Falling Water Healthcare Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY

Based on observation, record review and interview, the facility failed to provide adequate care and services to prevent a second degree burn on the Resident #68's right hand.

Actual Harm occurred on 12/03/24 when Resident #68 sustained a second degree burn to her right dorsal hand after spilling hot noodle soup onto her right hand. The soup had been heated in a microwave by nursing staff at an unknown hot temperature and then handed to the resident who was standing in the area. This affected one resident (#68) of three residents reviewed for accidents/hazards.

Findings include:

Review of Resident #68's medical record revealed the resident was admitted on 06/28/24 with diagnoses including unspecified dementia, essential hypertension and bipolar disorder.

Review of Resident #68's physician orders revealed an order dated 06/28/24 for a regular diet, regular texture with regular consistency.

Review of Resident #68's Hot Liquid Evaluation form dated 09/26/24 revealed the resident did not have indicators for severe cognitive impairment, poor safety awareness, tremors, contractures, weakness or posture concerns. The assessment revealed there were no other indicators not listed above.

Review of Resident #68's quarterly Minimum Data Set (MDS) 3.0 assessment dated 10/05/24 revealed the resident exhibited moderate cognitive impairment. The resident resided on the secured memory care unit on the second floor.

Review of a facility Occurrence Form #1223725 dated 12/03/24 at 4:11 P.M. revealed the nurse was sitting at the nursing station charting and the resident was handed a cooked noodle cup by the Certified Nursing Assistant (CNA). The resident sat the noodle cup on her roller walker and took a step backwards and lost her balance falling onto the floor. The incident was witnessed by staff.

Review of Resident #68's Acute Visit Nurse Practitioner (NP) note dated 12/03/24 authored by NP #815 revealed the resident had a past medical history (PMH) of hypertension, diabetes, bipolar fell onto the floor in the secured unit. This was a witnessed fall. She hit her head to the floor with no bleeding, no hematoma and neurological checks were initiated. Her mental status was per the baseline and range of motion was per the baseline. The resident stood up with assistance and started walking with the walker. She also had spilled hot soup on her right hand and complained of burning. No blisters and an ice pack was applied.

Review of Resident #68's Skin Grid Non-Pressure form dated 12/03/24 at 4:12 P.M. revealed the resident had right hand (back) redness which was classified as a burn. The wound measured one cm (centimeter) length by 2.0 cm width with no depth. The wound was red, moist grainy, with optimal granulation color and pain.

Review of Resident #68's progress note dated 12/03/24 at 8:31 P.M. authored by Licensed Practical Nurse (LPN) #810 revealed while the nurse was sitting at the nursing station charting, the resident was handed a cooked noodle cup by the CNA. The resident sat the noodle cup on the roller walker and took a step backwards. She lost her balance and fell onto the floor. The resident was observed hitting her head but denied pain due to the recent fall. The skin was intact, and no injury was noted. The resident complained of pain to the right hand and stated the noodle cup got on her hand. The NP was made aware and assessed the resident. An ice pack to the right hand was ordered and neurological checks were ordered. The power of attorney (POA) was made aware, and urine was sent to the lab this morning.

Review of Resident #68's progress note dated 12/04/24 at 1:00 A.M. authored by NP #815 revealed the encounter was a follow up post fall and burns to the right hand. The resident was seen in the hallway sitting in the walker seat. The resident denied a new headache, mental status at baseline and neurological checks continued. The resident complained of right elbow pain post fall and elbow redness was found on the bony area. No dislocation was identified and burns to the right hand. Bacitracin external ointment twice daily was ordered.

Review of Resident #68's physician orders revealed an order dated 12/04/24 at 5:00 P.M. authored by NP #815 for bacitracin external ointment 500 units/gram apply to right hand/wrist two times a day.

Review of Resident #68's physician orders revealed an order dated 12/04/24 to apply an ice pack to the right hand due to complaints of pain as tolerated by the resident; an order dated 12/04/24 for bacitracin external ointment 500 units/gram apply to right hand/wrist topically two times a day for seven days for a burn; and an order dated 12/12/24 to cleanse the right dorsal hand second degree burn with wound cleanser, apply Silvadene cream 1% (silver Sulfadiazine) to base of the wound, leave open to air and complete twice daily and as needed.

