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OAH Docket No.
3-0900-19384-2 |
STATE OF
OFFICE OF
ADMINISTRATIVE HEARINGS
FOR THE COMMISSIONER OF HEALTH
|
In the Matter of
Infinia at Survey Exit
Date: October 18, 2007 |
RECOMMENDED DECISION |
The above matter was the subject of an independent informal dispute
resolution (IIDR) conducted by Administrative Law Judge Kathleen D. Sheehy on
January 22, 2008. The record of the
Office of Administrative Hearings (OAH) closed at the conclusion of the IIDR
conference that day.
Marci Martinson, IIDR Coordinator, Licensing
and Certification Program, Division of Compliance Monitoring (Division),
David Grant, General Counsel, Infinia Healthcare
Companies, LLC, 450 S. 400 East, Suite 200, Bountiful, UT 84010; Bev Bauer, RN
Director of Nursing, and Mary Ann Higgins, Activity Director/Fall Committee
Member, 201 Southwest 18th Street, Owatonna, MN 55060, appeared for Infinia at Owatonna (the
facility). Patricia Howell, RN
Consultant, Health Information Consulting,
Under
Minn. Stat. § 144A.10, subd.16 (d)(6), this recommended decision is not binding
on the Commissioner of Health. Under
Department of Health Information Bulletin 04-07, the Commissioner must mail a
final decision to the facility indicating whether or not the Commissioner
accepts or rejects the recommended decision of the Administrative Law Judge
within 10 calendar days of receipt of this recommended decision.
FINDINGS OF FACT
1.
On October
18, 2007, the Division issued a Statement of Deficiencies to the facility,
citing violations of Tag F323 (quality of care, provision of an environment
that remains as free as possible from accident hazards and provision of adequate
supervision and assistance devices to reduce the risk of falls). The Division found deficient practices with
regard to Residents # 6, 15, 5, 10, 1, and 14.[1]
2.
Based
on observations made during the survey, the Division also determined that there
was an immediate and serious threat to resident health and safety beginning at
11:30 a.m. on October 18, 2007, with regard to Residents # 6 and 15. The immediate jeopardy continued through 3:30
p.m. that afternoon, when a corrective plan was approved.[2]
The plan of correction required, among
other things, that the facility take immediate action to update care plans,
conduct staff training on the use of bed and wheelchair alarms, and ensure that
a staff member was present on the nursing wing to respond to alarms when they
sounded.[3][4]
Resident # 6
3.
Resident
#6 was an 85-year-old man who was admitted to the facility in March 2005 with
diagnoses of myocardial infarction, congestive heart failure, coronary artery
disease, and dementia from anoxic brain injury.[5] At that time he independently walked,
transferred, and got himself into and out of bed. In August 2006, the care plan was revised to reflect
that he was at risk of falling due to psychotropic drug use, unsteady gait,
poor safety awareness, and history of falls.
The interventions implemented at that time were to monitor for the
following: unsteadiness with walking and transferring, bowel and bladder urgency,
and side effects of medications. In
addition, he was to have a quarterly risk assessment.[6] On April 14, 2007, staff conducted a fall
risk assessment, found him at risk for falls, and concluded staff would
“[proceed] to care planning.”[7] Although the facility appears to have
implemented new interventions at this time, it does not appear that the
resident’s care plan was revised to include them.[8]
4.
On May 13,
2007, the resident fell in his room, hit his head, and sustained a right hip
fracture.[9] The incident report reflects that wheelchair
and bed alarms were in place and working when the resident was found and that he
was currently using anti-slip shoes/socks (although these interventions are not
reflected on the care plan). The report
also provides that obstacles were in his path, but it does not describe what
the obstacles were or how the facility changed the environment, if at all, to
remove the obstacles.[10]
5.
When the
resident returned to the facility after surgery and hospitalization, the care
plan was revised to provide for assistance with transfers, referral to physical
and occupational therapy, education regarding safe transfer and mobility
techniques, and the use of a motion sensor on his bed and wheelchair to alert
staff to the resident’s need for assistance.[11] Nursing notes taken between May 22, 2007, and
May 25, 2007, reflect that the resident continued to attempt transfers without
assistance and that alarms were not always activated or responded to by staff
in time to prevent the transfers.[12]
6.
On June
11, 2007, the resident fell in his room at 7:15 a.m. while attempting to walk
to the bathroom. The bed and chair
alarms were not hooked up. The resident
sustained two skin tears on his left hand.
