State Findings:
Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to be free from neglect for 3 of 15 residents (Resident #s 48, 13, and 103) whose care was reviewed in that:
1. a. The facility neglected to complete fall risk evaluations, implement new fall interventions, and ensure that staff knew what fall interventions were supposed to be in place for Resident #48. Resident #48 sustained 9 falls from 6/1/19 to 7/30/19, 3 of which involved hitting his head. Resident #48 was sent to out to the hospital for a laceration to the back of his head on 7/22/19 which required staples. He had 3 more falls after the fall on 7/22/19.
b. The facility neglected to ensure that Resident #48 was wearing compression stockings as ordered by his physician, was seen by an opthamologist for his vision impairment, and was served a pureed texture diet.
2. The facility neglected to perform a fall risk evaluation and put new interventions in place for Resident #13 after he fell on [DATE] and sustained a head injury.
3. The facility neglected to implement individualized interventions for Resident #103 to prevent further falls. Resident #103 sustained 5 falls within a week. New interventions were not put in place after each fall as per facility policy.
These deficient practices could affect all residents at risk for falls and with recent falls by placing them at risk for recurrent falls with/without injury and could result in furthur neglect, injury, or harm.
During an interview with the DON at 11:47 a.m. on 7/23/19 (the surveyor saw him in the hallway and asked him what was going on with Resident #48 because Resident #48 wasn’t in his bed), he confirmed that Resident #48 was lying in a bed that was not his, that the bed was not in a low position, and that the fall mat was not down. The DON said that Resident #48 fell the night before, had to be sent out to the hospital, and got staples to the back of his head.
When asked how CNAs and other staff knew what fall prevention interventions were in place for each resident, the DON stated Word of mouth. The DON said that the at-risk plan was general and not specific to certain residents. The DON said that Resident #48 could sometimes use his call light and that, even if he couldn’t, staff were still advised to keep it in his reach. When asked what was meant by increased rounding, the DON stated Ideally, at least every 30 minutes. He’s on a busy hall. We tried to move him to another room, but that confused him. I’d like to do 1:1, but that’s not possible.
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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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