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 Follow Fall Interventions: A resident with dementia, ESRD on dialysis, impaired mobility, and a history of falls was observed ambulating and self-transferring in her room and bathroom without staff assistance, despite orders and a care plan requiring one-person assist with a walker, call light use, frequent safety checks, and skid strips by the bed. Staff interviews confirmed the resident was transferring independently and that the skid strips were not in place as documented.
A resident assessed as high risk for falls did not receive the physician-ordered fall mat on the right side of the bed. Surveyors observed no mat during multiple checks, and the TAR did not reflect the intervention. The resident said the mat had been removed after a new bed was placed, while an RN and the DON acknowledged the order remained in place even though the mat was no longer being used.
Smoking safety interventions were not consistently implemented for four residents who smoked. Two residents were observed smoking with staff supervision but without the smoking aprons listed in their assessments and care plans, and two other residents were also observed smoking in wheelchairs without aprons despite care plan interventions requiring them. The DON confirmed the apron requirement for two of the residents, while the ADON stated residents sometimes complained about the aprons and that he did not know when smoking assessments were completed.
A resident with cerebral palsy, severe cognitive impairment, wheelchair use, and a care plan requiring a mechanical lift for all transfers was manually transferred by a CNA instead of using the lift. During observation, the CNA lifted the resident by the upper back and moved him between the wheelchair and bed without mechanical assistance, despite having completed lift competency training and despite the DON confirming the resident required a mechanical lift for all transfers.
Failure to supervise a resident at risk for elopement led to repeated exit-seeking and wandering events, including being found off the unit and near exterior areas. The resident had dementia with cognitive impairment, hemiplegia, and diabetes, and staff notes described missing documentation of several wandering episodes, an incomplete care plan intervention, and incidents involving a broken alarmed door, a Wanderguard, and an unknown visitor letting the resident off the unit.
A resident with severe cognitive impairment fell during a lift transfer when a sling strap came loose and the chest strap clip broke, and two other residents were observed being transferred with total body lifts using slings that were not verified against their care plans or mobility assessments. Staff interviews showed some CNAs relied on the sling already in the room or on how it fit, rather than consistently checking the care plan or Kardex for the correct sling size and transfer method.
Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure that a resident's fall interventions were in place for one resident reviewed for falls. The resident had diagnoses of dementia and end-stage renal disease requiring dialysis, was documented as having intact cognition but needing supervision with ADLs, transfers, and walker use, and was identified as a fall risk due to ESRD, impulsive behavior, and impaired mobility. The resident's nursing and provider orders directed staff to assist with ambulation, remind the resident to use the call light and wait for staff, and complete frequent safety checks each shift. The resident had a documented fall in which she was found sitting on the floor between her drawer and walker with bleeding from a forehead injury and a skin tear to her jaw, and she was transferred to the hospital where she received stitches. The incident report stated the resident lost her balance when she walked to her drawer to close it. The resident's care plan later identified a self-care performance deficit related to actual falls, weakness, and impaired mobility, and included interventions such as assistance from one staff member with a walker and gait belt, assistance with transfers and toileting, use of assistive devices, skid strips next to the bed, and frequent monitoring for safety. During observations, the resident was seen ambulating and self-transferring in her room and bathroom without staff assistance and at times without using her walker or call light. Staff observed the resident walking independently in her room, and an unidentified staff member passed by without entering the room. The resident stated that she walked and used the bathroom by herself and did not need to follow instructions. Staff interviews confirmed that the resident transferred independently and ambulated without a walker or staff assistance, while another nurse stated the resident was not supposed to self-transfer and that skid strips were not present despite being listed in the care plan. The DON stated that staff were expected to follow resident orders and care plans for safety.
Missing Ordered Fall Mat for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident assessed as high risk for falls received the physician-ordered fall prevention intervention of a fall mat positioned on the right side of the bed. Resident #50 was admitted with diagnoses including orthostatic hypotension, lack of coordination, reduced mobility, and communication deficit. The resident’s fall risk assessment showed a score of 50, indicating high risk for falling, and the care plan identified the resident as at risk for falls and fall-related injury due to a history of falls with fracture, cognitive impairment, and decreased safety awareness. During multiple observations, the resident was seen at the bedside and no fall mat was present on the right side of the bed or located in the room. The physician order dated 6/7/2026 specified a mat on the right side of the bed, but the MAR and TAR did not reflect the fall mat as an implemented intervention. The resident stated the fall mat had been removed after a new bed was placed and had been gone for a long time. An RN stated the resident was a fall risk and that the order for the fall mat should be followed or cancelled if no longer needed. The DON stated the bed had been changed out and the mat would get in the way, and the order should have been cancelled.
