State Findings:
Based on record review and staff interviews the facility failed to have two staff assist when providing care and repositioning a resident in bed to prevent the resident from falling from bed and sustaining an injury for 1 of 4 residents sampled for accidents (Resident # 12). Resident # 12 fell from bed during incontinent care and sustained a right distal femur fracture that required an immobilizer.
Review of the facility Event Summary Report, completed by Nurse # 1 dated 11/29/18 at 11:35 AM read in part, Nurse Aide NA # 1 reporting resident fell out of bed. Upon entering room found resident on the floor to the left side of the bed with her head lying at the foot end of the bed, urine noted on floor under resident. Right lower leg angled out to the side of her body. NA reporting that she was changing resident and had her turned on her left side, resident had a hold of the bedrail,
reports somehow she flipped out of the bed to the floor. NA reports states that right leg slid in some food that was on the floor. Asked Resident if she was having some pain in her neck and head. Asked in Spanish from Spanish speaking NA, she shakes her head yes. Also shakes head yes for leg pain. Called office to report incident and that resident was being sent out to the hospital. Called doctor ‘ s office to report the incident and that the resident was being sent out t the hospital. 911 called. Family was called by another nurse. Leaves out of facility via stretcher. The root cause/ conclusion: Improper positioning during ADL care.
An interview was conducted with the Director of Nursing (DON) on 2/26/19 at 1:43 PM. The DON stated after the fall, the NA involved came to report Resident # 12 had a fall. The NA reported the head of the bed was stuck up at a 90 % angle and when she was using a draw sheet the resident flipped out of bed. The NA stated she had not reported the bed was not working to the Maintenance man or nurse. The DON revealed when other staff entered the room to check the bed, it was working fine. She stated the NA was suspended pending their investigation and later terminated.
An interview was conducted with the Administrator on 2/28/19 at 2:42 PM. The Administrator stated they discussed Resident # 12 ‘ s fall and afterwards instructed staff to use 2 person assist with all resident transfers. He stated he would have expected the NA to get help when caring for Resident # 12. The Administrator stated the facility ‘ s investigation of Resident #12 ‘ s fall revealed the NA #1 failed to do anything right.
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