The Springs, A Grace Living Community

MUSKOGEE, OK Unsupervised Resident with history of falls suffers fractured pelvic, rib fractures, and frontal scalp hematoma/laceration.

THE SPRINGS, A GRACE LIVING CENTER COMMUNITY

FACILITY FAILED TO ENSURE THAT A NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND PROVIDES ADEQUATE SUPERVISION TO PREVENT ACCIDENTS.

State Findings:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for one (#300) of three sampled residents reviewed for falls. The facility failed to: a) Thoroughly investigate falls to determine root causes of falls. b) Determine frequency of needed supervision to prevent falls. c) Modify/revise interventions and/or update care plans as necessary to prevent falls. d) Monitor effectiveness of interventions to prevent falls.

The resident sustained [REDACTED]. The resident sustained [REDACTED]. The resident complained of hip pain and was sent to the emergency room . The hospital emergency room record, dated 06/14/18, documented the resident had a fractured pelvic with internal bleeding, two left rib fractures, and a left frontal scalp hematoma/laceration.

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