Every finding on record at Heartland Senior Living

Neoga, Illinois · CCN 146030

27 findings across 16 inspections, in the inspector's own words, 15 of them at actual harm or above.

7 findings

F689G · Actual harm, isolated

Based on observation, interview and record review the facility failed to prevent injuries from multiple mechanical lift transfers (R10) and failed to supervise a dementia resident to prevent an elopement (R56) for two of two of residents reviewed for accidents from a total sample list of 33 residents. Failing to safely transfer R10 using the mechanical lift resulted in R10 suffering skin tears to bilateral legs. Findings include: 1.) On 6/11/24 at 1:15PM, R10's bilateral shins have open areas, with dried, blood soaked dressings approximately the size of a knee cap covering the tears. The facility skin and wound evaluation dated 4/24/24 documents a new skin tear on R10's right front shin. No new interventions were documented in the medical record after this skin tear occurred. The facility risk evaluation dated 5/3/24 documents a new skin tear on R10's left shin caused by the mechanical lift hitting R10's legs. The facility weekly wound report-non pressure dated 5/27/24 documents a left shin skin tear and nothing about a right shin skin tear. On 6/12/24 at 8:20AM, V2 Director Of Nursing said that the cause of R10's skin tears on her shins was from the mechanical lift hitting her legs during transfer. We wrapped the mechanical lift to prevent it from happening again. 41970 2.) R56's undated Face Sheet documents R56's medical diagnoses as Dementia, Cognitive Communication Deficit, Senile Degeneration of Brain and history of falls. R56's Minimum Data Set (MDS) dated [DATE] documents R56 as severely cognitively impaired. This same MDS documents R56 as requiring maximum assistance for bed mobility, transfers, toileting, bathing, dressing and transfers. R56's Initial Report to the State Agency dated 6/10/24 documents (R56) was witnessed by (V7) Medical Records sitting out the back door by (V20's) Visitor's car. (V20) had propped the back door open to unload a piece of furniture. On 6/10/24 at 3:21 PM R56 was sitting in a wheelchair in the loading area beyond the facility sidewalk next to V20's car. R56 had removed her own foot pedals and was holding them in her lap. R56 was sitting next to V20's back passenger car door. On 6/10/24 at 3:20 PM V20 (R14) visitor reported that R56 had followed him out of the facility and into the parking lot waiting for a ride home. V20 stated he had paused the alarm on the back sliding doors so that he could bring items in and out of facility for R14. V20 stated (R56) must have followed me out. She said she is waiting for a ride home. I don't think I am supposed to do that. I don't think (R56) should be loose. On 6/10/24 at 3:30 PM V1 Administrator stated V20 (R14's) visitor held the back sliding doors open which allowed R56 to wheel herself out of the facility unnoticed. V1 stated either way the staff should have been watching more closely. V1 stated R56 has little safety awareness and she should not be out of the facility unattended. V1 Administrator stated the facility policy on Elopements only covers what to do after someone is found to be missing. V1 stated the facility does not have a separate policy to instruct staff to monitor residents. V1 Administrator stated That is just standard of care. Our staff should know to supervise residents when a door is left open.

