Failure to Secure Rehab Equipment Leads to Resident-to-Resident Assaults
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Failure to assess the safety of perimeter mattresses for two residents. Both residents had severely impaired cognition and significant mobility limitations, and both care plans included use of a perimeter mattress to define the edges of the bed. However, their Mobility, Physical Device, and Fall Risk assessments lacked documentation of a perimeter/defined edge mattress assessment. Staff interviews showed inconsistent understanding of the required order, IDT review, engineering review, and safety assessment before use.
Improper Mechanical Lift Transfers: A resident with dementia, spinal cord dysfunction, and dependence for transfers was supposed to be moved with a full-body mechanical lift and two staff members, but a TMA stated she transferred the resident alone. The resident reported that staff sometimes used only one person for lift transfers because of staffing shortages, while other staff and the DON stated this was unsafe and against policy.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Failure to Ensure Effective Fall Alarms and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for two residents who were reviewed for fall precautions. One resident had diagnoses including unspecified dementia, age-related osteoporosis, a history of transient ischemic attack, and cognitive impairment, and was described by the POA as weak, bedbound, and unable to participate in physical therapy after a prior right femur fracture. The resident was completely dependent on staff for eating, hygiene, mobility, and toileting, and the care plan included a bed alarm per orders. The resident was found on the floor next to the bed after an unwitnessed fall. The POA reported receiving a call from the facility that the resident had been found on the floor and was not injured, and stated the resident frequently forgot to ask for help and had tried to get up without assistance before. A nurse stated the bed alarm was not heard when the resident fell, and the facility was unable to provide evidence that the bed alarm functioned as intended or alerted staff before the resident was found on the floor. The event report identified the fall as unwitnessed and did not indicate that a bed alarm alerted staff. The facility also failed to ensure the Smart Caregiver sensor pad monitoring system used for another resident was functioning properly and set at an audible volume. Two Smart Caregiver monitor boxes at the nurses' station for that resident's bed and recliner were observed set to LOW volume, and the chime settings faced the back wall of the desk. When a CNA tested the recliner alarm from the resident's room, the monitor at the nurses' station did not illuminate or sound an alert on either attempt. The CNA changed the batteries but did not retest the device, and both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall training on operation or testing of the devices. The facility director stated the facility did not perform preventive maintenance on the devices and relied on staff to ensure they functioned properly.
Failure to Assess Safety of Perimeter Mattresses
Penalty
Summary
The facility failed to ensure that 2 residents with perimeter mattresses were assessed for safety. One resident had a significant change MDS showing severely impaired cognition, dementia, reduced mobility, muscle weakness, and need for assistance with bed mobility, sitting, standing, and transfers. That resident’s care plan identified limited physical mobility related to dementia with mood disturbance and anxiety, a genetic muscle disorder, spinal stenosis, and osteoarthritis, and included use of a perimeter mattress to help find the edges of the bed for bed mobility. However, the resident’s Mobility, Physical Device, and Fall Risk assessment lacked documentation of an assessment for a perimeter/defined edge mattress. The second resident’s annual MDS showed severely impaired cognition, dementia, multiple sclerosis, repeated falls, and need for partial to moderate assistance with bed mobility. The care plan identified limited physical mobility related to weakness, falls, incontinence, hypertension, renal disease, dementia, MS, depression, and delusional disorder, and included use of a bariatric sized bed with a perimeter mattress to define the edges of the bed. That resident’s Mobility Physical Device and Fall Risk assessment also lacked documentation of an assessment for a perimeter/defined edge mattress. During observation, the resident was in bed asleep with a perimeter mattress. Staff interviews showed differing understanding of whether a physician order, assessment, IDT review, engineering review, and safety assessment were required before use of a perimeter mattress, and the DON confirmed both residents’ most recent assessments lacked documentation of a perimeter/defined edge mattress assessment.
Improper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure transfers were performed according to R24’s assessed needs, care plan interventions, and facility policy. R24’s records showed she had diagnoses including non-traumatic spinal cord dysfunction, diabetes, dementia, depression, heart failure, and asthma. She was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had care plan directions for assistance with transfers using a full-body mechanical lift and two staff members. During interviews, a TMA stated she transferred R24 with the full-body mechanical lift by herself because R24 needed to use the bathroom and she felt the transfer was safe. R24 stated staff sometimes transferred her with only one staff member and said they told her there was not enough staff. Other staff interviewed stated transfers with the full-body mechanical lift using one staff member were unsafe and should not occur. The facility policy for using a mechanical lift stated that at least two trained associates are needed to safely move a resident with a mechanical full-body floor-based lift or ceiling/overhead full-body lift.
