Inadequate Supervision and Care Plan Adherence Leads to Resident Falls
Penalty
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