In response to this incident some type of staff education took place.[13]
A physical therapist noted that she
spoke to nursing staff about having alarms on the bed and wheel chair
“activated at all times as patient will need supervision with transfers for
safety.”[14] Physical therapy was discontinued in mid-June
2007.
7.
On July
7, 2007, the resident fell onto his left side at 3:30 a.m. while walking to the
bathroom. He sustained a skin tear on
his left hand. He was wearing socks and
no shoes. The bed alarm was sounding,
but staff did not respond before he fell.[15] No incident report was completed, and no
further investigation of this fall took place.
8.
On July
14, 2007, the resident fell in his room at 2:45 a.m. while attempting to walk
to the bathroom. The resident had
unplugged the bed alarm. According to
the incident report, a new intervention of wearing gripper socks to bed would
be implemented.[16] This intervention was not added to the care
plan.
9.
On
October 7, 2007, the resident was found at 10:20 a.m. on the floor of his
room. According to the incident report,
this incident followed a pattern similar to previous falls when the resident
was transferring himself to get to the bathroom. The bed alarm was not activated and did not
sound. No new interventions were
implemented to prevent future falls.[17] On October 11, 2007, a nurse reviewed the
incident report and noted that the resident self-transfers and shuts off
alarms. The suggested intervention was “Remind
res. to use call light.”[18]
10.
During
the survey process on October 14, 2007, a surveyor observed the resident in his
wheelchair during the early evening hours.
The cable from the seat alarm to the alarm box on the wheelchair was not
connected. The resident wheeled himself
to the dining room to eat; he then wheeled himself back to his room, where he
transferred himself from his wheelchair to the toilet. The alarm did not sound because it was not
connected. A staff person then entered
the room and assisted the resident to bed.[19]
11.
On
October 17-18, 2007, in response to the finding of immediate jeopardy, a number
of interventions were implemented for Resident # 6. A physical therapist screened the resident
and recommended continual use of alarms.
A high-low bed with a concave mattress was obtained to reduce the risk
of injury. A bed alarm was placed
permanently at the foot of the bed, so the resident could not remove it. The wheelchair alarm was re-positioned out of
the resident’s sight and reach, so he could not disconnect it. Floor mats were placed by the bed, but the
mats were removed after it was determined they might pose a tripping hazard. His care plan was updated to reflect these
changes.[20]
Resident # 15
12.
Resident
# 15 is a 93-year-old man who was admitted to the facility in 2003 with
diagnoses including moderate Alzheimer’s dementia and degenerative arthritis.[21] On January 19, 2007, he was moved to a room
in the 300 wing to provide “more consistency in staffing patterns.”[22] As of January 24, 2007, his care plan
addressed the risk of falling and contained interventions including use of
non-skid footwear while transferring and ambulating, monitoring for
unsteadiness, and cueing resident to use the call light when needed.[23] A fall risk assessment completed on April 12,
2007, found him to be at risk for falls because of arthritis, confusion,
psychotropic medication use, and balance and coordination problems. He had fallen one to two times in the prior
90 days.[24]
13.
On May
5, 2007, the resident fell in the bathroom at 10:30 a.m. and sustained a 2- by
4.5-cm lump on his head. He attributed
the fall to poor vision. The incident
report noted that this was not an isolated occurrence but followed a pattern
similar to previous falls attributable to the resident’s failing vision and
refusal to accept additional help with transfers. Facility staff asked the resident’s family
for permission to refer him to physical therapy, which the family denied. The only new intervention suggested was to
leave the light on in the bathroom at all times, but this intervention was not
added to the care plan.[25] There are undated entries to the care plan
calling for staff to assist the resident with transfers to ensure he has shoes
on, and “bed/chair alarms on at all times.”[26]
14.
On July
6, 2007, the resident was moved back to a bed in the 100 wing “to provide
resident an independent environment.”[27]
15.
On July
13, 2007, at 10:00 a.m., the resident was found lying on his right side on the
bathroom floor. The incident report
indicates the resident had bed and wheelchair alarms, which sounded
appropriately, and that he had a pattern of attempting to transfer without
seeking assistance because of dementia.
No new interventions were noted except to “continue with position
alarms.”[28]
16.
On July
14, 2007, at midnight, the resident fell onto his left side attempting to get
to the bathroom. He was bleeding
profusely from a cut over his left eye, and he was unable to stand on his left
leg. The position alarms were not in
place and were not activated. The
resident was sent to the emergency room, where a pelvic fracture was
identified, and he received sutures above his left eye.[29] When he returned to the facility he was moved
back to a room in the 300 wing for additional supervision.[30]
17.