F686G · Actual harm, isolated

Based on observation, interview and record review the facility failed to provide ordered interventions to prevent the development of deep tissue injuries and worsening of a pressure injury and failed to provide weekly measurements and assessments for pressure injuries for four of five residents (R10, R47, R39 and R53) reviewed for pressure injuries from a total sample list of 33. These failures resulted in R10 and R47 developing deep tissue injuries and R47's unstageable pressure injury worsening. Findings include: The facility provided Prevention of Pressure Ulcers Policy dated August 2008 documents that the purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and intervention for specific risk factors. When in bed, every attempt should be made to float heels by placing a pillow from knee to ankle or with other devices as recommended by the physician. Additional factors that increase risk of pressure injuries include a healed ulcer. 1.) R10's care plan dated 4/20/22 documents that R10 is at risk for pressure ulcer development due to decreased strength and mobility and that the facility is to ensure that R10 wears heel boots to decrease the potential for pressure injury. The facility weekly pressure ulcer wound report dated April 26, 2024 documents an unstageable, left heel wound resolved for R10. On 6/11/24 at 1:15PM, R10 was observed laying in bed, without heel protectors or any type mechanism to float R10's heels. On 6/11/24 at 1:17PM, V2 Director of Nursing said that R10's right heel is boggy, and is developing a new deep tissue injury. On 6/12/24 at 8:30AM, V2 Director of Nursing said that R10 was supposed to have heel protectors on while in bed because she had a history of deep tissue injuries. On 6/12/24 at 8:45AM, V39 Licensed Practical Nurse said that the likely reason for R10's deep tissue wound is because her heels aren't being protected. I've seen her in bed a couple of times without her heel protectors on. On 6/12/24 at 8:50AM, V15 Certified Nursing Assistant stated, Yesterday (R10) didn't have her heel protectors on and she should have had them on. 2.) R47's physician orders dated 4/24/24 document an unstageable left heel pressure injury. R47's physician orders dated 9/30/23 document to ensure that heel protector boots are on while in bed. On 6/11/24 at 2:00PM, R47 was laying in bed without wearing protective heel coverings. On 6/12/24 at 8:30AM, R47 was sitting in her chair wearing non-slip socks, resting on the floor. R47's left foot had a scab on it and R47's right heel was turning light purple and was boggy, as with a deep tissue injury. The Weekly Wound Report dated 5/20/24 documents R47's left heel unstageable injury measures 0.2 centimeters (cm) x 0.7 cm x 0.4 cm. The Weekly Wound Report dated 5/27/24 documents R47's left heel unstageable injury measures 0.5cm x 1 cm x 0.7 cm and declining. The Weekly Wound Report dated 6/3/24 documents R47's left heel unstageable injury is measured at 0.7cm. No other measurements were taken, nor evaluation of the wound made. On 6/12/24 at 9:00AM, V2 Director of Nursing said that he was unaware of a new deep tissue injury on R47's right foot and that as his wound nurse had left the facility, he was trying to fill in as best that he could. On 6/12/24 at 8:45AM, V39 Licensed Practical Nurse said that the likely reason for R47's deep tissue wound is because her heels aren't being protected. I've seen her in bed a couple of times without her heel protectors on. On 6/12/24 at 12:22PM, V24 Nurse Practitioner said that if the interventions aren't put into place such as the heel protectors, the wounds will continue to worsen and I would expect both (R10 and R47) to be wearing (heel protectors) in bed as well as being monitored weekly. 32853 3.) R53's electronic medical record documents diagnoses including Congestive Heart Failure, Acute and Chronic Respiratory Failure. R53's Physician's Orders dated 6/12/24 document orders for a Stage 3 pressure to the Sacrum, cleanse with wound cleanser, pat dry, apply a hydrocolloid wound dressing and cover with a bordered foam dressing. R53's Skin and Wound Evaluation dated 4/22/24 documents a new area to the Sacrum measuring 2.9 cm (centimeters) x (by) 3.5 cm x 1.3 cm and is documented as MASD (Moisture Associated Skin Damage) due to Incontinence Associated Dermatitis. R53's medical record has no further measurements or assessments of the area to the Sacrum until 5/2/24. R53's Skin and Wound Evaluation dated 5/2/24 documents a Stage 3 pressure wound to the Sacrum with no measurements of the area. The next Skin and Wound Evaluation is dated 5/17/24, 15 days later, and the area is documented as an Unstageable pressure wound to the Sacrum measuring 1.8 cm x 4.9 cm x 2.9 cm. R53's medical record documents two Skin and Wound Evaluations dated 5/23/24 for the pressure wound on the Sacrum. One assessment documents measurements of 5.7 cm x 4.5 cm x 1.8 cm and the other Skin and Wound Evaluation dated 5/23/24 documents measurements of the wound on the Sacrum as 2.0 cm x 2.7 cm x 1.1 cm. There is no explanation as to why there are two different assessments of the same area for R53 on 5/23/24. R53's Skin and Wound Evaluation dated 5/30/24 does not have any measurements of the pressure wound on the Sacrum. The next measurements for R53's pressure wound on the Sacrum are 14 days later on 6/6/24. R53's Skin and Wound Evaluation dated 6/6/24 documents measurements of the pressure wound on the Sacrum as 0.9 cm x 1.5 cm x 0.8 cm. On 6/12/24 at 11:25 AM, V2 Director of Nursing confirmed there were missing weekly assessments and could not explain why they were missing. V2 stated that their wound nurse is no longer with them. V2 stated that the wound logs that he has, document on 5/4/24 and on 5/30/24 that the nurse was unable to measure the wound but V2 stated there is no documented reason as to why they were not able to get measurements of the pressure wound on R53's Sacrum on those dates. On 6/12/24 at 11:55 AM, V29 Licensed Practical Nurse completed a wound treatment on R53's pressure wound to the Sacrum. The area was bright red and approximately 1 cm around. R53 was laying in bed on a low air loss mattress with a pillow under her right hip and the head of the bed elevated slightly. 4.) R39's Care Plan dated 4/23/24 documents diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy and Nutritional Deficiency. R39's Skin and Wound Evaluation dated 4/30/24 documents measurements of an unidentified wound as 0.3 cm x 0.9 cm x 0.5 cm. This wound assessment does not document what type of wound it is or where the wound is located or any other assessment of the wound. R39's Treatment Administration Record (TAR) dated 5/1/24 through 5/30/24 documents an order for a Stage 2 wound to the Coccyx and to cleanse with wound cleanser, pat dry, apply a hydrocolloid wound dressing and cover with a bordered foam dressing once a day every three days for wound management with a start date of 5/2/24. R39's medical record does not document any other wound assessments or measurements of the area on the Coccyx. On 6/10/24 at 10:02 AM, R39 was in her room in her recliner with her feet elevated. R39 stated that she has a wound on her bottom and has an extra cushion in her recliner. On 6/10/24 at 10:11 AM, V29 Licensed Practical Nurse stated that R39 has a pressure ulcer on her Coccyx. On 6/12/24 at 11:25 AM, V2 Director of Nursing confirmed there were no other measurements besides the ones on 4/30/24 for R39's wound on her Coccyx.

