**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observations, resident and staff interview, review of hospital report, review of employee education and in service records, review of the facility fall investigation, review of policy, review of facility audits, the facility failed to ensure Resident #84 was safely assisted during a wheelchair transport resulting in an avoidable fall. This resulted in Actual Harm when Administrator #15 failed to apply foot pedals to the wheelchair prior to transporting Resident #84, who placed his feet on the ground resulting in Resident #84 falling from the wheelchair and suffering bilateral First Cervical (C1) lamina fracture with minimal displacement. This affected one (Resident #84) of three residents reviewed for accidents. There were 35 current residents documented by the facility requiring foot pedals for transport. The facility census was 56. Findings include: Review of medical record for Resident #84 revealed admission date of 09/30/22. Medical diagnoses included but were not limited to heart failure, dementia, anxiety, and hypotension. The resident remains in the facility. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognition and was totally dependent upon staff for locomotion off the unit which included from the dining area. Review of the significant change MDS assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of nine indicating impaired cognition. He required extensive two-person assistance for bed mobility, toileting, supervision for eating and total dependence for transfers. Review of the nursing progress note dated 06/07/23 at 3:37 P.M., revealed Resident #84 was observed face down in the service hallway, he was placed on his back and assessment revealed pupils were non-reactive and he was sent to the hospital for evaluation. Review of the care plan related to risk for falls initiated 10/18/22 related to immobility, cognitive impairment, incontinence medications and fracture revealed individualized interventions with measurable goals. Interventions included: for staff to assist resident with transfers as needed with full mechanical lift; ensure floor is free of foreign objects; keep call light and frequently used items within reach; bed in lowest position at all times when not receiving care; use call light for assistance; provide fall mats on the floor beside the bed; (initiated 06/23/23) utilize foot pedals at all times as resident will tolerate and allow to support feet; and Dycem® (nonslip material) to seat to reduce risk of sliding out of chair, initiated 06/08/23. Review of the hospital documentation dated 06/07/23 revealed the Resident #84 presented to the hospital following a fall out of his wheelchair. A Computed Tomography (CT) scan was performed which revealed Odontoid (toothlike projection from the second cervical vertebra on which the first vertebra pivots) fracture and bilateral First Cervical (C1) lamina fracture with minimal displacement. Review of the 06/07/23 fall investigation completed by the facility for Resident #84 revealed Resident #84 had been assisted by a team member from the dining room, in a wheelchair without foot pedals. Resident #84 planted his feet down and slid forward out of the wheelchair and onto the carpet. This resulted in a C1 fracture, the root cause was documented as being pushed without foot pedals. Review the Interdisciplinary Team (IDT) notes dated 06/08/23 at 10:37 A.M., revealed on 06/07/23, Resident #84 was being assisted by Administrator #15, from the dining room when Resident #84 planted his feet, stopping his wheelchair, sliding forward, and landed face down on the carpet. The fall was witnessed and Resident #84 was immediately assessed and after denying pain and answering questions appropriately, he was assisted onto his back. Resident #84 was not documented as complaining of pain, was observed talking and joking with staff prior to Emergency Medical Services (EMS) arrival. A large rug abrasion was noted to his forehead. Interventions upon return were to always have foot pedals as Resident #84 tolerated and a Dycem® will be applied to the seat of the wheelchair to reduce sliding. Review of all staff education dated 06/08/23, provided by the Director of Nursing, regarding wheelchair safety and propelling included educating staff residents were not to be transported without foot pedals at