F0689

G

Failure to Adequately Supervise Resident Outdoors and Maintain Ordered Fall-Prevention Interventions

Youngstown, Ohio Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and monitoring to prevent accidents, including hypothermia and falls, for two residents. One resident with respiratory failure, COPD, kidney disease, hypertension, arthritis, and tobacco use had a known history of staying outside for long periods and had previously been hospitalized for hypothermia while living in the attached residential care facility. After admission to the skilled nursing facility, the resident’s care plan identified behavior problems of refusing treatment and oxygen and staying outside for long periods, but interventions were limited to education on motorized wheelchair use, offering choices, emotional support, and maintaining a routine schedule. The care plan did not include comprehensive or individualized interventions addressing the resident’s safety risk or supervision needs when outside, nor did it specify a frequency of monitoring or checks for safety and supervision, despite the resident’s known behavior and prior hypothermia episode.

On the day of the incident, nursing documentation showed an assessment of the resident at approximately mid-afternoon, with no further nursing notes until late that night when the resident was found unresponsive. EMS records documented that the resident was found slumped over in his wheelchair outside the facility, very cold to the touch, with slow and shallow breathing, bradycardic peripheral pulses, and pinpoint, non-reactive pupils. Staff reported to EMS that the resident had been outside for an unknown amount of time. EMS was unable to obtain an accurate temperature, administer IV medications, or perform an ECG due to the resident’s condition and cold exposure, and they initiated warming measures. Hospital records later documented significantly low body temperatures and admission to critical care with altered mental status, low oxygen levels, and hypothermia. Interviews with the Administrator, DON, and Medical Director confirmed that the resident was known to stay outside for hours, that staff used routine one- to two-hour checks as a standard for all residents, and that more frequent checks specific to this resident’s risk had not been considered. There was no documentation of checks completed for the resident on the day of the incident, and the facility’s written investigation lacked staff statements, details of what the resident was wearing, and the temperature of the outdoor smoking area at the time he was found.

The second component of the deficiency concerns the facility’s failure to ensure that ordered fall-prevention interventions were in place for another resident with dementia, cognitive communication deficit, heart failure, and a history of falls. This resident was admitted from the on-campus assisted living unit due to falls and later sustained a left femoral neck fracture after a fall requiring hospitalization. The resident’s care plan included multiple fall-prevention interventions, such as keeping the call light within reach, maintaining a clutter-free room, providing a visual reminder to call for assistance, bilateral floor mats on each side of the bed, and a defined perimeter mattress. The resident’s fall risk assessment later identified the resident as high risk for falls, and progress notes and fall investigations documented multiple falls, with neuro checks and review of fall risks and interventions after each event. However, during an observation, the resident was found in bed with only one floor mat in place on the left side of the bed, while the other floor mat, which was ordered to be on the opposite side of the bed, was propped against a wall behind an empty bed across the room. A CNA confirmed at the time of observation that the floor mat was not in place as ordered, indicating that the prescribed fall-prevention intervention was not consistently implemented.