Review of Resident #68's medication administration records (MARS) and treatment administration records (TARS) from 12/03/24 to 12/17/24 revealed treatments were completed as ordered.

Review of Resident #68's Skin and Wound Note dated 12/13/24 at 3:30 P.M. revealed the visit was for a new skin and wound consult. Resident #68 presented with a burn to the dorsal right hand. The wound was new and was 1.5 cm length by one cm width with 0.1 cm depth with dryness to the peri wound and scant amount of serous exudate. The wound was classified as a right dorsal hand second degree burn. The order was to cleanse the right hand with Silvadene cream 1% to the base of the wound and leave open to air twice daily.

Interview on 12/17/24 at 6:57 A.M. with CNA #808 revealed Resident #68 did not like the facility food and the resident's daughter would bring in ramen noodle cups for the resident. She revealed on 12/03/24 at approximately 8:25 P.M. she heated up a ramen noodle cup for Resident #68 at (approximately) one minute and 30 seconds in the microwave. The CNA stated the resident said it was not hot enough and she heated it for another 60 seconds in the microwave and then handed it to the resident. She revealed Resident #68 put the soup down on her walker and some of the soup splashed onto her hand. CNA #808 revealed the resident became startled and took a step back falling to the floor and hitting her elbow and head. CNA #808 revealed she was aware the facility policy indicated not to heat foods for residents, but she stated she had always heated Resident #68's noodle soup. She confirmed the resident had cognitive impairment and resided on the secured memory care unit.

Interview on 12/17/24 at 7:26 A.M. with LPN #810 revealed he was sitting at the nursing station on 12/03/24 when CNA #808 handed Resident #68 her soup. LPN #810 confirmed the resident's family does bring in food for the resident. He revealed at the time of the incident, the resident stepped back and fell backwards to the floor striking her elbow and head on the floor. He revealed he did not see injuries to her hand but was more concerned about the injuries to her elbow and head. He confirmed staff were not supposed to be heating soup up for the residents and he stated he called the resident's daughter and NP following the incident with the resident.

An attempted interview on 12/17/24 at 10:47 A.M. with Resident #68 revealed she was not able to answer interview questions. Observation of Resident #68's right hand at the time of the interview revealed she had a healing burn on the right hand between the thumb and first finger which appeared shiny pink and it had a scabbed area in the middle of the shiny pink area which appeared to be a healing blister.

Interview on 12/17/24 at 12:22 P.M. with NP #815 revealed on 12/03/24 Resident #68 had soup on the seat of her walker) and burned her hand on it which caused her to fall backwards to the floor and hit her head. NP #815 revealed she had assessed the resident while she was still on the floor because she was in the building. She revealed Resident #68 did not have injuries to her shoulder and had a bruise to the right elbow and a burn to the right hand. She revealed at the time of the observation the resident's hand was just reddened, and she ordered an ice pack to be applied to the area. NP #815 revealed she assessed the resident on 12/04/24 and noted the resident's top layer of skin on the resident's right hand was peeling. She denied the resident had blisters at this time.

Interview on 12/17/24 at 12:50 P.M. with the Interim Director of Nursing (DON) revealed Resident #68 developed a blister on 12/06/24 between the thumb and pointer finger (top uppermost part) as a result of the burn on 12/03/24.

Review of the undated Storage of Resident Food policy indicated dietary services would provide any re-heating of foods but in the event dietary staff were not available, a trained staff member may re-heat foods brought in from outside sources. Foods must be re-heated in 15 second increments until the temperature reaches 165 degrees Fahrenheit. Allow the food to cool prior to serving for resident preference and palatability.

The deficiency was corrected on 12/04/24 when the facility implemented the following corrective actions:

On 12/03/24 at 4:08 P.M., LPN Unit Manager (UM) #825 completed a skin assessment on Resident #68 and noted redness to the right hand measuring one cm length by two cm width with no depth. The resident's skin was intact at this time.

On 12/03/24 at 4:20 P.M. LPN UM #825 completed interviews with unit staff. The staff reported Resident #68 lost her balance due to being distracted and talking to other residents.

