Resident Left Unattended in Bathroom Resulting in Fall and Neck Fracture
Penalty
Summary
The facility failed to provide adequate supervision for a resident during toileting, resulting in a fall and a fracture of the neck. The resident, 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. Despite these needs, the resident was left unattended in the restroom by a nurse aide during a shift change. The incident occurred when the nurse aide assisted the resident onto the toilet and then left the resident unattended, informing the incoming staff that the resident was in the bathroom and needed assistance. The incoming staff acknowledged this information, but the resident was later found on the floor by another nurse aide, having sustained bruising and a significant neck injury. The resident was subsequently sent to the emergency room for evaluation and treatment. Interviews with staff confirmed that the resident was left unattended, which was against the facility's practice of ensuring residents are monitored in the restroom for safety. The facility's policy on fall prevention was not adhered to, leading to the resident's fall and injury. The deficiency was confirmed through staff interviews and a review of the resident's care plan and clinical records.
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.