F552D · No harm, potential for more than minimal, isolated

Based on interview and record review the facility failed to obtain a consent to administer a psychotropic medication for one (R10) of five residents reviewed for psychotropic medications from a total sample list of 33. Findings include: The facility provided Psychotropic Medication Use- Management Policy dated 10/1/2019 documents that consent will be obtained from the resident or resident's representative to administer the psychotropic medication ordered and that consent must be obtained prior to administration of the medication. Additionally, consent in writing will be obtained on the psychotropic medication consent form. A telephone order may be obtained and recorded and then the consent form will be printed and forwarded for signature. R10's physician order dated 4/26/24 documents an order for Seratraline (Antidepressant) 75 milligrams (mg) to be administered daily. R10's medical record does not contain a signed consent for Seratraline 75mg, nor Seratraline 100mg. On 6/11/24 at 11:05 AM V2 Director of Nursing stated, I don't have a consents for the 75mg or the 100mg doses of Seratraline that have been ordered. I only have consents for Seratraline 25mg and Seratraline 50mg.

F609D · No harm, potential for more than minimal, isolated

Based on interview and record review the facility failed to report an allegation of physical abuse to the Abuse Coordinator for one (R22) resident out of one resident reviewed for abuse in a sample list of 33 residents. Findings include: R22's undated Face Sheet documents R22's medical diagnoses of Non Traumatic Intracerebral Hemorrhage, Diastolic Heart Failure, Paroxysmal Atrial Fibrillation, Hypertension, Unsteady on Feet and Abnormal Posture. R22's Minimum Data Set (MDS) dated [DATE] documents R22 as cognitively intact. This same MDS documents R22 as requiring maximum assistance for transfers using a total body mechanical lift and dependent on staff for dressing, toileting, bed mobility and person hygiene. R22's Care Plan intervention dated 4/12/23 instructs staff to report any signs of abuse to the Abuse Coordinator. On 6/10/24 at 9:46 AM R22 stated (V3) Certified Nurse Aide (CNA) pushed me around this morning. (V3) throws me around like a sack of potatoes. (V3) pushed me so hard one day she left bruises on my Right Arm. I didn't know who to report it to but I told (V4) Certified Nurse Aide. (V4) told me (V3) has been rough with other people too. I know I have told other people too but I don't remember who. (V4) CNA told me who to report it to but I never saw them. They (facility) didn't do anything with (V3) CNA. (V3) CNA gets me up every morning and slams me around. (V3) doesn't talk to me, she just comes in and pushes me so hard it hurts and then throws me in my chair. (V3) doesn't need to be taking care of people. On 6/10/24 at 12:15 PM V1 Administrator and V2 Director of Nurses (DON) both stated R22's allegation of abuse by (V3) Certified Nurse Aide (CNA) was never reported to V1 nor V2. R22's Initial Incident Report to the State Agency dated 6/10/24 documents R22 (identified as R1 on the report) alleged that V3 Certified Nurse Aide (CNA) pushed her arm leaving fingerprints. On 6/10/24 at 12:26 PM V6 Registered Nurse (RN) stated R22 has Left sided neglect due to a Cerebral Vascular Accident (CVA). V6 RN stated R22 has had several bruises on her Right Upper Arm several times. V6 RN stated I didn't think the bruises were abuse or anything. (R22) gets incidental bruises. I don't report every bruise or do a skin investigation on every little bruise. I never reported anything to (V1) Administrator. On 6/10/24 at 3:30 PM V4 Certified Nurse Aide (CNA) stated R22 has complained about V3 CNA 'multiple times.' V4 CNA stated (V3) does have a bit of a reputation for being rough. (R22) has told me every time I have worked over there (on R22's hall) or even gone over to help (R22) with something. I have seen bruises on (R22's) Right Upper Arm but I didn't think that was abuse or anything. I never reported them. I didn't ever see (V3) hit (R22) or anything so I thought I had to actually see an abuse to report it. I don't tell my nurse about every little bruise. I didn't tell (V1) Administrator about (R22's) bruises. On 6/11/24 at 12:50 PM V3 Certified Nurse Aide (CNA) stated (V15) Certified Nurse Aide (CNA) and I were helping (R22) a week ago Wednesday (5/29/24) and (R22) said 'you (V3) are mean to me. You hurt me.' We (V3, V15) just thought that is something (R22) says. I didn't report anything to (V1) administrator. (R22) is just like that sometimes. (R22) is alert and oriented but sometimes she says people hurt her when I don't think they do. That is just (R22). V3 CNA stated she should have reported R22's allegation of abuse to V1 Abuse Coordinator/Administrator. The facility policy titled 'Abuse Prevention Program' dated October 2022 documents employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the Administrator or to a compliance hotline or compliance officer.

