State Findings:
Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure five (5) of twenty-two (22) sampled residents received adequate supervision and assistance devices to prevent accidents (Residents #9, #18, #21, #24, and #75). Two of the five residents (Residents #9 and #18) sustained injury.
The facility assessed and care planned Resident #9 at risk for falls and required two (2) staff to provide assistance with bed bath and bed mobility. However, on 02/01/19, Certified Nurse Aide (CNA) #1 failed to follow the care plan when he/she provided bathing care and assisted with bed mobility alone. Resident #9 fell from the bed and sustained a fractured left femur. Surgical intervention was not performed due to the resident’s condition; however, the resident was hospitalized from [DATE] to 02/07/19. In addition, Resident #9 had an increase in pain and required an increase in pain medication.
Review of the Falls Investigation Reports revealed Resident #18 sustained thirty (30) falls at the facility from 07/03/18-02/05/19. However, there was no documented evidence the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor determined any corrective action to try to prevent future falls and revised the care plan to address the residents’ need for increased supervision due to the numerous unwitnessed falls, per facility policy and interviews with Interdisciplinary Team {IDT} members related to the facility’s falls protocol/process. In addition, staff failed to conduct Fall Risks assessments after each fall per facility protocol. Resident #18 sustained a left femur fracture that required surgical repair and he/she was hospitalized for [REDACTED].
In addition, review of the Fall Investigation Reports revealed Resident #24 sustained falls on 09/25/18, 10/08/18, 11/25/18, 11/26/18 and 12/07/18; Resident #75 sustained falls on 10/30/18, 11/06/18, and 12/27/18; and Resident #21 sustained a fall on 02/19/19. However, the facility failed to conduct fall risks assessments and identify appropriate interventions to prevent future falls per facility policy and protocol.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
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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Personal Note from NHA-Advocates
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