F0689

J

Failure to Implement Fall-Prevention Orders and Bathroom Supervision Leading to Serious Resident Injuries

Jacksonville, Florida Survey Completed on 12-10-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistive devices to prevent falls, resulting in serious injuries to two residents. One resident with a history of hip replacement and documented right lower extremity weakness had an orthopedic follow-up visit where the physician specified weight bearing as tolerated with a walker and a hinged knee brace locked in extension with all weight bearing until quadriceps strength returned. An ARNP subsequently entered an order for the right lower extremity to be non‑weight bearing with a hinged knee brace locked in extension when weight bearing, every shift. The resident’s passport, dated several days before the fall, instructed that the brace be locked in extension, with hip precautions and no walking backwards or pivoting on the right lower extremity. However, the brace requirement was not added to the OT/PT precautions until nine days after the fall, and on the day of the incident the resident was not wearing the physician‑ordered hinged knee brace.

During an OT session, the resident participated in a simulated laundry task with a COTA. The resident was filling a basket attached to her walker when the basket started to fall. As the COTA attempted to adjust the basket, the resident stepped back on her unsupported right leg, lost her balance, and fell to the floor. She was wearing a gait belt and non‑skid socks but did not have the hinged knee brace in place. She immediately complained of right knee pain and was unable to move the knee. Initial x‑rays were negative, but an MRI later revealed a nondisplaced fracture of the proximal tibia and fibula, a tear of the body and posterior horn of the medial meniscus, moderate hemarthrosis, and mild subcutaneous edema. The facility’s investigation concluded that the resident was not wearing her physician‑ordered hinged brace, locked in extension, at the time of the accident, and that the brace order had not been incorporated into therapy precautions or the daily therapy schedule prior to the fall.

The second resident involved had multiple diagnoses including a right femur fracture with routine healing, a history of fall on the same level, malignant neoplasm of the lung with secondary brain neoplasm, long‑term anticoagulant use, history of TIAs, and severe protein‑calorie malnutrition. A fall risk assessment identified this resident as high risk, and she had active orders for Xarelto and a fall risk protocol including frequent rounding and toe‑touch weight bearing to the right lower extremity. She was care‑planned for risk of falls and injury related to falls, with interventions such as assessing footwear, observing for unsteadiness, and maintaining a clutter‑free environment. After an earlier fall event with family present outside the facility, her passport color was changed to indicate a fall, and red rounding signage was placed on her door to denote high fall risk and the need for frequent safety checks.

On the day of the second incident, a PTA took this high‑risk resident to the bathroom at her request before therapy. He transferred her to the toilet, placed the call light across her lap, and instructed her to pull it when she was finished, then left the room to treat another resident without remaining in arm’s length or line of sight and without notifying the nurse or CNA that she was on the toilet. The PTA later stated he did not see the fall‑risk sign on the door. Staff interviews and facility policies confirmed that residents with a STOP sign or high fall‑risk indicators required staff to remain in the bathroom within arm’s length or line of sight and that high fall‑risk residents were not to be left unattended on the toilet. Shortly after the PTA left, a CNA responding to the call light found the resident on the bathroom floor with a hematoma to the left forehead, an abrasion and hematoma to the left ear, and additional abrasions. A CT scan at the hospital revealed a subarachnoid hemorrhage in the right posterior temporal lobe, and the resident was admitted. The facility determined that the PTA failed to recognize posted fall‑risk signage and the requirement for stand‑by supervision while toileting and failed to inform nursing staff that the resident was in the bathroom alone before leaving.

The surveyors determined that these failures to ensure therapy orders were current, to integrate orthotic device orders into therapy precautions and passports, and to ensure therapy staff followed care‑plan safety interventions and bathroom safety protocols resulted in Immediate Jeopardy. The identified issues affected residents who required orthotic devices and those on the active therapy caseload, as the systems in place for communicating and implementing fall‑prevention measures, including passports, signage, and therapy precautions, were not consistently followed or updated.