ANNVILLE, KY – SIGNATURE HEALTHCARE AT JACKSON MANOR REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, and review of the facility policy there was sufficient evidence to determine the facility failed to ensure Resident #1 received adequate supervision and assistance devices to prevent accidents. The facility developed a care plan that required two staff persons to assist the resident with transfers and for only therapy staff to assist the resident with ambulation. However, on 02/26/19, Resident #1 suffered a fall when State Registered Nurse Aide (SRNA) #4 failed to follow to the resident’s care plan and attempted to assist the resident to the bathroom on her own. Resident #1 sustained a fracture to the right elbow as a result of the fall.

Interview with State Registered Nurse Aide (SRNA) #4 on 03/12/19 at 2:50 PM revealed she answered Resident #1’s call light on the morning of 02/26/19. She stated the resident wanted to go to the bathroom so she proceeded to assist the resident out of bed and to assist the resident with walking (ambulating) to the bathroom. SRNA #4 stated the resident reached for the bathroom doorframe and the resident’s hand slipped and the resident fell . The SRNA stated she was not aware that Resident #1 required two (2) staff persons’ assistance with transfers and did not know the resident was only supposed to walk with therapy staff’s assistance. Further interview with SRNA #4 revealed she was aware she was required to review resident care plans every shift, but had not reviewed Resident #1’s care plan that day. She stated she just did not get around to reviewing the care plan.

Review of the facility’s investigation dated 02/26/19 revealed the facility investigated the circumstances of Resident #1’s fall and determined staff did not follow the resident’s care plan that stated staff should not ambulate the resident and that the resident required two staff persons for transfers.