CITATION NUMBER: 92-1313-0008483-F
CLASS AA CITATION -- PATIENT CARE
§483.25(h) Quality of Care Accidents
The Facility must ensure that:
1. The resident environment remains as free of accident hazards as is possible; and
2. Each resident receives adequate supervision and assistance devices to prevent accidents.
On October 19, 2010, the Department received a written complaint that alleged Resident 1, who was at a high risk for falls, was found on the floor and no one in the facility knew how long he had been there. On September 6, 2010, at 8:15 a.m. the resident was transferred to an acute care hospital where he was placed on life support for three days, until he was pronounced dead due to blunt head trauma.
On October 29, 2010, an unannounced visit was made to the facility to investigate the above allegation.
Based on observation, interview, arid record review, the facility failed to ensure Resident 1, who had a history of falls and was assessed as being a high risk for falls, received adequate supervision and necessary care to prevent severe fatal brain injury from a fall for one out of one sample residents (1).
A review of the Skilled Nursing Facility's admission record dated September 5, 2010, at 11 p.m. indicated Resident 1 was an 89 year-old admitted from the acute care hospital after being hospitalized for a fall and for hematuria (blood in the urine) from September 3 to September 5, 2010. The resident had the first fall at an Assisting Living Facility and had sustained a laceration to his left forehead that was repaired with sutures at the hospital. The cranial computerized tomography (CT) scan dated September 4, 2010, done after the first fall indicated there was no evidence of acute hemorrhage (profuse bleeding) from the first fall. However, the resident did not return to the Assisting Living Facility because he required Skilled Nursing Care.
The resident's admission diagnoses to the skilled nursing facility (SNF) included status post fall, history of falls, hematuria, open wound of the scalp, urine retention, hypertension, and benign prostate hypertrophy(enlargement of the prostate that leads to symptoms of urinary hesitancy and frequent and painful urination) without urinary obstruction.
The Fall Risk Assessment dated September 5, and 6, 2010, indicated the resident scored 15 and 18 respectively. According to the fall assessment tool, a score of 10 and above represents a high risk for falls. The fall risk assessment also indicated the resident was disoriented at all times, ambulatory, incontinent, had poor vision, and had a balance problem while standing and walking.
The admission physician's order dated September 5, 2010, indicated the resident was supposed to have both side rails up while in bed.
The Physical Restraint/Device Assessment dated September 5, 2010, indicated the resident's cognitive status, memory, and hearing were impaired and he required assistance for transfers.
There was a care plan initiated on September 5, 2010, that indicated the resident had a fall in the last 30 days and was a fall risk. The approach was to keep the bed in the lowest position with both upper side rails up for turning and repositioning, and to include the resident in the "Restraint Alternative Program" (which includes specially ordered high/low beds).
The care plan also indicated the resident required extensive assistance in bed mobility, transfers, walking in his room, and eating, and was totally dependent on staff for dressing, personal hygiene, and bathing. The plan of care however, did not specify how the nursing staff members would be able to remind a resident assessed as disoriented, not to get up unassisted.
During an interview with the Director of Nursing (DON,)after review of the care plan, she stated the Restraint Alternative Program means the use of a low bed, remind the resident not to get up unassisted, and side rails up for positioning. However she stated there was no documentation to address what interventions the Restraint Alternative Program included.
According to the Daily and Q (every) Shift Charting form dated September 6, 2010, 1 a.m., (two hours after the resident was admitted to the facility), Certified Nurses Assistant 1 (CNA 1) found the resident on the floor trying to crawl, saying he had to go to his "office." According to the licensed nurse's note, the resident had a bump on his left upper forehead that measured 2 centimeters (cm) by 2 cm. The sutures on the forehead from the previous fall were opened and there was a small amount of bleeding. The resident was put back to bed. There was no documentation to show how long the resident had been on the floor. And there was no documentation whether the bed was in the "lowest position" as indicated in the initial care plan. There was a two hour interval between the time the resident was observed alert, and the time he was observed on the floor.
A review of the Post Fall Assessment dated September 6, 2010, 1:00 a.m. indicated, the resident was found on the floor next to his bed, alert and confused, kneeling and crawling. According to the assessment, the side rails were in an upward position. However, the post fall assessment did not indicate how the resident managed to fall out of bed with both side rails in an upward position. In addition, the implementation of the care plan to keep the bed in the lowest position was unknown. The notes indicated that the physician was notified and orders for a skull x-ray and neuro checks every 2 hours for 72 hours were obtained.
The Neurological Observation Form dated September 6, 2010, from 1:30 a.m. to 6 a.m., indicated the resident's neurological status was not monitored as ordered by the physician. For example, according to the Neurological Observation Form sections that called for assessment of the resident's pupil sizes and reactions, responsiveness, and neurological conditions of the extremities, were blank and not assessed.
The skull x-ray report dated September 6,2010, done at 4:24 a.m., indicated the multiple views of the skull demonstrated a normal ossification pattern. There was no linear or depressed fracture. The orbits were grossly intact.
