F0689

D

Failure to Supervise Resident With Alcohol Dependence After LOA and Improper Wheelchair Transport Securement

Philadelphia, Pennsylvania Survey Completed on 12-22-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with alcohol dependence following a leave of absence, and failure to ensure proper securement of another resident during wheelchair transport. The facility had a Substance Use Disorder (SUD) policy dated October 24, 2022, which defined SUD, required assessment of residents with a history of SUD, and called for interventions such as resident/family counseling and education on the SUD policy upon admission. A resident with diagnoses including alcohol dependence with withdrawal, hypertension, prostate cancer, and a history of falls was admitted and had a physician’s order to continue Naltrexone for alcohol cessation. Social work documentation noted the resident’s self-report of a history of drinking alcohol, and the admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact and able to make needs known.

The resident’s care plan dated September 30, 2025, identified a behavior problem of alcohol abuse related to physical and verbal aggression, but did not include a care plan or interventions addressing education or counseling of the resident or family regarding substance use during a leave of absence or the facility’s SUD policy. Nursing notes documented that on November 7, 2025, at 10:46 a.m., the resident went on an escorted leave of absence with a family member in stable condition. A Release of Responsibility for Leave of Absence form was completed with the resident’s name, date, time of departure, and expected return time, and contained the resident’s signature and an illegible escort signature, but no times were documented next to the signatures. The DON reported that the form was completed by the unit nurse and given to the front desk, and also stated there was no logbook at the front desk to sign residents in and out. The DON further indicated that the resident returned from the escorted leave on the same day.

On November 8, 2025, at 2:44 p.m., an incident fall report documented that the resident’s roommate notified the nurse that the resident was on the floor. The nurse found the resident sitting on the side of the bed with a cut on the forehead, holding a cup containing beer, and a bag on the floor with six cans of beer, four of which were opened. Four empty beer cans and one small empty bottle of unknown liquid were also found with the resident, and the resident had a smell of alcohol. The resident stated that they were sitting on the side of the bed, started to fall asleep, and fell, hitting their head. The resident was described as alert and oriented to place, people, and time, and independent with transfers and ambulation at baseline, and had been last seen by staff around 2:00 p.m. in stable condition in the room. Diagnostic imaging at the hospital was positive for a C1 fracture. There was no documented evidence in the clinical record that the resident was assessed upon return from the leave of absence or that any additional supervision was provided after the leave, despite the resident’s history of alcohol dependency.

A separate deficiency involved the facility’s failure to ensure that a resident was properly secured during transportation to an outside appointment, resulting in the resident sliding out of a wheelchair in a contracted transportation van. The facility’s undated Wheelchair Transportation Safety Policy required that transportation staff be trained, that vehicles be properly equipped and maintained, and that wheelchairs be fully secured using manufacturer-specified restraint systems before the vehicle moved. The policy also required visual inspection of equipment, confirmation that wheelchair brakes were engaged, and application of safety restraints before raising the lift and moving the vehicle. A cognitively intact, wheelchair-dependent resident with anxiety and a left below-knee amputation, who required partial assistance for sit-to-stand and supervision for transfers, was transported to an appointment with a nursing assistant escort.

Documentation submitted to the State Survey Agency indicated that on July 16, 2025, at approximately 2:00 p.m., the resident was returning from an appointment in a contracted transportation van when the driver hit a bump, causing the resident to partially slide out of the wheelchair. The escort reported that the wheelchair was only partially locked. The resident was transported to the hospital, where no fractures were found. In an interview, the resident stated that during the return trip they did not have a safety belt and the wheelchair was not secured, and that when the driver hit a bump, they fell out of the wheelchair and the wheelchair landed on top of them, causing excruciating pain. The nursing assistant escort confirmed that she was seated in the front seat of the van when the driver hit a pothole and the wheelchair moved, and that the driver stopped, re-secured the resident, and returned to the facility. The nursing assistant also confirmed she had not received any education on safety protocols or wheelchair securing or transport protocol since the incident. Facility documentation from July 16, 2025, showed that the transportation company reviewed video of the incident and determined that the driver did not properly secure the resident and was at fault.