KINDRED TRANSITIONAL CARE AND REHAB-THE GREENS
LOCATED: 1575 BRAINARD ROAD, LYNDHURST, OH 44124

KINDRED TRANSITIONAL CARE AND REHAB – THE GREENS was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS

LEVEL OF HARM – ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, the facility failed to ensure a resident was safely turned in bed. Harm occurred when Resident #96, who was totally dependent on staff for care, fell out of bed while staff was providing care and sustained a left knee fracture. Review of a late entry progress note dated 03/12/15 at 10:30 A.M., revealed Resident #96 was receiving care from two State-tested Nurse Aides (STNA #1 and #2) and while the STNAs were turning the resident, the resident continued to roll until she rolled out of bed and onto her bilateral knees. The physician was notified and x-rays of both knees were ordered. Review of the progress note dated 03/12/15 at 10:32 P.M. revealed Resident #96 sustained a left knee fracture from the fall. The physician ordered the resident be sent to the hospital for evaluation and treatment. The resident was admitted to the hospital and returned to the facility on [DATE]. Review of a Patient Nursing Evaluation (part two) dated 03/12/15 at 4:15 P.M. revealed Resident #96’s bed safety assessment was completed and indicated the resident was non-ambulatory, unable to get out of bed without assistance, and was totally immobile in bed.

Continuing: Interview with the DON on 05/11/15 at 4:30 P.M. revealed an investigation of the fall was conducted but the DON would not permit the surveyor to read the investigation. The DON read the results of the fall investigation as follows: Two STNAs (STNA #1 and STNA #2) were in the room. STNA #1 turned Resident #96 on her side to provide incontinence care and stated the resident just kept rolling. The DON stated STNA #2 was a new employee on orientation. STNA #2 was standing on the opposite side of the bed at the foot of the bed. STNA #2 stated the resident’s foot slid off the bed, causing her whole body to go down. STNA #2 stated STNA #1 came around the bed and when the nurse (unidentified) entered the room, the three of them returned Resident #96 to bed. The DON revealed STNA #1 was suspended and received a corrective action. The DON stated STNA #2 did not receive a corrective action, but she was verbally educated on the need to be actively involved in the care of dependent residents. Interview on 05/12/15 at 12:27 P.M. with Registered Nurse (RN) #4, revealed she had conducted the post-fall investigation. RN #4 verified STNA #2 was standing at the foot of bed observing, but not assisting in the resident’s care. RN #4 verified she did not document the height of the bed at the time of the fall and verified the resident was not mobile in bed and did not resist care. The Administrator was present during the interview and stated she did not understand what the deficient practice was, and that the STNA had a lapse in judgment and this was an isolated incident. Observation of Resident #96 on 05/11/15 at 12:20 P.M. with STNA #5 revealed the resident was lying on her back and did not voluntarily move. An interview with STNA #5 at this time revealed the resident would grimace to show pain sometimes when moved; the resident was on a turn schedule and required two hour checks for bowel incontinence. STNA #5 stated Resident #96 had no fall precautions. Observation on 05/12/15 at 1:20 P.M. revealed Resident #96 lying on her left side and mucus was drooling from her mouth. RN #4, who was present in the room, cleansed the resident’s mouth. The resident did not move during the care.

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have 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.

We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

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