F0684

D

Failure to Adequately Supervise Hospice Resident With Terminal Agitation and Repeated Falls

Canton, Connecticut Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and individualized care for a hospice resident experiencing terminal agitation who sustained multiple unwitnessed falls within a 24‑hour period. The resident was admitted with COPD, lung cancer, anxiety, depression, and was on hospice care. On admission, the nursing assessment documented that the resident was oriented to person, drowsy, confused, and required maximal assistance with toileting, personal hygiene, and rolling, but did not assess ambulation. The resident’s care plan identified fall risk related to new admission and cognitive impairment, with limited interventions such as leaving a urinal at bedside, while the CNA care card later documented that the resident required one‑person assist for transfers and could ambulate without an assistive device.

Over the course of one night and the following day, the resident experienced a series of unwitnessed falls. An A&I report documented a fall at midnight where the resident was found scooting on the floor near the bed, with gripper socks in bed added as a post‑fall intervention. A second unwitnessed fall occurred at 3:00 a.m. from a wheelchair at the nurse’s station, after a loud thump was heard, and “frequent checks” were added as an intervention. Later that morning, an APRN documented that the resident was experiencing increased agitation, had fallen twice during the night, appeared to be actively transitioning, and that the agitation was likely terminal agitation, but the record did not show new interventions or treatment related to terminal agitation. Additional unwitnessed falls occurred at 5:00 p.m., with the resident found on the floor by the window side of the bed and sustaining skin tears, and at 9:00 p.m., with the resident again found on the floor; post‑fall interventions at these times were limited to placing the call light within reach and keeping the bed in low position.

During this period, the hospice RN was notified of the falls and escalating agitation, including reports that the resident was banging his or her head on the floor, had blood on the floor with an unidentified source, and verbalized a desire to die. Multiple doses of morphine and Haldol were administered, and the hospice RN obtained a modified Haldol order, but no documentation showed implementation of enhanced supervision such as 1:1 monitoring. A facility RN reported requesting 1:1 supervision due to the repeated falls, but this was denied by the ADNS due to staffing, and staff instead informally tried to monitor the resident more closely. Later that night, an LPN found the resident on the floor repeatedly striking his or her head; another RN documented the resident lying face down in a pool of blood, repeatedly hitting the head and striking all four limbs on the floor before EMS transported the resident to the hospital. Interviews with facility and hospice staff confirmed that the resident exhibited abnormal and unpredictable behaviors consistent with terminal agitation, that 1:1 supervision was not implemented, and that the DNS was not informed of the earlier fall and self‑harm incident.