Rule/Regulation Violated:
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver:
2. Documents the following:
a. The date and time of the accident, emergency, or injury;
b. A description of the accident, emergency, or injury;
c. The names of individuals who observed the accident, emergency, or injury;
d. The actions taken by the caregiver or assistant caregiver;
e. The individuals notified by the caregiver or assistant caregiver; and
f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.
Evidence/Findings:
Based on documentation review, record review, and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver documented the date and time of the incident, the names of individuals who observed the incident, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future, for five of ten current and former residents sampled who had an accident, emergency, or injury resulting in the need for medical services. The deficient practice posed a risk if the facility did not take action to prevent the accidents, emergencies, or injuries from occurring in the future to ensure the health and safety of residents.
Findings include:
1. A review of facility policies and procedures revealed a policy titled, "Incident Reporting Policy & Procedure... Revised 11/16/2018." The policy stated: "It is the policy all employees are responsible for completing an Incident Report immediately after the incident not to exceed 24 hours after incident (i.e...cut, scrape, burn, fall, bruising...etc.) involving anyone in or on the Community premises...The employee(s) who experienced or witnessed (or was first to the scene of) the incident, should report exactly what they observed on an Incident Report form as soon as possible and...prior to leaving their shift...The Administrator retains the completed reports in the incident report binder..."
2. A review of R7's medical record revealed a note dated August 16, 2022 at 10:44 PM. The note stated: "...reported by the med tech on duty on 8-14-23 that [R7] was lethargic...not wanting to eat...had pain/discomfort, as well as swelling in...right arm...AA advised med tech to get a set of vitals and get assistance from the DHS...vitals could not be gotten. The decision was made to send [R7] out non-emergency to JCLNM Hospital...POA was present when the decision was made." R7's medical record also contained another note dated August 16, 2022 at 11:02 PM, which stated: "...reported on 8-14-2023, by POA that [R7] had UTI, dehydrated and renal failure...had infection under skin that developed after the blood draw last Friday..."
3. In an interview, O2 reported R7 had blood drawn on August 11, 2023, and the phlebotomist could not find a vein, resulting in bruising of R7's arm. On August 14, 2023, R7 was observed to be "bedbound, difficulty breathing, swollen left arm with fluids dripping into a pad..." and facility staff reported resident "refused to eat on Sunday." R7 was sent to the hospital on August 14, 2023 to receive medical services.
4. In an interview, E8 confirmed R7 was sent to the hospital on August 14, 2023. E8 reported an incident report was completed when R7 was sent to the hospital. However, no further documentation of a report was provided to the Compliance Officers for review.
5. A review of R1's medical record revealed a document titled "Internal Occurrence Report," which detailed an emergency and accident involving R1. The report indicated the incident took place on May 5, 2023 at 9:30 AM and stated, "Resident was in the process of being sent to hospital for high blood pressure and no medications taken since move in while waiting for paramedics to show up resident slipped out of wheelchair onto the floor on [R1's] back. Paramedics arrived 1 minute after fall and lifted resident off floor and began getting [R1] ready to be taken to [hospital] per POA...Was the person involved taken to the hospital? Yes...If yes, by whom? 911." The document contained a section titled, "Follow-Up" which stated, "Briefly describe any follow-up action that has occurred since occurrence." However, the section was blank and the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future.
6. A review of R2's medical record revealed a document titled "Internal Occurrence Report," which detailed an accident involving R2. The report indicated the incident took place on September 10, 2023 at 3:00 AM and stated, "When med the (sic) was doing rounds med tech discover resident on the floor on [R2's] right side resident stated that [R2] was trying to go use the restroom when lost balance and fell, Res had no shoes on, well next to bed side resident did not call for help. Non injury fall...Was the person involved taken to the hospital? Yes...If yes, by whom? 911." The document contained a section titled, "Follow-Up" which stated, "Briefly describe any follow-up action that has occurred since occurrence." However, the section was blank and the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future.
7. A review of R3's medical record revealed a document titled "Internal Occurrence Report," which detailed an accident involving R3. The report indicated the incident took place on April 26, 2023 at 5:00 PM and stated, "Resident was found by the caregiver with [R3's] left legs (sic) stuck in between the wheelchair. Call the paramedics for assistance...Was First Aid administered in-house? No. Was the person involved taken to the hospital? No...If no, was resident seen by physician? Yes, Paramedics...Follow-up: Resident is doing ok no complaints." The document contained a section titled, "Follow-Up" which stated, "Briefly describe any follow-up action that has occurred since occurrence." However, the section was blank and the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future.
8. A review of R5's medical record revealed a document titled "Internal Occurrence Report," which detailed an accident involving R5. The report indicated the incident took place on April 10, 2023 at 2:30 AM and stated, "Caregiver found [R5] on the ground when [E9] was doing [E9's] nightly checks, resident said [R5] was trying to walk to [R5's] bathroom...Was the person involved taken to the hospital? Yes...If yes, by whom? 911." The document contained a section titled, "Follow-Up" which stated, "Briefly describe any follow-up action that has occurred since occurrence." However, the section was blank and the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future.
9. In an interview, E1 acknowledged the aforementioned reports for R1, R2, R3, and R5 did not document any actions taken to prevent the accidents, emergencies, or injuries from occurring in the future.
Summary:
An on-site investigation for complaint 00132842 was conducted on June 9, 2025, and the following deficiencies were found: