GREEN MEADOW HEALTH CARE CENTER 1
LOCATED: 310 BOXWOOD RUN ROAD, MOUNT WASHINGTON, KY 40047
GREEN MEADOW HEALTH CARE CENTER 1 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 MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS
LEVEL OF HARM – IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
On [DATE] at 5:30 AM, Resident #20 sustained a fall with injury. The resident sustained [REDACTED]. The facility did not complete a root cause analysis as to the cause of the fall. Resident #20 sustained a second fall on [DATE] at 11:55 PM, which resulted in a head injury and required transfer to the hospital for treatment where the resident subsequently expired on [DATE]. Record review and interview revealed Resident #20 has sustained a total of seven (7) falls from [DATE] through [DATE] with no evidence the facility had revised interventions to prevent further falls. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #20 sustained a fall on [DATE] at 11:55 PM, and the physician was not notified of the fall until eight and one-half (8.5) hours later at 8:30 AM on [DATE]. In addition, the facility did not notify the resident’s responsible party of the fall on [DATE] until 8:40 AM on [DATE] when preparations were underway to transfer the resident to the emergency room. Review of the Nursing Notes for Resident #20, dated [DATE] and timed at 11:55 AM, revealed Resident #20’s door was found closed and the resident’s bed alarm was heard faintly sounding from outside the door. When the nurse opened the door the resident was found standing behind the door and inside the closet. The nurse documented that opening the door had startled the resident and the resident tried to grab the door while it was opening and lost his/her balance, fell and hit his/her head on the foot board of the roommate’s bed. The nurse noted Resident #20’s brief was down around the ankles, and wet with urine. There was feces on the resident’s buttocks. Nursing noted neuro-checks were started after the fall. However, review of the facility’s Neurocheck Protocol document, dated [DATE], revealed the neuro-check block, timed at 6:55 AM, and the last one completed while the resident was in the facility, had a check mark in the box indicating findings were within normal limits. There was no documented evidence neuro-checks were completed after the [DATE] fall.
Continuing: Interview with Certified Nursing Assistant (CNA) #3, on [DATE] at 10:55 AM, revealed CNA #3 and CAN #2 checked on Resident #20 around 6:30 AM on [DATE], during change of shift rounds, and found the resident breathing differently. She stated the resident’s face was bruised and the bruising extended down the neck to the shoulder. The CNA stated the resident had the largest hematoma (localized swelling filled with blood caused by a break in the wall of a blood vessel) to the forehead she had ever seen; it protruded out about one to two inches. She stated she nudged the resident to wake him/her to try and see if he/she wanted to get up for breakfast. The CNA stated the resident did not seem like him/her self and she had not received information in report that the resident had experienced a change in condition. CNA #3 stated this was not reported to nurse at that time. She stated she just kept an eye on the resident and came back around 7:45 to 7:50 AM to deliver the breakfast tray. She stated again the resident still did not seem right and was lifeless. CNA #3 stated she reported this to the nurse and the nurse came to assess the resident. Interview with CNA #2, on [DATE] at 11:10 AM, revealed she and CNA #3 went into Resident #20’s room around 6:00 to 6:30 AM to get the resident cleaned up. CNA #2 said Resident #20 had bruising to the face, neck and shoulder and the resident complained about his/her face hurting so she did not wash it. She stated Resident #20 was squinting the left eye and complained of eye pain. She stated she left and came back about an hour and half (1.5) later, during breakfast tray delivery, to check on the resident and found the resident lifeless and unresponsive. She stated she was told in report the resident had fallen during the night, but no information was provided that indicated the resident had experienced a decline or was expected to pass soon. She stated she informed the nurse and the nurse came and assessed the resident. The CNA stated she was not aware the resident was on blood thinning medication. She stated that type of information was important to know because of the potential for bleeding if the resident experienced an injury. The resident expired 20 hours later at 6:00 AM [DATE]. Interview with Resident #20’s Responsible Party (RP), on [DATE] at 4:05 PM, revealed the facility did not contact them at the time of Resident #20’s fall; it was not until the facility was in the process of transferring the resident to the emergency department were they notified 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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