F690D · No harm, potential for more than minimal, isolated

Based on observation, interview, and record review the facility failed to maintain a urinary catheter in a safe, sanitary, and dignified manner for one resident (R38) of four residents reviewed for catheters in a sample list of 33. Findings include: The facility's policy Catheter Care Urinary revised September 2005 states The purpose of this procedure is to prevent Urinary Tract Infections. This policy also states Be sure the catheter tubing and drainage bags are kept off the floor. The policy also states The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The policy also states Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (note: catheter tubing should be strapped to the resident's inner thigh.) R38's Care Plan revised 6/12/24 includes the following diagnoses: Chronic Kidney Disease Stage 3B, Benign Prostatic Hypertrophy with Lower Urinary Tract Symptoms. On 6/10/24 at 12:00PM R38 was observed sitting in the hall with the catheter tubing dragging on the floor. The catheter bag was hanging under the wheelchair and was not contained in a dignity bag. On 06/12/24 at 2:05 PM V26, Certified Nurse's Aide (CNA) and V28, Certified Nurse's Aide (CNA) were providing catheter care for R38. When transferring R38 to bed per sling type mechanical lift V26 lifted the catheter bag to the level of R38's chest and urine was noted to back flow into the catheter tubing. V26 stated V26 was not aware the drainage bag should be kept below the level of the bladder. R38's catheter was not anchored to prevent torsion on the tubing. R38 stated When you pull on the tube it hurts. Redness was observed around R38's urinary meatus. R38's Medication Administration Record (MAR) for June 2024 includes a physician's order for Macrobid (antibiotic) Oral Capsule Give 100 mg by mouth one time a day for recurrent UTI (Urinary Tract Infection). On 6/12/24 at 12:30PM V2, Director of Nursing stated The catheter bag should not be above the level of the bladder. We do usually use an anchor device. (R38) likes to pull on his catheter and has pulled it out in the past.

F694D · No harm, potential for more than minimal, isolated

Based on observation, interview and record review the facility failed to properly administer intravenous medication to prevent infection for one (R316) of one residents reviewed for intravenous medication administration from a total sample list of 33 residents. Findings Include: The facility Medication Administration, Intravenous Administration of Fluids and Electrolytes documents that staff will be knowledgeable regarding the safe and aseptic administration of intravenous fluids and electrolytes for hydration. Prime tubing of administration set, disinfect needleless connection device with alcohol wipe, flush catheter using normal saline per facility protocol, connect primed administration set to needleless connection device, and then open roller clamp. R316's diagnosis list includes: Cellulitis of left finger, Diabetes Mellitus Type Two, Rhabdomylosis, Insomnia, Depression, Hypertension and Joint Pain. R316's physician orders dated 6/11/24 document an order for Vancomycin (antibiotic) 1 gram (gm) to be given intravenously, daily for five days. On 6/12/24 at 9:10AM, V23 Licensed Practical Nurse (LPN) administered Vancomycin 1gm per intravenous line. V23 LPN unscrewed the needleless cap from end of the intravenous catheter opening the catheter line to air. V23 LPN then used an alcohol swab on and inside the open end of the intravenous catheter and then flushed the catheter with normal saline. V23 LPN then allowed the open catheter to drip blood on the floor while she primed an unknown amount of Vancomycin through the tubing and into the waste basket. V23 LPN then connected the Vancomycin line directly into the open port. On 6/12/24 at 10:00AM, V2 Director of Nursing said that he went over intravenous administration with V23 LPN the other day and showed her to leave the cap on and not open the system. She needs more training on (intravenous lines). I would expect the system to remain intact and she should not have wiped the open catheter with alcohol. Managing R316's intravenous line the way that V23 LPN could cause R316 an infection.