On 12/03/24 at 4:30 P.M., the Interim DON was notified of the incident by LPN UM #825.

On 12/03/24 at 4:31 P.M. the Interim DON reviewed Resident #68's diet order. The order was for a regular/regular/regular diet with no devices.

On 12/03/24 at 4:45 P.M., the Interim DON reviewed Resident #68's MDS and Care Plans and no diet modifications were noted.

On 12/03/24 at 4:45 P.M. the Interim DON completed an audit by assessing all residents in house for potential for risk of injury due to hot food items/liquids. No abnormal findings were identified.

On 12/03/24 at 6:05 P.M. LPN UM #825 educated all facility staff on Hot Liquids and initiated an in-service.

On 12/03/24 at 6:38 P.M., NP #815 ordered an ice pack to Resident #68's right hand twice daily as tolerated, and the ice pack was added to the resident order list.

Review of the Outside Food policy by the Administrator and DON on 12/4/2024 revealed no changes were made.

On 12/04/24 at 4:15 P.M. NP #815 assessed Resident #68. No swelling to the head was observed. Redness to the right hand was observed with intact skin. Neurological checks were within normal limits (WNL) and range of motion (ROM) was WNL. A verbal order for an ice pack was received and initiated.

On 12/04/24 at 9:50 A.M., an interdisciplinary team meeting was held regarding the incident which included the Administrator, Interim DON, LPN UM #832, LPN UM #825, LPN MDS #861, Therapy #602, Licensed Social Worker (LSW) #603.

On 12/04/24 at 2:30 P.M., NP #815 followed up with Resident #68 and treatment orders were obtained and implemented. On 12/04/24 at 3:00 P.M., NP #815 ordered bacitracin ointment to the right hand twice daily.

On 12/04/24 at 4:00 P.M. the Interim DON initiated ongoing monitoring audits three times a week for four weeks related to monitoring residents for risk for injury related to hot liquids/foods. The audits were being monitored for compliance by the DON in conjunction with the Administrator daily during the clinical meeting and weekly during the nursing risk meeting.

On 12/04/24 at 5:00 P.M. LPN UM #825 completed Storage of Resident Food Hot policy in-service with focus on hot liquids/foods to all facility staff.

On 12/05/24 at 11:46 A.M., Speech Therapy evaluation was completed by Speech Therapist #604 and an order received for ST services three times a week for four weeks for cognitive skills development

On 12/06/24 at 10:33 A.M., a skin evaluation was completed on Resident #68's right hand burn. The resident was added to wound care rounds with Wound NP #985 (routine). The burn to the right hand measured one cm length by two cm width with no depth and was red in color with no exudate and no pain. The physician orders were to continue the treatment of Bacitracin topically twice daily. The resident's right hand had an intact blister which was noted to the center of the burn.

On 12/12/24 at 4:00 P.M. a wound assessment was completed with the facility wound nurse LPN UM #825 and Wound NP #985. The burn to the right hand measured at 1.5 cm length by one cm width with 0.1 cm depth. Dryness was noted to the periwound with scant serous exudate. The treatment orders was changed to Silverdene cream 1% twice daily and as needed. On 12/12/24 at 8:04 P.M. the treatment order for Resident #68 was changed to Silvadene twice daily and as needed by Wound NP #985.

This deficiency represents non-compliance investigated under Complaint Number OH00160640.

Based on closed record review and interview, the facility failed to implement comprehensive, individualized and effective behavioral health interventions for Resident #107, who was diagnosed with dementia and had a history of inappropriate sexual behaviors, to prevent additional inappropriate sexual behaviors from occurring. This affected one resident (#107) of nineteen residents who resided on the SMCU.

Findings include:

Review of Resident #107's closed medical record revealed the resident was admitted on 08/16/24 and discharged on 10/28/24 with diagnoses including vascular dementia, anxiety disorder and depression. Resident #107 was listed as the resident representative.

