State Findings:
Res #1 sustained a total of 18 falls from 03/10/21 to 09/12/21. Two falls resulted in major injuries which included, right [CONDITION(S)], right humerus and right wrist fracture. Eleven falls resulted in skin tears, lacerations and/or abrasions.
The DON acknowledged there were no interventions put into place or implemented to reduce or prevent falls for 15 documented falls from 03/10/21 to 09/12/21.
At 08:50 a.m., LPN #3 was asked to trigger the motion sensor in the residents’ room. She walked into the room and put her legs in front of the motion sensor. No alert sound was audible while standing in the hallway near the Res #1’s room. LPN #1 located CMA #1 in the medication room, the door was observed to be shut. CMA #1 was observed coming out of the medication room and was wearing the sensor alarm clipped to the front of her shirt. LPN#3 asked CMA#1 if the alarm was had gone off. CMA#1 was observed to shake her head no. No sound was audible. LPN #1 had another staff member trigger the alarm and stood approximately 40 feet down the hall near the dining area, no alert sound was audible. LPN#1 was asked if Res #1 had a BSC in her room at night. She stated, No
At 08:59 a.m., LPN#3 was asked if she had been trained on the use of the motion sensor and alarm. LPN #3 replied, she had no formal instruction and thought it worked throughout the building. CMA#1 was asked if she had been instructed on the motion sensor use. She replied, I was told if there was any movement, if she [resident] put her feet down it (sensor alarm) would go off.
An incident report, dated 06/27/21, documented Res #1 was heard pounding on her door. Upon entry into the room, Res #1 was found to be laying on the floor. Res #1 complained of pain to the right wrist and right shoulder. She was transported to the ED and diagnosed with fractures to the right wrist and shoulder.
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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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