The Avenues Transitional Care Center

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

skills check description and rationale. Review of Resident 1's Order summary report dated [DATE REDACTED], Order summary report indicated, may use of low air loss mattress to prevent skin breakdown. Review of Resident 1's Nurses Progress note dated [DATE REDACTED] at 10:49PM, the nurse progress note indicated, Heard License Nurse (LN) overhead page calling writer to go to the 3rd floor, upon arriving saw resident on the floor face down on his right side CNA 1, behind resident supporting his torso and head. Repositioned resident on his back. Upon assessment, bump on right forehead 4cm x 4cm reddish discoloration, linear cut on right eyelid 4cm, skin tear on right cheek 1 cm, abrasion on right elbow 1 centimeter (cm, small unit used to measure length) , abrasion right thigh 1 cm, and skin tear on right thigh 1 cm. Transferred resident back to bed, first aid provided. Emergency services 911 contacted for urgent transfer. MD (Medical doctor) informed. Review of Resident 1's Minimum Data Set (MDS, a standardized, comprehensive assessment tool) Section C (Cognitive Patterns, how your brain thinks, learns, remembers, and understands things.) dated [DATE REDACTED], the MDS indicated, BIMS (Brief Interview for Mental Status which evaluates cognition, the ability to remember and think clearly) score of 4, which indicated had severe cognitive impairment (significant challenges with memory, orientation, and recall). Review of Resident 1's MDS section GG (Functional Abilities) at 0115 (Functional Limitation in Range of Motion) dated [DATE REDACTED], MDS indicated Resident 1 showed both upper and lower extremities had impairment on both sides. The MDS also indicated Resident 1 was dependent on two or more staff is required for the resident for toileting hygiene and roll left and right; the ability to roll from lying on back to left and right side and return to lying on back on bed. Review of Resident 1's Care Plan Report, initiated on [DATE REDACTED], care plan report indicated, Resident 1 is At risk for falls and injury related to: Cognitive Impairment, Spinal cord injury C5-C7.( Bones in your neck support your head, protect your spinal cord, and control movement and feeling in your upper body) The goal is for Resident 1's risk factors to be managed to minimize falls and injury. The intervention includes keeping Resident 1's bed in a low position.

Review of Resident 1's records titled Fall Risk Evaluation, dated [DATE REDACTED], The fall risk evaluation indicated, Gait was impaired, . at high risk of fall with a score of 51, where Fall scoring: High risk 45 - and higher.

Review of Resident 1's History and Physical (H&P) from the General Acute Care Hospital (GACH) Intensive Care Unit (ICU), dated [DATE REDACTED] at 5:13 AM, the H&P indicated, Resident 1 living at a nursing home fell off his bed and hit his head, found to have a right subdural hematoma (a buildup of blood on the right surface of the brain) and extensive subarachnoid hemorrhage (a medical emergency where a significant amount of bleeding occurs in the space surrounding the brain). Review of Resident 1's Death Summary (DS) from the GACH, dated [DATE REDACTED] at 12:39 PM, The Death summary indicated Resident 1 died on [DATE REDACTED] at 10:57 AM.

The DS also indicated, Resident 1's preliminary cause of death was Traumatic brain injury (TBI). Review of

the facility's 5 Day Summary of Investigation, dated [DATE REDACTED], indicated On [DATE REDACTED] at about 9:40 PM, Resident 1 experienced a fall incident, when Resident 1 rolled from their (sic) bed onto the floor. Resident 1 sustained injuries and was transferred to the hospital via 911. On [DATE REDACTED] facility received the hospital report that Resident1 expired on [DATE REDACTED] with a diagnosis of Traumatic Brain Injury.Based on medical record review and staff interviews, the facility determined Resident's positioning in the bed and use of a low-air-loss mattress were contributing factors. Review of the facility's (Policy & Procedure) P&P titled Falls Management Program, revised on 1/2019, The P&P indicated To provide residents with hazard free environment, adequate supervision and reduce risk factors leading to falls and injury. It is the policy of this facility to provide residents with a safe environment which is free from accident hazards as possible. The facility will provide residents with adequate supervision and assistive device to prevent accidents.

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