Failure to Ensure Safe Transfer and Timely Post-Fall Assessment After Head Injury
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not ensuring safe transfers, timely post-fall assessment, neurological monitoring, and prompt physician notification after a fall with a head injury. The resident had Alzheimer’s disease and a severely impaired cognitive status, with a BIMS score of 3, and physician orders for a Hoyer lift with two staff for transfers. She was also receiving aspirin and Plavix, both antiplatelet medications. On the night in question, while a CNA was providing incontinent care and repositioning the resident onto her side, the resident grabbed the bed or sheet and pulled herself toward the edge, slipping between the bed and the wall and falling to the floor on her right side. Following the fall, the CNAs manually lifted the resident back into bed by her arms and legs without using the ordered mechanical lift and without a licensed nurse present to assess her at the time of the incident. Although CNA staff reported that they notified certain LPNs, those LPNs later denied being informed at the time of the fall. The facility’s incident report and late nursing documentation did not accurately capture the actual date and time of the fall, instead reflecting later dates and omitting the true timing of the event. The incident report also documented that the resident was assessed only after bruising was noted on the right shoulder, and it did not specify when the fall actually occurred. Over the next one to two days, staff identified bruising and a hematoma on the resident’s head and right shoulder, with tenderness and guarded but functional range of motion. Neurological checks were not initiated immediately after the fall, and when a hematoma on the resident’s head was observed by an LPN, the medical provider was not notified at that time because the nurse believed the injury appeared old. The DON was not informed of the fall until two days after it occurred and did not review the earlier nursing notes documenting the hematoma, nor did he physically assess the resident’s head when he did assess her. The medical provider was not informed of the head hematoma and was only notified of the fall days later, at which point he ordered a right shoulder X-ray but no immediate evaluation for the head injury. The resident continued to receive aspirin and Plavix from the time the head injury was first documented until she was later transferred to the hospital for altered mental status, where imaging revealed a large right hemispheric subdural hematoma with midline shift. The facility’s failures in safe transfer technique, immediate licensed nurse assessment, timely neurological monitoring, and prompt physician notification after the fall and head injury were determined to constitute neglect and resulted in serious harm to the resident.
Removal Plan
- The Director of Nursing was notified by a Licensed Practical Nurse regarding discoloration observed on Resident #1's right shoulder.
- A Registered Nurse assessed Resident #1 and obtained an order for a right shoulder X-ray.
- The Director of Nursing contacted a Licensed Practical Nurse to inquire about any knowledge regarding Resident #1's fall.
- The Director of Nursing interviewed a Certified Nurse Assistant regarding Resident #1's fall and obtained a verbal account of the incident.
- The Director of Nursing interviewed a Licensed Practical Nurse regarding Resident #1's fall and obtained a verbal account of the incident.
- A Licensed Practical Nurse initiated a facility-based incident report regarding Resident #1's fall and completed the associated documentation of the event.
- The Director of Nursing reviewed Resident #1's neuro check log to ensure no abnormalities and continued neuro checks to monitor for neurological deficits.
- Nursing staff completed neuro checks for Resident #1 and found no neurological deficits, with the resident remaining at baseline.
- Resident #1 was noted to have drooping to the left side and slurred speech; the Nurse Practitioner was notified and orders were obtained to transfer to the local hospital.
- Resident #1 was transferred to the local hospital.
- The Director of Nursing conducted an audit of all current residents who had an accident or incident in the past thirty days to determine whether any other residents were potentially affected.
- The Director of Nursing provided education to all licensed nurses and Certified Nursing Assistants on fall prevention, safe handling, and proper resident transfers, including neuro checks, change in condition notifications, Abuse and Neglect protocols, Resident Rights, and the Vulnerable Adult Act, with staff required to complete the training before returning to work.
- The Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing, and Corporate Clinical Specialist held an ad hoc QAPI meeting regarding Resident #1's fall, the investigation, the immediate jeopardy, and the corrective action plan; the fall prevention policy was evaluated and reviewed to incorporate updated procedures and training for new staff on adhering to the Interact Care Path for acute mental status changes.
- A Resident Council meeting was held to inform residents that the facility received an Immediate Jeopardy citation due to inadequate lifting techniques and failure to assess a resident after a fall.
- The Administrator, Director of Nursing, and Corporate Clinical Specialist conducted a comprehensive review of the investigation to perform a root cause analysis and identified a failure in communication as the primary issue.
- A Certified Nurse Assistant received individual training on identifying each resident's lifting status per the care plan and safe handling/lifting procedures and received a disciplinary action.
- A Licensed Practical Nurse received a one-to-one inservice on Abuse and Neglect, Resident Rights, the Vulnerable Adults Act, notification of change in condition, fall prevention, and safe patient handling/moving protocols and received a disciplinary action.
- A Certified Nursing Assistant received individual training on identifying each resident's lifting status per the care plan and safe handling/lifting procedures and received a disciplinary action.
- The Director of Nursing conducted a training session for all licensed nursing staff regarding adherence to the Interact Care Path for acute mental status changes following post-fall assessments, with completion mandatory prior to return to work.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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