Review of Resident #107's behavior care plans revealed interventions including administer medications as ordered dated 08/19/24; speak in a calm manor dated 08/19/24; encourage to express feelings dated 08/19/24; intervene as necessary dated 08/19/24; monitor behavior episodes and attempt to determine underlying causes dated 08/19/24, observe and anticipate resident needs dated 08/19/24; behavioral health consults as needed dated 08/19/24; and monitor for inappropriate sexual behaviors dated 10/07/24. Review of the plan of care revealed no updated or new interventions were included following an incident on 09/29/24 until 10/07/24 when the intervention to monitor for inappropriate sexual behaviors was added.

Review of Resident #107's Admission MDS 3.0 Assessment dated 08/23/24 revealed the resident exhibited intact cognition.

Review of Resident #107's Behavior Note dated 09/29/24 at 9:45 P.M. revealed the resident was observed by staff being sexually inappropriate with a male resident. The note indicated staff separated the residents.

Review of a facility submitted Self-Reported Incident (SRI) Investigation, Tracking Number 252563, completed 10/02/24 for an allegation of sexual abuse revealed on 09/29/24 Resident #107 and Resident #57 were on the couch in the common area of the SMCU engaging in a sexual interaction.

Review of Resident #107's Psychiatry note dated 10/08/24 revealed the resident had an encounter with another resident where they both appeared to be fondling one another. The resident's hands were allegedly near or in another male resident's pants and the other resident's hands were allegedly near or on this resident's breast per reports of staff. The resident denied the incident reported by staff and stated there was no physical interactions between her and any other residents. The resident did not appear to be sad, anxious or in any distress. The provider did not identify any safety concerns for Resident #107 or any other resident at this time. However, the note included frequent monitoring was encouraged when the resident was interacting with other residents. The resident denied any recollection of the incident and had very poor insight.

Review of a facility submitted SRI, Tracking Number 253264, dated 10/23/24, for an allegation of sexual abuse revealed per conversation with CNA, she observed Resident #107 and Resident #60 in bed together. At the time of questioning the CNA reported that when she opened up the door to the room that both residents moved very quickly and she could not state if they had been touching one another, only that they had not been facing one another in bed. The CNA reported she was unsure if the male resident had both his pants and briefs lowered or just his pants. The CNA reported Resident #107 was fully unclothed and that her clothes were lying next to the bed on the floor. The CNA reported she had seen Resident #107 15 minutes prior and noted her to be positioned in the living room area.

Review of the undated SRI Witness statement revealed on 10/23/24 at approximately 7:45 P.M., Resident #107 was in the living room wearing a sweatshirt and pants. The CNA went to provide care to another resident and upon return noticed Resident #107 was not in the living room. A search of the SMCU found Resident #107 in Resident #60's room. Upon entering Resident #60's room, the resident was in bed with Resident #107. Resident #60 had on a shirt, but his brief and pants were down to his knees. Resident #107 was completely naked. They were laying against each other with Resident #107's back facing Resident #60's stomach.

Review of Resident #107's Behavior Note dated 10/23/24 at 8:45 P.M. revealed the resident was observed by a CNA in another resident's room in an inappropriate situation. Both residents (Residents #60 and #107) were immediately separated and the note revealed one to one maintained for the remainder of the shift. The family and doctor were notified.

Review of Resident #107's Telehealth Notification progress note dated 10/24/24 revealed the resident was in bed with a male resident and both were undressed but had only been in bed for a short while. The Administration was notified. The note included, both resident's have dementia, not clear that either can consent but it did not appear that anything happened against either's will. The resident's brother was notified.

Information obtained via email on 12/19/24 at 11:14 A.M. from Registered Nurse (RN) Regional #801 revealed on 10/07/24 in conjunction with the investigation, behavior monitoring orders were implemented for Resident #107's sexually inappropriate behaviors such as touching others inappropriately or touching herself in public locations with five non-pharmacological interventions listed to implement if necessary.

A second email dated 12/19/24 at 12:04 P.M. from RN Regional #801 revealed Resident #107 was assessed by psych services after the first incident in September 2024, was cleared and her medications were reviewed. The resident had behavior monitoring implemented to reduce the risk, but the facility did not provide one to one monitoring indefinitely nor was this intervention included on the resident's plan of care. Regional #801 confirmed Resident #107 exhibited inappropriate sexual behaviors on 09/29/24 and displayed inappropriate sexual behaviors a second time on 10/23/24.

