F0689

G

Failure to Implement Fall and Hazard Prevention Measures for Multiple Residents

Dubuque, Iowa Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents for multiple residents. For one resident with coronary artery disease, hypertension, peripheral vascular disease, cerebrovascular accident, non‑Alzheimer’s dementia, severe memory problems, and severely impaired decision‑making, the MDS showed dependence on staff for personal hygiene and dressing, substantial assistance needed for bed mobility, and a history of falls. This resident was found with his left knee resting against a metal heater while lying on his side in bed, with his pants pulled up to the knee, resulting in open areas and later‑described superficial burns/abrasions to the left knee. Staff and hospice documentation and interviews described the wounds as skin tears, abrasions, popped blisters, or possible burns, with full‑thickness skin loss in multiple irregularly shaped areas and a large surrounding area of redness. Temperature checks of the heater in the resident’s room showed metal surface temperatures ranging from approximately 107°F to over 139°F, and staff acknowledged the resident’s knee had been against the heater and that the heater was hot or warm to the touch.

The same resident, who was care planned as high risk for falls with an intervention that he not be left alone in his room in a wheelchair (identified by a “wheelchair star” tag), experienced a fall when CNAs left him alone in his room in his wheelchair while they went to get an EZ stand lift. He was later found face down on the floor in front of his wheelchair with an abrasion and hematoma to the forehead, a bruise to the nose, and a skin tear to the left elbow. Observations and interviews revealed that the star tag was not present on his wheelchair at the time of survey, some staff were unaware of or stated they no longer used the star program, and there was inconsistency in how staff were informed of residents’ transfer and supervision requirements. Staff interviews confirmed that the resident was not supposed to be left alone in his room in a wheelchair, and the DON stated staff did not follow the plan of care when they left him alone, after which he fell.

Another resident with hypertension, diabetes, depression, severe cognitive impairment, and a need for maximal assistance with transfers was care planned to require two‑person assistance with an EZ stand lift. Despite this, one CNA transferred the resident alone using a pull‑up bar, and on a later date another CNA attempted to transfer the resident from an electric recliner using a gait belt and walker after the resident stated she could walk, rather than using the EZ stand with two staff as required. During the latter event, the CNA raised the power recliner, attempted to have the resident bear weight, and the resident slid out of the chair to the floor. The following day, the resident was found with a bruised, swollen, and painful right ankle, unable to move it, and an x‑ray showed a mildly displaced fracture of the lateral malleolus. Multiple CNAs and nurses reported inconsistent or unclear methods for determining transfer status (door signs, wing sheets, binders, magnets, or the electronic kardex), and agency staff reported they had not been educated on where to find transfer information.

A third resident with repeated falls, weakness, gait abnormalities, and moderate cognitive impairment was care planned to ambulate with assistance of one and a front‑wheeled walker, to have gripper socks applied, to have auto‑lock brakes on the wheelchair, and to have wheelchair foot pedals removed unless being propelled. The care plan also directed removal of white socks from the room because the resident removed shoes and gripper socks. Observations on multiple days showed the resident repeatedly in bed or standing and transferring while wearing only white socks, without shoes or gripper socks, and often without a gait belt. The resident was seen standing from bed and transferring to a wheelchair without gripper socks or shoes, self‑transferring between bed and wheelchair, and ambulating in the room with wheelchair pedals attached and brakes not locked. During one observation, the resident stood up with the wheelchair brakes not effectively engaged, and the wheelchair rolled backward and bumped into furniture. Staff acknowledged the anti‑lock brakes were not functioning properly and required maintenance, and the DON later stated the resident was not supposed to have white socks in the room, indicating the care‑planned interventions to prevent falls and accidents were not consistently implemented.