State Findings:
Based on facility policy review, medical record review, and interview, the facility failed to prevent a fall resulting in actual Harm for 1 resident (#9) of 5 residents reviewed for falls of 24 sampled residents.
Telephone interview with CNA #3 on 3/19/19 at 5:15 AM revealed CNA #3 was sitting at the nurse’s station and heard CNA #1 hollered out to me from the resident’s (Resident #9’s) room door . Further interview revealed CNA #1 had .not asked for help all night .
Telephone interview with CNA #1 on 3/19/19 at 12:55 PM, revealed CNA #1 was providing care to the resident on 3/2/19 at 5:45 AM .changed her by myself .I always changed her (alone) . Continued interview revealed Resident #9 was rolled onto the right side to provide peri-care, the left leg shifted .and threw her off the bed before I could catch her .
Interview with CNA #5 on 3/19/19 at 2:46 PM, in the conference room, revealed the CNA had worked in the facility for 7 months. Continued interview revealed the CNA was aware Resident #9 required the assistance of 2 staff for bed mobility, and had always required the assistance of 2 staff since he had been employed in the facility.
Interview with CNA #4 on 3/20/19 at 2:20 PM, in the conference room, revealed .we knew she was a 2 person assist by the care guide and by looking at her .she was obese, not active, non-verbal, just needed assistance with everything .
Interview with Registered Nurse (RN) #4 on 3/20/19 at 2:50 PM, on the 400 Hall, revealed CNA care guides are updated daily and printed and left in a folder at the nurse’s station daily for the CNAs which clearly document the level of assitance Resident #9 required.
Interview with the Director of Nursing (DON) and the Administrator, on 3/19/19 at 4:05 PM, in the DON’s office, confirmed Resident #9 required 2 person assistance with bed mobility, Resident #9 sustained multiple rib fractures, and the facility failed to provide the required 2 person assistance which resulted in a fall and actual harm to Resident #9.
In summary, Resident #9 had been assessed as requiring the assistance of 2 staff members for bed mobility. Resident #9’s MDS assessment, Care Plan, and CNA Care Guide all documented Resident #9 needed the assistance of 2 staff members for bed mobility. During interviews conducted with multiple CNAs during the survey, all were aware of the level of assistance Resident #9 required. Interviews confirmed other CNAs were available and nearby when CNA #1 assisted Resident #9, and interviews confirmed CNA #1 only asked for help after Resident #9 had already fallen from the bed.
Your Experience Matters
...and we want to hear it.
NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
You can make a difference, even if your loved one has already passed away.
Please give us a call at 1-800-645-5262 or fill out our form detailing your experience.
Personal Note from NHA-Advocates
NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety.
If you are struggling and upset, click here to understand your options, or contact us through our contact form or call our toll free hot line number: 1-800-645-5262.
