Lack of Supervision Leads to Resident Fall from Transportation Bus
Summary
The facility failed to provide necessary supervision to a cognitively impaired resident, leading to an avoidable accident. The resident, who had a history of poor safety awareness and was at moderate risk for falls, was left unattended on a transportation bus after returning from an outing. Despite being instructed to remain seated, the resident unbuckled her seatbelt and attempted to exit the bus without assistance. She was wearing slip-on shoes, which came off, causing her to lose her footing and fall down the bus steps onto the asphalt. The resident sustained multiple injuries from the fall, including a right shoulder bone dislocation, skin tears, abrasions, a tongue hematoma, a cracked tooth, and a head hematoma. She also experienced dizziness and vomiting, leading to a hospital assessment that revealed a left temporal subarachnoid hemorrhage, a right clavicle fracture, a right humeral fracture, and bilateral rib fractures. The incident occurred because no staff members remained on the bus to supervise the residents, despite the resident's known cognitive impairments and fall risk. Interviews with staff members involved in the outing revealed that the Activities Director, Activities Assistant, and Transportation Driver all exited the bus, leaving the residents unattended. The staff assumed the residents would remain seated, but the resident's impulsive behavior and lack of supervision led to the accident. The facility's failure to ensure adequate supervision and appropriate footwear for the resident directly contributed to the incident.
Removal Plan
- The affected resident, Resident #79, was immediately assessed by the onsite nurse practitioner prior to her being moved. Upon the initial assessment, it was deemed the resident was safe to be transported into the facility where she was placed in bed and continued to be assessed. Emergency Medical Services (EMS) was notified to transport the resident to the hospital for additional tests and exams. Resident #79 was readmitted to the facility.
- The Director of Nursing inquired if any other resident had fallen or had any other near miss on the van. No other residents were identified.
- The Interdisciplinary Team consisting of all department managers, Administrator and Director of Nursing met to review residents with outside appointments. They met to identify residents scheduled for transport using the medical record to identify residents that were unable to make their needs known, appropriately respond to direction, had a BIMS score less than 10, and those unable to comply with standard safety precautions. Identified residents will have increased supervision on their transport to and from the facility as well as proper footwear.
- Residents must have safe and appropriate footwear on at the time of the transfer. The Administrator, Director of Nursing, Social Services Director and Activities Director, inspected 100% of the residents to ensure all residents had appropriate footwear for any potential transport, whether scheduled or not. Only one resident did not have appropriate shoes for their given shoe size. The Director of Nursing purchased him a pair of lace up shoes for outings and medical appointments.
- The Director of Nursing will ensure adequate supervision is provided by determining the need of each resident being transported. This will be conveyed to the Van Driver to ensure compliance with the level of supervision required.
- All residents will be required to have appropriate footwear which, at the minimum, must have closed toes, a closed heel and non-skid soles. Slippers and other slide on footwear will be strictly prohibited in order to be transported by the facility van or approved vendor.
- Residents with confusion and poor safety awareness will require a staff person or trained volunteer to increase basic supervision during transport. The weekly transportation schedule will be reviewed in morning meeting prior to any transport and if a resident needs increased supervision, the Director of Nursing will ensure it is available at the time.
- Increased supervision will be assigned by the Transportation Coordinator after notification by the Director of Nursing. Those individuals assigned for increase supervision, will be trained verbally by the Administrator or Director of Nursing prior to service and will include how to encourage the resident to remain seated and fastened until the van driver can safely help them off the transport vehicle.
- Volunteers will be instructed on identifying unsafe situations-such as when a resident might unbuckle a seatbelt while the van is in motion, or when a resident is at risk of falling out of their seat-and will be trained to take appropriate measures to minimize potential negative outcomes such as encouraging the resident to remain seated and refastening the buckle, and alerting the driver.
- The Social Services Director or Director of Nursing will bring the transportation schedule to the morning meeting, Monday through Friday. The Director of Nursing and Social Service Director will ensure that any resident requiring increased supervision is properly identified and that necessary measures are in place.
- The Administrator informed the Staff Development Coordinator and Human Resources Specialist of the need to add training to orientation for all new hires regarding the need for residents to wear appropriate footwear. This will be covered as part of the general orientation for all departments.
- All activity staff, facility transportation driver, and contracted vendor that provides outside non-emergency transportation when the facility transportation is not available were educated by the facility Administrator and Director of Nursing that each resident must be dressed appropriately for any outing which includes safe (closed toe, closed/strapped heel, non-slip) footwear.
- Education was provided to all staff by nurse managers, department heads, and/or special assigned nurse on the need for each resident to be dressed appropriately for any outing which includes safe (closed toe, closed/strapped heel, non-slip) footwear. This in servicing was to be completed.
- The Van Driver was educated by the Director of Nursing that they were the ultimate stop gate to ensure everyone has safe footwear on prior to transfer. If a person does not have proper foot attire, they are to immediately notify the Director of Nursing or Administrator for further direction.
