurse aide, Employee E3's statement failed to reveal evidence bilateral 1/4 side rail enablers were utilized at the time.
Interview with hospice nurse aide, Employee E3 on Friday, May 9, 2025, at 10:40 a.m., revealed Employee E3 was not aware the resident's care plan and physician's order indicated the need for bilateral side rails as mobility enablers.
The facility failed to ensure hospice staff were aware of Resident R24's care plan interventions related to the use of 1/4 side rails while in bed for safety. This failure resulted in actual harm to Resident R24 who was holding onto nurse aide, Employee E3's pocket while in bed, fell out of bed when Employee E3 moved away from resident, sustaining four sutures to left forehead/eyebrow and four sutures to the back of the head.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(1)(e)(1) Management
28 Pa Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 06/03/2025
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R24 - The facility cannot go back retroactively to address the issue. The DON/designee conducted an audit of residents that are care planned for enablers to ensure hospice staff are aware of the intervention of enablers to assist with bed mobility. Hospice staff were educated on the use of enablers for bed mobility by the staff Educator. The DON/designee will conduct audits of hospice residents to ensure if the resident is care planned for enablers to assist with bed mobility and that hospice staff are aware of this care plan intervention. Audits will be done weekly x 4 weeks then monthly x 2 months. Audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
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