F0689

G

Failure to Provide Care-Planned Supervision During Smoking Resulting in Hip Fracture

Plainville, Kansas Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide care-planned supervision to prevent a fall with major injury for a cognitively impaired resident with a known history of falls, dizziness, and weakness. The resident’s EMR documented diagnoses including paroxysmal atrial fibrillation, orthostatic hypotension, dizziness, and tobacco use. A Significant Change MDS dated 12/03/25 showed a BIMS score of 4, indicating severely impaired cognition, and documented that the resident required moderate assistance for sit-to-stand and transfers, maximum assistance for toileting, dressing, and personal hygiene, and was dependent for bathing. The MDS and CAAs documented that the resident had experienced two or more falls with injury (not major) since 10/08/25 and was identified as a fall risk. A Morse Fall Scale dated 12/08/25 showed a score of 70, indicating high fall risk.

The resident’s care plan, initiated 08/09/22, documented a history of syncopal episodes and risk for falls, with directions for staff to encourage the resident to call for assistance if feeling weak, dizzy, or unsteady before transferring or ambulating. The care plan also directed staff to observe and monitor the resident for changes in gait or balance when or after smoking, as the resident had been noted to become dizzy after smoking, and to provide a safe environment. A smoking safety evaluation dated 11/17/25 documented that the resident had problems with balance while sitting or standing, had previously burned skin, clothing, furniture, or other items, and dropped ashes on self. The evaluation and care plan required staff to light the resident’s cigarette and monitor the resident while smoking. The facility’s smoking policy stated that any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer at all times while smoking.

In the weeks prior to the incident, multiple notes documented the resident’s increasing weakness, dizziness, and decline in functional status. On 11/20/25, staff found the resident on the floor after feeling weak and dizzy while going to get coffee, with reported head and neck pain. On 11/23/25, a CNA found the resident on the floor again, with the resident reporting dizziness, head impact, weakness, and confusion, leading to an ER transfer. Subsequent notes on 11/25/25, 11/26/25, 12/28/25, and 01/02/26 documented that the resident was weaker, had difficulty getting out of bed and into a wheelchair, had decreased appetite and fluid intake, was more fatigued, and had declined from being more independent to requiring one to two staff for ADLs. A note dated 12/23/25 documented the resident was found on the ground outside after attempting to transfer from a wheelchair to lawn furniture and slipping from the chair cushion to the ground.

On 01/08/26 at approximately 8:57 PM, a licensed nurse assisted the resident to the north patio smoking area, placed a smoking apron, and lit the resident’s cigarette. The nurse then went back inside the facility, leaving the resident outside on the patio without direct physical presence. The facility’s incident report later stated the nurse monitored the resident through the windows while at the nurse’s cart until the resident finished smoking, but the nurse then stepped away from the window when another staff member asked about another resident’s pain medication. At approximately 9:05 PM, the nurse heard the resident yell for help, went outside, and found the resident on the ground lying on the left side, with one slipper off. The resident reported losing balance when standing up and that the slipper came off, causing the fall. The resident was transported to the hospital, where imaging showed a non-displaced subcapital hip fracture and a mid-left femoral neck fracture, and surgery was performed to repair the hip. During interview, an administrative nurse stated she considered watching the resident from the window to be direct supervision and acknowledged that the resident’s slippers were at least two sizes too big, and that staff should have had the resident wear tennis shoes to go out to smoke.