Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for a resident with a history of falls and other medical conditions. The resident, who was legally blind and hard of hearing, had a care plan that included interventions such as assistance with toileting and reminders to use the call bell for help. However, the resident attempted to go to the bathroom unassisted, resulting in a fall and a major injury that required hospital admission and surgical repair. The incident occurred when a registered nurse found the resident on the floor in front of the bathroom door, with the call light not engaged. The resident had attempted to go to the bathroom unassisted, despite being known to require assistance. The Director of Nursing (DON) acknowledged that the resident had toileting times in place and was known to be at risk, but there was no documentation of specific interventions or monitoring frequency. The resident's room was moved closer to the nursing station after the incident, but the call light was still not within reach, and the privacy curtain and room door made observation difficult. Interviews with staff revealed that monitoring and supervision were inconsistent, with no set times for checking on the resident. The facility's Quality Assurance Performance Improvement Plan showed no reduction in incidents, and education was provided to staff, but there was no documentation of new care plan interventions to prevent further accidents. The facility's failure to implement and document adequate supervision and interventions contributed to the resident's fall and injury.
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 Resident #850 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On Resident #8500's care plan was reviewed with the Interdisciplinary Team and revised to reflect appropriate interventions to minimize risk of. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On a quality review was completed by Director of Nursing/designee on Residents identified to be at increased risk for to ensure that appropriate interventions have been put into place and reflected on the care plan. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By, Licensed Nurses and Certified Nursing Assistants were educated on the components of F689 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk for by the Director of Nursing/Designee. Newly hired licensed nurses and Certified Nursing Assistants will be educated on the components of F689 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk for by the 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 audits of 5 residents care plans 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that appropriate interventions were put into place to minimize risk of. The findings of these quality monitoring...s to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.