F0689

D

Failure to Assess Lift Chair Use and Complete Post-Fall Neurological Monitoring

Emporia, Kansas Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assessment to prevent accidents. One resident with diabetes, restless leg syndrome, peripheral neuropathy, impaired vision and hearing, morbid obesity, pain, and documented moderate cognitive impairment used an electric lift recliner brought in by family. The resident’s care plan and CAAs identified fall risk factors and need for supervision with mobility and transfers, and fall risk assessments showed the resident was at risk for falls. However, the electronic health record contained no assessment for the resident’s use of the electric lift chair, despite its arrival months earlier and the resident’s cognitive and physical limitations.

The same resident later experienced a fall from the electric lift recliner when she raised the chair to a high position and slid forward out of it. Staff responded to yelling and found the resident on the floor with the recliner fully elevated. The resident reported attempting to get out of the recliner and raising it too far, which caused her to slide out of the chair. An assessment identified a skin tear to the back of the resident’s hand. Administrative nursing staff later confirmed that the facility had not completed an electric lift chair assessment when the chair was brought in, and that such an assessment should have been completed at that time, annually, and with any change in condition, as part of the facility’s fall risk identification and intervention process.

Another resident with diagnoses including repeated falls, right arm fracture, anxiety, difficulty walking, and muscle weakness had a history of falls, including a fall with major injury. The resident’s falls CAA and care plan documented risk factors such as prior falls with fracture, incontinence, impaired vision, impaired mobility, and medication use, and directed that the resident be instructed to use the call light for assistance. After a fall in the resident’s room that resulted in visible injuries and transfer to the emergency room, the neurological assessment documentation in the EMR showed multiple required checks either missing or populated with vital signs time-stamped from dates prior to the fall. Several 15‑minute, 30‑minute, 60‑minute, and shift neurological checks were not completed or lacked completion times, and some entries used vital signs recorded days before the fall, contrary to the facility’s neurological assessment policy that required a structured series of timely neurological screenings after a head injury.