Inadequate Supervision and Care Plan Adherence Leads to Resident Falls
Summary
The facility failed to ensure adequate supervision and adherence to care plans, resulting in accidents involving two residents. Resident #1, who required a two-person assist with a mechanical lift, was improperly transferred by a Certified Nurse Assistant (CNA) who was not trained by the facility. The CNA mistakenly attempted to transfer Resident #1 alone, leading to a fall that resulted in multiple fractures. The resident was later found unresponsive and was transferred to the hospital, where they were pronounced deceased. Resident #2, who had severe cognitive impairment, was left unattended on the toilet by another CNA. This resulted in a fall that caused a hematoma on the resident's forehead. The CNA violated the facility's policy by leaving the resident alone, although there was no documented evidence in the care plan indicating that the resident should not be left unattended in the bathroom prior to the incident. The facility's policies and procedures were not adequately communicated or enforced, leading to these incidents. The CNAs involved were either not properly trained or did not follow the care plans, resulting in harm to the residents. The facility's failure to provide adequate supervision and ensure staff adherence to care plans contributed to these deficiencies.
Plan Of Correction
Plan of Correction: Approved January 8, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DP(NAME) F689 1. Immediate Correction: 1) The facility respectfully states Resident # 1 expired on [DATE] while in the hospital. 2) On [DATE] CNA #1 was terminated from employment and the Agency was notified of the reason for termination. 3) On [DATE] the DNS provided LPN# one with education and counseling on the need to conduct a thorough Shift report for all staff and the need to adjust CNA assignment as needed. 4) On [DATE] Rehab assessed resident post fall and there were no changes. 5) On [DATE] the DNS provided education and counseling for CNA #2 on the need to provide residents at risk for falls and/or with impaired cognition constant supervision when seated on the toilet. 6) On [DATE] resident #2 was assessed by the Rehab Department for the need for any assistive device to use when using the toilet. CCP was updated to reflect current toileting needs and supervision required. Instructions were carried over to CNAAR. 7) On [DATE] the facility contracted with GNYHCFA to develop and implement a DP(NAME) and Directed Inservice. 8) On [DATE] the GNYHCFA QA Consultants convened the Facility QA Meeting to review causative factors, specific interventions, and systems to maintain compliance with ensuring that the environment is as free of accident hazards as possible and that each resident receives adequate supervision to prevent accidents. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) The DON /RNS will reassess all facility residents for fall risk. The RNS will review/revise Fall risk CCP and CNAAR for individualized safety interventions as indicated. 3) A list of all residents requiring substantial to maximum assistance with transfer to the toilet was generated by the MDS Coordinator from the medical record. 4) The DON, RNS and MDS Coordinator reviewed each resident to determine the supervision required when sitting on the toilet considering fall risk, cognition, and behaviors. The residents CCP will be updated and instructions carried over to CNAAR. Any identified issues will be addressed. III. Systemic Changes: 1) The DON and GNYHCFA Consultant reviewed and revised the Policy and Procedure for Fall Prevention. 2) The DON and GNYHCFA consultant reviewed and revised the Policy and Procedure for CNA Accountability /Assignments. 3) All Nursing Staff and Rehab staff will receive Education by GNYHCFA on ensuring that the environment is as free of accident hazards as possible and adequate supervision and assistance is provided to residents to ensure resident safety. Highlights of the Lesson Plan include: - All residents are assessed for Falls Risk on admission, readmission and quarterly and as needed. - Any resident at High risk for Falls will be placed on the Falling Star identifier program with a green star in Electronic Medical Record (EMR), on Resident door and assistive mobility device if indicated. - Any resident requiring physical assistance getting on/off toilet and/or with cognitive impairment cannot be left unattended in the bathroom. - The joint responsibility of Rehab and Nursing to determine the amount of staff assistance required for all ADL's. - The responsibility of the RNS to clearly communicate and document on the CNAAR/CCP the assistance needed for resident safety. - The responsibility of the RNS to conduct Unit Rounds to supervise direct care staff for care provided to residents. - The responsibility of the licensed unit nurse to complete assignments for CNAs and print from EMR a current list of residents requiring Mechanical lift with two persons and provide Shift Report to all CNAs. - The responsibility of each CNA to identify the transfer status of their assigned residents and the steps to take to perform task. - The steps the Nursing Assistant needs to take if he/she feels the directives for Residents care needs should be reviewed by the RNS/ IDT. - The responsibility of all Nursing Staff to be aware of each resident's need for assistance and supervision as documented in the resident's CCP/CNAAR to prevent accidents. IV. Quality Assurance: 1) The GNYHCFA Consultant in conjunction with the DON developed an audit tool to monitor the facility’s compliance with: A) Ensuring that each resident is provided with adequate supervision and assistance to ensure Resident safety while assisting residents with toileting and transferring care needs. B) Ensuring that all residents at high risk for falls will be identified and individualized interventions will be communicated to Direct Care staff. 2) Audits will be done by the RNS on five randomly selected residents, and five randomly selected staff members on each unit on random shifts weekly x 4 weeks followed by monthly x 6 months. 3) Findings from the audits that require corrective actions will immediately be rectified and brought to the Morning QA Meeting for review. 4) Findings will be reviewed during the Quarterly QA Meeting to ensure sustainability. V. Person Responsible for this FTag: Director of Nursing
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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