STERLING, CO- STERLING LIVING CENTER

Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and failed to provide supervision and assistance to prevent falls with injuries. The facility failed to ensure one (#13) of two residents reviewed for smoking safety was safe while in the facility smoking area. The facility further failed to failed to prevent falls for three of five residents (#15, #16, and #19) reviewed for falls out of 29 sample residents.

Record review and interviews revealed the facility failed to ensure Resident #13 had adequate access back into the facility after smoking outside in sub-zero temperatures. The resident suffered frostbite to his fingers while outside, and when he attempted to gain entry back into the facility he became stuck between the door and the wall, and waited for approximately 20 minutes before staff found him and assisted him back into the facility.

Resident #15 had four consecutive falls in less than one month. The facility failed to put in place interventions to prevent the falls after the third fall. The fourth fall resulted in a fracture of the resident’s left arm. Resident #15 was not assessed by an RN for any injuries after the fall. The next morning the resident developed arm discoloration and swelling. She called 911 herself and was transferred to the emergency room for evaluation. The facility failures contributed to the resident’s fall with fracture. The behavior section indicated the resident did not resist care, and had no hallucinations, delusions or other types of behaviors. 

For Resident #19, the facility failed to properly assess, develop and implement interventions to prevent recurring falls. Fall risk assessments were not consistently documented accurately or timely, neurological checks were not consistently performed, and the resident was not consistently assessed by registered nurses after falls.

Resident #16 sustained six falls over a period of two months. Two of the falls resulted in major injuries. One fall caused re-opening of the surgical wound on his amputated leg, and another fall resulted in a head injury with subdural hematoma. The facility failed to provide adequate and timely supervision and assistance to prevent multiple falls, resulting in two major injuries for Resident #16.

The resident was interviewed on 3/23/21. He said he was admitted to the facility after a recent below the knee amputation of his left foot. He said he was very dissatisfied with the care he received in the facility. Specifically, he had multiple falls since he was admitted that complicated his physical condition and resulted in the longer need for care at the facility. He said due to his amputation he was no longer able to use his left leg for ambulation and was dependent on staff for everyday care, such as transfers and bathroom use. He said when he called for assistance, it frequently took 35 to 45 minutes for someone to answer his call lights. He said on multiple occasions he was trying to get to the bathroom and had a fall. He said he complained about the call light response time to the director of nursing (DON) and nurses on the floor, but never received any feedback from anyone. The staff did not discuss falls with him and did not ask him what would help to prevent falls in the future. He felt as if he was treated as an old man who can’t remember anything. He said staff kept telling him to use the call light and kept putting signs on the walls as a reminder to use the call light, but that was not the problem. He said the problem was that no one responded to the call light on time, and he ended up transferring independently. He said he felt like no one really cared about anything and was not trying to make things better for him. (Cross reference F725, sufficient nursing staffing.)