Observations:
Based on review of facility policy, clinical records and incident reports and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervison and assistance to prevent accidents for one of five residents (Resident R1).
Findings include:
A review of the facility's policy, "Safe Resident Handling Program," dated 1/18/24, indicated that the facility will maintain a safe care environment.
A review of the clinical record revealed that Resident R1 was admitted to the facility on 2/10/24, with diagnoses that included pneumonia, bladder dysfunction, and seizure disorder.
A review of the MDS (Minimum Data Set - resident assessment and care screening) dated 2/14/24, indicated that Resident R1 was alert and oriented and able to make needs known.
A review of the care plan dated 2/10/24, indicated that Resident R1 required a one person assist with all ADL's (activities of daily living).
A review of a nurse progress note dated 2/18/24, indicated that while care was being provided, Resident R1 rolled out of the bed onto the floor. The resident had a three cm (centimeter) laceration to the left forehead.
A review of facility provded documentation by the facility, dated 2/18/24, indicated that Certified Nursing Assistant (CNA) Employee E1 rolled Resident R1 away from them during care and neglected to follow proper procedure.
A review of a personnel file for CNA Employee E1 indicated a date of hire 9/20/22. CNA Employee E1 received training for resident turning and positioning, body alignment, and moving in bed, on 9/24/22 and 9/8/23.
During a telephone interview on 3/21/24 at 1:00 p.m., CNA Employee E1 was confused about what happened and could not remember what side of the bed they were on, or how it happened. Stated "He just fell." CNA Employee E1 confirmed they had training on resident turning and positioning, body alignment, and moving in bed.
During an interview on 3/21/24, at 1:30 p.m., Resident R1 indicated the CNA rolled him away from her onto his right side and he "just kept rolling out of the bed onto the floor."
During an interview on 3/21/24, at 10:30 a.m. the Director of Nursing (DON) confirmed that the facility failed to follow proper procedure during care which resulted in a fall out of bed.
During an interview on 3/21/24, at 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain each resident received adequate supervison and assistance to prevent accidents for Resident R1.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.10(c) Resident care policies.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(1)(5) Nursing services. 28 Pa. Code 201.29(a) Resident rights.
| | Plan of Correction - To be completed: 04/26/2024
What Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The resident was immediately assessed. Family and Doctor informed and Dr. ordered transferred to the emergency room for further evaluation and treatment.
How will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? To ensure other residents are not affected education was provided to certified nurse aides to ensure competency and knowledge on how to change a bed with an occupied resident.
What Measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? A weekly audit for 2 weeks of 3 nurse aides will be completed during hands on care as well as at new hire orientation. This will ensure all proper procedures are followed.
How The Corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? All competencies will be reviewed at the next quality assurance meeting to determine if further monitoring will be necessary.
Dates of when the corrective action will be completed. Apr 26, 2024
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