Review of the Secured (Locked) Unit policy revised 2017 revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of those residents.

Review of the undated Behavioral Management General policy revealed it was the policy of the facility to identify and safely manage residents who are exhibiting behaviors related to psychiatric diagnoses or who may present a danger to themselves or others.

This deficiency represents non-compliance investigated under Complaint Number OH00159742.

Based on record review, interview and policy review, the facility failed to ensure notification of a resident's change in condition and subsequent hospitalization. This affected one resident (#31) of one resident investigated for notification. The census was 108.

Findings include:

Review of Resident #31's record revealed an admission date of 10/02/23. Diagnoses included multiple sclerosis, diabetes mellitus II and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated 07/05/24 revealed Resident #31 required staff assistance with all activities of daily living. Further review of the medical record including progress notes revealed no documentation Resident #31's family was notified of a change in status with subsequent hospitalization.

Review of the Telehealth notification dated 08/24/24 at 7:19 P.M. revealed Resident #31 on video, repeating, I feel good, I feel good

Based on interview and record review, the facility failed to ensure dependent residents received routine showers. This affected two residents (Resident #13 and #31) of three residents (Residents #13, #31, and #70) reviewed for activities of daily living (ADLs). The facility census was 108.

Findings include:

1. Review of the medical record for Resident #13 revealed an admission date of 08/11/23 with diagnoses including history of traumatic brain injury, depression, anxiety disorder, and seizures. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/06/24, revealed Resident #13 had intact cognition and was dependent for ADLs. Further review of the medical record revealed no documentation of Resident #13 refusing showers.

Interview on 09/24/24 at 9:30 A.M. with Resident #13 revealed he did not receive showers as scheduled. Resident #13 stated that he had to repeatedly ask for showers.

Interview on 09/25/24 at 9:07 A.M. with Licensed Practical Nurse (LPN) #316 revealed LPN #316 could only find one completed shower sheet for Resident #13. LPN #316 confirmed this was the only documentation indicating Resident #13 received a shower in the past three months.

Review of Resident #13's shower sheets revealed that only one shower was documented for the past three months.

2. Review of the medical record for Resident #31 revealed an admission date of 10/02/23 with diagnoses including multiple sclerosis, major depressive disorder, and anxiety disorders.

Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/06/24, revealed Resident #13 had intact cognition and was dependent for all ADLs except eating.

Interview on 09/24/24 at 9:28 A.M. with Resident #31 revealed she did not get showered like she was supposed to.

Interview on 09/25/24 at 9:07 A.M. with Licensed Practical Nurse (LPN) #316 revealed LPN #316 could only find one completed shower sheet for Resident #31. LPN #316 confirmed this was the only documentation indicating Resident #31 received a shower in the past three months.

Review of the facility's policy Routine Care

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on record review, interview, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 108 residents residing in the facility.

Findings include:

Review of the PBJ Staffing Data Report form submitted from 10/01/23 to 12/31/23 revealed on the following dates submitted for the first quarter of the fiscal year 2024, the facility was low on RN hours in the building on 10/01 (Sunday); 10/14 (Saturday); 10/15 (Sunday); 10/28 (Saturday); 10/29 (Sunday); 11/11 (Saturday); 11/12 (Sunday); 11/25 (Saturday), and 11/26 (Sunday).

Interview on 09/25/24 at 7:54 A.M. with the Administrator revealed she began working at the facility in April 2024 and at that time was told there was a concern with getting registered nurses hired. The administrator stated they hired RNs since then and they should be okay now.

Review of schedules and assignment sheets from 10/01/23 to 12/31/23 with Payroll Specialist (PS) #279 on 09/25/24 at 8:47 A.M. confirmed a RN was not present in the building for at least eight consecutive hours a day, seven days a week as required on the following dates during the first fiscal quarter of 2024: 10/01 (Sunday); 10/14 (Saturday); 10/15 (Sunday); 10/28 (Saturday); 10/29 (Sunday) 11/11 (Saturday); 11/12 (Sunday); 11/25 (Saturday), and 11/26 (Sunday).

