Facility I.D. Number: 0043398
Date of Survey: 07/31/02
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
An owner, licensee, administrator, employee or agent of a facility shall not neglect a resident.
These requirements are not met as evidenced by:
Based on closed record review, staff interviews, and review of facility side rail protocol, the facility failed to ensure that one resident (R3) was free from harm and neglect. The facility failed to correctly assess and then reassess a cognitively impaired resident for alternative or less restrictive methods after this resident suffered 2 previous falls from bed while using side rails. R3 subsequently sustained a total of four fractures to both lower legs after getting legs caught in side rails while attempting to get out of bed on 6/22/02.
R3's clinical record revealed R3 has diagnoses including Anemia, Alzheimers and Chronic Renal Failure. Review of R3's Minimum Data Set of 5/2/02 denotes R3 's cognition as a 2 (moderately impaired), bed mobility 4/2 (total dependence with 1 person physical assist) transfer 4/3 total dependence and 2 plus person physical assist, range of motion 0 (no limitation or loss) modes of transfer bed rails, and restraints 2 (full side rails daily).
Facility incident report dated 6/22/02 indicates that R3 was found on 6/22/02 at 12:45 PM by staff on "side of bed with both legs caught in between side rails". Facility report indicates that the bed rails were present and resident was confused. Diagram location of injury indicates R3 sustained a bruise to the left side of face, 1 centimeter skin tear to the right hand, bruising and swelling to the right lower leg, 1 centimeter skin tear on left forearm, and bruise left lower leg. R3 was sent to the hospital emergency room and was admitted with diagnoses of Hypotension; bilateral leg fractures which included obliques fracture through left proximal lateral tibia, fracture of right proximal tibia, fracture of the distal femur and non-displaced fracture of right fibular head; urinary tract infection and urosepsis.
Review of nurse notes, dated 6/22/02, at 12:45 p.m. document that staff observed R3 with both legs caught in between side rails. R3 was unable to explain what happened. No loss of consciousness noted. Staff put her back to bed. The following injuries were noted: left side of face with bruise, left forearm 2 cm skin tear, with minimal bleeding, right thumb and middle finger 1 cm skin tear, left leg 3 bruised areas, right leg with approximately 1cm cut and knees with swelling. R3 was sent to hospital at 1:30 p.m. per private ambulance.
Facility incident reports from April/May 2002, indicates R3 had 2 previous falls on 4/26/02 and on 5/2/02. In both incident R3 was found on the floor next to the bed. The report of 4/26/02 did not indicate if the side rails were up. Nurses notes dated 4/26/02 indicate "R3 was observed on floor at bedside and stating to nurse "I fell from bed." The incident report of 5/2/02 indicated both rails were up at the time of R3's fall. R3 sustained abrasions and skin tears and did not require hospitalization. Nurse notes of 5/2/02 indicate "Resident was found on floor supine. R3 stated to staff "She tried to get off bed and slipped."
Review of fall risk assessment dated 2/28/02 and 5/20/02 indicates R3 has a history of falls, was alert, and R3's gait and balance was unable to be assessed due to R3 not being able to perform this function. R3 was not scored high risk for falls on the above date even after R3 had fallen.
Side rail screen dated 4/22/02 indicates that R3 is not ambulatory, has cognition decline in safety awareness, requires assist to transfer from lying to sitting on the side of the bed, and demonstrates poor or dependent bed mobility, uses the side rail as an enabler to promote in bed independence, has history of falls in past 3 months, requires frequent monitoring by staff. MDS dated 5/20/02 scores indicate that R3 would not have been able to use the side rails as an enabler. The facility policy on side rail use was reviewed with E1 and E2 on 6/25/02 at 2:55 p.m. states that "Confused residents often try to climb over side rails. Side rails are not to be used to prevent residents from getting out of bed. Use of low bed is indicated in this situation." Chart review did indicate that R3 was confused and had attempted to climb over the side rail, and yet the facility neither removed the side rails or used the low bed.
Review of R3's nursing care plan dated 5/20/02 indicates R3 is at potential risk for additional falls related to fall history, decreased cognitive skills, severely impaired motor function. Under "Approach" staff are required to monitor R3 every 2 hours for comfort and safety, keep side rails up to aide in bed mobility and fall assessment every 3 months. There was no documentation to show that R3 was monitored or could use the side rails for mobility.
During interview with E9 (rehab coordinator) on 6/25/02 at 2:15 p.m., E9 verified that she did do the side rail assessment on 4/22/02. E9 stated an assessment includes reviews of the medical record of the resident and assessing the resident face to face. E9 stated R3 is disoriented and is able to move upper extremities and that R3 has a deformity to one leg and both legs are very skinny. Upon review of side rail assessment and review of R3's incident reports with E9, E9 stated she was not aware of R3's previous falls on 4/26/02 and 5/2/02. E9 further stated that a reassessment is usually done after a fall, and the resident is further observed, and if resident sustains another fall then the resident is assessed for alternative measures. E9 stated in this instance with R3's fall, a low bed would have been indicated.