A review of the Daily and Q (every) Shift Charting dated September 6, 2010, at 7:55 a.m. indicated the resident was not responding to touch, verbal stimuli, and his eyes were closed. The resident's vital signs were: blood pressure was 130/64, pulse was 100, respirations were 20, temperature was 97.8 degrees Fahrenheit, and his oxygen saturation was 96 percent (%) on room air. The physician was notified and the paramedics transferred the resident to the acute care hospital emergency room.
On October 29, 2010, at 1:45 p.m., during interviews with the DON and the Administrator (AS 1), the DON explained the "Restraint Alternative Program" included the use of a "low bed" (specially ordered bed that is lower than a normal bed), to remind the resident not to get up unassisted: and side rails up for positioning. AS 1 stated the facility uses low beds and wheelchair alarms (for residents assessed as a high risk for falls). He stated he thought the facility had 24 hours after admission to obtain equipment, . including ReSident 1 's special "high/low" bed. According to AS 1, the facility's regular bed, Which can be lowered to a height of two feet above the floor, differs from the "high/low bed" which can be lowered to 12 inches above the floor (from the bottom of the frame, not the top of the mattress). According to AS 1, if a resident attempts to get out of bed unassisted, he/she would roll out of bed onto the floor and not fall. However, he did not explain how the resident would roll out of bed onto the floor if both bedside rails were in an upward position as ordered by the physician.
During an interview with Family Member 1 (FM 1) on November 1, 2010, at 10:45 a.m., she stated she called the facility at 9 a.m. on September 6, 2010, to check on Resident 1. At that time, she was informed the resident had a fall, was unresponsive, and was transferred to the acute care hospital emergency room. According to FM 1, she rushed to the acute care hospital and observed the resident with a knot about the size of a goose egg, on the left side of his head behind the laceration sustained on a previous fall at the Board and Care/Assisted Living Facility. When she asked, the doctor at the hospital informed her that the resident was unconscious an unknown period of time.
According to the Emergency Room (ER) report dated September 6, 2010, the resident was unresponsive on arrival to the ER and was admitted to an intensive care unit (leU) for a higher level of care after he was Intubated (insertion of a tube into the trachea for assisted or mechanical breathing). At the hospital, while the resident was having a (CT) scan, he had ventricular tachycardia (abnormally rapid and ineffective heart beats), a "code blue" was called and the resident had cardioversion [a medical procedure performed to restore a normal heart rhythm for people who have certain types of abnormal heartbeats (arrhythmias)] performed and normal sinus rhythm was established. The CT scan revealed a large subdural hematoma (SOH) that measured 3 centimeters with midline shift and radiographic evidence of brainstem herniation (deadly side effect of very high pressure inside the skull that occurs when the brain shifts across structures within the skull).
The resident was diagnosed as having a large left subdural hematoma (a collection of blood on the surface of the brain usually caused by a serious head injury and often requires surgical intervention). There was no surgical procedure performed. The neurological evaluation from the General Acute Care Hospital deemed the resident a poor surgical candidate and no intervention was offered. He was made "comfort measures only". The resident's neurological status worsened and he was pronounced dead on September 8, 2010, at 11.20 a.m.
A review of the Certificate of Death dated September 8, 2010, obtained from the acute care hospital revealed the cause of death was "Blunt Head Trauma" from a ground level fall at the, nursing home.
On NoVember 1, 2010, at 3:48 p.m., during an interview CNA 1 stated that Registered Nurse 2 (RN 2) found the resident on the floor and called her to the resident's room to help put the resident back to bed. The resident was too big, so she, with the assistance of RN 2 and RN 3, put the resident back to bed. According to CNA 1, she asked the resident why he did not call for help, and he replied he had to get something from his home. CNA 1, further stated the resident was bleeding from his eyebrow, but she did not remember which one. CNA 1 stated the resident, who was in Room 33, had an alarm on his bed, but she could not hear it because she was in Room 4 at the time of the resident's fall. However, the plan of care did not indicate a bed alarm had been applied, and if one was applied as indicated by CNA 1, it was not audible enough to alert the nursing staff members.
On December 14, 2010, at 10:05 a.m. during an interview, RN 2 stated on the day of the incident he saw the resident sitting on the floor while he was on his way to the supply room. According to RN 2, when he asked the resident if he was ok, the resident responded he was fine. RN 2 stated he called for CNA 1 and RN 3. RN 3 checked for injuries while the resident was still on the floor. After a few minutes all three employees put the resident back to bed. RN 2 stated he saw a bruise on the resident's forehead but he could not remember which side. He also stated he could not remember if the bed used was in a low position. When asked about the bed alarm, RN 2 stated he did not hear the sound of a bed alarm. According to RN 2 the bed alarm, when activated, would continue to sound until it is reset.
The faCility failed to ensure Resident 1 who had a history of falls and assessed as being at a high risk for falls received adequate supervision and necessary care to prevent severe fatal brain injury from a fall for one out of one sample residents (1).
The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of death of Resident 1.