Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, identified as Resident #850, who had a history of falls and was legally blind and hard of hearing. The resident's care plan included interventions such as assistance with toileting, encouraging the use of a call bell, and wearing appropriate footwear. Despite these interventions, the resident attempted to go to the bathroom unassisted, resulting in a fall and a major injury requiring 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 acknowledged that the resident had no prior falls since admission and that interventions were in place, but there was no documentation of specific supervision or monitoring times. 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 door were often closed, making observation difficult. Interviews with staff revealed that monitoring and supervision were inconsistent, with no set times for checking on the resident. The Director of Rehab noted that the resident required assistance with all activities and could roll over in bed with minimal help. Despite the facility's efforts to educate staff on fall prevention, the care plan for Resident #850 had not been updated with new interventions to prevent further falls, and there was no documentation of increased supervision or monitoring.
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? Resident #850 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. Resident #850'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: A quality review was completed by Director of Nursing/designee on Residents identified to be at increased risk 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: Licensed Nurses and Certified Nursing Assistants were educated on the components of N201 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk by the Director of Nursing/Designee. Newly hired licensed nurses and Certified Nursing Assistants will be educated on the components of N201 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk 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 monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.