F695D · No harm, potential for more than minimal, isolated

Based on observation, interview and record review the facility failed to ensure a resident had an order for the use of oxygen and failed to ensure oxygen/nebulizer tubing/equipment was changed according to facility policy for two of three residents (R265 and R266) reviewed for respiratory care in a sample list of 33 residents. Findings include: The facility's Oxygen policy with effective date of 1/1/2015 states that tubing must be changed weekly and must be labeled with date and initials of individual who changed the tubing. The facility's undated Nebulizer policy documents nebulizer tubing and mask or t-tube (T shaped tube) device must be changed every 24 hours and rinsed post treatment. 1.) On 6/11/24 at 10:42 AM, R265 was in R265's room and there was an oxygen concentrator in the room. The hydration bottle on the concentrator and the oxygen tubing were not dated to indicate when they were changed. R265's Medication Administration Record and Treatment Administration Record dated 6/11/24 do not document an order for oxygen or an order for tubing changes for the oxygen or for the nebulizer. R265's Order Summary Report dated 6/11/24 does not document any orders for oxygen administration, oxygen tubing changes or nebulizer mask and tubing changes. This Order Summary documents an order for Albuterol Sulfate Inhalation Nebulization Solution 2.5 MG (milligrams)/3ML (milliliters) 0.083% one vial, inhale orally via nebulizer every 4 hours as needed for Wheezing or SOB (Shortness of Breath) with a start date of 6/7/24. R265's Care Plan with an admitted [DATE] does not document the use of nebulizer treatments or oxygen therapy. R265's Nurse's Note dated 6/11/24 at 9:59 AM documents R265 continues to use oxygen via nasal cannula. On 6/11/24 at 11:15 AM, V2 Director of Nursing confirmed there was no active order for R265's oxygen administration. V2 stated he personally brought R265 to the facility and R265 was on room air, not oxygen, at that time. 2.) On 6/11/24 at 12:09 PM, R266 was in R266's room sitting in the recliner with the nebulizer machine sitting on windowsill. The tubing and the mask were attached to the nebulizer machine and were laying open on top of a clear bag. The Nebulizer mask and tubing did not have the date on them to indicate when they were changed. R266 stated he had used the nebulizer at least three times that day. On 6/12/24 at 9:55 AM, V2 stated all tubing is changed on Saturday nights and that task is documented on the resident's Treatment Administration Record. R266's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 6/10/24 does not document an order for nebulizer tubing or mask changes. R266's MAR/TAR documents an order for Ipratropium Bromide Inhalation Solution 0.02% (percent) 2.5ml (milliliters) inhale orally via nebulizer three times a day for Pneumonia for 10 days with a start date of 6/4/24 and an order for Levalbuterol HCL (Hydrochloride) Inhalation Nebulizer Solution 0.63mg(milligrams)/3ml; 3ml inhale orally via nebulizer three times a day for Pneumonia for 10 days with a start date of 6/4/24. R266's Order Summary Report dated 6/11/24 does not document an order to change the nebulizer tubing or the nebulizer mask.

Inspection of November 6, 2023

2 findings

F686G · Actual harm, isolated

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of an unstageable pressure ulcer for one of three residents (R23) reviewed for pressure ulcers on the sample list of 31. This failure resulted in R23 developing an unstageable pressure ulcer to the left outer ankle. Findings include: On 4/21/21 at 2:02 PM, R23's left ankle had a dime size open area to the left outer ankle. The center area of the ulcer had slough (yellow material) covering the entire surface of the wound bed. The facility's incident audit report dated 1/1/21 documents R23 has a unstageable pressure ulcer with eschar due to R23 not keeping feet still while in bed. This incident documents R23 rubs feet while sleeping. The facilities skin and wound evaluation dated 4/21/21 documents R23 has an in house acquired, unstageable: Obscured full thickness skin and tissue loss pressure ulcer. R23's impairment of skin integrity care plan dated with a 9/16/20 revision date does not include interventions to prevent pressure related to R23 rubbing R23's feet on the bed until 1/4/21 after the pressure ulcer was identified on 1/1/21. On 4/21/21 at 12:17 PM, V1 Administrator stated R23's pressure ulcer was identified on 1/1/21 and was in house acquired. V1 stated R23 would lay with R23's foot on R23's bed. V1 confirmed R23's intervention of increase monitoring of pillow placement while R23 is in bed was not put into place until 1/4/21 after R23 had already developed the pressure ulcer. The facility's Prevention of Pressure Wounds policy dated January 2017 documents preventive measures as identifying risk factors for pressure injury development and that, 11. The care process should include efforts to stabilize, reduce, or remove underlying risk factors; to monitor the impact of the interventions: and to modify the interventions as appropriate.

