Failure to Prevent Accidents and Complete Required Assessments
Penalty
Summary
The facility failed to provide necessary care and services to prevent accidents for three residents. One resident left the facility unsupervised after dinner without informing staff and was pulled by another resident on an electric chair. While passing over a gate frame, the resident's chair tilted, causing her to fall and land on her right shoulder. Although there were no head or skin injuries and vital signs were normal, the resident was transferred to an acute care hospital. The care plan for this resident included interventions such as educating her on the importance of informing staff before leaving the facility and explaining the risks of not doing so. However, there was no documented evidence that this education or explanation of risks was provided. Additionally, the resident's smoking assessment was not completed upon readmission, as verified by staff review. Two other residents experienced falls and were placed on care plans that required post-fall neurological checks for 72 hours. One resident was found sitting on the floor with no injuries, and the other was found lying on the floor after attempting to reach for a diaper, also with no injuries. Despite care plan interventions specifying neuro checks, medical record reviews for both residents failed to show any documented evidence that these assessments were completed following their falls. Staff interviews confirmed that neuro checks should have been performed and documented, but no such documentation was found. The Director of Nursing and other nursing staff verified the lack of documentation for both the education regarding leaving the facility and the required post-fall neuro checks. The facility's policies and procedures require comprehensive care planning, accurate assessments, and documentation of all relevant care and interventions, but these were not followed in the cases reviewed. These failures had the potential to negatively affect the health and well-being of the residents involved.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: For Resident 1, who was directly affected, corrective actions were taken immediately. On 8/1/25, the resident was re-educated by the DON and SS on the facility's out-on-pass policy, including the requirement to notify staff before leaving the premises. The charge nurse will monitor the signing in and out book. The resident was also informed of the potential dangers and/or risks associated with going out on pass, including the possibility of accident or injury. Specific safety concerns were addressed, such as nearby streets with vehicle traffic, and environmental hazards like uneven pavement, gravel, curbs, driveways, sidewalk cracks, steps, and stairs. This education was provided verbally and acknowledged in writing by the resident. A smoking assessment for Resident 1 was accurately completed by the LN per facility procedure, and all documentation was placed in the medical record on August 1, 2025. Residents 2 and 3 did not experience any harm as a result of the missed post-fall neuro checks. Both residents have since been discharged from the facility in accordance with their individual discharge plans. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, regarding their responsibility to initiate and document all resident education about the risks of leaving the facility without staff notification and monitoring the sign-in and out book. The RN Supervisor or designee reviews the resident signing in and out book daily for completeness and accuracy. To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to complete smoking assessments for all identified smokers at admission, re-admission, and quarterly. Medical Records verifies weekly that all residents identified as smokers have a current smoking assessment for completeness and accuracy. The DON and Medical Records director are responsible for ensuring these processes are maintained. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to initiate post-fall neuro checks in accordance with the facility's policy. The RN supervisor or designee now reviews all changes of condition daily to ensure neuro checks are initiated and documented. The DON and Medical Records Director are responsible for ensuring these processes are maintained. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. To ensure sustained compliance, the Medical Records conducts daily audits of the residents with an out-on-pass orders. The RN Supervisor or designee will monitor the completeness and accuracy of the signing-in and out book. Any omissions are reported immediately to the DON for corrective action and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the out-of-the-facility education and monitoring of the sign-in and out book for completeness and accuracy. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records completes a weekly review of smoking safety assessments for all identified smokers, ensuring they are complete, accurate, current, and incorporated into the care plan. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the smoking assessments for completeness, accuracy, currency, and incorporation into the care plan. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records conducts daily audits of all new falls to verify neuro checks and resident education are documented. Any omissions are reported immediately to the DON for corrective actions and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews care plan compliance quarterly to confirm interventions for falls. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. Compliance will be submitted to the QA committee monthly (Aug-Sep-Oct) or until substantial compliance is maintained. The Administrator will ensure compliance.