cms_TN: 35
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 35 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 689 | K | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, interview, facility investigation review, and observation, the facility failed to implement an effective fall prevention program for 7 residents (#119, #40, #39, #80, #28, #34, #47) of 7 residents reviewed for falls with injuries, of 40 residents in the facility with falls. The facility's failure to implement new interventions and have an effective falls prevention program resulted in injuries for 6 Residents (#119, #40, #80, #28, #34, and #47) and placed Residents (#119, #40, #39, #80, #28, #34, #47) in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 8/18/18 at 8:20 PM, in the conference room. The Immediate Jeopardy (IJ) was effective 11/10/17 and is ongoing. The facility was cited F689 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The findings include: Review of facility policy Falls-Clinical Protocol-Assessment and Recognition, last revised 9/12, revealed .5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observation of the events, etc. 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification- 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke. b. Often, factors in varying degrees contribute to a falling problem .Treatment/Management - 1.Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. 3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example, dizziness or musculoskeletal pain) has resolved. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. 5. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful . Review of facility policy, Accident and Incident Report-Resident, dated 1/1/17 revealed .When an accident or incident involving a resident occurs, any person witnessing the incident will call for appropriate assistance .To assure appropriate follow-through on all accidents and incidents. To study the cause of accident and incidents and to give guidance for corrective/preventive action .Do not move the resident until a licensed nurse evaluates the condition . Medical record review revealed resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #119's Brief Interview for Mental Status (BIMS) score was 0, indicating the resident had severe cognitive impairment. Continued review of the MDS revealed the resident was extensive 2 person assist for bed mobility, transfers, and toilet use and was frequently incontinent of urine. Review of facility documentation revealed Resident #119 had 9 falls between 7/9/17 to 7/10/18 and 2 falls resulted in traumatic injury. Medical record review of Resident #119's ongoing care plan revealed the resident was at risk for falls and interventions implemented included on 12/24/15: non-slick footwear that fits and assist with transfers as needed; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions; keep personal items within easy reach; bed to be in lowest position with wheels locked; call light within reach when in room; invite/escort to activities of choice; instruct/remind to call for assist with mobility/transfers; use of proper assistive device wheelchair/walker. On 1/8/16 a sensor alarm in chair was added; on 2/5/16 a bed sensor was added; on 4/15/16 floor mat due to resident transfers self to from wheel chair was added; on 5/9/16 posey grip in wheelchair due to increased falls was added; 10/14/16 toileting as needed and Call Before You Fall signs was added; and on 5/30/17 anti-tip bars and anti-lock brakes to wheelchair was added. Medical record review of a Clinical Notes Report dated 7/1/17 at 10:16 PM, revealed, .res (resident) alarm heard sounding at same time of a loud crash .res in bathroom, on the floor, wheelchair by sink. Brakes on wheelchair not on .no injuries .Will continue to monitor closely and respond to alarms . Interview with the DON on 8/17/18 at 10:25 AM, in the conference room, confirmed an investigation was not conducted for the fall on 7/1/17 in order to determine the cause of the fall and to implement interventions to prevent further falls. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #119 scored a 22 (high risk for potential falls). Review of a facility Incident/Accident Report dated 8/20/17 revealed on 8/20/17 at 5:00 PM the resident had a fall. Further review revealed .Resident observed lying in hallway in front of her w/c (wheelchair). Lying with face down and toward right side. Laceration to right forehead, scratch on right cheek .Additional comments and/or steps taken to prevent recurrence: Will ask PT (physical therapy) eval (evaluation) for cushion . Review of a Written Statement for the accident on 8/20/17 revealed, I just sat (Resident #119) back in her chair, she had been leaning forward. I sat down at kiosk by kitchen to chart my vitals. I also noticed before incident she was dragging rt (right) foot under chair. I told her several times from 3 - 4:30 pm to slow down and sit back in her chair so she wouldn't fall (Resident #119 had severe cognitive impairment). As I started charting .another CNA (Certified Nursing Assistant) said oh no, I turned to see (Resident #119) w/c rolling over her, she was on the floor, the w/c flipped . Review of a Written Statement for the accident on 8/20/17 revealed, This nurse was notified that resident had fallen out of her w/c in hallway. Observed lying on the floor in front of her w/c (wheelchair) .Was lying with face down on floor and toward her right side large amt (amount) of blood from laceration on right forehead . Medical record review of a physician's orders [REDACTED].#119 to the emergency room (ER) for evaluation. Medical record review of a Clinical Notes Report dated 8/20/17 at 11:13 PM, revealed, .Resident has stitches in right forehead . Review of the Interdisciplinary Team Review for the accident on 8/20/17, revealed, Interventions implemented was not completed and Probable Cause was leaning forward in w/c. Request eval for cushion . Interview with the Clinical Therapy Manager on 8/17/18 at 3:55 PM, in the therapy room, confirmed .She (Resident #119) was not evaluated for wheelchair seating and positioning after 8/20/17 .No recommendations were done, there was no eval . Medical record review of a Significant Change in Status MDS assessment dated [DATE] revealed the resident's BIMS was 0 and was occasionally incontinent of urine. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #119 scored a 23 (high risk for falls). Medical record review of a Clinical Notes Report dated 10/15/17 at 11:16 PM revealed, This nurse was informed that resident was sitting in the floor in the bathroom .Resident sitting beside commode trying to get self up. States that she slid off the commode after she went to the bathroom. No injuries found .Resident reminded by staff and family to please ask for assist when needing to go to the bathroom (Resident had severe cognitive impairment) . Review of an Incident/Accident Report dated 10/15/17 revealed the actual time of the fall was 5:15 PM. Review of the CNA's Written Statement revealed I was getting (another resident) up for supper. I heard (Resident #119) calling HELP ME. I found her on floor in .bathroom. She was trying to get in her w/c and slid into floor . Further review revealed, .steps taken to prevent recurrence: try to keep resident in sight of staff to help her go to BR (bathroom) . Review of the Interdisciplinary Team Review for the fall on 10/15/17 revealed Interventions implemented was to toilet the resident at least every 2 hours (an expected nursing intervention) and the Probable Cause was Toileting self et (and) fell . Medical record review of a Clinical Notes Report dated 11/10/17 at 8:53 AM revealed, 0805 (8:05 AM) Notified by CNA that chair alarm was activated and she entered room and observed resident sitting in the floor in the bathroom. Resident was attempting to pull herself up from a sitting position. CNA assisted resident into w/c and then notified this nurse. This nurse observed resident and noted to have deformity to right lower extremity . Further review revealed at 1:35 PM, .[DIAGNOSES REDACTED]. Review of the Incident/Accident Report for the accident on 11/10/17 revealed the steps taken to prevent recurrence was not completed. Continued review of a Written Statement by the CNA revealed The alarm was going off on the chair in (Resident #119) room and she was in the bathroom trying to get up hanging on the rail and on the floor and her right leg was around bottom of the toilet between the wall. She was hanging so help transfer her to the wheelchair and let the nurse know . Medical record review of ER (Emergency) Trauma Worksheet dated 11/10/17 revealed .unwitnessed fall .fell this morning out of her wheelchair while attempting to stand .Granddaughter states this happens quite frequently at patients nursing home and has resulted in several injuries in the past .Patient complains of right lower leg pain . Review of the Investigation Tool for the accident on 11/10/17 revealed for the Interdisciplinary Team Review, Interventions implemented was not completed and Probable Cause: Res transferring self. No safety awareness. Medical record review of the acute care Hospital Discharge Summary dated 11/14/17 revealed .Right tib-fib (tibia-fibula) fracture following a fall .suffered a fall at (facility) and sustained a right tib-fib fracture .cast was applied . Interview with Licensed Practical Nurse (LPN) #3 on 8/16/18 at 3:00 PM, in the 1 North nurses station, revealed .