On July
16, 2007, at 3:10 a.m., the resident was found on the floor in the doorway to
the bathroom. He had been pushing a bedside
table to assist with ambulation.
According to the incident report, the position alarms were in place, but
it does not reflect whether the bed alarm was turned on or sounding at the
time. A new intervention of “staff
training” was noted, but the content of the training is not described. Based on the recommendation of the nurse
practitioner who evaluated the resident on that day, the reviewing nurse
directed staff to continue with position alarms.[31]
18.
On
August 21, 2007, the resident fell at 9:10 a.m. while trying to get to the
bathroom. The incident report reflects
that the chair alarm was off. The form
states that the resident’s toileting habits would be reviewed, and “staff
reminded that position alarms are to be in place at all times.”[32] There are no records to suggest that the
review of toileting habits took place.
19.
On
September 22, 2007, at 1:10 a.m., the resident was found on the floor of his
room. He had fallen attempting to get to
the bathroom and sustained a large lump and bruise on the back of his head. The incident report reflects that the
lighting in his room was poor at the time.
The bed alarm was on, but it did not go off. A new
bed alarm was installed. No new
interventions were implemented.[33]
20.
On
October 1, 2007, at 7:00 p.m. the resident was found on the floor in front of
his wheelchair in the doorway to the bathroom. The alarm on his chair was sounding, but staff
did not respond before he fell. The
incident report states that the resident was on a toileting program but
nonetheless attempted to use the bathroom many times on each shift. No new interventions were noted.[34]
21.
During
the survey process on October 17, 2007, the surveyor observed that the
Resident’s chair alarm sounded at 9:10 a.m. while the Resident was transferring
himself from his wheelchair to the toilet, without assistance. The alarm sounded for eight minutes, during
which time no staff were present on the wing.
Not until a staff member entered the wing and heard the alarm did anyone
go to assist the Resident.[35]
22.
On
October 17-18, 2007, in response to the finding of immediate jeopardy, a number
of interventions were implemented for Resident # 15. A physical therapist screened the resident
and recommended physical therapy, to which the family gave consent. In addition, the physical therapist
recommended the continual use of alarms.
A high-low bed with a concave mattress was obtained to reduce the risk
of injury. Floor mats were placed by the
bed, but the mats were removed after it was determined they might pose a
tripping hazard. The facility agreed to
complete a comprehensive bladder assessment to establish a toileting
schedule. The resident’s care plan was
updated to reflect these changes.[36] In addition, the facility arranged to sit the
resident at the last table to be served in the dining room and to have a
nursing assistant present on the floor during all meals to assist residents; in
addition, the facility agreed that a staff member would be on the nursing wing
whenever the resident was present to ensure that staff could respond in a
timely manner if his chair alarm sounded.[37]
Resident # 5
23.
Resident
# 5 is a 79-year-old man with Alzheimer’s dementia and Parkinson’s disease. He cannot stand or walk and is dependent on
staff for all transfers. His care plan
provides that he is to use a self-releasing seat belt in his wheelchair to keep
him from sliding forward and help him to maintain correct posture. He was assessed as being at high risk for
falls and had fallen most recently during the night when he attempted to get out
of bed to look for his recently deceased wife.[38]
24.
During
the survey process on October 14, 2007, a surveyor observed that the resident
released his seat belt, after which an alarm sounded. A staff member came to his room, shut off the
alarm, and left the room without reapplying the seat belt. The seat belt remained off for about 20
minutes, until the resident was transferred to bed with a mechanical lift. A nursing assistant told the surveyor that
the Resident sometimes removes the belt when he becomes uncomfortable.[39]
Resident # 10
25.
Resident # 10 is a 77-year-old woman who has
a seizure disorder and a history of depression and anxiety, for which she takes
various medications. She had fractured
her right ankle before admission to the facility and had problems with her gait
and balance. She has some memory
problems, and she uses a walker but does not require staff assistance with
transfers.[40] As of October 2006, her care plan called for
the following interventions (among others) aimed at preventing injury from
falls: assist with mobilities as needed,
monitor for problems with transferring and walking; physical therapy and
occupational therapy as ordered (discontinued June 4, 2007); assure resident is
wearing eyeglasses, assure glasses are clean and in good repair; monitor
medications for effectiveness.[41]
26.
