Village of St Edward at Wadsworth The

Based on medical record review, staff interview, and policy review, the facility failed to ensure individualized care plan interventions were developed and updated with each fall occurrence and failed to ensure an accurate and thorough post-fall investigation was completed to establish the root cause of the fall.

Actual harm occurred on 03/07/25 when Resident #88, who was identified to be a high fall risk and required staff supervision for showers, was left unattended in the bathroom during a shower. Resident #88 subsequently fell out of the shower chair, resulting in a right femur fracture and subsequent hospitalization. This affected two residents (#88 and #104) of three residents reviewed for falls. The facility census was 103. The facility census was 103.

Findings include:

1. Review of the closed medical record for Resident #88 revealed an admission date of 08/14/24. Diagnoses included but were not limited to neurocognitive disorder with Lewy bodies, dementia with anxiety, depression, cerebral infarction, type II diabetes mellitus with neuropathy and stage III chronic kidney disease, acquired absence of eye, unsteadiness on feet, and other abnormalities of gait and mobility. Resident #88 was transferred to a local hospital on 03/07/25 and did not return to the facility.

Review of the most recent fall risk assessment for Resident #88 dated 08/14/24 revealed he had a history of falls and was at high risk for falls. No fall interventions were listed.

Review of the service plan dated 08/16/24 for Resident #88 revealed he was alert and oriented to person, place, and sometimes time. Resident #88 was noted to require supervision for dressing, bathing, washing up, toileting, and incontinence care. Resident #88's service plan did not indicate Resident #88 was high risk for falls and no fall prevention interventions were listed on the service plan.

Review of the memory care level of care assessment dated 09/18/24 for Resident #88 revealed he was oriented to self, others, and location. Resident #88 was noted to be incapable of independent decision making, had a diagnosis of depression, history of hallucinations/ delusions, and demonstrated anxious/paranoid/suspicious behaviors. Resident #88 was noted to require minimal assistance from one staff member for transfers, used a wheelchair and was able to self-propel, and required staff set up and cueing assistance for showers. Resident #88 required verbal reminders or occasional assistance to use the bathroom. Resident #88 was noted to demonstrate fall risk behavior. Resident #88 was noted to require encouragement and remind assistance for all activities of daily living (ADLs) and safety factors. Resident #88 was noted to walk with a walker for short distances in his room with supervision and use wheelchair for long distances.

Review of the facility incident log between October 2024 to April 2025 revealed Resident #88 had sustained a witnessed fall on 11/04/24, a witnessed fall on 01/18/25, and an unwitnessed fall on 03/07/25.

Review of the active and discontinued physician orders for Resident #88 revealed no orders for safety interventions or orders to be sent out for evaluation related to the fall on 03/07/25.

Review of the 03/08/25 nursing note timed at 12:09 A.M. written by Licensed Practical Nurse (LPN) #207 revealed an unidentified aide called to say Resident #88 had fallen getting out of the shower. Aide believed he may have slipped on the bathmat that was in the bathroom on the floor. Resident #88 stated he did not hit his head but thought his hip was broken. LPN #207 noticed a small red bruise to Resident #88's right leg. Resident #88 stated he stepped on the bathroom mat, and it slipped from underneath his feet. The nursing manager, physician, and family were notified. Resident #88 was sent out to the emergency room (ER) for evaluation.

Review of 03/08/25 nursing note timed at 7:08 A.M. revealed LPN #207 spoke with an unidentified nurse from a local hospital who informed the facility Resident #88 was admitted to the local hospital with a right femur fracture.

Interview on 04/14/25 at 12:02 P.M. with the Director of Nursing (DON) revealed the fall investigation reports were a facility internal report. DON was willing to read what was documented on the fall incident report but refused to provide the document for review upon multiple requests. The DON read the fall incident dated 03/07/25 for Resident #88, and stated an unwitnessed fall occurred on 03/07/25 at 9:20 P.M. in Resident #88's bathroom. The report stated the aide caring for Resident #88 was Certified Nurse Assistant (CNA) #208 and the nurse was LPN #207. CNA #208 came upon Resident #88 lying outside of the shower. Resident #88 was noted to have gotten himself in the shower without notifying staff. Resident #88 stepped out of the shower onto the bathmat and slipped. Resident #88 stated he did not hit his head but thought his hip was broken. LPN #207 came to assess Resident #88, called the manager, physician, and Resident #88's family. Resident #88 was sent out to the hospital. The DON confirmed Resident #88's service plan dated 08/16/24 stated Resident #88 required supervision for bathing. DON confirmed there were no written witness statements other than what the nurse reported in the incident report.

