Country Health

F 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Level of Harm - Actual harm Residents Affected - Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to implement interventions to prevent a fall for one resident (Resident R1) of three residents reviewed for falls in a sample list of three residents. This failure caused Resident R1 to fall sustaining an acute nasal Fracture and a laceration to (Resident R1's) nose requiring five sutures to close.Findings Include:Resident R1's Care Plan updated 10/14/25 includes the following diagnoses: Osteoarthritis, Heart Disease, Lumbar Disc Displacement, Anxiety, Vertigo, Repeated Falls, Glaucoma, Type II Diabetes, Difficulty in Walking, and Psychotic Disturbance with Hallucinations.Resident R1 Fall Risk assessment dated [DATE REDACTED] document Resident R1 as being at high risk for falls and having a recent history of falls. Resident R1 has current physician's orders for the following narcotics and psychotropic medications: Haldol (Antipsychotic) one mg (Milligram) every eight hours as needed, Dilaudid (Narcotic) two mg every four hours as needed, and Fentanyl (narcotic) transdermal patch 50mcg/Hr (Microgram/Hour). Change patch every 72 hours. All these medications list an increased risk for falls as a side effect in manufacturer's inserts. R1s Fall Incident Report and progress notes dated10/4/25 at 7:10AM document Resident R1 was found on the floor while alone in Resident R1's room. Resident R1's emergency room report dated 10/4/25 at 9:05AM documents Resident R1 required five sutures to repair the laceration on R1s nose resulting from the fall at the nursing home and sustained an acute nasal bone fracture. On 10/21/25 at 10:41AM, V3 Certified Nurse's Aide (CNA) verified V3 was the first staff to respond to Resident R1 on 10/4/25. V3 stated I got report on 10/4/25 from an agency CNA who told me (Resident R1) had been restless during the night, but she was now asleep in her room. A little later I heard (Resident R1) call out and went right to (Resident R1's) room. There were no fall mats on the floor. The bed was not in the low position. The nightstand was between the wall and the bed on (Resident R1's) right side. Resident R1 was under the bed from the waist down. The nightstand and the bed were covered in blood. I called and V4, Certified Nurse's Aide (CNA) came into the room with the nurse. We got (Resident R1) out from under the bed and put her on the bed. The nurse cleaned (Resident R1's) face and found the big cut on her nose. (Resident R1) was then sent out to the emergency room and came back with bruises and stitches. On 10/21/25 at 10:45AM, V4 CNA stated I came to (Resident R1's) room with (V6), Licensed Practical Nurse (LPN) when I heard (V3) calling for help. (Resident R1) is a high fall risk, but the fall mats were not in place, and the bed was not low, because (Resident R1) had her legs and hip all the way under the bed between the wall and the bed. The nightstand on the side (Resident R1) fell was covered with blood. We helped

the nurse clean up (Resident R1) and the nurse sent (Resident R1) out to the hospital to get stiches. Resident R1 was observed on 10/20/25 at 1:35PM lying in her bed. The bed was not in the lowest position. V2 Director of Nursing verified

the bed was not in the lowest position. V2 lowered the bed to its lowest position. V2 verified if the bed had been in the lowest position at the time of the 10/4/25 fall it would not have been possible for Resident R1 to have gotten her lower half under the bed as the space is too small between the bed and the floor.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

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If continuation sheet

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