GREELEY, CO- LIFE CARE CENTER OF GREELEY

Based on record review, observations and interviews, the facility failed to ensure a safe environment, effective interventions and adequate supervision to prevent accidents for five (#50, #27, #42, #39 and #148) of eight residents reviewed out of 20 sample residents.

The facility failed to implement effective interventions after the first fall to prevent a second fall with major injury for Resident #50. Due to the facility’s failures to develop appropriate interventions to effectively anticipate cognitively impaired residents’ needs resulted in several unwitnessed falls, it contributed to Resident #50’s femur fracture and hospitalization .

The facility failed to ensure adequate supervision and effective interventions were in place to prevent multiple unwitnessed falls that ultimately resulted in major injury to Resident #27. Due to the facility’s lack of supervision and effective interventions, it resulted in four unwitnessed falls in less than a month, in which she sustained fractures to her left hand; causing her pain, and requiring the application of a cast, resulting in limited use of her left hand.

The facility further failed to:
-Implement effective and appropriate interventions after each of three falls sustained within a four day period to prevent recurrent falls for severely cognitively impaired Resident #42;
-Implement effective and appropriate interventions to prevent two falls sustained within one week for Resident #39; and,
-Implement effective interventions to prevent a fall for cognitively impaired Resident #148, who was admitted with their left upper extremity immobilized after a fracture.

Resident #50, age 89, was admitted on [DATE] with diagnoses of concussions, polyneuropathy, heart failure, pain and repeated falls.

-A 9/28/21 nursing note revealed: Patient having AMS (altered mental status) and garbled speech this morning after unwitnessed fall yesterday. Pt (patient) reported he did hit his head. Neuros WNL (within normal limits). Pt c/o (complained) increased pain to pelvic area. Pt received first dose of [MEDICATION(S)] (blood thinner) yesterday. (Name) PA (physician assistant) notified and orders were received to send pt to ED (emergency department) for evaluation. Pt left facility at approximately 10 a.m.

On 9/28/21 the emergency department physician documented: I performed a face-to-face diagnostic evaluation of the patient in the emergency department. I was present in the emergency department around 1015 hours (10:15 a.m.), just prior to the patient’s arrival. EMS reported that the patient is an [AGE] year-old male with a past medical history that includes cardiac disease on systemic anticoagulation with [MEDICATION(S)] and dementia who was brought in from his nursing care facility to the (hospital) emergency department as a full trauma activation after reportedly sustaining a ground-level fall yesterday evening around 1800 (6:00 p.m.) hours .Secondary survey revealed age-indeterminate bruising of the right lateral chest, flank, and knee, as well as an approximately 2 cm in diameter superficial skin tear of the right elbow area .

The patient was found to have a fracture of the right femur just below the femoral head .
Diagnoses this visit:
-Right proximal femoral (thigh bone) fracture
-Bilateral pleural effusions (fluid buildup between the lungs and chest)
-Fall on anticoagulation.
From the emergency department, the resident was admitted for surgery. He did not return to the facility after hospitalization .

Licensed practical nurse (LPN) #1 was interviewed on 10/21/21 at 8:20 a.m. She said Resident #50 should have been checked by staff as frequently as every 15 minutes after his first fall. She said additional interventions should be implemented. She said it should not have been another resident alerting staff about Resident #50’s fall.

Resident #27  

Fall #1, 9/22/21 unwitnessed fall: The 9/22/21 fall investigation and event note documented by certified nurse aide (CNA) #2 and registered nurse (RN) #4 at 7:30 p.m. read in part: (Resident #27) was crying for help in the bathroom. She was sitting with her back to the wall and her legs out in front of her. Her wheelchair was by the sink. Resident assessed, states pain to left knee when attempting to move her leg. Able to move right leg without difficulty, bruising
noted to inner left knee. Able to move arms without any pain or discomfort. No injuries to head noted, continues to complain of left knee pain when palpated, just above the knee. The resident stated she was trying to get to the bathroom by herself, the call light was not on. The intervention for this fall was to place a sensory alarm on the bathroom door.

–There were no interventions to conduct 15-minute checks, how to anticipate and provide the resident’s needs, or a toileting plan.

Fall #2, 10/1/21 unwitnessed fall:
The 10/1/21 fall investigation documented by licensed practical nurse (LPN) #1 at 3:30 p.m. read in part: This nurse was in another room and walked into the hall to see two CNAs and another nurse lifting (Resident #27) off the floor with a mechanical lift. There was bruising above her right eyebrow, a small cut on her bottom lip and a skin tear to her right ‘pinky’ finger knuckle with bone exposure. Resident stated that her wrists hurt. The physician was notified and stated to continue to monitor. Skin tear dressed. The resident said she fell forward out of the wheelchair. She had been in the hall outside her room self propelling in her wheelchair. The cause of the fall was felt to be due to her diagnosis of dementia. The intervention for this fall was to do frequent checks on the resident and staff were to supervise and cue the resident when up in her wheelchair to not lean forward to pick items off the ground.

–However, the DON did not provide documentation of frequent checks completed for Resident #27. Further, there was no documentation of how often the frequent checks should be conducted.
-There was no pain evaluation completed after this fall.

The 10/2/21 health status note documented by LPN#1 at 9:00 a.m. read in part: Noted bruising to right side of jaw this morning, as of yesterday after fall no bruising was noted, bruising is light purple in color. Moderate purple bruising noted to right forehead bump, slightly darker in color from previous day. Right hand down to mid forearm [CONDITION(S)] noted as previous date none was noted, moderate purple bruising noted to this area as well as previous date none was noted. Resident complains of pain with and without touch to her right wrist. Physician notified to obtain orders for right wrist x-rays.

The 10/2/21 transfer to hospital summary, documented by RN #4 at 2:55 p.m., read in part: Resident with left hand blackened from fingertips to down below the wrist, hand deviated slightly outward and very painful, swollen and hot. Unable to manipulate joint as it was too painful. Resident was transferred to the hospital. She was alert but confused at time of transfer.

The 10/2/21 emergency department x-ray result indicated Resident #27 had a minimally displaced spiral fracture along the left third metacarpal shaft and a nondisplaced fracture at the base of the second metacarpal with possible intra-articular (fracture that crosses a joint surface) extension at the carpometacarpal (CMC) joint (at base of thumb) with soft tissue swelling along the left hand and wrist.