Phone interview on 04/14/25 at 12:22 P.M. with CNA #208 revealed she was not working with Resident #88 when he fell, she was working in another part of the building.

Phone interview on 04/14/25 at 12:25 P.M. with Caregiver #209 revealed 03/07/25 was the first time she had worked with Resident #88. Caregiver #209 stated she was told Resident #88 was a one person assist and a standby for bathing. When Caregiver #209 entered Resident #88's room, he was sitting on the bed and had a brief, clothes, and a towel set out on the bathroom sink with the shower running. CNA #209 supervised Resident #88 into the bathroom and onto his shower chair. Resident #88 asked for privacy, so CNA #209 walked out of the bathroom, shut the bathroom door, only leaving it open a crack and stayed in his room. Caregiver #209 stated she was trying to peak through the crack of the door to monitor him through the mirror. Caregiver #209 stated she heard a noise and went to check on Resident #88. Resident #88 had dropped his shampoo. She proceeded to pick up the shampoo, gave it back to him, and went back out of the bathroom. Caregiver #209 stated she did not see Resident #88 try to stand up, but when she looked again, she saw him slipping out of the shower chair to the ground. Caregiver #209 stated the shower chair appeared to be sideways in the shower with suction cups on the bottom of the legs. Caregiver #209 stated she observed Resident #88 on the floor outside of the shower with the shower mat underneath his legs. Caregiver #209 called for the nurse. Upon assessment, Resident #88 indicated pain, and Resident #88 was sent to the hospital.

Phone interview on 04/14/25 at 12:41 P.M. with Caregiver #210 revealed she had only assisted with Resident #88 but was never assigned as his primary caregiver. Caregiver #210 stated she was in Resident #88's room with Caregiver #209 while Resident #88 was showering but was not assisting him. Caregiver #210 stated she was told Resident #88 was mostly independent for care but needed queueing and reminders. Caregiver #210 stated Resident #88 was mostly undressed when she and Caregiver #209 entered the room. Resident #88 asked for privacy to finish undressing in the bathroom. After Resident #88 was in the shower, Caregiver #209 went to check on Resident #88 since it was quiet, and when Caregiver #209 opened the bathroom door, Resident #88 was on the floor outside of the shower and appeared like he had slipped on the bathmat when he stepped out of the shower. Caregiver stayed with Resident #88 and Caregiver #210 called for the nurse. Resident #88 was sent out to the hospital.

Phone interview on 04/14/25 at 2:40 P.M. with LPN #207 revealed prior to Resident #88's fall he was alert and oriented to person, place and time, used a walker and required assistance of one staff for bathing and mobility. LPN #207 stated Resident #88 was impulsive at times and would get up on his own without staff present. On 03/07/25, she was notified by the Caregiver #210 Resident #88 had fallen. LPN #207 stated when she entered Resident #88's room, Resident #88 was lying flat on his back outside of his shower on the bathroom floor. Resident #88 told LPN #207 he went to step out of the shower and the rug slid out from under his feet and he fell onto the floor. Resident #88 stated he was in pain and felt like he broke his hip. Paramedics were called and Resident #88 was sent to the hospital.

Interview on 04/14/25 at 3:31 P.M. with the DON confirmed supervision for bathing in the memory care would mean the caregiver would be in the bathroom with the resident during bathing. If a resident requests privacy, it would be the expectation to leave the bathroom and leave the bathroom door open and stay in the resident room for safety. DON confirmed she was told Resident #88 had gotten himself into the shower unsupervised prior to his fall on 03/07/25. DON confirmed she spoke with LPN #207 about the fall but did not speak with the two aides who were in the room to verify if their statements matched the fall investigation.

