Brodie Ranch Nursing And Rehabilitation Center

Summary of IJ and corrective action results will be reviewed by QAPI Committee monthly x 3 months beginning [DATE] or until substantial compliance established to ensure ongoing compliance.

jeopardy to resident health or The Surveyor monitored the POR on [DATE] as followed: safety During interviews conducted on [DATE] between 1:38 PM - 3:40 PM, two RNs and five LVNs from both shifts

recent shifts.

They all stated if a resident was found on the floor, they would treat it as an unwitnessed fall which included a head-to-toe assessment, ROM, and neuro checks would be initiated.

All stated they would complete an incident report and would document thoroughly in the resident's chart.

They stated they would report the fall to the DON, family, and NP immediately after assessing the resident.

They all stated they would not get a resident off the ground until they were assessed because they needed to make sure they were not injured before moving them.

They stated if they were combative/resisting, they would stay with the resident because anything could happen quickly especially if they possibly hit their head.

They stated they would call another nurse for assistance and if they still could not get the resident to comply, they would contact the NP.

They all stated documentation was imperative because if you did not document, it did not happen, and it was important for the following nurses to know the details of the incident.

Review of the facility's Ad Hoc QAPI agenda, dated [DATE], reflected the MD, ADM, DON, CRN, two ADMs from sister facilities, two DONs from sister facilities, and two Regional Nurses were in attendance.

Review of an Audit of Incident Reports, from [DATE] - [DATE] and conducted by the CRN, reflected all incident reports were reviewed to ensure residents had been assessed appropriately after their falls and the appropriate parties had been notified.

Review of an in-service entitled Falls and Documentation, dated [DATE] and conducted by the CRN, reflected the ADM and DON were in-serviced on the following:

If a fall occurs or patient observed on floor, Nurse should complete a full head to toe skin assessment, including ROM to ensure no injuries immediately, if fall is unwitnessed neuro checks should be started, if neuro checks are already being conducted from prior incident, then new neuro checks should be initiated.

Neuro checks should also be initiated for witnessed falls if patient has injury to head. An incident report should be completed, a pain assessment and fall risk assessment, if skin injury occurs then a skin assessment should be completed as well. If patient refuses assessment, document and call MD/NP/RP immediately.

Review of an in-service entitled Falls and Documentation, dated [DATE] - [DATE] and conducted by the CRN, reflected nurses from all shifts (Including RN H) were in-serviced on the following:

If a fall occurs or patient observed on floor, Nurse should complete a full head to toe skin assessment, including ROM to ensure no injuries immediately, if fall is unwitnessed neuro checks should be started, if neuro checks are already being conducted from prior incident, then new neuro checks should be initiated.

Neuro checks should also be initiated for witnessed falls if patient has injury to head. An incident report should be completed, a pain assessment and fall risk assessment, if skin injury occurs then a skin assessment should be completed as well. If patient refuses assessment, document and call MD/NP/RP immediately.

676267

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 676267 B.

Wing 08/08/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748