Inadequate Supervision and Care Plan Violations Lead to Resident Injuries
Summary
The facility failed to ensure a safe environment and adequate supervision for four residents, leading to accidents and injuries. Resident #534, with a history of falls and cognitive impairments, was left unattended in a dining room, resulting in a fall that caused fractured ribs and a scapula. Despite multiple previous falls, the resident's care plan was not adequately updated to prevent further incidents. Staff failed to notify the nursing supervisor or physician immediately after the fall, delaying necessary medical assessment and treatment. Resident #70, who required a mechanical lift and two-person assistance for transfers, was improperly transferred by a single Certified Nurse Aide using a sit-to-stand device, contrary to the care plan. This resulted in the resident striking their head and sustaining a bruise. The incident was not reported to the nursing supervisor in a timely manner, and the care plan was not followed, leading to the resident's injury. Resident #207, who required two-person assistance for transfers and had a history of combative behavior, was left in the care of a single Certified Nurse Aide. This deviation from the care plan resulted in the resident sustaining a bruise on their forehead. The facility's investigation concluded that the injury was due to a violation of the care plan, as the resident was not provided the required level of assistance during care.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 Directed Plan of Correction 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Nursing staff identified as responsible for the deficient practice were suspended and reeducated on the appropriate procedures or terminated by the Director of Nursing including: - The CNA who did not utilize the correct mechanical lift in transferring the resident was suspended and counselled on the facility policy regarding following the resident’s plan of care on (MONTH) 7, 2024. - The CNA who provided care alone when the resident required two persons due to behavioral issues was suspended and counselled on the facility policy regarding following the resident’s plan of care on (MONTH) 13, 2024. - The Agency LPN and CNA involved with moving the resident after a fall in the dining room before a nurse assessment was completed were terminated on (MONTH) 27, 2024. - The Agency CNA who used the Hoyer lift without a second CNA in attendance was terminated on (MONTH) 4, 2024. 2. 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 have the potential to be affected by the deficient practice. The Director of Nursing and the Nursing Management team have reviewed all incidents over the last 90 days and have not identified any other residents who were affected by the same deficient practice. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? Based upon the root cause analysis conducted by the QAPI committee, the following corrective actions will be put into place: - The policy/procedure for Fall Prevention and Management will be revised to address the areas identified during the QAPI meeting including timely notification of the RN prior to moving the resident and the purpose/function of purposeful rounding including the monitoring for pain and the new rounding schedule for all residents after a fall. - The policy/procedure on Mechanical lifts will be updated to address the use of a Sit to stand lift and the requirements to verify the appropriate lift to be used as indicated in the resident’s task list in the Electronic Medical Record (EMR). - New/revised policies and procedures will be developed to address all of the areas identified by the QAPI Committee including the start/end of shift huddle, safety committee guidelines, and supervision in the dining room. - In-service training will be provided for all nursing staff on the new/revised policies and procedures regarding falls management including reporting of incidents, the timely notification of the RN at the time of the incident, supervision of residents in the dining room, use of mechanical devices, purposeful rounding and rounding schedules, and shift huddles and notification of the Nursing Supervisor when a licensed nurse does not respond to the incident. - In-service will include a pre and posttest to measure staff’s understanding and competency related to all of the new/revised policies and procedures. - In-service will be provided to the Dietary staff who work in the Dining rooms on the protocol when there is a resident incident in the dining room and how to notify the Nursing Supervisor when a nurse does not respond to an incident. - In-service will be provided to all ancillary staff (Housekeeping/Maintenance/Social Service/Recreation/Rehab Therapy) on their role in responding to an incident and the procedure for notification of the RN when a resident falls. A handout will be provided which details the process for managing the incident and notifying the RN Supervisor. 4. How will the corrective action be monitored to ensure the deficient practice will not recur? Audit tools will be developed based on the new/revised policies including Dining room Supervision, use of mechanical devices, observation of staff for residents requiring two CNAs during care delivery, documentation of RN Assessment at the time of the fall, and the Frequent Falls Committee process. Audits will be conducted on each of the nursing units on two separate days on different shifts and different observation of different staff on the nursing unit. Audits will be conducted by the Nursing Management team, and the Managers/Supervisors in the individual departments as appropriate. Audits will be completed weekly for 4 weeks, then monthly for 3 months, and results will be collated and presented to the QAPI Committee at its monthly meeting. The QAPI Committee will determine a plan for additional ongoing monitoring based upon the results of the audits. A QAPI Meeting will be held prior to the Completion date to ensure that compliance is being achieved and that no additional training is required. The Director of Nursing and the RN Consultant will be responsible and will oversee the completion of this Directed Plan of Correction.
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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