(on 11/10/17) CNA assisted her to the wheelchair .then came to get me .when I went in there observed a clear deformity to right lower leg .the CNA was not supposed to move her . Interview with the DON on 8/16/18 at 9:52 AM, in the conference room confirmed it did not appear an intervention to prevent falls was put in place after the fall on 11/10/17. Medical record review of a Clinical Notes Report dated 11/16/17 at 10:30 AM revealed, CNAs report that chair alarm was activated and staff went to investigate alarm and observed (Resident #119) sitting in the bathroom .This nurse entered room and observed resident sitting in the floor beside the toilet with both legs stretched out in front of her. No apparent injuries .Resident had an incontinence episode of stool and was assisted on toilet. Resident transferred to sunroom and seated in bean bag chair . Review of an Incident/Accident Report dated 11/16/17 revealed the steps taken to prevent recurrence: Res had just been toileted @ (at) 9:30 (fall occurred at 10:30). Will ask res more freq (frequently) if toilet needs. Bean bag utilized as well . Review of a CNA's Written Statement for the accident on 11/16/17 revealed, Chair alarm was going off .(Resident #119) was trying to get on the toilet alone . Review of the Interdisciplinary Team Review for the accident on 11/16/17 revealed, Interventions implemented: Toilet more freq. Utilize bean bag. Probable Cause: apparently attempting to toilet self. Medical record review of a Clinical Note Entry dated 11/19/17 at 12:45 PM revealed, .Observed resident sitting in the floor next to the bed with bilateral legs outstretched in front of her. W/C was also next to the bed and alarm had activated. When resident was asked what she was doing, she places her hands on her hand and states 'I don't know' .no apparent injuries .Daughter states that during a visit this week her mother told her she needed to go to the bathroom, and before she could get help, her mother was attempting to go to the bathroom unassisted . Review of a CNA's Written Statement for the accident on 11/19/17 revealed, Light was going off in (Resident #119) room and when I went in she was on the floor beside her bed. Review of the Incident/Accident Report for the accident on 11/19/17 revealed .steps taken to prevent recurrence .therapy picked her up . Review of the Interdisciplinary Team Review for the accident on 11/19/17 revealed no documentation a review was conducted, no interventions were implemented, and a probable cause was not indicated. Medical record review of Resident #119's ongoing care plan revealed an intervention on 11/24/17 of self-releasing safety belt in the wheelchair. Medical record review of a quarterly MDS assessment dated [DATE] revealed Resident #119's BIMS was 0 and the resident was frequently incontinent of urine. Medical record review of a Clinical Notes Report dated 4/13/18 at 2:36 PM revealed 1400 (2:00 PM) Called to sunroom by CN[NAME] CNA reports walking into dining room and observing resident laying in the floor in the sunroom. Reports that resident was previously sitting at the dining room table for meal. Upon assessment, observed resident laying on her left side in front of her w/c which was left in the sunroom during meal .Resident crying and yelling out in pain .resident does grab at her left hip and leg . Review of a Clinical Notes Report dated 4/13/18 at 11:42 PM revealed, .resident was admitted to (hospital) with a Lt. (left) femur fx. Medical record review of an acute care hospital Surgical Consultation Note dated 4/13/18 revealed .female who has profound dementia fell today injuring her left hip. X-rays in the emergency room reveal comminuted angulated intertrochanteric [MEDICAL CONDITION] hip . Review of the Incident/Accident Report for the accident on 4/13/18 revealed the .steps taken to prevent recurrence was not completed. Review of the Investigation Tool revealed under Devices .Ordered sensor, alarm in place it was written N/A (not applicable). Under Interventions, (indicating interventions that were to be in place at the time of the fall) was a self-releasing seat belt, mats, pressure sensor alarm, nonskid socks, low bed, and night light. Review of the Interdisciplinary Team Review for the accident on 4/13/18 revealed no documentation a review was conducted, no interventions were implemented, and a probable cause was not indicated. Medical record review of the acute care hospital Discharge Summary dated 4/16/18 revealed .Left proximal femur fracture postop (postoperative) 4/15 (4/15/18) ORIF (open reduction internal fixation) . Interview with LPN #3 on 8/16/18 at 3:08 PM, in the 1 north nurses station, revealed .