CINCINNATI, OH- AVENTURA AT WEST PARK

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury and the facility also failed to ensure fall prevention interventions were in place. This resulted in Actual Harm when Resident #38 experienced repeated falls resulting in a fractured femur which required surgery. This affected two (#38, #74) out of three residents reviewed for falls. The facility census was 73.

Findings include:
1. Review of the medical record for Resident #38 revealed an admitted [DATE] with a diagnosis of dementia with behavioral disturbance.
Review of the Minimum Data Set (MDS) for Resident #38 dated 11/10/22 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.)
Review of the fall risk assessment for Resident #38 dated 07/04/22 revealed resident was at a high risk for falling.
Review of the care plan for Resident #38 initiated 01/06/22 revealed resident was at risk for falls related to fluctuations in functioning due to health issues, cognitive deficits, mood/behavior issues, impulsivity and use poor safety judgment at times, use of [CONDITION(S)] medications, and history of falls. Interventions included the following: bed against the wall, bed wheels locked and bed in lowest position, enabling devices as needed, keep call light and frequently used items within reach when in room, medications as ordered, notify physician as needed for adverse effects to medications, non-skid footwear, observe for changes in safety and intervene as necessary, pathways well- lit and clutter free, staff to offer/assist with toileting tasks as needed, and therapy services as indicated.

Review of the nurse progress note for Resident #38 dated 10/29/22 timed 10:29 A.M. revealed resident was noted on 10/28/22 in the evening in his room bent over and he then went into a squatting position and stating he was looking for his video. Nurse told him he did not have any video and to stand up, but resident stated he wanted to find it. The nurse left the room and then later walked past the resident’s room, and he was laying on the floor flat on his back. Resident was unable to stand up and was lifted onto his couch per three staff. Review of note revealed resident complained of pain to his hips and his left hip was swollen and left leg was shorter than the right. Resident reported pain on a level of 8 out of 10 on a scale of 1 to 10 with 10 being the worst pain. The physician was notified and gave an order to send resident to the hospital for an evaluation.
Review of the post fall assessment for Resident #38 dated 10/29/22 timed at 11:54 A.M. revealed resident was confused, obeyed commands, had full range of motion to arms, partial range of motion to legs, complained of pain 8 out of 10, and vital signs were as follows: blood pressure 145/78, pulse 84, respirations 18, temperature 98.6, oxygen saturation 95 percent (%.)
Review of MDS for Resident #38 dated 10/29/22 revealed resident was discharged to the hospital with a return anticipated.
Review of entry MDS for Resident #38 dated 11/05/22 revealed resident was readmitted to the facility.
Review of the hospital note for Resident #38 dated 10/29/22 revealed x-ray showed an acute displaced comminuted fracture of the left proximal femur which occurred following a fall in the facility. Resident was admitted and referred to orthopedics for surgical repair of the fracture.
Review of the progress note per Nurse Practitioner (NP) for Resident #38 dated 11/07/22 revealed resident was examined for skilled admission follow up for left femur fracture. Resident had a fall on 10/29/22 and was sent out to the hospital. The left leg had two incision sites covered with [MEDICATION(S)]. While in the hospital, the resident had surgery to repair the fracture of the left femur and was to follow up with the orthopedic surgeon in two weeks.
Review of the facility incident log dated 09/01/22 through 11/30/22 revealed it did not include Resident #38’s fall on 10/29/22.
Observation on 12/12/22 at 1:28 P.M. of Resident #38 revealed resident was resting in bed with a fall mat propped against the wall by the window and another fall mat propped against the wall by the door.

Interview on 12/12/22 at 1:28 P.M. with Resident #38 confirmed he was not sure why the fall mats were in his room and why they were propped up on the walls.
Interview on 12/12/22 at 1:30 P.M. with State tested Nursing Assistant (STNA) #821 confirmed Resident #38 was in bed and had fall mats propped up against his walls. STNA #821 confirmed she was an agency aide, and she was unsure if the mats were supposed to be on the floor while resident was in bed.

Interview on 12/12/22 at 1:33 P.M. with Licensed Practical Nurse (LPN) #822 confirmed she was an agency nurse, and she was unsure if the mats propped up on Resident #38’s walls were supposed to be on the floor while resident was in bed.
Observation on 12/12/22 at 2:02 P.M revealed resident was still resting in bed with fall mats propped against the walls.

Interview on 12/12/22 at 3:41 P.M. with the Director of Nursing (DON) confirmed the facility incident log did not include Resident #38’s fall on 11/25/22 and the facility had not conducted a fall investigation for Resident #38’s fall. DON further confirmed Resident #38 sustained a left femur fracture during the fall on 10/29/22 which required surgical repair.

Interview on 12/15/22 at 8:42 A.M. with the DON confirmed Resident #38 did not have an order fall mats to be placed at his bedside when he was in bed nor had this information been added to the resident’s care plan. DON confirmed she was not sure when the fall mats were placed in resident’s room, but she was going to contact the physician and get an order for fall mats to the bedside while resident was in bed, because she thought it was a good intervention for the resident due to his history of falls.

2. Review of the medical record for Resident #74 revealed an admitted [DATE] with a diagnosis of acute pyelonephritis and a discharge date of [DATE].
Review of the MDS for Resident #74 dated 11/18/22 revealed resident was cognitively intact and required supervision and physical assistance of one staff with ADLs.
Review of the fall risk assessment for Resident #74 dated 11/12/22 revealed resident was at high risk for falls.
Review of the care plan for Resident #74 dated 11/22/22 revealed the resident was at risk for falls related to confusion and weakness. Interventions included to ensure the call light is within reach.
Review of the facility incident log dated 09/01/22 through 11/30/22 revealed it did not include Resident #74’s fall on 11/25/22.
Interview on 12/12/22 at 3:41 P.M. with the DON confirmed the facility incident log did not include Resident #74’s fall on 11/25/22 and the facility had not conducted a fall investigation for Resident #74’s fall on 11/25/22.

Review of the facility policy titled Managing Falls and Fall Risk dated 08/2022 revealed 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. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The staff will monitor and document each resident’s response to interventions intended to reduce falling or the risks of falling.

This deficiency represents non-compliance investigated under Complaint Number OH 968.