The
resident was found on the floor in December 2006 and January 2007. The care plan was revised in March 2007, in
response to these falls, to “remind resident to ask for assistance with socks
and shoes” in the morning.[42] The incident reports suggest that the
resident was referred for a physical therapy evaluation and that pressure
alarms would be used on her bed, but this intervention was not added to the
care plan.[43]
27.
The resident
fell five times in May 2007. On May 1, 2007,
she was attempting to sit on a chair in the dining room. The incident report reflects that the
facility notified physical therapy and moved a popcorn machine to make more
room for the resident to maneuver around the dining table.[44]
This intervention was not added to the
care plan. On May 2, 2007, the resident
fell in her room while attempting to stand from the side of her bed, and she was
found lying on her stomach on the floor.
She said that she was looking for bugs on the floor and that kids were
jumping off the roof. In response to
this incident the resident was referred to physical therapy, and the dosage of
one of her psychotropic medications was reduced.[45]
On May 7, 2007, the resident was sitting
on her bed and fell off while bending over to put on her shoes. The incident report reflects that a bed alarm
was in place, but the resident had disconnected it because she did not like the
noise. In addition, the report indicated
the Resident’s bed was in the low position, but this intervention was not
written into her care plan. The
reviewing nurse noted that the physical therapist concluded the resident was at
increased risk for falls because she lacked awareness of personal safety.[46]
On May 19, 2007, the resident stood up from a chair in her room and was using
her walker to turn around when she fell.
She hit the back of her head on the open drawer of a bedside table. The incident report reflects new interventions
of referral for an eye exam, use of a padded undergarment, and trial use of bed
and wheelchair alarms.[47] The care plan was revised only to reflect use
of a padded undergarment.[48] On May 24, 2007, the Resident fell in the day
room while getting up from the couch.
The resident said she tripped on the carpet. The interventions noted on the incident
report were staff training and counseling (not specified) and checking the
level of the anti-seizure medication.
The form reflects that the resident was currently on the facility’s
Fallen Angel program, although this intervention was not listed on the resident’s
care plan.[49]
28.
The resident
fell twice in June, once in July, and once in August 2007. On June 12, 2007, she fell because she was
carrying a radio while pushing her walker.
The interventions noted were that staff would continue to monitor the
resident and remind her of safety concerns.[50] On June 14, 2007, the resident let go of her
walker to push another resident out of the way.
She lost her balance and fell against the wall, sustaining a 12-cm
scrape on her forearm. The resident was
reminded to use her walker at all times and to ask for assistance.[51] On July 4, 2007, the resident fell in her
room while standing up from her chair.
She tripped on the leg of the chair and fell onto her left side. The incident report states that staff will
continue to monitor for obstacles that could be in the resident’s path and
remind the resident on safety. The form
suggests that some furniture was moved, but it does not describe what or how,
and no changes were made to the care plan. On August 23, 2007, the resident tripped on
oxygen tubing between her bed and chair.
She fell to her knees. No new
interventions were implemented.[52]
29.
On September
8, 2007, the resident came out of her room and tripped on the doorway while
reaching for the hall banister. The
incident report provides that the resident would be encouraged to slow down and
use a wheelchair. No interventions were
added to the care plan.[53]
30.
On
September 27, 2007, October 4, 2007, and October 16, 2007, the resident fell
while attempting to sit on a chair. She
sustained a 19- by 2.5- cm scrape on her back and a hematoma to the back of her
head. No interventions or other
assessments were initiated. The resident
was encouraged to slow down.[54] On October 12, 2007, the intervention of
“assist with mobilities as needed, monitor for problems with transferring and
walking” was added to the care plan.[55] The last fall on October 16, 2007, was
witnessed by a surveyor.[56]
Resident # 1
31.
Resident
# 1 is a 76-year-old woman who was admitted to the facility on July 10, 2007,
with Alzheimer’s dementia. Her cognitive
skills are severely impaired, and she was semi-comatose from numerous sedative
medications when she was admitted. The
medication orders were changed on July 12, 2007, when one of the medications
was discontinued and another reduced.[57] Initially the resident was almost completely
dependent on staff for assistance with all activities of daily living, but she
became more alert and active within a few weeks of admission. On July 16, 2007, she was found sitting on
the floor next to her bed. Bed alarms
were applied at this time.[58] In the next two days, she rolled out of bed three
times after becoming agitated. On two of
those occasions, position alarms were in place and sounded. Staff implemented a low bed to reduce the
risk of injury.[59] On July 19, 2007, a nurse faxed a request to
the resident’s physician to use a concave mattress to prevent her from rolling
out of bed.[60] This intervention was not written onto the
care plan, and it is not clear whether the mattress was put in place. The care plan’s initial interventions for
preventing falls were a lap buddy to prevent her from sliding out of her
wheelchair and a high-low bed with mattress on the floor to prevent injury.[61] At some point position alarms were added to
the care plan, but that entry is not dated. On July 28, 2007, the resident was found lying
on a mat next to her bed, with the alarm sounding. No incident report was completed.[62]
32.
