State Findings:
Based on observation, interview, and record review, the facility did not provide adequate supervision to prevent R#1, who was identified with risk for falls from falling in the dining room. This resulted in a [MEDICAL CONDITION].
This failure could place residents with a fall history at risk for additional falls and injuries.
Observation on 04/17/20 at 6 PM of facility’s video revealed on 04/13/20 at 7:36 Resident (R#1) was sitting at the dining table with Certified Nurse Aide (CNA#1). CNA#1 assisted R#1 by feeding her a spoonful of food and then got up from the dining table and left the dining room. This left R#1, who was in her wheelchair, by herself as she continued to eat her meal. In addition, R#2, R#3 and R#4 remained in the dining room without any staff present in the dining area. Afterwards, the video’s timer revealed at 19:36:56 R#1 stood up and walked away from her wheelchair approximately 4 feet while holding onto the dining table; she turned around and released the table; she attempted to walk away when she lost her balance and fell on to the floor at 19:37:46; at 19:37:59 R#2, who was in her wheelchair, wheeled himself from the dining table towards the nurses’ station, and at 19:38:08 ADON#1 and CNA#1 responded by entering dining area and going towards R#1, after R#3 pointed them towards R#1, who was on the floor.
Interview on 04/20/20 at 2:40 PM with facility’s Medical Director (MD) indicated Resident (R#1) is an [AGE] year-old female with [DIAGNOSES REDACTED]. MD indicated on 04/13/20 R#1 fell and sustained a fracture to her femur. R#1 was sent to the local hospital and then transported to another hospital for surgeon to evaluate and pursue surgery; however, surgeon decline to perform surgery due to R#1’s age and her medical condition. MD indicated R#1 should not have been left unsupervised in the dining area, because even if she is directed not to get up she will get up; however, if staff were in the area they could intervene by assisting her.
Administrator confirmed, when resident R#1 fell and broke her femur in the dining area, there were no staff present in the dining room as seen on the facility’s video.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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Personal Note from NHA-Advocates
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