Failure to Prevent Accident Hazards for a Resident
Penalty
Summary
The facility failed to prevent accident hazards for one of the residents, identified as Resident 2, who had a history of heart failure and chronic kidney disease. On November 1, 2024, Resident 2 was found lying face down in the bathroom by a nurse aide after a fall, which resulted in a hematoma to the face and required hospital transport. The incident occurred despite the resident's care plan, which included interventions such as 15-minute checks and assistance with transfers and ambulation to prevent falls. The care plan for Resident 2 also specified that the resident required staff participation for toilet use and assistance with a rolling walker and two-person support for transfers. However, the clinical record indicated that Resident 2 needed varying levels of assistance for toilet use, ranging from limited to total staff dependence. During an interview, the Nursing Home Administrator stated that staff should have stayed with Resident 2 in the bathroom until assistance was no longer needed, highlighting a failure to adhere to the care plan and provide adequate supervision.
Plan Of Correction
1. This event is unable to be corrected as it is a past event. 2. Audit of residents on frequent monitoring for falls to ensure supervision in bathroom is care planned. Audit of ADL and Fall Care Plans completed to ensure level of assistance with ADLs is current and reflected on Kardex. 3. Education provided to nursing staff that residents on frequent monitoring for falls to be supervised while in bathroom. Education being provided to nursing, therapy and MDS staff to ensure understanding of updating care plans when issue has been resolved. 4. Daily audit Monday - Friday of fall investigation(s) completed x4 weeks; then 3x per week for 2 weeks; then monthly x2 months to ensure ADL assistance was provided per care plan by DON or designee, results to QAPI. Date of compliance 01/14/2025.