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Based on medical record review, staff and patient interview, review of incident documentation and facility documentation, and policy review, the facility failed to meet the Condition of Participation for Provision of Services. The findings were:

Review of the medical record, incident documentation, facility documentation, and policies, and patient and staff interviews showed staff failed to provide nursing services to meet the needs of 1 of 4 sample patients (#1) with falls (C294). Staff did not provide adequate supervision/assistance for patient #1, who fell and fractured a wrist. The seriousness of the outcome resulted in the determination that the Condition of Participation for Provision of Services was not met.

Based on review of facility policies, staff and patient interviews, and review of grievances, the facility failed to follow its policies regarding grievances for 1 of 8 grievances reviewed. The findings were:

1. Review of the facility's "Grievances and Complaints Information" (undated) showed "All grievances and complaints are investigated, resolved, and documented. ..Grievances and complaint may be submitted orally and in writing..The administrator will review the finding with the person investigating the complaint to determine what corrective actions and resolutions need to be made...The patient or patient representative will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. This report will be completed by the administrator, or his or her designee, within 3-5 working days of the receipt of the grievance."

2. Interview with patient #1 on 6/27/18 at 12:50 PM revealed s/he had a fall in March 2018 while s/he was in the facility. The patient stated a CNA did not use a gait belt and did not walk with the resident while s/he was walking back from the bathroom. The resident fell and broke his/her wrist, which required surgery. The patient stated s/he filled out a form to file a complaint and gave it to the case manager. The following concerns were identified:
a. During the interview on 6/27/18 at 12:50 PM the patient stated the facility has not resolved the complaint.
b. Review of the grievance log showed no complaints related to patient #1.
c. During an interview on 6/27/18 at 1:39 PM the quality and risk manager stated the patient did have a written complaint, but they were unable to find it. She stated staff have had conversations with the patient and his/her family member, but there was no written documentation or evidence to show the complaint was resolved and the findings were communicated to the patient.
d. On 6/27/18 at 2:30 PM the administrator stated she saw the handwritten complaint, but does not know where it went. She stated she did not consider the complaint resolved and further confirmed there was no documentation that the complaint was investigated or resolved.
e. During an interview on 6/27/18 at 3:09 PM the CNO stated she read the patient's written complaint and she has had conversations with the patient. However, she stated there was no documentation related to the complaint. She stated the facility had already discussed reviewing the grievance policy and looking at ways to improve the system.

Based on medical record review, staff and patient interview, review of incident documentation and facility documentation, and policy review, the facility failed to ensure nursing services were provided to meet the needs of 1 of 4 sample patients (#1) with falls. Staff did not provide adequate supervision/assistance for patient #1, who fell and fractured a wrist. The findings were:

1. Review of a fall risk assessment dated 3/8/18 showed patient #1 was moderate risk for falls and interventions included a gait belt. Review of the physician's discharge summary dated 4/18/18 showed the patient was admitted to the hospital on 2/21/18 for a cerebrovascular accident (CVA), and was admitted to swing bed on day 7 for continued rehabilitation. Further review of the discharge summary showed "...Hospital Day 17...The patient experienced a fall about 1230 am. Pt was returning to bed from the bathroom and lost [his/her] balance falling backwards. Pt reports did not have gait belt in place. When falling back [s/he] hit the back of [his/her] head on the sink and broke [his/her] fall with [his/her] left hand...Hospital day 20...scheduled for surgical repair on left wrist today..." Review of the operative report dated 3/20/18 showed the patient had an ORIF for a radius fracture. The following concerns were identified:
a. Review of the incident report showed on 3/9/18 at 1:30 AM the patient had an observed fall which resulted in a fracture. The patient was returning from the bathroom, lost his/her balance, and fell in the presence of CNA #1. The follow-up indicated the employee would receive verbal counseling regarding the patient care and all staff would be educated on patient ambulation and assistive devices.
b. Review of the "Employee Reprimand/Disciplinary Report" for CNA #1 dated 3/15/18 showed the CNA received a verbal warning. The report read "March 9, 2018, you assisted swing bed patient to the bathroom. As patient was attempting to get into bed [his/her] leg gave out and [s/he] fell hitting [his/her] head and attempted to catch [herself/himself] with [his/her] left hand breaking [his/her] wrist. You were not walking with the patient and you did not have the gait belt on the patient creating a significant patient safety event."
c. During an interview on 6/27/18 at 12:50 PM the patient stated the CNA did not use a gait belt and stood against the wall while the patient was ambulating back from the bathroom. The patient stated s/he broke his/her wrist, which required surgery. The patient further stated that staff did not always use gait belts. S/he stated another time after his/her fall, a nurse was not going to use a gait belt, but the patient insisted on it.
d. When asked about the facility's policy on gait belts on 6/26/18 at 3:30 PM, the quality and risk manager stated the facility used Lippincott and handed the surveyor a copy of some pages from "Lippincott Nursing Procedures, Seventh Edition." According to Lippincott, "...A gait belt is a safety device...provides a secure grasping surface to aid with patient transfer and ambulation...commonly used for patients who are at risk for falling, a gait belt can help safely lower a patient to the ground if the patient begins to fall or loses balance during transfer or ambulation."
e. During an interview on 6/27/18 at 1:39 PM, the quality and risk manager stated the employee received a verbal warning and transfers and gait belts were discussed at a nursing meeting since the incident. However, she stated the facility had not conducted any audits or monitoring to ensure staff were utilizing gait belts.