On
August 5, 2007, at 8:00 a.m., the resident was rocking herself in a wheelchair,
attempting to remove the lap buddy. The
wheelchair tipped on its side. The
incident report reflects that the chair alarm was on, but it does not say
whether it sounded. A new intervention was
proposed to add tip bars to the wheelchair.[63]
33.
On
August 13, 2007, the resident fell two times on the evening shift, once in her
room and once in the day room. No
incident reports were completed for these falls. The resident had a 6 by 3.5 cm bruise on her
left side. On August 14, 2007, the
resident was referred for physical therapy. [64]
34.
On
August 18, 2007, at 7:00 a.m., the resident was in a wheelchair. She removed the lap buddy and stood up in
front of the chair, then her knees buckled and she slid to the floor. The chair alarm was in place, but the
incident report does not indicate whether it was sounding. A new intervention of adding tip bars to the
wheelchair is noted, which suggests the tip bars had not been added since the
previous incident.[65]
35.
On
August 19, 2007, at 7:00 a.m., the resident again removed the lap buddy and
tried to stand up from her wheelchair.
The incident report does not indicate that a position alarm was in
place; the new intervention recommended is “chair alarm put in place.”[66] The care plan was amended that day to require
the use of a chair alarm and again on August 26, 2007, to require use of a seat
belt on the wheelchair.[67]
36.
On
September 3, 2007, at 1:00 a.m., the resident was found sitting on the floor
mat next to her bed.[68] No incident report was written, and this was
not investigated as a fall.
37.
On
September 13, 2007, at 1:15 p.m. the resident was found sitting on the floor
mat next to her bed. She said “I tried
to reach my table and landed here.”[69] The bed alarm was sounding. No new interventions were implemented.[70] A note by the director of nursing dated that
day indicates the resident often crawls out of bed and positions herself on her
knees with her upper body lying over the bed.
She is in a low bed with a contour mattress, floor protection and pressure
alarm.[71] On September 17, 2007, the lap buddy was
removed and replaced with an alarm belt so that staff would be aware if the
resident unbuckled it.[72] This intervention was not written onto the
care plan.
38.
On
October 4, 2007, at 4:00 p.m. the resident was found lying on the floor mat
next to her bed. The bed alarm was
sounding. No new interventions were
implemented.[73]
39.
On
October 15, 2007, the resident was found on her knees on the floor mat next to
her bed with her hands folded in front of her on the bed. This was described as a fall in the nursing
notes, but no incident report was completed and no new interventions were
implemented.[74]
Resident # 14
40.
Resident # 14 is an 83-year old man who was
admitted to the facility in March 2007 with a recent hip fracture. He is moderately cognitively impaired and has
a history of macular degeneration, peripheral vascular disease, and
osteoporosis. Upon admission he required
extensive assistance with transfers, mobility, and toilet use.[75] The care plan initially provided that staff
would remind the resident of his functional limitations and risk of falling,
remind him to call for assistance, and reorient him to the environment and
safety measures as needed.[76]
41.
On May
5, 2007, the resident was found on the floor after he attempted to transfer
himself to the toilet. No new
interventions were implemented.[77]
42.
On June
24, 2007, the resident was in the courtyard of the facility with family
members, who put him in a wheelchair swing.
When the swing was pushed, he fell backwards onto concrete and hit his
head. In response to this incident,
staff members instructed the family on proper use of the swing and the
activities manager was to write up an instruction form on use of the swing for
residents and family members.[78]
43.
On June
27, 2007, the resident fell while attempting to transfer himself from the
toilet to a wheelchair. The incident
report reflects that a bed alarm was in place.
In response to this incident, the facility concluded the resident
required both wheelchair and bed alarms.[79] The care plan was revised to reflect this
intervention.[80]
44.
On July
3, 2007, at 3:00 a.m., the resident was found sitting on a pad beside his bed
after he had tried to get up by himself.
