MESA, AZ – MISSION PALMS POST ACUTE

Based on clinical record review, staff interviews and facility and hospital documentation, the facility failed to ensure that adequate supervision was provided to one (#193) of two sampled residents during care, resulting in a fall with a fracture.

A written statement by a RN (registered nurse/staff #110) dated (MONTH) 28, (YEAR) documented the supervisor (staff #110) was notified that the resident was involved in a fall. The CNA (certified nursing assistant/staff #136) reported that he was cleaning the patient in bed without the assistance of another CN[NAME] Per the statement, he had the resident roll on his side with the resident’s body facing toward him. The CNA reported that the resident began to roll into his body and off the bed and that he attempted to break the patient’s fall with his body, but the resident ultimately fell to the ground. The CNA was asked how hard the resident had hit the floor and the CNA responded with some force. The CNA was asked if the resident hit his head and he responded no. The floor nurse reported that he entered the room to find the resident on the floor face down. When supervisor entered the room, the resident was already placed back in bed. Supervisor assessed the resident. His face was pale and he had a dazed look in his eyes. Pupils were sluggish to react. Resident was asked if he was feeling any pain and stated that he had a headache which he rated at a 7 out of 10, with 10 being the worst pain he ever felt. Also noted a 12 centimeter circular skin tear to the right arm. When asking the resident if he was experiencing any pain in his arm, he stopped responding to questions. His head fell back onto the pillow and he seemed to lose consciousness. MD was notified. He advised to send the resident to the emergency department for assessment.