MINERVA, OH – ARBORS AT MINERVA

Based on observation, record review, policy and procedure review and interview the facility failed to implement individualized and effective fall risk safety interventions for Resident #3, who was cognitively impaired and at risk for falls to prevent falls including a fall with injury. Actual Harm occurred on 06/10/21 when Resident #3, who had a history of turning off her bed safety alarm, fell out of bed, when the alarm was off, resulting in a spiral fracture of the shaft of the right tibia and fibula requiring hospitalization . This affected one resident (#3) of three residents reviewed for falls.

On 06/21/21 at 6:32 P.M. interview with the Director of Nursing verified Resident #3 was confused and interventions reminding the resident to use her call light on 09/29/20 an 03/01/21 were not effective to decrease fall risk. The DON verified the safety alarm was not functioning due to a dead battery at the time of the 03/30/21 fall. The DON verified the facility was aware the resident had a history of turning off her safety alarm and verified the alarm was not put out of reach of the resident and was turned off when the resident fell on [DATE] and on 06/10/21 when she fell out of bed and fractured her tibia and fibula. In addition, based on the identification of the resident turning off the alarm, there was no evidence the facility evaluated the resident for or implemented any other individualized and effective fall safety interventions to decrease the resident’s risk of continued falls and/or sustaining an injury from a fall. The DON indicated she though if the alarm box was out of sight of the resident it was a restraint and did not think this would be allowed.