- To ensure on-going compliance, the van drivers will receive annual training on proper foot attire for all residents before the transportation is provided. This annual training will be completed by the Administrator and Maintenance Director.
- A letter was initiated by the facility Administrator to families notifying them of the facility's new requirement on safe (closed toe, closed/strapped heel, non-slip) footwear for residents to be transported.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
A cognitively impaired resident with dementia and prior stroke was seated in a crowded dining room with about 50 residents and two activity aides when another resident reported that a male resident with schizoaffective disorder and frontotemporal neurocognitive disorder was inappropriately touching her. An activity worker removed the male resident to the nurses’ station after being told he was feeling the female resident’s thighs and breast and putting his hands in her pants, but the male resident was later observed back in the dining room near the same resident with his hand on her inner thigh and was also reported to have kissed her. Although nursing staff documented that the male resident had been placed at the nurses’ station for supervision, he was able to return to the dining room and have further contact with the cognitively impaired resident, and the facility’s investigation lacked resident witness statements and a statement from the second activity worker who was present.
A resident with Alzheimer’s disease, muscle weakness, and moderately impaired cognition, assessed as high risk for falls and dependent for transfers and toileting, experienced multiple falls in the dining room when staff did not consistently follow the fall-prevention care plan. The plan required non-slip footwear, not leaving the resident unattended in the dining room after meals, keeping the resident in a wheelchair rather than a dining chair, using an antithrust cushion with Dycem, and removing the Hoyer sling from the wheelchair after transfers. Fall investigations documented that the resident was found on the dining room floor on several occasions, including after not being offered toileting post-meal and when the lift sling had not been removed. Observations showed the resident being transported with the sling still under her and sling straps looped on wheelchair handles, while staff acknowledged the resident’s impulsivity and history of falls, demonstrating inadequate supervision and failure to implement care-planned interventions.
A resident with CVA, hemiplegia, hemiparesis, and expressive aphasia, care-planned for slide board and two-person assistance for wheelchair-to-bed transfers, was instead lifted by the back of her pants by a CNA without using the slide board or a second staff member. The resident’s pants were ripped, she became upset and cried, and she later reported feeling unsafe during the transfer due to inability to use her right arm and leg. A cognitively intact roommate witnessed the event, confirmed that the CNA hoisted the resident by her pants without assistance, and stated the CNA declined an offered gait belt. Nursing documentation and staff interviews corroborated that the prescribed transfer method and required assistance were not followed, and the resident told the NP that the CNA had been rough, though no physical injury was found.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Failure to Adequately Supervise Resident After Reported Inappropriate Touching
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent resident-to-resident inappropriate touching involving a cognitively impaired resident. The facility’s abuse policy states that when an incident or suspected incident of abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation and ensure any further potential abuse, neglect, exploitation, or mistreatment is prevented. Resident R1 had diagnoses including dysphagia, aphasia, dementia, and cerebral infarction, and was documented as cognitively impaired on a recent MDS assessment. Resident R2 had multiple medical and psychiatric diagnoses, including diabetes, seizures, chronic kidney disease, schizoaffective disorder, and frontotemporal neurocognitive disorder, and was documented as awake, alert, and oriented on a recent MDS. On the date of the incident, documentation submitted to the State Survey Agency indicated that another resident (R3) reported that R1 was inappropriately touched in the dining room by R2. An activity staff member (Employee E4) stated that R3 told him he witnessed R2 touching R1 inappropriately and asked him to remove R2 from the dining room. The activity worker reported that there were two activity aides and approximately 50 residents in the first-floor dining room at the time. He stated that R2 was feeling R1’s thighs and breast and putting his hands in her pants, after which he took R2 to the nursing station and reported the situation to a nurse. The activity worker later observed that R2 had returned to the dining room and was again near R1, with his hand on her inner thigh close to her genital area, and he again removed R2 to the nursing station. A licensed nurse (Employee E5) documented that R2 had been observed by another resident earlier and was placed at the nursing station for supervision, but that R2 went back into the same dining room and was seen kissing the same female resident, R1. The nurse reported that she notified the Nursing Home Administrator and Unit Manager after the first incident and again after the second incident. A nursing supervisor (Employee E6) documented being notified that R2 was seen inappropriately touching R1’s breast area and that by the time she left her office, the residents had been separated. A body assessment of R1 found no bruises or injuries. The facility’s investigation ultimately unsubstantiated the allegation of resident-to-resident abuse, but the investigation file lacked dated, signed statements from residents present in the dining room, from R3 who initially reported the inappropriate touching, and from the second activity worker (Employee E7) who was present. During interviews with the DON, NHA, and Regional NHA, it was acknowledged that when the first allegation of inappropriate touching was reported by R3 and R2 was removed from the dining room, R2 was able to return and was again observed touching the cognitively impaired resident, which was attributed to inappropriate supervision by the facility.