any time unless they have been care planned as such due to their refusal and safety education had been provided to them first. Review of the 06/11/23 progress note revealed Resident #84 returned to the facility around 9:00 P.M., with a C1 fracture and a neck collar to be always worn. Bruising to left elbow, skin tear to left ankle due to fall and abrasion to forehead were documented. Interview on 07/06/23 at 11:12 A.M., with Registered Nurse (RN) #10 revealed she was working on 06/07/23 when Resident #84 fell from his wheelchair. She stated he was being pushed by Administrator #15 in his wheelchair, without his foot pedals. Resident #84 fell, after he planted his feet during transport, which caused him to fall forward onto the carpet. Interview on 07/06/23 at 11:24 A.M., with Administrator #15 revealed on 06/07/23 Resident #84 went to lunch late and she attempted to assist him back to his room. She acknowledged he usually had foot pedals on his wheelchair, however, on that day he did not. She admitted it was completely my fault, she did not ensure the foot pedals were in place prior to transport. Resident #84 dropped his feet as she was assisting him down the hall, which caused him to fall from the wheelchair. Administrator #15 stated after the incident, therapy did a facility audit to identify the residents who required foot pedals, education was provided to the staff in general and she received one on one education from the Director of Nursing, Dycem® was also placed on Resident #84's wheelchair and his care plan was updated. Interview and observation on 07/06/23 at 12:29 P.M., revealed Resident #84 was observed in his room with cervical collar in place, sitting in his wheelchair with foot pedals present. Resident #84 was unable to recall the exact events of his fall. Interview on 07/06/23 at 1:37 P.M., with Physical Therapist (PT) #16 revealed residents who could not self-propel in a wheelchair were identified by the therapy staff and the name list was provided to the facility to ensure pedals were in place. PT #16 stated Resident #84 had leg strength to self-propel for a short time up to around 30 feet upon discharge from therapy in April, but he required assistance from staff to and from the dining room to his room (111 feet) and for any outings, and appointments. Review of the policy titled, Fall Management Program Guidelines revised 03/16/22 revealed the facility strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. As a result of the incident, the facility took the following action to correct the deficient practice by 06/09/23. • On 06/08/23, one-on-one education for general safety measures when assisting residents while in wheelchairs and the use of adaptive equipment such as foot pedals and to review profiles and care plans for prevention of falls or injury provided for Administrator #15 by the Director of Nursing. • On 06/08/23, all staff in-service was provided on the use of adaptive equipment and wheelchair safety, by the administrative staff or designee. All staff signed as receiving the training via electronic signature or in person signature. • On 06/08/23, the Therapy department assessed all residents and identified 35 residents as requiring foot pedals for wheelchair transportation. • On 06/08/23, care plans for the identified residents utilizing foot pedals/rest were updated by the MDS nurse. • On 06/08/23, the Quality Assurance team met and discussed corrective action plan of in-service and audits for safely transporting resident with wheelchair pedals on. • On 06/09/23, audits of wheelchairs utilizing foot pedal/rest during transports were completed by the Administrator or designee and will continue for six weeks. • Review of wheelchair audits revealed audits were completed on 06/09/23, 06/12/23, 06/15/23, 06/22/23, 06/28/23 and 07/05/23 revealed foot pedals were present on the wheelchairs of each of five random residents reviewed on those dates. • Interview on 07/10/23 from 2:57 P.M. to 3:07 P.M., with Registered Nurse #10 and State Tested Nurse Aides (STNA) #18, #19 revealed each acknowledged they had received education on wheelchair safety and the use of foot pedals for residents who were not able to propel the wheelchair on their own. All staff was able to verbalize the procedure. This deficiency represents the non compliance investigated under Complaint Number OH00143687.