Phone interview with E8 (housekeeping) on 6/26/02 at 11:00 a.m., E8 stated she heard R3 calling for help/saying "Help me, help me." E8 stated at that time she could see R3's bed but not R3. E8 stated she went to the nurse's station to inform staff.
Interview with E4 (nurse) on 6/25/02 at 11:50 a.m. in first floor conference room verified that E4 was working the 7-3 shift on 6/22/02. E4 stated at 12:40 p.m. on 6/22/02, E8 came out of R3's doorway calling for someone to help. E4 stated upon arrival to R3's room, E4 found R3 in bed, lying on her left side, with her head and arm dangling from the bed. E4 stated R3's both legs were caught in the side rail. E4 stated the side rail was holding up R3. E4 stated he pulled R3's legs from out of the side rail and bed. E4 stated R3 had no abrasions, no laceration or bruising noted.
Interview with E7 (Certified nursing assistant/CNA) on 6/25/02 at 12:15 p.m. in the first floor conference room revealed the following: At approximately 12:45 p.m., housekeeping informed staff that R3 was yelling for help. E7 stated she observed R3 in bed lying on her left side with both legs caught in between side rails holding on to side rails. E7 stated side rails were in the up position at that time. E7 stated she noted bruising to right leg and upper shin and bleeding a little bit. There was no bruise on left leg. E7 stated she was unsure of bruising to face. E7 stated she wasn't familiar with R3's fall history.
In an interview with E6 (nurse) on 6/25/02 at 12:05 p.m., E6 stated upon arrival to R3's room, R3 was lying in bed. E6 stated that R3's right leg looked disfigured and wobbly and had bruising and skin tear to area. E6 stated R3 had a bruise to the left side of her face and the area was reddened. E6 stated R3 is confused, bedridden and has heard from other staff that "(R3) tries to get out of bed."
Interview with E2 (DON) on 6/25/02 at 11:45 p.m. in the first conference room E2 stated that R3 had no previous history of falls in the last 3 months. She could provide no further information and was not familiar with R3's clinical record.
Review of facility transfer form of 6/22/02 documents "Observed patient sitting on side of bed. Both legs caught in side rails of bed. Appears patient was trying to get out of bed. Following injuries sustained: Approximate 1 centimeter (cm) skin tear between right thumb and right forefinger. Noted bruise on left face, right leg has a bruise. In middle of left leg there is a 1 cm cut."
Review of hospital emergency room record dated 6/22/02 p.m. revealed that R3 was admitted to the Emergency Room at 2:34 p.m. on 6/22/02 with diagnosis of Hypotension, Bilateral leg fractures, Urinary Tract Infection and Sepsis. Phone interview with Z2 (ER nurse) on 7/30/02 at 9:40 a.m. stated that upon R3's arrival in the ER, R3 was found to have obvious fractures and deformities noted to both lower legs. Z2 stated R3 was "semi-conscious and appeared obtunded." Further review of ER record revealed vitals were temp 97.4, pulse 80, blood pressure 50/27.
Review of hospital Xray report dated 6/22/02 revealed the following:
Left Knee: Oblique fracture through the proximal lateral tibia.
Right Knee: Fracture involving the proximal tibia, fracture of the distal femur , right fibular fracture.
During a phone interview with Z1 (physician) on 7/29/02 at 2:50 p.m. Z1 stated Z1 was informed by hospital staff that R3 caught legs up in bed rails. Z1 stated that R3 does have severe osteoporosis and could have sustained these fractures if R3 had twisted legs in the side rail. Z1 stated that spiral fractures or oblique fractures are usually caused by a "twisting mechanism" and transverse fractures are usually caused by a "direct force." Z1 further stated that staff pulling the legs out of the rails may have aggravated the fractures.
Phone interview with Z4 (physician) on 7/29/02 at 3:30 p.m. Z4 stated he surmised the mechanism in which R3 sustained lower legs fractures on 6/22/02 was consistent with R3's legs getting caught under the side rails and maybe attempting to stand up and fall forward with legs remaining under side rails.
The facility failed to identify that the side rails were inappropriate for R3, who could neither use them for mobility or as an enabler, and then failed to re-assess or discontinue them R3 suffered multiple fractures as a direct result of side rail use.
The facility failed to follow their side rail protocol for confused residents. This failure resulted in R3 sustaining 3 falls, the last of which caused multiple injuries requiring hospitalization. The facility failed to acknowledge that the side rails were inappropriate for R3 and were a potential source of injury for R3 for at least 3 months. R3's multiple fractures were avoidable if the restraints had been properly assessed and the side rails removed and a low bed used as per facility policy and E9.