Smoking Safety Interventions Not Followed
Penalty
Summary
The facility failed to ensure adequate assessment and implementation of smoking safety interventions for four sampled residents who smoked. Residents #12 and #85 were observed smoking in the designated smoking area with staff supervision on multiple occasions, but neither was observed wearing a smoking apron even though the smoking binder and care plan indicated they needed one. During an interview, the ADON confirmed both residents were listed as needing aprons and stated the residents sometimes complained about the apron, but they should not smoke unless they put it on. The ADON also stated he does not go out with smokers often and does not know when assessments are completed. Resident #12 had diagnoses including COPD, muscle weakness, and epilepsy, and smoking evaluations noted tobacco use and balance problems while sitting or standing; smoking was added to the care plan with a clothing protector intervention. Resident #85 had diagnoses including hemiplegia and right-hand contracture, and although initial smoking evaluations indicated tobacco use with no impairments, smoking was later added to the care plan with a clothing protection requirement. Resident #52, who had CVA with right-sided weakness and paralysis, diabetes, mood disorder, major depressive disorder, and right hand and upper arm contracture, was observed smoking in a wheelchair without a smoking apron despite a care plan intervention requiring one. Resident #11, who had TBI, schizoaffective disorder, major depressive disorder, paraplegia, and upper extremity contractures, was also observed in the smoking area in a wheelchair without a smoking apron, and no attempt was made by the smoking monitor to get the apron on. The DON confirmed that Residents #52 and #11 were supposed to wear smoking aprons when smoking, and the facility smoking policy required residents to be educated and evaluated for smoking upon admission, re-admission, and quarterly.
Failure to Use Required Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure Resident #5 was transferred with a mechanical lift as required. Resident #5 was admitted with diagnoses including cerebral palsy, BPH, and hypertension, and a quarterly MDS showed severe impairment in thinking with a BIMS score of 4. He required substantial to maximal assistance with toileting hygiene, used a wheelchair for mobility, and his care plan documented a history of falls with interventions initiated for a mechanical lift for all transfers to wheelchairs. A POC task also indicated he required a mechanical lift for transfers every shift, and he was listed among residents requiring a sling/mechanical lift. During observation, CNA C provided incontinent care and transferred Resident #5 from his specialized wheelchair to the bed and back without using a mechanical lift. Instead, she manually lifted him by placing her arms around his upper back and interlocking her fingers. In interview, CNA C stated she had been employed for a month, had completed lift competency during orientation, but did not use the lift because she felt comfortable transferring him without assistance and had never used the mechanical lift on him, although other staff did. The DON stated Resident #5 required a mechanical lift for all transfers and that staff could see this in the POC. The facility policy stated mechanical lifting devices shall be used for lifting and moving residents when necessary.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident elopement for a resident who was identified as at risk for elopement and did not reside on a secured unit. The resident had diagnoses including hemiplegia, diabetes, and dementia, and the MDS indicated cognitive impairment. The record showed multiple elopement evaluations with changing results, including several assessments that identified the resident as at risk for elopement in July 2026, while earlier assessments had indicated not at risk or were incomplete. The care plan identified the resident as an elopement risk/wanderer related to impaired safety awareness, but the record contained only one incomplete intervention related to wandering, and no resident preferences were included. Behavior monitoring documented exit-seeking and wandering behaviors on multiple occasions in May, June, and July 2026, but progress notes did not document the behaviors noted on 5/21/26, 6/21/26, and 7/14/26. A physician order for a Wanderguard was created after the resident was found wandering outside on the curb, and staff notes described discussions with family and assessments after the resident was returned to the unit. The resident was later involved in additional elopement-related events. Staff statements and progress notes described the resident being found near a door, in the front hall, in the assisted living area, and off the unit near common areas, with staff searching for her after she was reported missing. One note stated the resident could escape through a security door because the alarm was broken and had not been fixed yet. Another investigation note stated the resident was found off the unit in a common area adjacent to the unit after being let off by an unknown visitor. The facility determined that the resident was cognitively unable to recognize the door requiring a code and would be physically unable to open it without assistance. The report states the facility was out of compliance with resident safety and supervision since 4/12/26.
Failure to verify correct sling size and safe lift use during resident transfers
Penalty
Summary
The facility failed to ensure staff followed accident prevention interventions and safe device use for three sampled residents who required total body lift transfers. The report states that four certified nursing assistants did not verify the correct sling size before transferring residents, despite care plans and the lift’s sling-size identification system directing staff to use specific sling sizes based on resident weight and transfer needs. Resident 39 had severe cognitive impairment, Alzheimer’s disease, dementia with behavioral disturbance, anxiety disorder, and muscle weakness. Her care plan and mobility assessments showed a progression from sit-to-stand lift use to total body lift use with two staff members and a medium sling. On 5/1/26, she was transferred from her wheelchair to her bed by a CNA using a sit-to-stand lift when the sling strap came loose from the hook on the lift and the chest strap clip broke, causing her to fall backward onto the floor. She sustained a skin tear on her right forearm, bruising to the right side of her face, redness to the right side of her body, and a bruise on her right frontal scalp. She was sent to the ER, where X-rays showed no acute findings or fractures. Observations later showed resident 39 being transferred with a total body lift using a large sling, and resident 8 and resident 25 were also observed with large total body lift slings on. Resident 8 had paraplegia, moderate cognitive impairment, and a care plan directing total body lift transfers with a medium and extra-large sling, while his mobility assessment indicated an extra-large sling and two staff members. Resident 25 had vascular dementia and muscle weakness; her care plan directed total body lift transfers with two staff members, and her mobility assessment indicated a large sling. Interviews with CNAs showed that staff sometimes relied on the sling already in the room or judged sling size by how it fit, rather than consistently referring to the care plan or Kardex. The DON and MDS coordinator stated that staff were expected to use the resident’s care plan or Kardex to determine sling size for safe transfers.
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