F0689

J

Failure to Secure Rehab Equipment Leads to Resident-to-Resident Assaults

Torrance, California Survey Completed on 05-09-2025

Penalty

Fine: $25,571

Summary

The facility failed to ensure that the rehabilitation (Rehab) room and its equipment were secured and supervised at all times, resulting in unauthorized access by residents. Specifically, a resident with a history of anxiety disorder, cognitive decline following a stroke, and intact cognition according to the Minimum Data Set (MDS), was able to enter the Rehab room without staff knowledge and obtain a dowel, a piece of equipment used for physical therapy. The Rehab room door was routinely closed but not locked when staff were not present, and weighted dowels and free weights were left unsecured and accessible on the wall.

This lack of supervision and security allowed the resident to use the dowel to physically assault two other residents on separate occasions. In one incident, a resident was struck on the left arm, and in another, a resident was hit on the right arm, right shoulder, and face, then pushed to the floor, resulting in a non-displaced fracture of the mid sacrum. Staff interviews and progress notes confirmed that the dowel used in the assaults was taken from the Rehab room, and that staff were unaware of the resident's access to the equipment until after the incidents occurred. Observations conducted nearly three weeks after the second incident revealed that the Rehab room equipment remained unsecured.

The facility's policy required individualized safety assessments and targeted interventions to reduce accident hazards, including appropriate supervision based on residents' needs and environmental risks. However, the interdisciplinary care team did not identify or address the risk of residents accessing Rehab equipment unsupervised, nor did they implement interventions to prevent such access. The failure to secure the Rehab room and its equipment, combined with insufficient supervision and lack of timely care plan updates, directly led to the incidents of resident-to-resident physical aggression and injury.

Removal Plan

• Resident 1 and Resident 3's incident was reported to the California Department of Public Health (CDPH) with final investigation completed and submitted. Resident 1 and Resident 3 were immediately separated from each other.
• Resident 3 was transferred to another room in a different wing with ongoing monitoring by staff of Resident 3's psychosocial wellbeing. Resident 3 was transferred to the hospital for assessment and returned the same day. Resident 3's care plan was updated to include a resident-to-resident altercation.
• Resident 1's care plan for behaviors was reviewed and updated to include physical aggressive behavior. Resident 1 was referred to a psychiatric mental health Nurse Practitioner but refused. The IDT met with Resident 1 and her family to assist Resident 1 to be seen by a psychiatrist. Resident 1 was sent to GACH for in-patient psychiatric evaluation and returned with a UTI diagnosis and antibiotics. Resident 1's care plan and IDT note was updated to address Resident 1's use of a dowel during the episode of aggressive behavior.
• A tracking system was implemented requiring Rehab staff to sign weighted dowels, free weights, and ankle weights in and out, noting their location and assigned user. If any item is found missing, staff must immediately notify the Rehab Manager and complete an incident log to initiate a prompt search and resolution process.
• The Executive Director was assigned to the Rehab Manager to ensure that weighted dowels, free weights, and ankle weights were properly locked and secured at the end of each treatment day. A log was created to document and verify daily compliance with this security measure.
• The Executive Director designated the Rehab Manager to ensure that access to the Rehab room is secured when staff were not present to supervise the gym. A log was created to document daily compliance and serve as evidence of adherence to this protocol with rehab staff assigned with responsibility of documenting the time the room was secured and verification that no residents remain inside.
• The IDT was in-serviced by the Senior Nurse Executive to review how to conduct an IDT meeting when reviewing resident to resident incidents.
• An ad hoc QAPI Committee meeting was scheduled to conduct a root cause analysis to determine key issues stemming from the recent resident to resident altercation to determine process breakdowns, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions.
• The Executive Director will oversee corrective actions initiated and monthly thereafter during QAPI meetings, based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical record audits and safety equipment monitoring of rehab equipment random audits, will be reviewed and revised with the QAPI Committee.
• Any new issues found during medical record audits on resident to resident altercation will be presented to the IDT members for immediate action. The Chief Clinical Officer will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
• Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, and Regulatory Compliance Nurse will perform specific roles in monitoring, oversight, education, compliance, and corrective action implementation.
• All residents were identified as potentially affected by the deficient practice.
• The Interdisciplinary Team (IDT) in-service by the Senior Nurse Executive to review how to conduct an interdisciplinary team meeting when reviewing resident to resident incidents.
• A log was created to document and verify daily compliance with securing weighted dowels, free weights, and ankle weights and locking the rehab room when no staff were present to supervise. The Activity Director and/or designee will use a monitoring tool to document compliance of logs created by the Rehab Department. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Issues found will be referred to the ED for further review and revision of the action plan and/or to determine any further training needed for staff involved.
• The Medical Records Department will use a monitoring tool to audit the documented IDT and care plan for change of conditions related to any resident-to-resident altercations. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Any issues found will be referred to the Chief Clinical Officer immediately for further review and revision of the action plan and/or to determine any further training needed for staff involved.
• Inservice training for staff license nurses was started on updating comprehensive care plans for residents that have been identified with physical aggression. The facility will continue training until all staff nurses have attended.
• Inservice training for IDT was started on updating comprehensive care plan and interdisciplinary team investigation and documentation for residents that have been identified with physical aggression and those with resident-to-resident altercations. Training will continue until all IDT members have attended.
• Inservice training for rehab staff was started on how to secure weighted dowels, free weights, and ankle weights and the rehab room door when no staff are present in the gym to supervise, as well as additional in-service initiated on how to track and sign equipment in and out, noting its location and assigned user. Training will continue until all Rehab staff have attended.