LOCATED: 8064 SOUTH AVENUE, BOARDMAN, OH 44512
GREENBRIAR CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO PROVIDE FALL PREVENTION INTERVENTIONS WERE IN PLACE AS ORDERED BY THE PHYSICIAN
Level of harm – Actual Harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure Resident #99 who was identified at high risk for falls had fall prevention interventions in place as ordered by the physician. Harm occurred on 07/11/14 when Resident #99 fell and sustained a subdural hematoma requiring a hospital admission.
Continuing: [DATE] with [DIAGNOSES REDACTED]. On admission Resident #99 was assessed as a high risk for falls. Review of a progress note dated 07/10/14 timed 3:20 P.M., revealed Resident #99 toppled out of chair onto her left side. The resident denied pain and stated she did not fall. The progress note indicated Resident #99 was confused and did not understand her surroundings. As a result of the fall, the physician ordered a low bed and bilateral mats to the floor next to the bed for the resident’s safety. Review of a progress note dated 07/11/14, revealed Resident #99 sustained an unwitnessed fall. The note indicated the nurse walked by Resident #99’s room and observed her on the floor with staff members administering first-aid. The progress note indicated Resident #99 was actively bleeding from a laceration to the back of her head. Resident #99 was sent to the hospital for evaluation. Review of a progress note dated 07/12/14, revealed Resident #99 was admitted to the hospital with [REDACTED].#99 remained in the hospital until 07/16/14, when she was readmitted to the facility. Review of the facility’s incident investigation for the 07/11/14 fall revealed Resident #99’s bed was not in the low position, the call light was not in reach and the floor mats were not on the floor on either side of the bed as ordered by the physician for fall prevention interventions. The director of nursing (DON) was interviewed on 08/19/14 at 8:25 A.M. The DON verified Resident # 99 was supposed to have a low bed and floor mats in place as a safety precaution and verified they were not in place at the time of the fall. The DON verified the resident was sent to the hospital on [DATE], as a result of the fall.
Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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