The bed alarm was sounding. The
incident report states that there was already a mat on the floor next to his
bed, although this intervention was not listed in the care plan. No new interventions were implemented, but nursing
notes indicate that staff members were to check the resident as frequently as
possible.[81]
45.
On July
16, 2007, at 3:20 a.m., the resident was found on the floor near the nursing
station in a large pool of blood. He was
bleeding profusely from cuts on his head and face. The resident was transported to the emergency
room. He had earlier attempted to get
out of bed several times by himself, so staff had put him in the wheelchair and
brought him to the area near the nursing station to supervise him. The incident report says the chair alarm was
in place, but does not say whether it was sounding or working properly when he
fell. The new intervention noted was
“seat belt in wheelchair.”[82] This intervention was not added to his care
plan until September 12, 2007.[83]
46.
On
August 28, 2007, at 1:55 a.m., the resident was found on the floor mat next to
his bed. The bed alarm was on and
sounding. The incident report reflects
that the following interventions were already in place: physical therapy referral, floor mat next to
bed, Fallen Angel program, bed/chair alarm implemented, anti-slip
shoes/socks. A number of these
interventions were not contained in the care plan. The new intervention noted was the
possibility of using a seatbelt in the wheelchair, to be discussed at the falls
meeting to be held on August 30, 2007.[84]
47.
On
September 10, 2007, at 3:40 p.m., the resident attempted to get out of his
wheelchair to use the bathroom, and the alarm sounded. A staff person got to him before he fell and
assisted him onto the floor beside the chair. No new interventions were implemented. A note on the incident report provides that
there was a possible need for a seatbelt on the wheelchair, to be discussed at
a falls meeting.[85]
48.
As
noted above, the care plan was revised on September 12, 2007, to require the
use of a seatbelt on the resident’s wheelchair.
49.
On
September 18, 2007, at 10:30 p.m., the resident was found on the floor next to
his bed. He fell while attempting to get
to the bathroom. The bed alarm was
sounding. According to the incident
report, he had a concave mattress in place prior to the fall (which was not on
the care plan). The proposed new
intervention was to move his room closer to the nursing station.[86]
Based upon the exhibits
submitted and the arguments made and for the reasons set out in the Memorandum
that follows, the Administrative Law Judge makes the following:
RECOMMENDED
DECISION
The citation with
regard to Tag F323 is supported by the facts and should be AFFIRMED as to scope
and severity.
Dated: January 31, 2008.
|
s/Kathleen D. Sheehy |
|
KATHLEEN D. SHEEHY |
|
Administrative Law Judge |
Reported: Digital recording (no
transcript)
MEMORANDUM
Because falls
are among the most common and serious problems facing elderly persons, the
Minnesota Department of Health has provided information to health care
providers regarding available resources to help health care providers assess
and implement interventions for individuals who have a recent history of falls
or who are at risk of falls. Falling is
associated with considerable mortality, morbidity, reduced functioning and
premature nursing home admissions from the community. Incidence rates of falls in nursing homes and
hospitals are almost three times the rates for community-dwelling persons over
the age of 65. The key concern is not
simply the high incidence of falls in older persons, but rather the combination
of high incidence and high susceptibility to injury.[87] The Division issued Tag F323 at severity level 4 (immediate jeopardy), isolated scope. The facility challenges the finding that its
practices were deficient as well as the determination of immediate jeopardy.
Tag F 323
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.[88] The facility must ensure that the resident environment remains as free from accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents.[89] The intent of this provision is to ensure that the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents.[90]
An “avoidable accident” is an accident that occurred because the facility failed to identify environmental hazards and individual resident risk of an accident, including the need for supervision; evaluate/analyze the hazards and risks; implement interventions, including adequate supervision, consistent with a resident’s needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; and monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice.[91] A “fall” means unintentionally coming to rest on the ground, floor, or other lower level, except as the result of an overwhelming external force (such as one resident pushing another). Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. “Adequate supervision” is defined by the type and frequency of supervision, based on the individual resident’s assessed needs and identified hazards in the resident environment.[92]
Section 483.25 does not make a facility strictly liable for accidents that occur, but it does require the facility to take all reasonable steps to ensure that a resident receives supervision and assistance devices that meet his or her assessed needs and mitigate foreseeable risks of harm from accidents.[93] A facility is permitted the flexibility to choose the methods it uses to prevent accidents, but the chosen methods must constitute an adequate level of supervision under all the circumstances.[94]
The Division argues that with regard to all six residents, the facility was or should have been aware of the risk of falls but failed to take adequate steps to prevent them, either because the facility failed to identify environmental hazards and individual accident risks for each resident, including the need for supervision; failed to adequately evaluate/analyze the hazards and risks; failed to implement interventions, including adequate supervision, consistent with a resident’s needs; or failed to monitor the effectiveness of the interventions and modify the interventions as necessary. The facility agrees that it could perhaps have done more to prevent falls for each resident, but denies that its practices were deficient.
