Failure to Analyze and Address Quality Deficiencies After Resident Fall and Unplanned Hospitalizations
Penalty
Summary
The facility failed to systematically analyze and address quality deficiencies related to a resident's adverse events, including a fall and two unplanned hospitalizations for altered mental status. The resident was completely dependent on staff for all activities of daily living, including toileting, bed mobility, and transfers, and required a two-person assist and mechanical devices due to weight. Despite these needs, staff did not ensure safety rails were secure before leaving the resident unattended, resulting in a preventable fall. The incident report for the fall was incomplete, lacking documentation on whether the care plan was followed and if appropriate transfer techniques were used. The root cause analysis did not identify that incontinence care was provided by only one staff member instead of the required two, and there was no reminder to staff about the two-person assist requirement. The facility also failed to ensure 24-hour physician availability for emergency care, as the physician could not be reached for over four hours after the resident's fall and condition change. Staff did not transport the resident to the emergency room in a timely manner when unable to reach the physician. The Quality Assurance and Performance Improvement (QAPI) program did not review or identify delays in physician response or unplanned transfers, and did not address staff feedback regarding these issues. QAPI meeting minutes did not include any discussion of the resident's fall or related unplanned hospitalizations, and data elements related to rehospitalization and medical record audits were marked as compliant or not applicable, despite the events. Nursing staff demonstrated deficiencies in competency, including failure to perform and document neurological assessments, identify medical emergencies requiring timely transfer, notify providers of baseline condition changes, and conduct comprehensive assessments after the fall. Leadership received staff feedback about these deficiencies but did not investigate or develop action plans. The Director of Nursing was aware of the fall but did not personally investigate or review the medical record, and the administrator confirmed that unplanned discharges were not routinely reviewed for quality improvement opportunities. As a result, system and process issues were not identified or addressed to ensure nursing care met recognized standards of practice.