F689G · Actual harm, isolated

Based on observation, interview, and record review, the facility failed to provide supervision and assessed fall interventions to prevent falls for two of three residents R41 and R28 reviewed for falls on the sample list of 31 residents. These failures resulted in R41 suffering a [CONDITION(S)] when staff failed to supervise R41 and R28 suffering fractured vertebrae when staff failed to follow care plan interventions. Findings include 1.) On 4/22/21 at 10:25 am V41 propelled R41's self out of the dining room and down the hallway. The Minimum Data Set, dated dated dated [DATE] documents R41 is severely cognitively impaired and requires limited assist of one staff member for transfers. The Physician Order Sheet dated 9/1/21-10/31/20 documents R41 has diagnoses of Muscle Weakness, Knee Pain, Unsteadiness on feet, History of Falling and Dementia with Behavioral Disturbance. The Fall Report dated 8/20/20 at 9:16 am documents R41 was found on the floor and that R41 was walking to the bathroom when R41 fell . The Report documents a root cause of the fall as resident with poor safety awareness attempting to ambulate to the restroom per self. (R41) has shown increased weakness this am. The Report documents a new intervention of resident placed in wheel chair today and educated on the importance of not ambulating per self. (R41) has the ability to propel self. The Fall Report dated 8/20/20 at 10:45 am documents R41 on the floor again and that R41 was sitting on the floor five feet in front of (R41's) wheelchair as (R41) was attempting to ambulate per self. The Report documents the root cause of the fall as the resident has poor safety awareness and was attempting to ambulate per self and a new intervention of Resident placed in eye view of the nurse's station to prevent any further falls. The Fall Report dated 9/30/20 at 4:00 PM documents R41 was found on the floor in front of R41's wheelchair in the lobby. The Report documents the root cause of the fall as resident is not used to using the wheelchair, usually walks independently. Not able to r/t (related to) strength and knee pain, not used to sitting down for longer periods. The Report documents a new intervention of If resident is noted to use wheelchair, staff to occasionally ask if resident wants help standing/walking. The Fall Report dated 10/3/20 documents This Nurse (V15) was assisting another resident in (resident's) room and was alerted by CNA (unknown Certified Nurses Aide) that resident (R41) was attempting to stand. CNA returned resident to chair and alerted nurse. When CNA and nurse returned to the hallway, resident had fallen in hallway on right side. The Report documents R41 stated I was trying to stand up and got tangled. I fell on my side. The Report documents R41 complained of extreme right hip pain and R41 was transported to the hospital. The Radiology Report dated 10/3/20 documents R41 has an intertrochanteric femur fracture. The Orthopedic Consult Note dated 10/7/20 documents R41 was admitted to the hospital on 10/3/20 after a fall at the facility and that a right [CONDITION(S)] was confirmed after R41 arrived at the Emergency Department. The Operative Report dated 10/4/20 documents R41 underwent a right femur nailing on that date for a right femur fracture The Fall Follow up note dated 10/4/20 documents Due to recent illness and weakness noted. Resident is not able to ambulate independently and needs assistance. Resident has dementia and does not recall to wait for help or to use (R41's) call light appropriately. Keep wheelchair pedals off the wheelchair when sitting in it to avoid getting feet tangled up when the resident attempts to get up and walk. On 4/21/21 at 1:40 PM V15 stated R41 had experienced several recent falls and R41 was frequently attempting to self transfer so on 10/3/20 R41 was in the hall in R41's wheelchair so staff could supervise R41. V15 stated a CNA came to resident's room where V15 was working and reported to V15 that R41 was trying to stand and CNA returned resident to the wheelchair. V15 stated when V15 and the CNA returned, R41 was on the floor. V15 stated R41 complained of hip pain and was sent to the hospital and diagnosed with a fractured hip. V15 stated R41 fell when the CNA walked away from R41 to find V15. V15 stated the wheelchair pedals were on the wheelchair and should have been positioned out of the way. On 4/22/21 at 10:15 am V9 Restorative Nurse reviewed R41's Fall Report dated 10/3/20 and stated the fall occurred when the CNA moved away from the resident to get help. V9 stated the 10/3/20 Fall Report documents R41 got tangled in the foot pedals of the wheel chair when R41 stood from the chair and fell . V9 stated the root cause of the fall appears to have been the wheel chair foot pedals. V9 stated R41 can propel R41's self in the wheelchair and wheelchair pedals should only be used when staff are transporting a resident. V9 also stated the fall might have been prevented if R41 had been supervised. On 4/22/21 at 1:15 PM V1 Administrator stated If a resident can propel their wheelchair they should not have pedals on the wheel chair because they might stand up. The undated Falls and Fall Risk, Managing policy states Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also states Staff will identify and implement relevant interventions (e.g. hip padding or treatment of [CONDITION(S)], as applicable) to try to minimize serious consequences of falling. 2.) On 4/19/21 at 1:30 PM, R28 was standing up walking between the wheelchair and bed. R28's was holding onto the wheelchair using the wheelchair to balance self. R28's nursing note dated 2/4/2021 at 8:18 AM documents, (R28) had unwitnessed fall at (5:00 AM) this morning. (R28) reported new onset [MEDICATION(S)] discomfort with difficulty in taking a full deep breath. This note documents that R28 was sent to the emergency room for an evaluation. R28's hospital encounter form dated 2/4/21 documents under history, fall, back injury, rib pain. This form documents R28 has a compression fracture of the 8th [MEDICATION(S)] vertebrae and a displaced fracture of the 1st lumbar vertebrae. R28's Fall Risk Assessment documents R28 fell on [DATE]. This investigation documents the root cause as, Wheelchair was not at resident's bedside at time of resident's fall. This investigation documents a new intervention to, Re-educate staff to keep locked wheel chair within (R28's) reach from (R28's) bed as (R28) has impaired safety awareness and will self ambulate. On 4/21/21 at 12:24 PM, V9 Restorative Nurse stated the staff are trained to ensure all items the residents use are within reach to prevent falls. V9 stated the intervention of ensuring R28's wheelchair was next to the bed was put into place on 11/9/20. V9 stated R28's wheelchair should have been at the bedside. V9 stated the root cause of R28's fall was the wheelchair not being at the bedside. On 4/22/21 at 1:15 PM, V1 Administrator confirmed that R28's wheelchair was not beside the bed when R28 fell on [DATE] and that this was the root cause of the fall. V1 confirmed that R28 did sustain fractures as a result of the fall on 2/4/21.

