Failure to Address Flooring Hazards Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for its residents, particularly in the memory care unit, where a clean-out drain in a high-traffic area was not properly repaired. This oversight led to an unsafe walkway, resulting in a resident tripping and suffering a significant injury. The resident, who had a history of difficulty walking and other medical conditions, was ambulating in the hallway when she tripped over the uneven flooring and tape that was not adequately securing the area. This incident caused a significant change in the resident's ability to walk independently and perform activities of daily living, necessitating surgical intervention. The facility's maintenance records revealed that a work order was created to address the missing clean-out cover, but the issue was not resolved promptly. Instead, temporary measures such as placing a metal sheet and tape over the area were used, which proved inadequate. The Director of Maintenance acknowledged the delay in obtaining the necessary materials to fix the problem and admitted to attempting to handle the repair in-house before calling in professional plumbers. This delay in addressing the hazard contributed to the resident's fall and subsequent injury. Interviews with staff members indicated that the area was known to be a hazard, yet it remained unrepaired for an extended period. The staff, including the Director of Nursing and Certified Nursing Assistants, were aware of the incident and the resident's condition post-fall. The facility's failure to promptly and effectively address the flooring issues and provide adequate supervision and assistance devices placed the resident and others at risk for serious injury.
Plan Of Correction
Immediate action(s) taken for the resident(s) found to have been affected include: Flooring was repaired to prevent further accidents. Resident # 6 is no longer resides in the facility. 2. Identification of other residents having the potential to be affected: NHA and Director of Maintenance performed rounds of the facility to identify any hazardous areas. Identified hazards removed and/or repaired. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: DCS/Designee provided education on Accidents and Supervision policy, redirecting residents with from environmental hazards, and recognizing and reporting potential environmental hazards. An additional staff member has been assigned to memory care unit as Hall Monitor to increase supervision. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will complete facility assessment rounds to make certain facility is free of hazards once weekly x 8 weeks; then every w weekly x 4 weeks and will continue weekly rounds ongoing. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Removal Plan
- Immediate Action: Environmental rounds completed, identified areas of concern noted.
- Summoned Corporate Plant Operations support team for assistance.
- Quality review completed for all current residents sustaining a fall to ensure plan of care is in place, no discrepancies noted.
- Medical Record Review of all residents with falls with major injury conducted: no discrepancies noted.
- 99.5% of all facility staff were educated.
- Initiated and assigned direct care staff member as 'Hallway Safety Monitor' on secure unit for additional supervision.
- Identification of others at risk was accomplished by reassessing all residents residing in the facility for fall risk via Fall Risk Evaluation.
- Facility implemented Activities Invitation Rounds for residents identified at risk for falls.
- The Care Plan Coordinator(s) completed review of care plans to ensure all residents identified as 'at risk' for falls had safety measures, as well as resident specific interventions in place.
- Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards.
- Identified environmental concerns addressed by priority level, initiated repairs and ongoing.
- Record review of Resident #6 completed.
- Actions to Prevent Occurrence/Recurrence: NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion.
- Regional DCS educated the DCS on the facility's Fall Prevention Program, all facility related policies, how to conduct an RCA, and how to ensure incident investigations are timely and complete.
- DCS/designee re-educated staff on facility Fall Prevention Program guidelines, following care plan/Kardex interventions, as well as all facility related policies.
- DCS/Designee re-educated staff on Abuse, Neglect, and Exploitation Policy.
- DCS/Designee re-educated staff on Residents' Rights.
- DCS/Designee re-educated staff on Accidents and Supervision Policy.
- DCS/Designee re-educated staff on Recognizing & Reporting Hazards.
- DCS/Designee re-educated staff on Redirecting Residents with Dementia from Environmental Hazards.
- DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm.
- The Director of Clinical Services/designee to conduct quality monitoring of new admission fall risk evaluation completion to ensure that risk factors, safety measures, and resident specific interventions are reflected on the care plan and Kardex.
- A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures.
- NHA/Plant Ops/Designee will round to ensure facility is free of hazards.
- DON/designee will review all falls at the clinical meeting with the IDT (interdisciplinary) to ensure appropriate interventions are implemented, the resident's care plan has been reviewed and revised, and the Kardex has been updated.
- Regional DCS will review to ensure a RCA (root cause analysis) has been conducted and that resident specific interventions are reflected in the care plan as well as updated on the Kardex.
- Verification of the facility's removal plan was conducted by the survey team.