Plan Of Correction
Plan of Correction:The facility reviewed the incident involving Resident R2 and Resident R1 related to supervision and inappropriate behavior. Resident R2 was immediately removed from the area. Following the incident, Resident R2 was placed on 1:1 supervision and sent to the hospital for evaluation and remained on 1:1 supervision post return from the hospital until cleared by psychiatry. Resident R1 was assessed with no adverse outcome noted. The provider was notified and the incident was reported to the Department of Health.All residents have the potential to be affected by this deficient practice.Education will be provided to staff on supervision requirements, including immediate intervention and ensuring residents who require supervision are appropriately monitored. The Administrator or designee will conduct weekly audits to ensure residents requiring supervision are appropriately monitored. Audits will be conducted weekly x4 weeks, then monthly x2 months. Findings will be presented to the QAPI committee.
Failure to Follow Fall-Prevention Care Plan and Supervise High-Risk Resident in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with a known high risk for falls, particularly in the dining room. The resident had diagnoses including Alzheimer’s disease, anxiety, atrial fibrillation, and muscle weakness, with a BIMS score of 8 indicating moderately impaired cognition. Assessments documented that the resident required partial staff assistance for eating and mobility, was dependent for transfers and toileting, did not ambulate, and had been identified as high risk for falls on multiple fall assessments. The care plan contained specific fall-prevention interventions, including ensuring non-slip footwear, use of a floor mat by the bed, not leaving the resident unattended in the dining room after meals, keeping the resident in the wheelchair rather than transferring to a dining chair for meals, use of an antithrust cushion with Dycem in the wheelchair, and removal of the Hoyer sling from the wheelchair after transfers. Despite these identified risks and documented interventions, the resident experienced multiple falls in the dining room. A fall on 12/21 was documented after the resident had been one-on-one all afternoon due to attempts to stand and walk and expressing a desire to go home; staff later found the resident on the dining room floor. A subsequent fall on 03/11 occurred when another resident called for help and staff found the resident seated on the floor in front of the wheelchair; the investigation identified that the sling from the mechanical lift had not been removed after transfer, and this was determined to be the root cause of that fall. Another fall on 03/28 occurred when the resident was found lying face down on the floor with the wheelchair at her feet, and documentation noted that the resident needed to go to the bathroom after a meal and had not been offered toileting. Observations and staff interviews further showed that the facility did not consistently follow the resident’s care plan interventions. On 04/06, the resident was observed being pushed to the dining room in a wheelchair with the sling still under her, contrary to the care plan directive to remove the sling after transfer. On 04/07, a CNA was observed leaving the sling partially under the resident in the wheelchair and looping the sling straps around the wheelchair handles after using the Hoyer lift. Staff, including a CNA and a licensed nurse, acknowledged that the resident was impulsive, had multiple falls, and required close observation. An administrative nurse stated that the resident should not have been left alone in the dining room because of her impulsivity and history of falls and that staff were expected to follow the care plan. The facility’s fall policy required review of the care plan and evaluation of the circumstances of falls to determine causes and implement appropriate interventions to prevent further falls, but the repeated falls and observed practices demonstrated that key care plan interventions were not consistently implemented.
Failure to Follow Care-Planned Transfer Method and Use Required Assistance
Penalty
Summary
The deficiency involves the facility’s failure to transfer a resident according to the care plan, specifically by not using a slide board and required assistance during a wheelchair-to-bed transfer. The resident had been admitted with a recent CVA, right-sided hemiplegia, hemiparesis, and expressive aphasia, and her care plan identified her as at risk for falls with an ADL functional deficit related to limited transfer ability. The care plan interventions required use of a slide board for transfers from wheelchair to bed, and the MDS documented that she had moderately impaired cognition and required substantial assistance for transfers. On the night in question, a nurse aide transferred the resident from her wheelchair to her bed without following the prescribed method. According to the resident and her cognitively intact roommate, the aide lifted or hoisted the resident by the back of her pants instead of using the slide board and a second person, resulting in the resident’s pants being ripped. The resident reported that the aide did not transfer her correctly, that she needed a slide board and two-person assistance, and that she felt upset, cried, and did not feel safe during the transfer because she could not use her right arm or right leg. The roommate stated she witnessed the transfer, saw the aide hoist the resident by her pants without assistance, and noted that the aide declined an offer to use the roommate’s gait belt. Staff accounts and documentation further described the events leading to the deficiency. A nurse progress note recorded that the roommate approached the nurse supervisor at the start of shift with concerns about the resident’s mood and the way the aide had transferred her, and the resident confirmed that the aide had pulled her up by her pants, ripping them. The nurse supervisor’s written statement indicated that when she arrived on the unit, the roommate reported concerns that the aide had needed assistance and should have used a gait belt, and that the aide responded argumentatively, stating she did the best she could because they were short staffed. The supervisor later found both residents upset and was told that the aide had returned to the room and told the roommate to come to her directly if she had a problem. The nurse practitioner’s note documented that the resident stated the aide was rough with her, although no physical injuries were found on exam. The assistant director of nursing and another aide reported that the aide did not request assistance with the transfer during the shift.
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