(on 4/16/18) After lunch saw her sitting at one of the dining room tables .was in a regular chair .wheelchair was in the sunroom .was attempting to ambulate to her wheelchair .I assessed her .Complain of pain left hip area .Was grabbing and grimacing Left hip/leg area . Medical record review of Resident #119's ongoing care plan revealed an intervention on 4/19/18 of Lap Buddy (cushion placed across the lap and hooks under arms of wheel chair) while in wheel chair and on 4/21/18 sensor alarm to wheel chair (an intervention that was to be in place since 1/8/16). Medical record review of a Clinical Notes Report dated 4/19/18 at 6:00 PM revealed, Interdisciplinary Meeting held this day, in attendance: (3 family members), Administrator, Medical Director, DON, Therapy Manager, Clinical Mentor, and Social Worker. Resident family concerned regarding resident numerous falls .remain concerned with number of falls that have occurred. Family understands that resident has a dx (diagnosis) of Dementia, which is advancing. Resident has no safety awareness due to her cognitive deficits. Current interventions reviewed and will remain, with the addition of a lap buddy to apply to w/c, unfortunately the current armrests on resident w/c will not accommodate this lap buddy. Therapy to order new arm rests for w/c, then we will apply further Velcro to add another layer of protection and another step for resident to attempt to self transfer or remove these intervention devices. We will continue with current lap buddy until these new arm rests arrive. Hipsters provided to staff and instructed on use and to also leave resident in her w/c for meals . Review of an undated letter addressed to the family of Resident #119 and written by the facility Administrator revealed, .Thank you for taking time to meet regarding (Resident #119)'s care plan. More specifically, we discussed your concerns regarding the potential for (Resident #119) to suffer an injury by falling .it is important you clearly understand that (the nursing facility) cannot eliminate the potential for falls to occur .as we discussed, we will not have a staff member consistently within close proximity of (Resident #119), nor are we required to do so. Even with a staff member nearby, a resident still may accidentally fall. It is simply an unavoidable risk .you may consider hiring a private duty aide to remain with (Resident #119) . Medical record review of a Significant Change in Status MDS assessment dated [DATE] revealed Resident #119's BIMS was 0 and the resident was frequently incontinent of urine. Medical record review of a Clinical Notes Report dated 6/27/18 at 8:09 PM revealed, Residents bed sensor alarm sounded and noted that resident was partly off bed onto bedside matt. Bed was in lowest position and resident had legs and bottom on matt and upper torso on bed hanging onto side rails. Noted that resident had a skin tear on back and left arm . Review of an Incident/Accident Report dated 6/27/18 revealed .steps taken to prevent recurrence: Pool noodles . Review of the Interdisciplinary Team Review for the accident on 6/27/18 revealed, .Interventions implemented: Pool noodles. Probable Cause: Climbing out of bed, side rails are padded, has low air loss mattress w/ (with) sensor alarm, mats et low bed. Medical record review of a Clinical Notes Report dated 7/10/18 at 3:10 AM revealed, Pt (patient) alarm going off when CNA went to room, found pt half in bed and half out of bed. Head and upper body in bed and legs and feet on floor. Pt. has abrasion in middle of forehead . Review of an Incident/Accident Report dated 7/10/18 revealed .steps taken to prevent recurrence: Velcro noodles to mattress rail . Review of the Interdisciplinary Team Review for the accident on 7/10/18 revealed, Interventions implemented: Velcro noodle to mattress. Probable Cause: Unknown due to cognition. Res could not explain. Interview with Registered Nurse (RN) #2 on 8/15/18 at 7:03 AM, in the 1 north nurse's station, revealed .She (Resident #119) has fallen on numerous shifts .when up has to be in wheelchair and has a belt .she knows how to unhook .she is like a Houdini . Interview with the DON on 8/16/18 at 9:05 AM, in the conference room, confirmed . She (Resident #119) has had frequent falls. She continues to fall with all the interventions she has. We even told family they might want to consider hiring a 24 hour sitter. We have a few frequent