Interview on 04/16/25 at 10:06 A.M. with the DON confirmed the fall incident report dated 03/07/25 for Resident #88 listed CNA #208 as the caregiver who found Resident #88 but was not listed on the facility assignment sheet as working with Resident #88 on 03/07/25.

Phone interview on 04/16/25 at 10:10 A.M. with Caregiver #212 revealed she was Resident #88's usual caregiver. Caregiver #212 stated Resident #88 usually took his clothes off sitting on his bed and she would walk beside him into the shower. Once Resident #88 was in the shower, she would have him sit on the shower bench which was attached to the shower wall and folded down. Caregiver #212 stated she would stand in the bathroom next to shower for Resident #88's safety. When Resident #88 stood up, she would assist him to get out of the shower and help to dry him off and get dressed. Caregiver #212 stated she never left Resident #88 alone in the shower due to his unsteadiness. Caregiver #212 stated Resident #88 required assistance with bathing and was not safe to only be supervised while bathing. Caregiver #212 stated the staff schedules and room assignments had recently been switched so some of the caregivers were not as familiar with their newly assigned residents.

Interview on 04/16/25 at 10:36 A.M. with the DON confirmed the original schedule provided to the surveyor following entrance for 03/07/25 had been changed and was not updated. DON brought the updated schedule and confirmed the aide listed on the fall investigation was not the aide working with Resident #88 when his fall occurred. DON also confirmed she had not requested a witness statement from the aides to verify who was working with Resident #88 at the time of the fall and ensure the accuracy of the fall investigation report.

2. Review of the closed medical record for Resident #104 revealed an admission date of 07/15/22. Diagnoses included but were not limited to Alzheimer's dementia, spinal instabilities, syncope and collapse. Resident #104 was transferred to a local hospital on 03/31/25 and did not return to the facility.

Review of 05/17/23 service plan for Resident #104 revealed it was last revised on 12/20/24. Resident #104 was noted to require assist of one staff for dressing, bathing, toileting, was noted to require supervision and require assist of one for ambulation, and transfers. Resident #104 was noted to use a walker or wheelchair. No fall interventions were listed on the service plan for Resident #104.

Review of the memory care level of care assessment dated 01/16/25 for Resident #104 revealed she was oriented to self, required redirection and orientation. Resident #104 was noted to be unable to make independent decisions, noted to have insomnia and requires hands on assistance with bathing, toileting (incontinent), and minimal assistance of one staff for transfers. Resident #104 was noted to use an ambulatory device, ambulated independently and requires reminders using queueing and coaching. Resident #104 was noted to demonstrate fall risk behaviors.

Review of fall assessment dated 01/16/25 for Resident #104 revealed she was at high risk for falls due to previous falls, used an ambulatory assistive device, and had impaired gait. No fall interventions were listed.

Review of the two-hour safety check task in Resident #104's medical record revealed from 03/16/25 to 03/31/25, no dates were signed off for all three shifts. On 03/20/25, 03/29/25, and 03/30/25 there was only the afternoon shift checked off for the three employee shifts.

Review of the nursing progress note dated 03/31/25 timed 11:27 A.M. written by Registered Nurse (RN) #213 revealed Resident #104 was using the community bathroom and after coming out of the bathroom, the caregiver observed Resident #104 on the floor in front of the bathroom. Resident #104 was not known to yell or call for help. An unidentified caregiver called for RN #213. RN #213 assessed Resident #104 in the same area as her walker. Resident #104 was noted lying on her back on the floor with the walker on top of her. Resident #104 was noted to only have one slipper on and right ankle was noted to be swollen. Resident #104 indicated pain when her leg was moved and grabbed her hip. Resident #104 was unsure if she hit her head. The family and physician were notified, and Resident #104 was sent to the hospital.

Review of the nursing progress note dated 03/31/25 timed at 2:19 P.M. written by RN #213 revealed Resident #104 was admitted to a local hospital with a left hip fracture.