Based on record review, interview and policy review, the facility failed to ensure a resident's pain was properly managed when the resident ran out of narcotic pain medication and no alternative pain relief was offered. This resulted in actual harm to Resident #171 who had uncontrolled pain. This affected one (Resident #171) of one resident reviewed for pain management. The facility identified 24 residents on a pain management program. The census was 71. Findings include: Record review for Resident #171 revealed an admission date of 10/06/19. Medical diagnoses included a Baker's cyst behind the left knee and pain from the cyst. Review of physician orders dated 10/09/19 revealed Tylenol 325 milligrams (mg), four times a day as needed for pain. On 10/11/19, Tramadol 50 mg three times a day was ordered for pain. Review of the admission Minimum Data Set (MDS) assessment, dated 10/15/19, revealed Resident #171 was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, and toilet use. Under Section J, Pain Management, the assessment interview was dashed out and the staff assessment for pain was not completed. Review of care plan revealed the resident was at risk for pain due to pain in the left knee related to a Baker's cyst. Interventions were to notify the physician of increased pain, and observe for and record verbal and nonverbal signs and symptoms of pain. Review of the Medication Administration Record (MAR) for October 2019 revealed Tramadol was not given on 10/19/19 at 8:48 P.M. because the medication wasn't available and the facility was waiting on a written prescription. The Tramadol was not given on 10/20/19 at 4:50 A.M. because the drug was still unavailable. According the MAR the last time Resident #171 received the Tramadol was on 10/19/19 between 11:00 A.M. and 2:00 P.M. No other pain medication was documented as given the evening of 10/19/19 or the early morning of 10/20/19. Tylenol was given on 10/20/19 at 10:17 A.M. and was documented as somewhat effective. Interview on 10/21/19 at 10:59 A.M. with Resident #171 revealed she was in excruciating pain on the night of 10/19/19 into the morning of 10/20/19. She rated her pain a 10 out of 10 on the pain scale and stated it made her feel so bad, terrible and the pain brought her to crying. She stated the night was rough. She stated the prescription was sent in on 10/20/19 at 6:30 A.M. and she didn't receive her Tramadol until about 12:30 P.M. She stated she received Tylenol on 10/20/19 at around 10:15 A.M. but it didn't help with the pain. Interview with Registered Nurse (RN) #55 on 10/24/19 at 7:31 A.M. revealed she took care of Resident #171 on 10/19/19 from 7:00 P.M. to 10/20/19 at 7:30 A.M. She stated she could not give the scheduled Tramadol doses on 10/19/19 at 8:45 P.M. and the dose for the morning of 10/20/19 because there was not a written prescription for the medication. She stated she had to have a new prescription for the drug to be able to get it out of the emergency medication box (E-box). RN #55 stated there was Tramadol in the E-box on this night, but since she didn't have a prescription, she could not access the E-box. She stated she called the physician on 10/19/19 at around 9:00 P.M. and he said he would call in the medication. She said she called the pharmacy but didn't know the time and they said they didn't receive anything from the physician so she said she called the physician again on 10/20/19 at 6:00 A.M. The physician said he would send it again. She stated the resident was crying in pain after midnight, but she didn't give her any Tylenol for her pain and couldn't remember what the resident's pain rating was either. She stated the Tramadol ran out on the day shift on 10/19/19 and she didn't know why it wasn't taken care of at that time. Interview with Pharmacy Technician (PT) #103 on 10/24/19 at 9:15 A.M. revealed it was the policy of the pharmacy that there has to be a written prescription for narcotics to be able to pull out of the emergency box in the facility. She stated if there a prescription on file for the resident then the staff could call the pharmacy for a code and pull from the E-box. She said if there wasn't a prescription on file then the facility staff person would have to get the physician to fax a prescription for the medication if it was a controlled substance, such as Tramadol, to the pharmacy. She stated there wasn't any documentation of prescription faxed to the pharmacy from the physician for Resident #17110/20/19 at 6:30 A.M. on 10/20/19. She further said there wasn't any communication from the facility until that time either. Interview with Pharmacist #102 for the facility on 10/24/19 at 9:27 A.M. revealed the first pull from the E-box for the Tramadol was on 10/20/19 at 12:00 P.M. and another one was at 6:00 P.M. Interview with Licensed Practical Nurse (LPN) #27 on 10/24/19 at 10:19 A.M. revealed she worked on 10/19/19 and 10/20/19 from 7:00 A.M. to 7:30 P.M. She didn't know the Tramadol had run out for Resident #171. She stated she called the pharmacy on 10/20/19 before her medication pass and they said they didn't get the prescription yet. She called the physician on 10/20/19 shortly thereafter, but the physician said he had faxed the prescription to the pharmacy and sent her the confirmation of it. She stated Resident #171 was in pain and was very uncomfortable. Review of progress notes from 10/19/19 through 10/20/19 contained no documentation the facility had called the physician for the prescription. Review of the facility policy titled Controlled Substance Prescriptions, dated 01/01/17, revealed before a controlled substance can be dispensed, the pharmacy must have a clear, complete, and signed written prescription from a person lawfully authorized to prescribe.