Inspection of August 24, 2012

1 finding

F323G · Actual harm, isolated

A. Based on interview and record review the facility failed to assess and develop targeted interventions related to fall potential and medication side effects for R11. R11 sustained a Subdural Hematoma related to a fall which required hospitalization . R11 is one of seven residents reviewed for falls in a sample of 15. Findings include: The physician's orders [REDACTED]. The facility's form titled Fall Risk assessment dated [DATE] lists R11 as High Risk for Falls and has a history of falls. The MDS (Minimum Data Set) dated 2/16/12 states R11 is an extensive assist with two plus staff for bed mobility, totally dependent on staff for all transfers and toileting. The Medication Administration Record (MAR) and Nurses Notes dated February 5, 2012 for R11 documents that R11 received the following medications: [REDACTED]. All three of these medications have an adverse reaction/side effect of sedation according to the reference Lexi-comp Geriatric Dosage Handbook 13th Edition. The facility's form titled Incident Log dated February 2012 states R11 had a fall on 2/5/12 in her room that required hospitalization . R11's Nurses Notes dated 2/5/12 at 10:31 PM reads "(R11) found on floor of her room at 9:40 PM next to her bed. She was lying on her left shoulder with her left buttock lodged on foot of IV (Intravenous) pole . (R11) screamed out in severe pain when repositioned to supine position. Unable to move extremities without complaints of severe pain." Nurses Notes dated 2/5/12 at 9:25 PM states R11 was transferred to the hospital per ambulance. The Facility's incident report dated 2/5/12 states "(R11) heard yelling and crying out. Upon entering residents room found (R11) lying on the floor next to her bed, face down with weight on left shoulder and right arm lodged behind her. (R11)left buttock was lying on the foot of IV pole. (R11) stated that her back and hips hurt badly. Incident report also reads R11 stated "I went to turn over and just kept on rolling off the bed." The same report continues to state under the section titled "Other" reads "(R11) has been crying with increased anxiety caused by severe pain this shift. Pain meds given at 8 PM." The Hospital X-Ray Report dated 2/5/12 titled "CT (computed tomography) HEAD WITHOUT CONTRAST" reads under "Impression" "Hyperdensities suggesting parenchymal hemorrhage in right parietal lobe adjacent to the tentorium medially and peripherally as well as in the high right parietal lobe in the parafalcine region. Thickened hyperdensity along falx compared to prior study represent small subdural hemorrhage..." R11's Nurses Notes dated 2/6/12 at 3:12 AM states the facility called the hospital emergency room for an update and was informed that R11 was admitted to ICU (Intensive Care Unit). On 8/24/12 at 10:10 AM E7, LPN (Licensed Practical Nurse) stated ".....Other than the initial protocol for high fall risk residents" E7 did not believe the nurse put anything into place for the fall (R11) had. E7 stated "there is a list of interventions that is available to the nurses to use for residents identified as high fall risk. I would of put (R11) into a low bed and floor mat....." E2, Director of Nurses stated on 8/24/12 at 11:10 AM " I would have expected the nurse to put on the communication sheet that (R11) was a fall risk and the medication (R11) received prior to her fall. I would of expected that (R11) to be given a low bed and /or a mat beside the bed. There should of been interventions in place for (R11) due to her high fall risk status." E8, LPN Restorative Nurse stated on 8/24/12 at 9:30 AM that she was not aware of any fall intervention R11 had in place for falls. R11's Initial Plan of Care dated 1/27/12 under the section titled "Falls" lists the following interventions, fall protocol, complete fall risk assessment, provide assistive devices as need and therapies to screen, evaluate and treat per physician's orders [REDACTED]. B. Based on interview and record review the facility failed to comprehensively assess for the root cause of resident to resident physical aggression involving R8 and R10. The facility failed to document behavioral tracking for the aggressor, R10, failed to develop and implement targeted interventions for R10, and failed to document this problem or interventions in the plans of care for R8 and R10. R8 and R10 are two of six residents reviewed for