Resident Neglect Due to Unattended Bathroom Incident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R5, was free from neglect during care. Resident R5, who had a history of Alzheimer's Disease, major depressive disorder, seizures, muscle weakness, hearing loss, chronic pain, history of falling, age-related physical debility, and macular degeneration, required substantial assistance for toileting. The resident's care plan indicated a need for extensive assistance from one to two staff members for toilet use and transfers. On the day of the incident, a Nurse Aide (NA) assisted Resident R5 to the restroom and left the resident unattended on the toilet during a shift change. The NA informed the incoming staff that Resident R5 was in the bathroom and needed assistance but then left the facility. The incoming staff acknowledged the information but did not immediately assist the resident. As a result, Resident R5 was found on the bathroom floor with bruising and a swollen knee, and was later diagnosed with a type 2 dens fracture. Interviews with staff confirmed that it was not the practice to leave residents unattended in the bathroom, and that staff should monitor residents for safety. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the resident was left unattended, leading to the fall and subsequent injury. The facility's policies on resident care and fall prevention were not adhered to, resulting in neglect of Resident R5's needs.
Plan Of Correction
What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? On 9/27/24, The DON (Director of Nursing) met with Employee 1, Employee 2 and the staff on 2nd floor and educated them not to leave Resident R5 on the toilet unattended. The residents care plan was reviewed and updated to reflect new toileting status. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents with a BIMS (Brief Interview for Mental Status) of less than eight (8) have the potential to be impacted. On 10/16/2024 the facility completed staff training regarding the safety risks associated with leaving residents unattended while on the toilet. A whole house resident BIMS audit was completed by the DON on 12/17/2024 to identify residents considered to have severe impairment (a BIMS score of 0-7). Any current resident, new admissions, or resident reviewed during the care planning process identified with a BIMS of 0-7 will have their care plans updated to reflect supervision while on the toilet. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The facility will identify those residents with severe impairment and the DON will place a GOLD star on the nameplate outside of the resident room and with a GOLD star above the resident bed. The facility will update the Fall Prevention and Investigation Policy to reflect the addition of the star. Whole house staff education on the change will be completed by the DON. The updated fall policy will be reviewed during our New Employee Orientation. The facility will continue to monitor its fall prevention program during weekly fall prevention meetings to ensure proper fall prevention procedures are in line with the facility fall protocol to include utilizing the stars on the door nameplate and above the headboard. The facility will continue to provide staff education on Abuse, Neglect, Exploitation and Misappropriation of Property through our online education portal while also offering an in-person Abuse education on January 14th, 2025 provided by the Pavilion's Social Service Director and on February 25th, 2025 with the Department of Human Services Area Agency on Aging. How the corrective action will be monitored to ensure that the deficient practice will not recur: i.e., what quality assurance programs will be accomplished? The prior week's resident fall event reports will be audited at the weekly fall prevention meeting to assess for resident care plan compliance and if modifications are needed. Audit results will be reported at the facility Quality Assurance Performance Improvement and Kaleida Health Quality Improvement Patient Safety monthly committees. Weekly audits will continue until 12 consecutive weeks of 90% compliance has been achieved. Modification may be made to the plan of correction to improve compliance. Changes will be reported to the facility QAPI monthly meeting.