The record supports the Division’s findings of deficient practices, sometimes multiple, for each of the above residents. Most of the time, the facility correctly assessed these residents at the outset as presenting a high risk of falling; and most of the time, the facility adequately investigated these falls by having staff members complete the required incident reports and fall investigation forms. The record reflects, however, that the facility failed to adequately guard against the assessed risks because it failed to provide sufficient individual supervision, failed to adequately analyze the information collected on the fall investigation forms, failed to consistently implement interventions, and failed to monitor the effectiveness of interventions and modify them as necessary. Most if not all of these residents had cognitive impairments that affected their judgment, awareness, and ability to stay safe. It was the facility’s responsibility to supervise these residents adequately to mitigate the foreseeable risk that they would fall and injure themselves, and the facility failed to meet this standard.
The facility also argues that the Division improperly found immediate jeopardy with regard to Residents # 6 and 15, contending there was no deficient practice that needed immediate correction and that the facility’s interventions had reduced the incidence of falls prior to the survey. Immediate jeopardy is a situation in which the provider’s noncompliance with one or more requirements of participation has allowed, caused, or resulted in (or is likely to allow, cause or result in) serious injury, harm, impairment, or death to a resident; and this noncompliance requires immediate correction, as the facility either created the situation or allowed the situation to continue by failing to implement preventive or corrective measures.[95] Only one individual needs to be at risk, and serious harm, injury, impairment, or death does not have to occur before a determination of immediate jeopardy is appropriate; the high potential for these outcomes to occur in the very near future also constitutes immediate jeopardy.[96]
In this case, Resident # 6 did suffer actual harm in the form of a right hip fracture. The facility’s interventions were not effective and were not always implemented, nor did the facility revise the interventions appropriately in response to his multiple falls. After the hip fracture, the resident fell again and sustained actual harm (skin tears) when the current interventions were not implemented (position alarms were not properly hooked up). He had two falls during early morning hours when he attempted to reach the bathroom by himself; when the alarms sounded on one occasion, staff did not respond in time to prevent the fall, and when the alarms did not go off on the second occasion staff did not modify the use of position alarms in response to the resident’s habit of unhooking them. Reminders to use the call light were clearly an ineffective intervention for a resident who was cognitively impaired and had fallen many times over a period of five months, once with a very serious injury. During the survey, the surveyor observed that the resident’s wheelchair alarm was not connected and that he continued to transfer himself without assistance. This is sufficient evidence that the facility’s noncompliant practices had caused actual harm in the past and that immediate correction was required to prevent the high likelihood of another serious injury.
Resident # 15 also sustained actual harm in the form of a pelvic fracture and facial cuts. Before this injury the facility had failed to reduce interventions to writing in the care plan, failed to modify interventions when the resident continued to transfer himself without assistance, and failed to use the position alarms properly or monitor them for their effectiveness. In addition, the facility failed to respond to this resident’s pattern of falling while attempting to get to the bathroom, by developing an individualized toileting schedule that would reduce his need to attempt these transfers on his own. This resident fell again in September 2007 and sustained a lump and bruise on the back of his head. During the survey, the surveyor observed him transferring himself without assistance, during which time the wheelchair alarm sounded for eight minutes before staff responded to it, because no staff members were present in the nursing wing. Again, this is sufficient evidence to support the finding of immediate jeopardy.
The corrective action plan required the facility to
address the systemic issues that
created the potential for serious harm, injury, impairment, or death to
individuals residing in the facility (staff education and training on
monitoring the effectiveness of position alarms, and ensuring staff were present
on the unit to respond to alarms), as well as to formulate individualized
interventions for the two residents determined to be in immediate jeopardy. The findings of deficient practices and the immediate
jeopardy determination should be affirmed.
K.D.S.
[1] Form 2567, Facility Exhibits.
[2] Exs. I & J.
[3] Ex. J.
[4] Ex. K-24b.
[5] Ex. K-4.
[6] Ex. K-24b.
