Inadequate Supervision and Assistive Devices Lead to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices were provided to prevent accidents for a resident who required two caregivers for care. Specifically, the resident, who was diagnosed with dementia, epilepsy, and major depressive disorder, was assisted by only one caregiver, and a bed bolster was not in place, resulting in the resident rolling out of bed. The resident was severely cognitively impaired and required total dependence with a two-person physical assist for bed mobility, as documented in their comprehensive care plan. An accident/incident report documented that the resident had a witnessed fall out of bed while personal care was being completed by a Certified Nurse Aide (CNA) alone, contrary to the care plan's requirement for a two-person assist. The CNA provided a written statement confirming they had provided care without additional assistance. The Director of Nursing confirmed that the CNA had received education on following the care plan to prevent accidents and injuries. The incident did not result in any injuries to the resident.
Plan Of Correction
Plan of Correction: Approved February 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #14 had a recorded witnessed fall on 12/22/24 from bed landing on floor mat beside bed. Certified Nurse Assistant #3 witnessed fall on 12/22/2024. Certified Nurse Assistant reported fall to Registered Nurse on 12/22/2024. Registered Nurse performed skin check and vital signs within normal limits on 12/22/2024. Provider, Manager on call and Administrator notified per state and federal guidelines on 12/22/2024. Resident #14 sent to emergency room on [DATE] and returned on 12/22/2024 with no findings. Certified Nurse Assistant was immediately removed from facility on 12/22/2024 pending investigation. Certified Nurse Assistant was provided care plan education on 12/23/2024. The education was provided by Nurse Educator on 12/23/2024. 2. All residents who have Activity of Daily Living care plans for bed mobility requiring 2-person assistance have the potential to be affected by this alleged deficient practice. A. A review of all current residents' Activity of Daily Living care plans was completed to identify all residents requiring two-person assistance with bed mobility on 2/21/2025. B. Twelve additional residents were identified as being care planned for 2-person assist for bed mobility. C. A review of all incident and accident reports since 12/22/2024 was completed on 2/21/2025 with no other incidents/accidents attributed to bed mobility care plan violations. 3. The incident and accident policy was reviewed by the Director of Nursing with no revisions made. A. Certified Nurse Assistant was provided care plan education on 12/23/2024. The education was provided by Nurse Educator on 12/23/2024. B. All current Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, and therapy staff will be educated on Activity of Daily Living care plans to include bed mobility requiring 2 assists. C. All new Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, and Physical Therapy staff will be educated at new employee orientation. 4. A random weekly visual audit of 10% (4) residents of the in-house census will be completed to ensure that staff are following compliance with the level of assistance identified in the care plan. A. Audit will be completed weekly by the Director of Nursing or designee and will include day, evening, and night shifts. B. Audit results will be reported to the monthly Quality Committee until 100% compliance is maintained for 3 consecutive months and then at the recommendation of the committee. 5. Responsible Party: Director of Nursing/Designee