behaviors on the sample of 15. Findings include the following: R10's Behavioral Progress notes dated 5-14-12 7:35 p.m. states R10 "...ran (wheelchair) into another resident and when other resident told him to move and stop running over her, he grabbed (her wheelchair) arm and began shaking it. When she told him to let go and stop he began hitting her on the right arm with closed fist." The intervention listed states "separated by this nurse". The resident response states "continued to yell at the nurse saying that the other resident needed to leave because she didn't belong here..." The note continues that the victim sustained no injuries. On 8-23-12 at 10 a.m. E8 Licensed Practical Nurse identified the victim to be R8. R10's Behavioral Progress Notes dated 6-27-12 at 9:02 p.m. states "...resident slapped another resident in the sun room...hit other resident's wheelchair and when other resident asked him to move he slapped her in the shoulder..." The intervention listed states "removed resident from sun room and instructed not to hit other residents". The resident response states "well she made me mad, and if she makes me mad I will hit her again..." The note states that the victim sustained no injuries. On 8-23-12 at 10 a.m. E8 Licensed Practical Nurse identified the victim to be R8. E8 indicated that both of these incidents occurred in the sun room. R10's August 2012 Physician order [REDACTED]. R8's August 2012 Physician order [REDACTED]. R10's Behavior Tracking documentation from March to August 2012 reflects no behavior monitoring, tracking, or documentation related to resident to resident aggression. Behavioral Tracking documentation is only specific to Verbal/cursing at staff, Physical to staff during ADL's (activities of daily living) care, Restlessness, fidgeting, repetitive movements, disrobing, tearfulness/due to loss of his wife, elopement attempts. R10's Care Plan dated 6-28-12 includes a problem which states "...has been verbal/cursing at staff when he is agitated, tearful, physically aggressive, restless, and attempts elopement..." Goals include "...will have no episodes of being physically aggressive through next review..." Interventions include "...Record behaviors on tracking forms..." The Care Plan fails to include a problem statement of aggression to other residents (R8) and fails to include planned interventions to address two previous assaults on the same resident, occurring in the same location, at the same relative time of day, over the course of the previous 45 days. E6, Social Service Director stated on 8-23-12 at 2 p.m. that she is responsible for behavioral management in the facility. E6 stated that while not documented, she had knowledge that R8 and R10 knew each other in the community prior to admission and had open conflict with one another. E6 stated familiarity with R10 and his long standing history of head injuries due to a motor vehicle accident, the death of his spouse, his frequent delusional tendencies, and his progressing dementia. E6 stated that R8 and R10 both often spent time in the sun room watching television at the same time. E6 stated that while not documented, the planned intervention following the 5-14-12 incident was to keep R8 and R10 separated. E6 stated that the expectation was for staff to continue keeping R8 and R10 separated. E6 stated that this plan or other specific, targeted interventions addressing R10's aggression toward R8 was never formalized and Care Planned. E6 stated that she had not been involved with an assessment of root causes leading to R10's aggression. E6 stated that E1, Administrator was mainly in charge of completing this. E1 stated on 8-23-12 at 4 p.m. that documentation related to R10's behaviors was incomplete and that a comprehensive root cause analysis was not completed. Facility policy titled Resident Allegation of Resident Abuse dated 11-11-12 states "...Any resident suspected of abuse to another resident, based on credible evidence, will be immediately evaluated to determine the most suitable intervention and resident placement...the Abuse Prevention Coordinator or his/her designee will arrange for the Director of Nursing/Administrator of Clinical Services to immediately contact the attending physician to request an evaluation to determine a suitable course of therapy or intervention...This intervention will be documented in the clinical record..." .

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