Failure to Follow Two-Person ADL Assistance Care Plan Resulting in Hip Fracture
Summary
The deficiency involves the facility’s failure to ensure that staff followed a resident’s care plan requiring two-person assistance for Activities of Daily Living (ADL) care, resulting in a fall and right hip fracture. The resident had multiple significant diagnoses, including cerebrovascular disease, a stage IV sacral pressure ulcer, malignant neoplasm of the breast, chronic pain syndrome, atrial fibrillation, and was receiving palliative care. The active care plan, revised in October 2025, documented that the resident had an ADL self-care performance deficit related to multiple conditions and required substantial/maximal assistance of two staff for bed mobility and dependent/total assistance with transfers using a mechanical lift with two staff and a medium pad. The care plan also identified the resident as being at risk for falls or fall-related injury due to impaired mobility and decreased safety awareness, and included interventions such as a bariatric mattress, bed in lowest position, bolsters, a left side mobility bar, and cues for safety awareness. On the date of the incident, the resident’s ADL care was provided by one CNA instead of two, contrary to the care plan. A review of the CNA task list from early December through early January showed that the resident had been documented as receiving one-person ADL assistance on 21 of 31 days reviewed, despite the care plan specifying two-person assistance for bed mobility and transfers. On the morning of the fall, a newly hired CNA (CNA B) reported that it was her first day of work and that she was being coached by another CNA (CNA A). When they entered the room, CNA A directed CNA B to care for the other resident in the room while CNA A cared for the resident with the two-person assistance requirement. CNA B pulled the privacy curtain and began providing care to the other resident. While doing so, she heard a thud and then heard CNA A exclaim that the resident was on the floor. When CNA B looked out from behind the curtain, she saw CNA A running toward the resident’s bed from the doorway, and observed the resident on her back toward her right side with her head toward the top of the bed; the bed was in a high position, and the resident was complaining of right hip pain. Further interviews and documentation clarified the circumstances of the fall. CNA B stated that she and CNA A had not reviewed the Kardex prior to entering the room and that, as a new employee, she did not know how to access the Kardex at that time; she later learned that the resident was obese and required two people for transfers and bed mobility. An LPN familiar with the resident reported that the resident was totally dependent for care by two staff members and confirmed that she was assigned to the resident on the day of the fall. The LPN stated that CNA A had asked her to obtain a wound dressing because the resident’s dressing was soiled, and while the LPN was getting the dressing, she heard CNA A yell that the resident was on the floor. The LPN found the bed raised and the resident lying on the floor between the beds, initially on her right side and then rolled to her back, with her head close to the wall and her hands on her head; the resident complained of head pain and stated she had hit her head. The resident was assisted back to bed with a mechanical lift and multiple staff, and shortly thereafter complained of severe right hip pain. Subsequent SBAR documentation, radiology reports, and hospital emergency department notes confirmed that the resident had sustained a mildly displaced right femoral neck fracture with femoral shaft impaction and an acute sub-capital fracture of the right femoral neck after being dropped by staff during a transfer, while taking Eliquis for atrial fibrillation and reporting right hip pain.
Removal Plan
- Suspended the CNA involved with the incident and terminated the CNA.
- Reported the CNA to the board of nursing.
- Held an ad hoc QAPI committee meeting with the Administrator, DON, and Medical Director to review the incident and plan to be implemented.
- Initiated and completed neglect education for licensed nurses and CNAs regarding proper positioning of residents in bed during routine care, wound care, and repositioning, with emphasis on abuse and neglect, and obtained staff signatures prior to the staff's first shift.
- Completed assessments to determine which residents required assistance with ADL care while in bed, proper positioning during care, and the number of people required to assist during care while in bed.
- Completed a comparison to ensure all residents' care plans and Kardexes accurately reflected residents' bed mobility needs and the number of staff required to assist.
- Initiated competencies for licensed nurses and CNAs in providing ADL care and repositioning residents during ADL care while in bed.
- Conducted an ad hoc QAPI meeting with root cause analysis and discussion.
- Completed the root cause analysis identifying the root cause as the CNA's failure to follow the resident's plan of care.
- Conducted an ad hoc QAPI meeting to ensure all QAA/QAPI components of the incident were addressed and in substantial compliance.
- Initiated ongoing monitoring of CNA documentation to ensure it matched the Kardex, visual confirmation that the appropriate number of staff provided care, and resident interviews when possible to confirm appropriate staffing was used for care.
- Provided education for all newly hired licensed staff and CNAs on reviewing the Kardex prior to providing care and using the appropriate number of staff for bed mobility.
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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