[7] Ex. K-20a.
[8] Ex. K-24b.
[9]
[10] Exs. K-31a to K-32.
[11] Exs. 26b, 27b, 28a.
[12] Exs. K-41b, K-42a, K-43a.
[13] Exs. K-33a to K-34.
[14] Facility Exhibits Resident # 6 (Physical Therapy note 6/11/07).
[15] Exs. K-45b, K-46a.
[16] Exs. K-35a to K-36.
[17] Exs. K-37a to K-38a.
[18] Ex. K-38b.
[19] Ex. K-3a.
[20] Ex. J-4.
[21] Ex. L-4.
[22] Facility Exhibits Resident # 15 (Room Change Notice 1/19/07).
[23] Ex. L-25b.
[24] Ex. L-15.
[25] Exs. L-27a to L-28.
[26] Ex. L-25b.
[27] Facility Exhibits Resident # 15 (Room Change Notice 7/6/07).
[28] Exs. L-29a to L-30.
[29] Exs. L-31a to L-33b.
[30]
[31] Exs. L-34a to L-35; Facility Exhibits Resident # 15 (Evaluation by Mary Funk, 7/16/07).
[32] Exs. L-36a to L-37.
[33] Exs. L-38a to L-39. See also Facility Exhibits Resident #15 (Evaluation by Mary Funk 9/24/07, no need for corrections or additions to plan of care).
[34] Exs. L-40a to L-41b.
[35] Ex. L-3.
[36] Ex. J-4.
[37] Exs. J-4 to J-5.
[38] Exs. M-10, M-11, M-14.
[39] Exs. M-1a, M-2.
[40] Exs. N-14, N-15.
[41] Ex. N-15.
[42] Ex. N-15.
[43] Ex. N-4a.
[44] Exs. N-20 to N-22.
[45] Exs. N-23 to N-25. The resident received physical therapy five times a week from May 3, 2007, to June 2, 2007, when the therapy was discontinued. See Facility Exhibits Resident #10 (Physical Therapy notes attached to Incident Report 5/1/07).
[46] Exs. N-26 to N-28.
[47] Exs. N-29 to N-31.
[48] Ex. N-15.
[49] Exs. N-32 to N-34. “Falling Angels” is the facility’s fall prevention program. The program requires, among other things, that at least one individualized intervention be added to the care plan within 24 hours of a fall. See Facility Exhibits Resident # 10 (Policy and Procedure/Falling Angels Program). The lab results showed that Dilantin and phenobarbital levels were in the normal therapeutic range.
[50] Exs. N-35 to N-37.
[51] Exs. N-38 to N-40.
[52] Exs. N-44-N-46.
[53] Exs. N-47 to N-49.
[54] Exs. N-50 to N-60.
[55] Ex. N-16.
[56] Exs. N3a and N-4a.
[57] Facility Exhibits Resident #1 (physician order 7/12/07).
[58] Ex. O-56b.
[59] Exs. O-32 to O-34; O-35 to O-37.
[60] Ex. O-57b (Nursing Note 7/19/07).
[61] Ex. O-29.
[62] Ex. O-59b.
[63] Exs. O-38 to O-40.
[64] Ex. O-62b.
[65] Exs. O-41 to O-43.
[66] Exs. O-44 to O-46.
[67] Exs. O-29, O-30.
[68] Ex. O-67a.
[69] Ex. O-69b.
[70] Exs. O-47 to O-49.
[71] Ex. O-50.
[72] Ex. O-70a.
[73] Exs. O-51 to O54.
[74] Ex. O-72b.
[75] Exs. P-4, P-5 to P-13.
[76] P-24.
[77] Exs. P-29 to P-31.
[78] Exs. P-32 to P-34.
[79] Exs. P-35 to P-37.
[80] Ex. P-21.
[81] Exs. P-38 to P-40.
[82] Exs. P-41 to P-43.
[83] Ex. P-21.
[84] Exs. P-44 to P46.
[85] Exs. P-47 to P-49.
[86] Exs. P-49 to P-52.
[87] Ex. E.
[88] 42 C.F.R. § 483.25.
[89] 42 C.F.R. § 483.25 (h)(1) & (2).
[90] Ex. G-1.
[91] Ex. G-2.
[92] Ex. G-3.
[93]
[94]
[95] 42 C.F.R. § 489.3; Ex. G-28 (CMS Interpretive Guidelines for Surveyors).
[96] Ex. D-1 to D-3 (SOM Appendix Q).