Failure to Prevent Resident Fall Resulting in Major Injury
Summary
The facility failed to prevent accidents for a resident, resulting in a fall with a major injury. The resident, who had a history of falls, was being transported in a wheelchair by the Activities Director when the wheelchair suddenly stopped, causing the resident to fall forward and hit her head. This incident led to a major injury, including a right forehead laceration, soft tissue hematoma, and a fracture involving the cervical spine. The resident had previously reported issues with sitting on the wheelchair cushion, noting that she was sliding forward. Despite this, no defects were observed in the cushion, and a physical therapy referral was ordered to assess and treat the issue. On the day of the fall, the Activities Director left the resident unattended in the hallway to respond to another resident, during which time the resident fell from the wheelchair. Interviews with staff revealed inconsistencies in the account of the incident, with some staff members unaware of the fall until days later. The Director of Nursing at the time did not conduct a thorough investigation, and the Administrator did not interview other staff members present during the incident. The lack of immediate and comprehensive investigation into the fall and the failure to address the resident's reported issues with the wheelchair contributed to the deficiency.
Removal Plan
- A therapy screen was done for R13 by the Physical Therapist. A Physical Therapy assessment was completed for R13. The Social Worker completed a behavioral assessment. No changes were identified for R13. A care plan conference was held with R13 and her family with the Social Worker, the RAI Registered Nurse (RN), the Licensed Practical Nurse (LPN), the Restorative Nurse, the Dietary Manager, the Charge Nurse LPN, the CNA. R13 stated she had no problems or concerns. Speech Therapy completed an assessment for R13. The Occupational Therapy department evaluated R13 for positioning and wheelchair review. A 16x18 inch cushion was placed in the wheelchair providing more even support to hips and the footrests were exchanged for more appropriate length allowing Bilateral Lower Extremity flexibility. The Registered Dietitian assessment was done for R13 weight loss, with a new order for a nutritional supplement (one carton by mouth q day was ordered. Continue weekly weight. Speech Therapy to evaluate and treat. No recommendation currently. A Medical Doctor assessed R13, with no concerns noted at that time. The Psych Physician conducted an evaluation post-fall for R3, no recommendation at this time. The plan of care was reviewed and updated by a licensed practical nurse, and by an RN for R13.
- The DON who conducted the original investigation is no longer employed; she resigned. Newly hired DON began a new root cause analysis. The root cause was completed for R13.
- An ad hoc Quality Assurance Process Improvement (QAPI) and performance improvement plan (PIP) was developed and initiated. The meeting discussion included plan development and citations. In attendance at the meeting were the Division [NAME] President, Administrator, Division Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI nurses, Wound Care Nurse, Environmental Services Director, AD, health information manager Environmental/ laundry supervisor, Admission Nurse, HR Partner Service, Scheduler, for the accident. The existing Fall Management policies and concluded no revisions were needed.
- The Division [NAME] President and Divisional Nurse provided education to the Administrator, DON, and Social Worker on the job description, roles and responsibilities, and duties to ensure the safety of all residents. Education provided on the falls management policy included that nurses should observe and interview the patient and/or witnesses to determine the possible cause of the fall and complete the Initial Event in the EMR to capture the investigation of the fall and assessment of the patient and how to use the QAPI tool The 5 Whys and that nursing is to complete therapy referral in EMR upon admission/readmission and post-fall as indicated. Nurses are to follow up with therapy to ensure a timely review of referrals. Therapy to complete an assessment post-fall as indicated to include completion of an evaluation of the wheelchair to determine if the wheelchair was appropriate for the patient. Resident transport safety to prevent falls/injuries. Nursing and social services to follow up and assess patients for psychosocial harm post-fall to determine if behavioral health services are needed. (Patient exhibiting any signs/symptoms of anxiety such as restlessness, nausea, elevated heart rate, difficulty sleeping). If the patient is noted to exhibit signs of anxiety, nursing to assess the patient and report to the provider as indicated. The Administrator, the DON, and the Social Worker received education.
- Corrective action for other residents having the potential to be affected by the same deficient practice: All residents who reside in the facility who are transported and have had a fall have the potential to be affected by the alleged deficiency.
- Systemic changes are made to ensure that the deficient practice will not recur. Oversight was provided by the Divisional Nurses (DN) to ensure the DON completed a root cause analysis of residents with falls. Oversight by DN to ensure that 8 of 8 therapy referrals were completed by the RAI coordinator was completed. Oversight by DN of Social Worker to confirm that eight or eight social visits were completed to ensure no evidence was noted of further treatment psychosocial harm post fall, including weight loss, increased anxiety, or further decline. One of eight patients identified with weight loss post-fall was reviewed by a Regional Dietitian. DVP and DN made observational rounds to supervise the Administrator, DON, and Social Director of the day-to-day operations to include adhering to the falls policy and that oversight was being provided by the administration to ensure patients were being transported safely. DN attended the clinical meeting to ensure that falls were being reviewed per the guideline to include performing a root cause analysis and 72-hour observations were completed to include observation of signs of psychosocial harm. DVP and DN confirmed that education had been completed with staff for falls and safety transportation.
- Quality Assurance plans to monitor facility performance to ensure corrections are achieved and are permanent. A quality improvement data collection Grid 3 tool was developed and initiated by the Administrator and is being utilized daily to monitor the implementation of the POC. The DON or Assistant DON will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this POC will be validated by the DVP and /or DN and submitted daily to the QAPI committee for review and further follow-up. The quality improvement data collection grid will continue until the QAPI committee deems it is no longer necessary.
- All corrective actions were completed. The facility alleges that the IJ was removed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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