Failure to Ensure Safe Transfers and Fall Prevention
Summary
Staff failed to safely transfer a resident with severe cognitive impairment and bilateral lower extremity functional limitations using a mechanical Hoyer lift. During a transfer to a recliner, staff used a Hoyer lift that was not wide enough to accommodate the recliner, but proceeded with the transfer regardless. As the resident was being lowered, the lift's bar swung back and struck the resident in the forehead, causing a laceration and bruising that required emergency room treatment and sutures. The incident involved both a hospice aide and a facility aide, and it was confirmed that the staff continued the transfer despite recognizing the equipment was not appropriate for the task. In a separate incident, another resident with bilateral below-knee amputations and chronic respiratory failure experienced a fall from bed during routine care. The resident, who was cognitively intact and required substantial assistance with bed mobility, was rolled onto his right side by a CNA working alone, after being unable to find another staff member to assist. The resident rolled out of bed and onto the floor. The fall report was found to be inaccurate, and the resident was not interviewed about the incident. The nurse on duty did not assess or interview the resident following the fall, and the fall investigation report was incomplete. Both incidents demonstrate failures in providing adequate supervision and assistance devices to prevent accidents, as well as failures in thoroughly investigating and accurately documenting resident falls. The facility's policies required staff to ensure resident safety during activities of daily living and to identify interventions related to specific fall risks, but these were not followed in the cases described.
Plan Of Correction
What corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #19 has been assessed and evaluated for appropriate transferring techniques, per facility policy, on multiple dates (note attached audit of completion). Through ongoing assessment, resident has been transferred, with no difficulty, and without injury obtained. Patient denies any concerns/discomfort with transferring techniques concluded. The oversized recliner was removed prior to survey initiation, per family request. Hospice provider has been advised to provide ample amount of time/notification for DME changes/removal to allow for appropriate transition of resident. Resident #25 has been interviewed for bed mobility preferences. Resident states he prefers to be a two person assist despite his ability to complete tasks with one individual. Resident's plan of care has been updated to identify specifics of patient preference (note attached). Facility staff educated on change of care, same date (included for reference). How will you identify other residents having the potential to be affected by the deficient practice and what corrective action will be taken: Managerial personnel will conduct random audits of bed mobility tasks and transfer completion guided per each individual's plan of care. Audits will be assessed daily, on each unit, at random time intervals x 1 week, twice weekly x 2 weeks, and once per week x 4 weeks. If concerns are identified, those individuals will be re-educated of the facility's transfer policy and procedures with hands-on guidance to be done. Initiation of a Performance Improvement Plan will be conducted, as needed. What measures will be put into place or what systemic changes will you make to ensure the deficient practice does not recur: Upon admission, each resident shall be assessed for safe transfers/bed mobility tasks guided per the functional status and personal preference expressed. Activities of daily living will be re-assessed quarterly, as needed, and with any significant medical changes following the initial admit, per facility designee, and will be reflected on the individualized plan of care. How the corrective actions will be monitored to ensure the deficient practice will not recur, ie., what quality assurance program will be put into place; and dates when corrective action will be completed: This plan of correction will be implemented, and the corrective action will be evaluated for its efficiency. The plan of correction is integrated into the facility's Quality Assurance Program. All auditing tools will be completed, as dictated, with thorough review. Any adverse findings/trends noted will be corrected immediately and brought to the Quality Assurance and Performance Improvement Committee for review. Please consider this plan of correction to be an allegation of compliance as if 07-18-2025. Resident #19's most recent assessment was done on 07/18/2025, which was completed by nurse on the unit. Hospice nurse was notified the date of the incident, which was 06/06/2025. The Director of Nursing, unit managers, and maintenance director reviewed wheelchairs and personal chair sizes to ensure mechanical lifts meet manufacturer guidelines when in use. No concerns were identified, and audit was completed the week of survey. Mechanical lift inspections are done monthly by the maintenance director. Maintenance Director reports any adverse findings to the Director of Nursing. A thorough investigation was completed per interdisciplinary team on 04/14/2025, which included Director of Nursing, Unit Manager, and MDS nurse. Initial interview incident was conducted per agency nurse at time of fall. Subsequent communication completed on 04/14/2025 per Unit Manager. In clinical care meeting on 04/14/25, resident #25 incident reviewed including preference stated by resident and during that time resident did not express any concerns with changes in the plan of care. During plan of correction review, resident was reinterviewed and expressed the desire to have two staff assist during bed mobility this time forward, which was 07/22/25. Plan of care updated with the following information. Yes, each fall investigation is led by the Director of Nursing and reviewed with the clinical team. The new processes were put into place and the implementation of the IPRO fall tracking tool alongside current facility policy and procedures for incident investigations. The licensed nurses and STNA are educated on transferring techniques including Hoyer lift policy and procedure at time of hire, annually, and with any manufacturer changes or new equipment. Upon hire would be our HR representative, annually or any changes would be completed by managerial nursing staff. Maintenance Director supplies any information regarding new lifts introduced into the facility. All nurses are oriented upon hire regarding risk management completion, interviewing staff/obtaining witness statements, and interviewing residents when applicable regarding cognition. In specific to this incident, agency staff was reeducated on thorough investigation; however, per risk management completion, it appears incident review was conducted accordingly. Director of Nursing reviews and signs each risk management. If concerns are identified, the Director of Nursing does a one-on-one reeducation with the staff member. Yes, all audits observed will include Hoyer transfers guided per resident’s individual plan of care. Yes, all falls are investigated to ensure thoroughness, including resident/staff interviews as applicable. Director of Nursing reviews with clinical staff. Every fall is reviewed and will continue to be reviewed indefinitely. Yes, it is the facility's utmost opinion that a thorough investigation was concluded on 04/14/2025 following the fall of resident #25. The initial interview of the incident was concluded immediately per agency nurse at the time of fall. Subsequent communication was completed, post ED return, per unit manager 04/14/2025. The new IPRO fall tracking tool was initiated 07/08/2025. The IPRO tracking tool has been utilized for all falls in July 2025. This new process will continue indefinitely. Yes, all staff (nurses and CNA's) have been educated on the proper transferring techniques, via Hoyer lift, post survey initiation and the AOC date, conducted per managerial nursing staff beginning 07/02/2025 through survey completion. Yes, all nurses have been re-educated on thorough fall investigation completion to include interviewing residents and staff (as applicable) after the survey start and prior to the AOC date. This guidance was transcribed per Director of Nursing and expressed to staff per nurse managers. The agency nurse was provided appropriate policy and procedure guidelines for incident/progress note completion on 04/14/2025 directly via the agency portal.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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