Ana & David Assisted Living

Based on documentation review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery to include continued competency training in fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention" (dated in October 2021). The policy and procedure stated "Fall Prevention and Recovery Training is required upon hire and at least every twelve months thereafter." 2. A review of E1's personnel record revealed training dated August 15, 2022, in fall prevention and fall recovery. However, continued competency training since August 2022 was not available for review. 3. A review of E2's personnel record revealed training dated April 5, 2022, in fall prevention and fall recovery. However, continued competency training since April 2022 was not available for review. 4. In an interview, O1 acknowledged E1's and E2's fall prevention and fall recovery training had not been administered per the facility's fall prevention and fall recovery program to ensure continued competency.

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver documented the names of individuals who observed the accident, emergency, or injury; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future, for two of two residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services. Findings include: 1. A review of R1's medical record revealed a progress note dated May 29, 2023 at 5:30 PM. The note stated, "[R1] very restless and temperature 102. Called 911." However, documentation of the aforementioned incident was not available to include the names of individuals who observed the accident, emergency, or injury; the individuals notified by the caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. 2. A review of R1's medical record revealed a progress note dated June 11, 2023, at 12:00 PM. The note revealed R1 returned from the hospital with a urinary catheter. 3. A review of R3's medical record revealed a progress note dated September 14, 2023, at 5:00 PM. The note stated, "[R3] was moved to the hospital today. [R3's] daughter was speaking with [R3] on the phone in the morning and felt... [R3] felt drowsy and couldn't speak. [R3's] daughter decided to... [R3] to St. Joseph Hospital. Before [R3] left for the hospital we checked [R3's] vitals and everything was normal." However, documentation of the aforementioned incident was not available to include the names of the individuals who observed the accident, emergency, or injury; the action taken by the caregiver; the individuals notified by the caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future. 4. In an interview, O1 reported the physician believed R3 had a miniature stroke which caused the aforementioned symptoms. 5. In an interview, O1 acknowledged R1's and R3's medical records did not include documentation of the names of individuals who observed the accident, emergency, or injury; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future.