State Findings:
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide effective supervision to prevent accidents for one (1) of two (2) sampled residents, Resident #36. Per interview, on 03/07/19, Resident #36 resident fell and sustained a [MEDICAL CONDITION] when he/she transferred without assistance in the bathroom. Per interview and record review, the resident was not wearing non-skid footwear, which was an intervention the facility had put in place for the resident to prevent falls.
Observation, on 04/01/19 at 7:19 PM, revealed Resident #36 lying in bed with an abductor cushion positioned between his/her legs. Interview during observation revealed the resident had fallen in the bathroom and fractured a hip. The resident stated he/she activated the call light but staff did not respond and he/she went to the bathroom unassisted because he/she did not want to pee on himself/herself.
Review of the Interdisciplinary Team (IDT) Post Fall Review, signed 03/08/19, revealed there were no predisposing diseases or conditions that might have contributed to the fall. The review revealed the resident was wearing open heel slippers at the time of the fall; however, review of the care plan revealed the resident was to have non-skid footwear when ambulating/transfer. Further review revealed an intervention to ensure the slippers were put up.
Interview with Certified Nursing Assistant (CNA) #5, on 04/05/19 at 8:38 PM, revealed she went to Resident #36’s room to pick up a lunch tray when she heard someone say help me. The CNA stated she looked in the bathroom, discovered the resident lying on the floor, and notified the nurse. Further interview with CNA #5 revealed she provided incontinent care later in the afternoon and stated the resident was still hurting. According to the CNA, the resident needed one (1) person to assist with transfers and toileting; however, the resident was good by himself/herself prior to the fall. The CNA did not recall if the resident’s call light was activated.
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