fallers . Interview with CNA #16 on 8/16/18 at 2:42 PM, in the 1 north hallway, revealed .We don't have enough supervision for her (Resident #119) . Observation and interview with the Director of Nursing (DON) on 8/17/18 at 7:33 AM, in Resident #119's room, revealed the resident was in bed lying on her left side. Further observation revealed Velcro pads were hanging downward, on the outer upper end of the bed rails, and the pool noodles were up against the wall. Interview with the DON confirmed .the Velcro noodles are not attached to the bed correctly and the pool noodles are not in the resident's bed . Interview with Licensed Practical Nurse (LPN) House Mentor #1 on 8/17/18 at 8:10 AM, in the 1 North dining room, revealed .If she is sitting in a regular chair a staff member has to be with her. No intervention to address resident supervision .she continues to try to transfer herself and fall. She has no safety awareness .The lap buddy I just an extra measure to free herself. It is to slow her down. The lap buddy is working to certain extent. Gives us more time to get to her . Further interview confirmed no interventions were put in place to prevent further falls after Resident #119's fall on 11/10/17. Interview with House Mentor #1 on 8/18/18 at 9:25 AM, in the Mentor's office, confirmed staff were not documenting toileting. Further interview confirmed Resident #119 needed more frequent toileting than every 2 hours. The Mentor stated . All of us are responsible to make sure intervention is to be implemented . Further interview revealed when a fall occurred, .Nurse Fills out incident report .IDT (Interdisciplinary Team) comes up with new intervention . Further interview confirmed a root cause analysis was not done for the falls on 11/19/17 or 4/13/18 to determine the probable cause of the falls in order to implement interventions to prevent further falls. Further interview revealed, .(Resident #119) needs supervision within eye sight .She wanders all over unit . Further interview revealed the interventions implemented of toileting more frequently and toileting as needed were not different and not specific. Interview with the DON on 8/18/18 at 10:36 AM, in the conference room, revealed .I don't know what Velcro noodles would be exactly, maybe pool noodles . Interview with the DON on 8/18/18 at 12:39 PM, in the conference room, revealed .I've not seen a bean bag chair since I've been here .The lap buddy slows her down. We have recommended to family they do the 24 hour sitter .A lap buddy wouldn't prevent falls .You can't really prevent falls . Telephone interview with CNA #23 on 8/18/18 at 1:00 PM revealed the CNA had never seen any pool noodles with Velcro and did not know what Velcro noodles (intervention that was to be put in place after the fall on 7/10/18) were. Interview with CNA #5 on 8/18/18 at 8:59 PM, revealed the CNA did not know what Velcro pool noodles were. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of Resident #40's care plan dated 5/23/18 revealed the resident was at risk for falls due to weakness, history of falls, Dementia, and Hypertension. Continued review revealed interventions included wear non-slick footwear, instruct the resident on safety measures to reduce risk of falls, attempt to engage in Activities of Daily Living (ADL's) that improve strength, balance, and posture, and keep areas free of obstacles to reduce the risk of falls or injury. Medical record review of the Admission MDS dated [DATE], revealed Resident #40 had a BIMS score of 3, indicating the resident was severely cognitively impaired, and required extensive assistance of 1 for mobility, toileting, and transfers. Review of a facility Incident/Accident report dated 6/27/18, revealed Resident #40 was found on her knees in her room with 2 skin tears to the left wrist. Continued review revealed steps taken to prevent recurrence included .Call before you fall signs - visual cueing . Review of the Interdisciplinary Team Review for the accident on 6/27/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Medical record review of a Nursing Note dated 7/6/18, revealed .Ambulates w(with) walker w/one assist, however she frequently forgets to ask for assist and attempts to get out of chair and ambulate to/from room by herself. Frequent reminders given to call for assist. Gait is unequal and unsteady . Medical record review of a Nurses note dated 7/30/18, revealed Resident #40 was in her recliner, attempted to pick up a cup that had fallen on the floor, and slid out onto the floor. Further review revealed the resident had non slip socks on. Continued review revealed the resident was instructed to