Review of schedules and assignment sheets from 01/01/24 through 03/31/24 with PS #279 on 09/25/24 at 8:47 A.M. revealed a RN was not present in the building for at least eight consecutive hours a day, seven days a week as required on the following dates during the second fiscal quarter of 2024: 01/06 (Saturday); 02/17 (Saturday); 02/18 (Sunday); 03/16 (Saturday); 03/17 (Sunday), and 03/31 (Sunday).

Review of schedules and assignment sheets from 04/01/24 through 06/30/24 with PS #279 on 09/25/24 at 8:57 A.M. revealed a RN was not present in the building for at least eight consecutive hours a day, seven days a week as required on the following dates during the third fiscal quarter of 2024: 04/13 (Saturday); 04/14 (Sunday), and on 06/30 (Sunday) when the scheduled RN left four hours early related to an emergency.

The deficient practice was corrected on 07/01/24 when the facility implemented the following corrective actions.

On 05/01/24 The scheduler, Director of Nursing (DON) and Administrator were in-serviced on the need to have a RN in the building 24 hours seven days a week by the Regional Director of Operations.

On 05/01/24, the corporation started daily meetings to ensure RN coverage. The attendees included the Administrator, DON, Regional Director of Operations (RDO), Facility Scheduler, and Divisional Director of Workforce Management. The daily meetings looked forward regarding staffing and reached out and offered overtime to staff in sister facilities to ensure appropriate coverage.

On 05/01/24, the corporation started weekly Zoom meetings to audit RN coverage. The attendees included the Administrator, DON, Regional Director of Operations (RDO), Facility Scheduler, and Divisional Director of Workforce Management. This weekly meeting monitored RN coverage and looked at the past week to ensure proper RN coverage.

On 05/01/24 the facility implemented an on-call RN, who would work eight consecutive hours if a RN called off on a weekend.

On 05/01/24, the facility implemented a corporate scholarship program within the facility for RNs from foreign countries that did not have Ohio RN licensure. This included curricular and practicum training at the facility. The Bachelor degreed RNs from their country of origin would sit for the United States National Council Licensure Exam (US NCLEX) exam and upon passing would be hired by the facility. The facility hired four RNs (RN #258, RN # 268, RN #252, and RN #900), who received housing, meals and transportation. The RNs were contracted for three years of employment and worked as State Tested Nurse Aides (STNAs) after becoming certified until passing the NCLEX.

Review of the personnel files for RN #258, RN # 268, RN #252, and RN #900 revealed each had required licenses and appropriate screening and hiring procedures were followed.

On 05/20/24, RN #252 was hired.

On 07/22/24, an Assisted Director of Nursing (RN) was hired.

On 08/20/24, RN #301 was hired.

On 09/19/24, RN #900 was hired.

Review of schedules and assignment sheets from 07/01/24 through 09/22/24 with PS #279 on 09/25/24 at 9:07 A.M. revealed a RN was present in the building for at least eight consecutive hours a day, seven days a week as required.

This deficiency represents non-compliance investigated under Complaint Number OH00157574.

Based on observation, record review, interview, and policy review the facility failed to ensure infection control measures were followed during medication administration. This affected one of four residents observed during medication administration, Resident (#59). The census was 108.

Findings include:

Record review for Resident #59 revealed an admission date of 11/13/23. Diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, epilepsy and alcohol abuse with intoxication. Review of the Minimum Data Set (MDS) 3.0 assessment revealed Resident #59 required assistance from staff for activities of daily living.

Review of Resident #59's physician orders revealed on order dated 12/08/23 for levetiracetam oral tablet 750 milligrams (mg). Give two tablets by mouth every morning and at bedtime for epilepsy.

Observation on 09/24/24 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #315 preparing to administer medication for Resident #59. LPN #315 popped two levetiracetam tablets directly into her hand from a blister pack then put them in the medication cup that was on the medication cart.

Interview with LPN #315 immediately after popping the two tablets of levetiracetam directly into her bare hand revealed she did it because they were large tablets.

Review of the facility policy Medication Administration

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on observation, medical record review, resident and staff interview, review of medial imaging results, review of staff statements, and review of facility corrective action, the facility failed to provide adequate and sufficient assistance during personal care to prevent a fall with major injury for Resident #30.

