State Findings:
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards and residents received adequate supervision and assistance devices to prevent accidents for two (Resident #52 and #60) of 26 residents reviewed for accidents.
Certified Nursing Assistant (CNA) J failed to ensure the safety of Resident #52 during a transfer from bed to wheelchair which resulted in Resident #52 falling and sustaining fractures. Four days after the fall and fractures Resident #52 died in the hospital.
In an interview on [DATE] at 2:00 PM Licensed Vocational Nurse (LVN) K said on [DATE] she was in the hallway just a couple of doors down when CNA J came and told her Resident #52 fell and was on the floor, LVN K said she went to room and found Resident #52 on the floor with her head toward the bottom of bed and her feet toward the head of the bed. Resident #52’s glasses were in the chair at the head of the bed. LVN K said Resident #52’s wheelchair was against the wall between the two resident’s TV’s, the breaks were off. LVN K said CNA J said the resident held onto the siderail and not the wheelchair like instructed. LVN K said CNA J said Resident #52 had a splint on her foot and when she stood up her foot splint slipped, and resident fell and hit the other bed in the room and then fell to the floor. LVN K said the resident, who was still on the floor, said that’s not true she (CNA J) threw me on the floor. The CNA denied it. LVN K said she had no idea why the wheelchair was against the wall if CNA J was getting the resident up into the wheelchair. LVN K said when she went into the room the resident did not have a gait belt on.
In an interview on [DATE] at 9:14 AM Assistant Director of Nursing (ADON) I said on the morning of [DATE] the Director of Nursing (DON) was out of the building and she was the on-call ADON. ADON I said as soon as she was notified she went to Resident #52’s room. ADON I said Resident #52 was on the floor with her head toward the foot of the bed and her feet toward the head of the bed, she did not have a gait belt on. ADON I said when Resident #52 accused CNA J of throwing her on the floor she immediately suspended CNA J.
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