always use the call light. Review of a facility Incident/Accident report dated 7/30/18 revealed Resident #40 had a fall in her room with no injuries noted. Continued review revealed steps taken to prevent recurrence .Reinstructed & (and) demo (demonstrate) call light use . Review of the Interdisciplinary Team Review for the accident on 7/30/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Review of a falls assessment dated [DATE] revealed Resident #40 scored 11 (at risk for falls). Review of an Incident/Accident report dated 8/2/18 revealed Resident #40 was found lying on her back in her bathroom with her walker on top of her. Continued review revealed .Two knots were found on the back of her head with a laceration on one of them .It was determined to send her out for evaluation . Review revealed interventions in place at the time of the fall were mats and non-skid socks. Further review revealed steps taken to prevent recurrence .Reiterate use of call light .Removal of hosiery and use slipper socks . Review of CNA #15 Written Statement revealed, (CNA #14) and I were in (another resident's room) with another resident, and heard someone yelling. Ran out to see what happened next door. Went into (Resident #40) room and found her lying on bathroom floor . Review CNA #14 Written statement revealed, (CNA #15) & (and) I were in (another resident room) and heard some one yelling and went to check in each room & it was (Resident #40) laying in bathroom floor . Review of the Interdisciplinary Team Review for the accident on 8/2/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Further review revealed no signature from the Medical Director, Administrator or DON to indicate the fall was reviewed. Review of a falls assessment dated [DATE] revealed Resident #40 scored a 14 (at risk for falls). Medical record review revealed the resident was admitted to an acute care hospital on [DATE] for .Mechanical fall .Subdural hematoma .[MEDICAL CONDITION] .Patient was admitted after falling backwards in bathroom at (facility) . Medical record review of a Computed [NAME]ography (CT) of the Head radiology report dated 8/2/18 revealed the resident had an acute subdural hematoma (SDH). Medical record review of a Nursing Note dated 8/6/18 revealed .Resident arrived back from (named hospital) 8/6/18 .Family at bedside .daughter states she is alert at times and does not recognize her. She has severe bruising to back of head and neck, w/a (with a) small scab to back of L (left) side of head. Bruising to R (right) arm, R index finger swollen and red. Small skin tears to bilateral arms. L lower arm skin tear . Medical record review of Resident #40's care plan dated 8/6/18, revealed the resident was at risk for falls related to weakness, History of Falls, Dementia, [MEDICAL CONDITION] medication use and status [REDACTED]. Medical record review of a Nursing Note dated 8/12/18 revealed the nurse heard Resident #40 yelling out, the nurse entered the room, and found the resident lying in the corner of her room with her back against the wall. Further review revealed the resident was found to have a large bruise to the left hip and a skin tear to the right arm. Continued review of the note revealed earlier the same day, the resident was found standing in the resident's room, going to the bathroom, and other staff reported she gets up without calling for assistance. Further review revealed the resident's call light was in reach at the time of the fall and staff re-educated the resident on the use of the call light. Review of a facility Incident/Accident Report dated 8/12/18, revealed the resident was found in the corner of her room between the bed and the bathroom and the resident stated she slipped. Continued review revealed under steps taken to prevent recurrence there were no interventions implemented. Review of the Investigation Tool for the accident on 8/12/18 revealed, under the section Interventions, which indicated the interventions in place at the time of the fall, none of the interventions were marked, and handwritten in the section was Re-Educate. Review of the Interdisciplinary Team Review for the accident on 8/12/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Further review revealed no signature of the Medical Director, Administrator or DON to indicate they had reviewed the accident. Medical record review of a falls assessment dated [DATE] revealed the falls assessment was incomplete and no score was documented. Medical record review of a physician's orders [REDACTED].Please get floor mat that alarms @ nurses station & place beside bed . Interview with RN #3 and medical rec (TRUNCATED) | 2020-09-01 |