Interview on 04/14/25 at 7:31 A.M. with CNA #205 revealed Resident #104 had fallen and had broken her hip a couple weeks ago. CNA #205 stated she was assisting in getting lunch ready in the kitchen serving area and turned around to see Resident #104 lying on her back on the floor outside of the bathroom adjacent to the common sitting area. CNA #205 stated she did not hear Resident #104 fall or any noise until she turned around and observed Resident #104 on the floor. CNA #205 stated she did not see Resident #104 go into the bathroom or come out of the bathroom, but thought she may have been trying to go to the bathroom, but someone was in there and when she tried to back up from the door, she fell.

Interview on 04/14/25 at 7:34 A.M. with CNA #206 revealed Resident #104 fell around lunchtime on 03/31/25. Resident #104 was found on the floor in the hallway by the common area outside the bathroom. CNA #206 did not observe the fall, but thought Resident #104 had attempted to use the bathroom in the common area but someone was in the bathroom. CNA #206 thought as Resident #104 was trying to back up, she lost her footing and fell. CNA #206 confirmed she did not see the fall but was what Resident #104 stated had happened. CNA #206 stated Resident #104 was independent for mobility with her walker.

Interview on 04/14/25 at 12:02 P.M. with the Director of Nursing (DON) revealed the fall investigation reports were a facility internal report. DON was willing to read what was documented on the fall incident report but refused to provide the document for review upon multiple requests. The DON stated the fall investigation dated 03/31/25 for Resident #104 stated the unidentified CNA was coming out of the bathroom and observed Resident #104 in the hallway outside of the bathroom on the floor near the common area in the memory care unit. Resident #104 was not noted to yell for help. Upon observing Resident #104, the unidentified aide called for the nurse to assess Resident #104. Following assessment, Resident #104 was sent out for treatment and was found to have a left hip fracture. DON confirmed Resident #104's service plan stated she is sometimes supervision for ambulation but if noted to be unsteady or confused, she is a one person assist for ambulation, and staff are to be within arm's reach of resident with ambulation. The DON also stated new staff are to ask the nurse about residents to see about their recent history as to what level of care they require. If two levels of care are noted in the service plan, such as supervision and assistance of one, staff are to use the higher level of assistance if they are unsure. DON indicated each shift the caregiver is to check off their two-hour checks as being completed for their entire shift under the two-hour safety check task in the electronic medical record.

Interview on 04/14/25 at 3:31 P.M. with the DON revealed she was told that Resident #104 was found outside of the bathroom by the common area with no staff present to observe the fall. DON stated she was told CNA #206 had assisted Resident #104 to the bathroom but was still in the bathroom cleaning up when Resident #104 fell in the hallway. The DON stated Resident #104 required supervision for mobility and assistance of one to get up to walk.

Phone interview on 04/16/25 at 10:12 A.M. with CNA #205 revealed she was helping get lunch ready near the kitchen and when she turned around, she observed Resident #104 on the floor outside of the bathroom door. Resident #104 had not made any noise and she did not hear her fall. Upon seeing her, CNA #205 yelled for the nurse. RN #213 assessed Resident #104, and she was sent to the hospital.

Phone interview on 04/16/25 at 1:13 P.M. with Registered Nurse (RN) #213 revealed she was in the nurses station at the time of Resident #104's fall on 03/31/25. RN #213 stated the aides saw Resident #104 go into the bathroom as she frequently does by herself. RN #213 stated the aides saw Resident #104 go into the bathroom but did not see her come out. When CNA #205 turned around, she saw Resident #104 on the floor outside the bathroom and called for RN #213 to come assess Resident #104. RN #213 stated she observed Resident #104 on the floor and noticed one slipper was missing. Upon touching Resident #104's hip, she grimaced, and RN #213 called to have Resident #104 sent out to the hospital. RN #213 stated she was not asked to fill out a witness statement, she was just asked to fill out the fall assessment report. RN #213 confirmed Resident #104's service plan stated supervision and they were to watch her walk independently. If Resident #104 was observed to walk a longer distance, staff will go check on her and assist her back due to the possibility of being unsteady on her feet.

Review of the undated facility policy called Fall/Found on Floor Protocol revealed complete statements by nurse and witness, or first responder and STNA assigned if no witness. With each fall or episode of being found on the floor, review the resident's care plan to assure the interventions are effective and appropriate.

This violation represents non-compliance investigated under Complaint Number OH00163891.