TUCSON, AZ- CATALINA POST ACUTE AND REHABILITATION

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42306

Based on clinical record review, review of facility records, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#1) was provided adequate supervision to prevent an unwitnessed fall with significant injuries that required hospitalization . The deficient practice could result in additional residents sustaining significant injuries from falls.

An Elopement/Wandering evaluation dated [DATE] at 11:17 p.m. included that resident #1 was confined to bed or chair.

A care plan initiated on [DATE] for falls included a goal that resident #1 would be free of falls. Interventions listed in the care plan included to avoid rearranging the resident’s furniture, and reviewing past falls to determine causative factors.

A physician’s order dated [DATE] at 4:30 p.m. included to for resident #1 to have a (repeat) chest X-ray.

A Nursing note dated [DATE] at 7:38 p.m. included that a diagnostic (X-ray) technician arrived at 6:15 p.m. and departed at 6:30 p.m. and that the when the technician exited, the RN asked a TNA (Temporary Nursing Assistant/staff #100) to reposition resident #1 post CXR (Chest X-ray). The note included that seconds later, when the TNA entered the resident’s room, the resident was found face down on the floor, the TNA called for help and immediately multiple staff responded to help. The note included that Respiratory Therapy (RT) began to provide respirations manually to the resident, and that at 6:28 p.m. 911 was called, and emergency personnel arrived at 6:35 p.m. The note included that resident #1 was transported via stretcher with a pulse at 6:45 p.m.

A Nursing note dated [DATE] at 8:17 p.m. included an RN (staff #17) was contacted by the County Coroner’s office regarding contusions found on resident #1’s face and forehead. The note included that the resident’s initial admission record and wound/skin care record had no presence of contusions noted. The note included that there were no witnesses to resident’s descent to the floor on left side of bed per colleagues.

An eMAR (electronic Medication Administration Note) dated [DATE] at 12:19 am. included that resident #1 was deceased per County Coroner’s Office.

An undated facility investigative record for resident #1’s fall on [DATE] included that resident #1 was found on the floor on the left side of her bed, lying on her back, and had blood visible over her lips, the tracheostomy was still intact, and the resident’s nasal gastric tube was out. The investigation included that the resident was incontinent of bowel and bladder and was unable to give a description of the fall, and that a CODE was called for emergent help. The investigation included that, a team of six staff lifted the resident from the floor, CPR (cardiopulmonary resuscitation) was initiated, and that resident #1 had an injuries to the face.

A diagnostic technician (staff #89) stated he had informed a nurse (staff #3) that resident #1 was trying to get up and needed help, and that staff #3, then instructed a TNA (staff #100) to go check on the resident.

-A Respiratory Therapist/staff #63 stated that when he was leaving shift report he heard the diagnostic tech tell the nurse that resident #1 needed to be repositioned, staff were on the way to the resident’s room the ventilator alarm activated and resident #1 was found face down on the floor.

-An RN (staff #3) stated that when the diagnostic tech came to resident #1’s room, she was notified that resident #1 needed to be repositioned and sent a TNA (staff #100) in to check on the resident (rather than staff #3 check on the resident who was experiencing symptoms of distress).

-There was no documented evidence that staff #100 had been interviewed for this investigation.

Attempts to contact staff #100 were attempted on [DATE] and [DATE] and were not successful.

During an interview conducted on [DATE] at 1:29 p.m. with an RT (Respiratory Therapist/staff #63), he stated that when he heard a TNA (staff #100) calling for help from one of the rooms, he entered the room and saw the resident face down between the bed and the wall. Staff #63 stated that resident #1 had a tracheostomy that was still connected to the ventilator while lying face down, and that the ventilator was not alarming which indicated the resident was still ventilating while face down. Staff #63 stated that staff turned the resident over onto her back, and that the resident appeared beat up because her face was covered in blood and there was blood all over the floor. Staff #63 stated the resident’s tracheostomy was in place and that he ventilated the resident manually. The RT stated that the resident was unresponsive and had a pulse.