Inadequate Supervision and Staff Training Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and staff training for a resident, identified as Resident #19, who was at risk due to the use of medications, decreased endurance, and a history of falls. The resident was found lying on the floor in her room, indicating a lack of supervision. The incident occurred after a staff member from the Activities department, who was not aware of the resident's specific needs, left her alone in her room without notifying the nursing staff. The resident's care plan did not include interventions to ensure she was always with staff while in her wheelchair, nor did it provide guidance for all facility staff to communicate with nursing staff when the resident was returned to her room. The facility's investigation revealed that only the Activity Assistant involved in the incident received education, rather than all staff. The Activities Director admitted uncertainty about how staff should know which residents need to be brought to the nursing station instead of their rooms, suggesting a lack of clear policy or training. The care plan lacked specific interventions related to the resident's need for supervision, contributing to the incident where the resident was left unsupervised, leading to her fall.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #19 was assessed by licensed nurse, no concerns identified. On 4.4.25 staff activities aid G was educated by the Assistant Director of Nursing on prevention and safety, and on specifics of resident #19 plan of care. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.14.25 a quality review was completed by Director of Nursing/designee on current residents who sustained a within the last 30 days to ensure follow up documentation in place, care plan updated, and staff education completed. Any concerns identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.22.25 Director of Nursing completed education with current nursing/activities staff on the components of F689 free from hazards/accidents/supervision with emphasis on ensuring staff education completed and follow up documentation in place for by the Director of Nursing/Designee. Newly hired nursing/activities staff will be educated on the components of F689 free from hazards/accidents/supervision with emphasis on ensuring staff education completed and follow up documentation in place for by the Assistant Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents who sustained a twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F689 free from hazards/accidents/supervision with emphasis on ensuring staff education completed and follow up documentation in place for. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.