Observations:
Based on review of facility policy and documents, clinical record, and staff interviews, it was determined the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a patella (knee) fracture, for one of two residents reviewed (Resident R1).
Findings include:
Review of facility policy, "Skilled Nursing - Investigation of incidents" update August 2024, indicated the purpose is to establish guidelines for investigations of incidents and accidents to determine the root cause of the event and to identify systemic changes and measures needed to prevent future incidents. The facility will conduct a thorough and timely investigation of incidents and accidents. If the accident/incident is related to resident care, in order to decide whether or not to substantiate abuse/neglect, begin by establishing the facts of the situation.
Review of the clinical record indicated Resident R1 was admitted to facility 4/7/2020.
Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/4/25, included diagnoses epilepsy (brain condition that causes reoccurring seizures), history of falls, and muscle weakness. Section C0500 the Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact. Resident 1's score of 15.
Review of Resident R1's clinical record progress note date 4/7/25, at 1:55 p.m., indicated "CNA (nurse aide) came to this nurse due to resident complaining of pain. Resident stated that the driver was transferring her off the van and her left leg fell off the footrest and her left leg dragged under the wheelchair, and she told him to stop, and he keep pushing her in the wheelchair and she then came back to the facility and keep feeling the pain in her left leg. This nurse contacted CRNP (certified registered nurse practitioner) to obtain x-ray on the left leg tib (tibia), fib (fibula), knee."
Review of facility submitted information dated 4/8/25, indicated, Resident R1 was complaining of left leg pain. Resident R1 stated her leg fell off the leg rest and got caught under the wheelchair during transport from her audiology appointment earlier in the day. The driver accidentally dragged her foot under the wheelchair causing her to say, "ouch, stop". The knee was painful to touch and slightly swollen. CRNP was notified and ordered imaging. Imaging showed a patella fracture to left leg. Order obtained to send Resident R1 to the hospital for evaluation. The driver stated, her leg fell off the footrest and he didn't notice. He also stated that he did not realize she was hurt so he did not notify anyone.
Review of facility provided document dated 4/7/25, indicated that Van Driver (VD) Employee E1 was transporting Resident R1 back to the facility from an appointment. He (Employee E1) took her (Resident R1) down the lift with no issue. After getting into building, Resident R1 said "Ouch", which alerted Employee E1 to stop and see what the issue was; he noticed that the footrest had fallen off and that her (Resident R1) left leg was caught under the wheelchair. He (Employee E1) pulled the wheelchair backwards to get her leg free. He picked up the footrest, placed it back on the wheelchair, and put her (Resident R1) foot back on the footrest.
Review of an employee statement written by Receptionist Employee E2 dated 4/17/25, indicated that Resident R1 was coming from an appointment. As the driver was pushing her through the first set of sliding doors, a "scream of pain" was heard. The second set of doors opened, and a bystander stopped them and put her foot back on the footrest; it was bent under the footrest. Resident R1 told him (VD Employee E1) that she was okay, and they went to the elevator.
Review of facility provided document dated 4/7/25, indicated a diagnostic X-ray (medical imaging used to capture pictures of the inside of the body, particularly the bones) was completed of the left knee revealing a mid-patella fracture.
Review of emergency room documentation dated 4/8/25, indicated that Resident R1 was treated for acute nondisplaced transverse fracture inferior patella of the left leg.
Review of Resident R1's clinical progress note dated 4/8/25, at 4:28 a.m., indicated resident returned from hospital. Left leg in locking brace. Discharge instructions reviewed and approved by physician services.
During an interview on 5/8/25, at 2:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a patella fracture, for one of two residents reviewed (Resident R1).
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.10(c)(d) Resident care policies.
| | Plan of Correction - To be completed: 05/29/2025
R1 had no lasting effects from a psychosocial standpoint from the deficient practice of the lack of adequate supervision leading to an accident. Our social services team completed a Trauma Informed Assessment/PTSD evaluation with R1, which showed no ill effects. Psych services also offered to R1 and she refused. All residents have the potential to be affected by the deficient practice. The Willows team will be educated via the directed in-service training about F689 regarding Accidents and Hazards, Supervision, and Devices. This in-person in-service will include a review of the federal regulations cited and the review of accompanying guidelines. PADONA is providing the directed in service education and will be on campus 5/27/25 to complete this. Community is also re-educating all team members on our current policies and procedures regarding investigation of incidents and this situation. A whole house audit was completed to ensure all residents have appropriate wheelchair leg rests in their rooms. Audits will be conducted on all neighborhoods to ensure team members pushing residents in wheelchair do this in a safe manner. Specifically, these audits will ensure leg rests are on appropriately and legs are properly positioned on the leg rests. These audits will also include contracted personnel. Audits will be conducted on 20 residents a day and will be completed for seven days a week for two weeks, five days a week for two weeks, and three days a week for two weeks. The results of these audits will be shared with the Administrator and reviewed with our QAPI. Below is the outline and post test PADONA will be using for the scheduled education:
Education Outline for Directed In-Service for
F689 – Free of Accident Hazards/Supervision/Devices
1. Review of the federal regulation F689
A. Review regulation
B. Outline regulation intent
C. Discuss regulation definitions of significant terms
D. Review regulation guidance
2. Discuss examples related to F689
A. Discuss the steps facility staff should implement to maintain a safe environment for residents internally and externally.
B. Distinguishing avoidable from unavoidable accidents,
C. Outline various safety hazards for residents in the long-term care facility
D. Review following standards of practice when providing resident care, including during transport.
E. Discuss determining the risk level for residents based on assessments and using the assessment data for the care plan.
F. Review sharing information with external agencies and families regarding resident needs and safe care, including transport.
G. Outline requirements to adhere to plan of care from the care plan for all resident care activities in all circumstances to ensure resident safety and prevent accidents.
H. Discuss examples of providing safe resident care to prevent accidents/injuries.
I. Review assessment of environmental and person-centered factors (including completion of safety assessments) to ensure resident safety.
J. Outline how all staff can assist with resident safety.
3. Discuss professional standards of practice
A. Review standards of practice related to timely risk and safety assessments
B. Outline standards of practice related to reviewing and revising person centered care plan to include new information from risk assessments and with resident changes
C. Discuss standards of practice related to education and following the information obtained from risk and safety assessments.
D. Outline standards of practice for transporting residents in wheelchairs for safety and sharing that information through education and information with anyone who transports the resident.
E. Discuss standards of practice for all staff involvement in maintaining a safe resident environment and reporting when there are discrepancies.
4. Review the actual deficiency cited in the 2567 for F689
References:
A. CMS federal regulation F689.
B. Perry and Potter Fundamentals of Nursing, 11th Edition; Medical Surgical Nursing.
C. Brunner and Suddarth Medical-Surgical Nursing, 15th edition; Preventing resident injuries/Safety.
D. AHRQ Patient Safety and Quality Improvement Toolkit
E. National Ombudsman Reporting System, Nursing Facility Complaints by Category and Sub-Category (2016) at http:// ltcombudsman.org/uploads/files/support/2016-B-2-NF-Comp-Full.xlsx.
F. The Willows 2567 from survey ended May 8, 2O25.
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