CLINTON, KY – CLINTON PLACE

Based on interview, record review, and facility policy review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents related to multiple falls for one (1) resident, in the selected sample of four (4) residents (Resident #1).

The facility assessed and care planned Resident #1 to have a pressure alarm to the bed and to offer toileting frequently; however, the resident had three (3) unwitnessed falls, and with each fall the bed alarm did not sound, two (2) falls on 02/09/2020 and one (1) fall on 02/12/2020. The falls resulted in a [MEDICAL CONDITION] with a subdural hematoma, a left scapular fracture, left clavicular fracture with multiple bruising and skin tears. The resident was admitted to the hospital for pain control and wound/fracture care.

Interview with LPN #1, on 02/20/2020 at 10:36 AM, revealed she was passing medications on 02/09/2020 on night shift at approximately 11:20 PM, when she was called into the room by a CNA, and found the resident lying on the floor. He/she complained of hurting all over, and was sent to the hospital for an evaluation. She revealed the bed alarm was not working, and believed that the resident had turned it off. She revealed she had not made rounds on him/her since coming on shift at 7:00 PM. She stated almost four and one half (4 1/2) hours had lapsed prior to her seeing him/her for the first time on that date, and she didn’t make rounds first thing. She stated she would usually start her med pass and assess the residents as she got to them. She further revealed she didn’t see anything wrong with waiting until medication pass to see the resident for the first time during the shift. She revealed she checked bed alarms at the time she was in the room giving medications.

Interview with the Clinical Educator, on 02/19/2020 at 3:41 PM, revealed she expected all nurses to do their rounds at the beginning of each shift. Alarms should be checked to ensure they worked properly. She revealed education had been provided for nurses and CNA’s regarding making rounds and checking alarms.

Interview with the Assistant Director of Nursing (ADON), on 02/20/2020 at 4:10 PM, revealed she expected nursing staff and CNA’s to make rounds to check alarms, and they should start at the beginning of the shift.