Actual harm occurred on 05/28/24 when Resident #30, who required staff assistance (care planned to require two-person assistance and/or substantial to maximal assistance with activities of daily living (ADLs)) sustained a fall out of bed resulting in a fractured left hip. At the time of the incident, one (1) staff member was providing care to the resident. This affected one (#30) of three residents reviewed for falls. The census was 99.

Findings Include:

Review of Resident #30's medical record revealed an admission date of 06/25/21 with diagnoses including anemia, orthostatic hypotension, retention of urine, muscle weakness, chronic kidney disease, congestive heart failure, anxiety, and major depression.

Review of a fall risk care plan dated 04/17/24 revealed Resident #30 was placed at risk for falls related to incontinence, weakness, anemia, end stage renal disease, diabetes mellitus, wounds, and immobility. Appropriate interventions were implemented to include use of non-skid footwear, maintain the resident's room free of accidents and hazards, ensure bed locks are engaged, place the call light in reach, and move the resident's room closer to the nurses' station.

Review of an annual Minimum Data Set (MDS) assessment dated 05/06/24 revealed Resident #30 was assessed with intact cognition with no range of motion impairments to the upper or lower extremities.

Review of Resident #30's plan of care revised 05/16/24 revealed the resident had an ADL self-care deficit and the resident required assistance with ADLs related to incontinence, diabetes mellitus, weakness, and immobility. Interventions included the resident was totally dependent on staff for toilet hygiene, showers/bathing, and chair to bed transfers requiring two (2) or more helpers to do all of the work. An intervention included the resident required substantial/maximal assistance where helpers do more than half the effort to complete upper body dressing, personal hygiene, and rolling left and right. An intervention was also implemented which indicated the resident's assistance level with ADLs may vary based on the time of day, pain, mood, or fatigue and staff should document and adjust as indicated.

Review of a late entry nursing progress note dated 05/28/24 at 7:45 P.M. revealed staff were alerted to Resident #30's room by a State Tested Nursing Assistant (STNA) and Resident #30 yelling out for help. As the writer of the progress note entered the room, Resident #30 was observed rolling out of bed from behind a privacy curtain. The resident was mechanical (Hoyer) lifted from the floor using four (4) staff members to get the resident into bed. Resident #30 was noted with abrasions to his head, a skin tear to the top of the right hand, an abrasion to the front of the right shin, and bruising to the left arm. The resident was to be assisted by two staff for hygiene care, repositioning in bed, etc. The physician was notified, and x-ray imaging was ordered for the resident's hips and pelvis as the resident complained of pain while moving back to bed. The resident was able to move all 4 extremities.

Review of a post-fall evaluation document dated 05/28/24 at 7:45 P.M. revealed Resident #30 sustained a fall in his room from bed which was in normal position. The resident was wearing non-skid socks and was not using any assistive devices. It was noted the last time the resident was toileted was on 05/28/24 at 7:45 P.M. and STNA #114 was the only witness to the fall. Vital signs were within normal limits, and the resident was complaining of pain in both hips and the left antecubital. The pain was described as achy and tender. Resident #30 was assessed with three (3) small abrasions on the top of his scalp, a skin tear on the back of the right hand, and an abrasion to the front of the right lower leg. Notification was made to the physician and resident's responsible party at 8:00 P.M. When the resident was asked what he was doing prior to the fall the resident responded that he was being changed and rolled off the side of the bed. The suspected root cause of the fall was the resident was holding onto a grab bar and started rolling off the edge of the bed. STNA #114 was not able to get to the other side of the bed fast enough to stop the resident from falling. It was also noted the resident was on an air mattress as a suspected root cause. Following the incident, staff identified the resident required two staff members to provide care at all times.

Review of a written statement dated 05/28/24 given by STNA #114 revealed at approximately 7:45 P.M. he was doing a bed change on Resident #30. STNA #114 documented he rolled the resident over to face the door and the resident was grabbing the side rail holding himself over. As STNA #114 was putting the corners of the sheet on the bed, Resident #30 started to roll off the bed. STNA #114 reached to grab for the resident and yelled for help. STNA #114 documented Resident #30 slipped from his grip and rolled off the bed just as staff members entered the room.

