PUEBLO, CO- BELMONT LODGE HEALTHCARE CENTER

Based on observations, record review and interviews, the facility failed to ensure three (#4, #3, and #6) of four residents reviewed for accidents out of six sample residents received adequate supervision to prevent accidents.

Specifically, the facility failed to develop and implement a person-centered care plan that identified Resident #4’s fall risk and put effective interventions into place to reduce falls and prevent an injury.

Resident #4 was admitted to the facility for long term care on 2/15/22 with a diagnosis of Lennox-gastaut syndrome ([CONDITION(S)]), diabetes mellitus type two, gastro-[CONDITION(S)] reflux disease (GERD), and chronic pain syndrome. On 2/16/22, one day after the resident’s admission to the facility, the resident sustained a fall. The facility failed to put effective interventions into place and the resident fell again on 2/19/22 (four days after his admission) and 2/20/22, for which he sustained a left humerus fracture.

After the resident sustained a left humerus fracture on 2/20/22, the resident sustained an additional four falls on 3/17/22, 3/26/22, 5/4/22, and 5/30/22. The facility failed to determine the root cause of the resident’s continued falls and put effective, person-centered interventions into place.

Additionally, the facility failed to:
-Conduct a root cause analysis and update the plan of care with effective person-centered approaches for Resident #3 and Resident #6; and,
-Ensure a registered nurse (RN) assessment was completed and documented following sustained falls by Resident #4, Resident #3, and Resident #6.

Resident #4

Fall incident on 2/20/22-unwitnessed with a sustained major injury

The 2/20/22 change of condition assessment documented Resident #4 appeared to have pain in his left arm, left shoulder, and was holding his left wrist. The resident had bruising to his mid upper left arm and swelling to his left shoulder, all sustained from an unwitnessed fall. The physician was notified and ordered an x-ray of the left shoulder, left humerus, and left wrist.

The 2/20/22 nursing progress note, documented the facility received the radiology report that the resident sustained an acute fracture of the left humeral neck with minimal displacement from an unwitnessed fall. The physician assistant was notified and orders were obtained to stabilize the resident’s left shoulder and administer pain medication as needed.

The 2/20/22 fall risk assessment documented the resident was a high risk for falls.

The 2/21/22 IDT progress note documented the resident was reviewed for an unwitnessed fall with
complaints of pain to the left shoulder and arm. The resident had bruises on the left arm. The resident was weak, unsteady and continued to transfer on his own without calling for assistance. The intervention included offering the resident assistance to transfer or use the toilet when staff were in his room.

-However, this intervention was also recommended and updated on the care plan for the 2/19/22 fall. A new person-centered fall intervention was not put into place after the resident sustained a fall with major injury on 2/20/22.
-The resident’s medical record did not include any additional information about the fall, indicating the facility failed to conduct a root cause analysis of the fall.

The care plan documented the resident was to have anti rollbacks to his wheelchair starting on 5/31/22.

On 7/6/22 at 3:17 p.m. Resident #4 was lying in bed without a urinal within reach.

-At 4:37 p.m. Resident #4 was sitting in his wheelchair in his room. Anti-rollbacks were not observed on the resident’s wheelchair and a urinal was not within reach (see interventions documented on the fall risk care plan).

On 7/7/22 at 12:06 p.m. Resident #4 was sitting in his wheelchair. The wheelchair did not have
anti-rollbacks.

CNA #1 was interviewed on 7/7/22 at 10:55 a.m. She said person-centered fall interventions should be documented on the resident’s care plan. She said when management placed a new fall intervention in place, they would notify the floor staff verbally of the new intervention. CNA #1 said the nursing staff were doing frequent rounding, every 30 minutes, to check on Resident #4,
however they had not been doing the frequent rounding for several weeks. 

The DON said the resident did not use the call light when he needed assistance. She said the facility had not implemented a toileting program after the resident sustained three falls while he was attempting to use the bathroom by himself. She said the facility had not implemented interventions to help prevent the resident from sustaining further falls with major injury.

Resident #6 

Resident #6 was interviewed on 7/7/22 at 3:53 p.m. She said she had fallen from the wheelchair a few times. She said the facility staff would take her to her room after she ate her meals in the dining room. She said they would leave her facing the window, sitting in her wheelchair.

She said she had asked the facility staff on multiple occasions to put her back to bed after she finished her meals because it was uncomfortable and hurt to sit up in the wheelchair for long periods of time. The resident said she started falling asleep in the wheelchair and would slip out and onto the ground.

She said the facility staff always told her she slipped out of the wheelchair on purpose. She said she was barely able to move her arms and thought it was ridiculous that the facility staff thought she was able to purposely move herself out of the wheelchair and onto the ground.

She said in the past two months, she had gotten better about not falling asleep in the wheelchair and that was why she had not had a fall recently. She said the facility never evaluated her for a new wheelchair, cushion or any other steps to prevent her from falling out of her wheelchair.

Resident #3 

Fall incident on 4/23/22-unwitnessed
The 4/23/22 nursing progress note documented at 10:22 p.m., Resident #3 was found on the floor next to his bed.

-It did not include any other details of the fall.

The 4/23/22 incident report documented the resident was found on the ground next to his bed.

There was poor lightning in the resident’s room at the time of the fall.

-It did not include any additional details of the fall or any immediate interventions to prevent further falls.

The 4/27/22 IDT review documented the resident was reviewed for a fall on 4/23/22. It indicated the resident was being treated for a urinary tract infection.

-No intervention was put into place to prevent Resident #3 from sustaining further falls after he fell on [DATE].