State Findings:
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, hospital records, facility post fall investigation and interview, the facility failed to prevent falls for 2 residents (#81 and #285) of 23 residents reviewed for falls. This failure resulted in actual Harm for Resident #81 and Resident #285.
Interview with CNA #6 on 2/28/18 at 3:50 PM by the East Shower Room door confirmed she was transferring Resident #81 without assistance when the resident fell into the bathtub on 12/15/17. Continued interview revealed the CNA#6 was asked if the resident was ever a 2 person assist with transfers and CNA #6 stated, She used to be, but she’s gotten stronger and I try to let her do as much as she wants to. She gets anxious when you touch her and likes to do things herself. Further interview revealed the CNA #6 was asked if she used the gait belt to transfer the resident after the fall and CNA #6 stated, No. I guess I should because we have enough of them.
Interview with the Director of Nursing (DON) on 2/28/18 at 11:41 AM in the Administrator’s office confirmed the resident was to be transferred with assistance from 2 or more people at the time of the fall on 12/15/17. Continued interview confirmed the facility failed to transfer Resident #81 with assistance of 2 people resulting in and a sacral fracture (HARM).
Interview with CNA #7 on 2/28/18 at 5:10 PM confirmed the resident was found sitting up on her buttocks in front of the sink with a laceration to the back of her head and small amount of bleeding.
Telephone interview with Family Member #1 on 2/17/17 at 8:30 AM confirmed a family friend notified her Resident #285 had staples to the back of her head after a fall. (HARM).
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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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