Review of a typed statement dated 05/29/24 at 2:25 P.M. given by Licensed Practical Nurse (LPN) #132 revealed she just had finished shift report and was at the nurses' station charting when she heard a yell for help and a thud. LPN #132 observed Resident #30 laying on the floor between the two beds in his bedroom and his nurse aide was on the opposite side of the bed moving toward the resident. LPN #132 stated the resident was alert and oriented and indicated he rolled out of bed when the nurse aide was providing care and was not sure how it happened as it happened so quickly. LPN #132 documented the resident was assessed and was able to move his hands and arms with no issues. The resident indicated he had discomfort in both hips and he was able to move his right left more than his left leg. There was no obvious external rotation or significant length differences when comparing the resident's legs.

Review of a nursing progress note dated 05/29/24 at 5:22 P.M. revealed Resident #30 complained of severe left arm pain in the morning and an order for x-ray imaging of the left arm from shoulder to fingertips was ordered. The resident was medicated with narcotic pain medications; however, the medication was not effective. Results of the resident's x-rays revealed a possible fracture of the left hip and the resident was sent out to the hospital. Review of a subsequent nursing progress note on 05/29/24 at 11:40 P.M. revealed Resident #30 was being admitted to the hospital due to a left hip fracture from a fall.

Review of x-ray imagine results dated 05/29/24 revealed Resident #30 was found with irregularity of the left intratrochanteric region and may represent a nondisplaced fracture. The femoral heads showed no concerns, and the surrounding soft tissue was normal. X-rays of the left hand to shoulder revealed no acute fractures and the surrounding tissue was normal.

Interview with the Administrator on 06/04/24 at 3:30 P.M. verified Resident #30 rolled out of bed approximately at 7:45 P.M. on 05/28/24. At the time of the incident, Resident #30 was holding the upper assist rail and his legs started going off the bariatric low air loss mattress with bolsters mattress. The Administrator revealed prior to the incident, the resident could hold the rail once assisted to roll onto his side, but stated the resident did not have the upper arm strength to roll himself over. The Administrator stated STNA #114 was providing incontinence care for the resident at the time of the incident. The Administrator indicated the facility notified the family, an x-ray was ordered, and the x-ray showed a possible fracture of the resident's left hip.

Observation of Resident #30 on 06/06/24 at 7:57 A.M. revealed the resident was laying in bed with no obvious concerns noted. An interview was attempted with the resident; however, no information was able to be provided regarding the fall on 05/28/24 from the resident.

Interview on 06/06/24 at 3:53 P.M. with STNA #114 via telephone revealed (on 05/28/24) he had to do a full bed change on Resident #30. While providing care, STNA #114 indicated he turned the resident to wipe his back side, and the resident was fine. STNA #114 stated Resident #30 was holding on to the upper side rail while he went to fit the corner of the sheet on the corner of the bed. STNA #114 stated, out of the corner of his eye, he could see Resident #30 started to slip. STNA #114 stated he got a little hold of Resident #30, but the resident slipped from his grasp. STNA #114 stated he called for help and Resident #30 fell off the bed as 2 staff members were coming in.

As a results of the incident, the facility implemented the following corrective actions to correct the deficient practice on 06/03/24:

On 05/29/24, Resident #30 was sent out to the hospital for evaluation and treatment of a suspected left hip fracture. The resident was readmitted to the facility on 06/04/24.

On 05/31/24, an audit was completed on all residents with air mattress to ensure there were not issues with the mattresses and application of the mattresses was appropriate. There were no concerns noted.

On 05/31/24, all resident care plans were reviewed and updated to ensure proper interventions were in place for assistance with care with no concerns noted.

On 05/31/24, all staff members were educated that all residents utilizing an air mattress required a 2-persons assistance with care and to check the resident's Kardex for updates to the resident's tasks.

On 06/03/24, audits were initiated to ensure 2-person assistance with utilized for residents with low air loss mattress. The audits were of three residents weekly for three weeks to ensure compliance. Review of the audits completed for the weeks of 06/03/24 and 06/10/24 revealed no concerns were identified.

This deficiency represents noncompliance investigated under Complaint Number OH00154514.