Inadequate Supervision and Care Plan Violations Lead to Resident Injuries
Penalty
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.