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F0689
J

Failure to Provide Required Bed Mobility Assistance Resulting in Resident Fall and Harm

Claxton, Georgia Survey Completed on 12-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with Alzheimer's disease, chronic pain, muscle weakness, severe contractures, lack of coordination, and blindness was not provided with adequate bed mobility assistance. The resident was completely dependent on staff for all activities of daily living and required two-person assistance for bed mobility, as documented in the care plan and the ADL plan of care. Despite this, a Certified Nursing Assistant (CNA) provided care with only one-person assistance while changing linens after bathing the resident. During this process, the CNA was on the opposite side of the bed, pulling sheets and pads, and observed the resident roll off the bed. Following the fall, a Registered Nurse (RN) was called to assess the resident and found a laceration on the top of the resident's head and was unable to obtain vital signs. Emergency Medical Services were called, and the resident was pronounced deceased upon their arrival. The incident was reported to the State Survey Agency by the Director of Nursing (DON), who also conducted an internal investigation, collected statements from involved staff, and reviewed the care plan and staff education records. Interviews with facility staff revealed inconsistencies in understanding and following the required level of assistance for bed mobility. Some staff referenced the plan of care for guidance, while others relied on their experience or knowledge of the residents. The care plan and ADL documentation clearly indicated the need for two-person assistance, but this was not followed at the time of the incident, resulting in a fall and subsequent harm to the resident.

Removal Plan

  • R1 is no longer at the facility.
  • Investigation initiated and the associate providing care to R1 was removed from the schedule. The associate received education regarding adhering to the plan of care with repositioning patients and the support staff needed for ADL care by the DON. Validation of associate education and competency was completed by the DON.
  • In-service education was initiated for all nursing staff and was completed regarding falls management, adhering to the plan of care with repositioning patients and the support staff needed. Education included how to access the level of care required on the POCs and turning and repositioning, bed mobility, plan of care, and residents' alerts. The facility's fall management program was reviewed. Education was provided by the Administrator, DON, ADON, and nurse managers. All RN, LPN, CNAs, CMAs, and RAI coordinator have been in-service, which totals 100%. No nursing staff shall work until they have completed in-service education. Newly hired associates will be educated upon hire.
  • Audit was completed by DON, ADON, and nurse managers on residents with falls to ensure the plan of care is being followed. No revisions needed after review.
  • 100% audit completed of residents' plan of care by DON, ADON, and nurse managers to ensure each resident had the appropriate level of assistance needed for bed mobility. All levels of assistance are noted to be accurate.
  • The facility's plan of care and ADL plan of care policy were reviewed by the administrator and medical director, with no changes required at this time.
  • Audits of staff providing care by the residents' plan of care are being monitored weekly by DON, ADON, Nurse Managers, and charge nurses and will continue weekly for six weeks across all shifts to include the associate involved in providing direct care to R1.
  • An ADHOC QAPI meeting led by the administrator was held and a performance improvement plan was developed and re-evaluated for F689. A root cause analysis was conducted, and no trends were identified; it was determined to be an isolated incident. CNA followed the plan of care. The interventions implemented included the PIP review, a review of the fall Program with no changes, and a process for adhering to the plan of care, which involved repositioning patients and the support staff needed.
  • All corrective actions were completed. The facility alleges that the IJ was removed.
See complete original report
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