§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 the review of clinical record, facility investigation, policies and procedures interview with staff, it was determined that the facility failed to ensure resident environment was free of accident hazard related to providing appropriate technique during resident care which resulted in resident falling from the bed during care for one of five residents reviewed (Resident R1)
Findings Include:
Review of facility policy "Fall Management Program" dated December 17, 2024, revealed that "The community will maintain systems designed and implemented to identify hazards and individual resident risk; evaluate hazards and risks; implement interventions to reduce hazards and risks; and monitor the effectiveness of measures implemented in an attempt to eliminate or reduce the risk of accidents as much as possible."
Review of Resident R1's clinical record revealed the diagnoses of lack of coordination, unsteadiness on the feet, obesity and muscle weakness.
Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated January 28, 2025, revealed that the resident required partial/moderate assistance on bed mobility and required substantial/maximum assistance on transfers to and from bed to chair. MDS also revealed that "substantial/maximum assistance" status coding indicated helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. "Partial/moderate assistance" status coding indicated helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
Review of care plan for Resident R1 dated July 22, 2024, revealed that Resident R1 required assistance with ADL's (Activities of Daily Living- bed mobility/transfers/eating/dressing/bathing and hygiene)
Review of facility investigation dated March 30, 2025, revealed that the nursing supervisor heard Resident R1 cry out then the Nurse Aide, Employee E3, called out that she needed help. Upon arrival resident's bed was in high position and the resident was laying on her right side with her head towards the top of the bed, she was complaining of severe right-side pain, resident stated "from my shoulder to my hip". Nurse Aide, Employee E3 was in the room at the time of the incident performing morning care. Nurse Aide, Employee E3 stated she resident was holding on the half side rail used for turning and repositioning her hands slipped off the rail rolling to the floor.
Further review of the investigation indicated that resident was an assist of one for bed mobility. Nurse Aide, Employee E3 stated after giving resident a bed bath, she was in the process of changing residents sheets while the resident was in the bed, she rolled resident away from her to roll over the sheets, while she was changing the sheet, the resident rolled over the sheets and fell away from her.
Review of progress note fir Resident R1 dated March 30, 2025, revealed that resident fell from bed and complained of severe right arm and shoulder pain. Resident was transported to the hospital via for further evaluation.
Further review of the progress note revealed that the resident returned from the hospital without any new orders. Resident complained of some discomfort to the right shoulder in the evening shift.
Review of a statement from Nurse aide, Employee E3 dated March 30, 2025, revealed that "attempting to do my final round changing the patient, she was holding on, she fell landing on her right side complain of right shoulder pain."
Another statement obtained from the same employee revealed that she was doing a complete bed change on Resident R1, she was turned towards the door (left side) with side rails up, Before she could turn her over the folded linen, she fell out of bed.
Interview with Director of Nursing, Employee E2 on April 22, 2025, at 12:00 p.m. stated on March 30, 2025, Employee E3 was providing morning care for Resident R1. After morning care, she decided to change resident's bed linen while resident was in the bed. Nurse Aide turned resident away from her, folded the linen towards the resident. Before resident rolling back over to the other side, while the resident was on sheet, Employee E3 pulled the sheet out and resident fell to the floor. Employee E2 stated if residents get linen change while they are in the bed, they should complete it with appropriate technique. Employee E2 stated the appropriate technique was staff should turn resident safely to one side, fold the linen, roll the resident to the other side over the folded linen, once the resident was off the sheet, staff should pull the sheet.
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: 05/14/2025
Add Description of violation:
1.R1 was re-assessed by rehab and care planned updated for 2 person assist. Resident is currently on restorative care services.
2. ADON/DON to audit incident reports within the last 60 days. Residents effected will be re-assessed and care plans will be updated according to outcome. Interdisciplinary team will be consulted in order to develop comprehensive care plan updates. Completion Date: 5/30/2025
3. DON/ED provided all care staff with in-service & educated on policy's & procedures specific to bed mobility
Completion date: 4/25/2025
4. ADON/DON/ have on-going audits of incident reports, and present any trends or decline to the ED/IDT during daily clinical meeting, weekly UR meeting and weekly risk management meetings to ensure an
on-going review of potential risks & identifying/implementing interventions proactively
5/30/2025
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