Failure to Implement Fall-Prevention, ADL Assistance, and Post-Fall Pain Assessment for High-Risk Resident
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and care in accordance with the resident’s assessed needs and care plan. Resident R2 was identified as bedbound, nonverbal, severely cognitively impaired (BIMS score 00), with multiple contractures of all extremities, functional quadriplegia, and a history of a displaced subtrochanteric fracture of the left femur. R2’s MDS documented total dependence for bed mobility and all ADLs, requiring the assistance of two or more helpers, and the restorative nurse confirmed that R2 was assessed as a two‑person ADL assist and a high fall risk prior to the incident. R2’s care plan and facility policies required that the bed be maintained in the lowest position, that approved repositioning techniques be used, and that the call light be kept within reach for safety. On the evening of 1/4/2026, CNA V11, who was assigned as R2’s primary CNA, provided in‑bed ADL/linen care to R2 alone, without a second staff member, despite R2’s documented need for two‑person assistance. V11 reported that R2 was bedbound, nonverbal, contracted in both arms and legs, and had a floor mat next to the bed. While changing linens, V11 moved the bed away from the wall, positioned themself between the bed and the wall, and turned R2 onto the right side, away from V11, to tuck a clean linen roll under R2. When V11 realized a new incontinence brief was not within reach, V11 leaned over R2 and pressed an arm into the low air loss mattress to reach for the brief at the foot of the bed. This caused R2 to slide toward the opposite edge of the bed. As R2 began to fall, V11 attempted to stop the fall by grabbing R2’s leg, but R2 continued to slide off the bed, landing partly on the floor mat and partly on the floor, with the head slightly off the mat. V11 observed pain in R2’s facial expression when grabbing the leg and reported seeing that R2 was in pain. LPN V8, who responded immediately while covering the primary nurse’s assignment, found R2 on the left side on the floor mat with a bleeding laceration on the left forehead. V8 performed a post‑fall assessment, palpating along R2’s contracted extremities and noted that when the left leg was palpated from the knee up to the hip, R2 grimaced and made moaning noises, indicating pain in the left leg. V8 cleansed and dressed the forehead laceration and assisted with lifting R2 back to bed, then medicated R2 with PRN acetaminophen. However, when V8 spoke with the APN (V31) during the post‑fall notification process, V8 did not report the new left leg pain findings from the assessment. The APN’s progress note documented a witnessed fall with a small head laceration and “no active pain, bleeding or complaints,” and no new orders were issued on the date of the fall. Subsequent documentation and interviews showed that R2 continued to exhibit pain and moaning with palpation of the left lower extremity, and an X‑ray obtained two days later revealed a proximal left femur fracture. The facility’s DON and NP both stated that nurses are expected to recognize and report nonverbal signs of pain, especially in nonverbal, contracted residents after a fall, and that new pain post‑fall should be communicated to the practitioner for possible imaging, but this did not occur immediately after R2’s fall. Additional observations by the surveyor and staff interviews highlighted further failures to consistently implement fall‑prevention interventions already in R2’s care plan and facility policies. R2 was listed on the unit’s high fall risk roster, and the restorative nurse stated that for bedbound residents, staff are to keep the bed in the lowest position, position the resident in the center of the bed during care, and ensure the call light is within reach. However, on a later observation date, R2’s bed was found at a higher position than previously observed, and the adaptive call light pad was hanging over the headboard toward the wall, away from R2, until an LPN lowered the bed and repositioned the call light near R2’s head. The primary nurse on the evening of the fall (V7) acknowledged that R2 was a two‑person assist for ADLs but did not inform the new CNA (V11) of this requirement at the beginning of the shift, only reiterating it after the fall. Collectively, these actions and omissions show that the facility did not follow its own fall prevention, ADL assistance, call light, and pain management policies for a high‑risk, fully dependent resident, resulting in a fall from bed with a head laceration and unreported post‑fall leg pain that was later associated with a left femur fracture. Family interviews further described the condition of R2 immediately after the fall and in the days following. R2’s healthcare power of attorney and another family member reported arriving shortly after being notified of the fall and observing blood dripping from the left side of R2’s head and blood on the floor. They questioned the nurse about sending R2 to the hospital for examination and were told that R2 was stable and would be monitored in the facility per practitioner direction. They also reported asking whether a full body examination for possible broken bones would be done and were told it would be performed. On 1/6/2026, the family was informed by facility staff that imaging suggested possible bilateral hip fractures, and later at the hospital they were told that R2 had a comminuted displaced left femur fracture. The family stated that R2 was in significant pain, making loud noises, and that they received conflicting information from the facility about the nature of R2’s injuries. These accounts align with the clinical findings that R2 exhibited nonverbal signs of pain in the left leg after the fall, which were not promptly communicated to the practitioner at the time of the initial post‑fall assessment.
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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