Unsafe Wheelchair Fit and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. Resident 27 was readmitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer's disease and was sometimes able to make needs known. On multiple observations, Resident 27 was seated in a slightly tilted back wheelchair with feet extending beyond the footrests, and the back of the lower legs rested against the hard footrests above the ankle/heel area. A pillow was observed either on the floor or behind the legs rather than padding the footrests. The focused care plan for skin integrity included padding to wheelchair footrests, and staff interviews confirmed the footrests were too short and needed adjustment or replacement, but staff had not notified therapy or otherwise addressed the wheelchair fit. Resident 50 was admitted with diagnoses including dementia, history of falls, and UTI and was sometimes able to make needs known. The care plan identified the resident as at risk for falls. After an unwitnessed fall in the 300 hallway, the incident investigation added interventions to monitor orthostatic blood pressures and refer to physical therapy. However, the record showed an orthostatic blood pressure order on 05/20/2026 was not completed, and subsequent orthostatic blood pressures recorded the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026, and 05/24/2026. Staff later stated they had not received a post-fall therapy referral, and the DNS stated the resident should have had orthostatic blood pressures taken accurately to rule out orthostatic hypotension.
Failure to assess electric wheelchair use and update fall interventions
Penalty
Summary
The facility failed to comprehensively assess a resident for the use of an electric wheelchair and failed to develop new interventions to reduce fall risk for another resident. The report states that the facility’s policies required a device evaluation before an electric wheelchair was initiated, resident education and consent, and an updated service plan identifying device use and other interventions. The fall management policy required individualized care plan updates, a systematic review after each fall, identification of root cause, and review of prior interventions when new interventions were implemented. Resident 73 was admitted with weakness and lymphedema and had an above-the-knee left leg amputation, requiring assistance with bed mobility, transfers, and locomotion. The resident’s record showed cognitive intactness, lower extremity impairment, supervision or touch assistance for bed-to-chair transfers, and use of a manual wheelchair. On 4/17/26, a newly issued electric wheelchair was delivered and the resident was assisted into it. The resident reported that the representative showed how the chair worked but not enough, and that the resident did not know how to stop it. The resident then returned to the room, could not stop the chair, and the chair continued forward into the bed, causing the resident’s right leg to strike the metal bed frame. The resident sustained a five-centimeter laceration to the right anterior lower leg, fractures of the right tibia and fibula, and a brief syncopal episode secondary to blood loss. The resident also received an anticoagulant, which contributed to significant bleeding. The clinical record contained no evidence that the resident had been assessed to safely operate the electric wheelchair before use. Resident 3 was admitted with a right total hip replacement with deep hardware removal and post-traumatic osteoarthritis of the right hip. The resident had a high fall risk on Morse Fall Scale assessments, cognitive impairment on OT evaluation, and a PT evaluation showing a score of zero on the Short Physical Performance Battery, indicating high fall risk and increased risk of mobility disability. The resident fell on 3/31/26 after getting up independently and sustained a right femur fracture requiring surgical repair, and fell again on 5/12/26 after getting up independently and sustained a skin tear to the right elbow. The care plan identified fall risk and included reminders to use the call light, non-skid socks, and one-person assistance for toileting and transfers, but revisions to the care plan did not add new or amended fall prevention interventions. Staff statements indicated the resident continued to self-transfer and toilet without assistance, staff believed the resident was independent, and the existing fall prevention interventions were ineffective.
Unsafe One-Person Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure safe use of a mechanical lift for 2 of 3 residents reviewed for accidents. During an observation on 6/2/2026 at 8:42 AM, Resident #4 was lying on his bed on top of a Hoyer pad while CNA Staff K stood on the right side of the bed with a mechanical lift; the lift hand bags were observed over the resident, and no other staff member was in the room. Staff K stated that he was weighing Resident #4 and that normally only one person uses the Hoyer lift for weights, although the resident’s care plan documented a Hoyer lift with 2 assist. On 6/4/2026 at 10:15 AM, CNA Staff D was observed using a Hoyer lift alone to obtain Resident #13’s weight, with the resident lifted approximately 12 inches off the mattress in the sling and no other staff present. Staff D stated that he was performing weekly weights and most of the time did the weights using the Hoyer lift by himself. Resident #13’s MDS Section GG coded the resident as dependent, and the facility’s mechanical lift competency checklist stated that two caregivers are present, while the facility policy for using a mechanical lifting device stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The DON and Director of Therapy both stated that a mechanical lift should always be used by two staff members.
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