State Findings:
Based on a review of clinical records, select incident and accident and information submitted by the facility and staff interviews, it was determined that the facility failed to provide necessary supervision with activities of daily living, consistently implement identified and individualized safety measures and maintain an environment free of potential accident hazards to prevent falls and accidents for two residents out of 25 sampled residents (Residents [AGE] and 28).
Review of a resident incident report dated October 20, 2019, at 1:48 AM revealed that the resident was found lying on the floor face down on the bathroom floor after attempting to self-transfer from the toilet to her chair. Employee 4 (nurse aide) and Employee 5 had helped the resident to the bathroom,but then the employees left the resident alone in the bathroom.A review of a statement from Employee 4 dated October 20, 2019, indicated that Employee 4 entered the resident’s room at 1:10 AM with Employee 5. Employee 4 and Employee 5 assisted the resident from the bed to the wheelchair and then to the toilet. Employee 4 exited the resident’s room. At 1:20 AM the nurse came to get the employee to help get the resident off the floor.
A review of a statement from Employee 5 dated October 20, 2019, indicated that Employee 5 entered the resident’s room at 1:10 AM with Employee 4. Employee 4 and Employee 5 assisted the resident from the bed to the wheelchair and then to the toilet. Employee 5 exited the resident’s room with Employee 4. At 1:20 AM the nurse came to get the employee to help get the resident off the floor.
An interview with Director of Nursing (DON) on January 14, 2019, at approximately 11:30 AM confirmed that the staff failed to provide sufficient assistance and supervision with transfers and toileting, as planned for the resident, to prevent a fall.
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Personal Note from NHA-Advocates
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