F0689

D

Failure to Provide Adequate Supervision and Safe Assistance Resulting in Multiple Falls and Injury

New Albany, Ohio Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and assistance to prevent falls and injuries, particularly for residents with cognitive deficits and those requiring extensive assistance. One resident with Alzheimer’s disease, dementia, a history of falls with fractures, and a high fall‑risk score experienced three falls within a short period. The care plan identified fall risk and listed general interventions such as keeping the floor free of objects, ensuring call light and personal items were within reach, providing nonskid footwear, and staff assistance with transfers. After the first fall, which occurred when the resident became anxious after family left and attempted to self‑transfer, the facility added dycem to the wheelchair and later an intervention to keep the resident in common areas after family visits. Despite these measures, the resident was next observed falling from his wheelchair in the hallway, striking his head and requiring ER evaluation, and then sustained a third fall in his room with painful and limited lower extremity range of motion. The record showed the resident was not assessed after these falls for further injury, including vital signs.

Another resident with dementia, moderate cognitive impairment (BIMS score 8/15), impaired mobility, and multiple medical conditions including peripheral vascular disease, heart failure, and a left below‑knee amputation was initially assessed as low fall risk. The care plan included general fall‑prevention interventions and later added toileting after meals and at bedtime and bilateral floor mats. This resident experienced multiple falls, most associated with attempts to self‑transfer for toileting or getting in and out of bed. The resident was found on the bathroom floor after attempting to go to the bathroom, again on the bathroom floor between the wheelchair and toilet after sliding during a transfer, on the floor in the room after attempting to get out of bed, and under the bed during a meal pass after stating he was trying to fix the bed. Later, the resident was seen sliding out of the wheelchair onto the floor and was found on the floor in front of the bed after attempting to get into bed. For at least one of these falls, the post‑fall investigation documented no root cause and no new intervention. The record also showed the resident was not assessed after falls for further injury, including vital signs.

A third resident, who had no cognitive deficit but was dependent on staff for toileting, lower‑body dressing, bed mobility, and required substantial/maximal assistance for showers and sit‑to‑stand, fell from bed during incontinence care. While a CNA was turning the resident away from herself, the resident rolled out of bed, struck her head on the closet, and sustained a bleeding abrasion that required ER evaluation. The facility later documented that the CNA had rolled the resident away from her while working alone, and the DON confirmed that no resident should be rolled away from staff when the staff member is working alone. Across these cases, staffing schedules showed three CNAs and two nurses on night shifts for 47–48 residents, with each CNA responsible for one hallway plus additional rooms and each nurse responsible for two hallways. A CNA interview indicated that with the usual staffing pattern, when staff are in a room or on another hallway, residents who require increased supervision cannot be adequately supervised. The facility’s fall management policy stated that nursing staff would monitor and document resident response and effectiveness of interventions for 72 hours after a fall, but the records for these residents did not show post‑fall assessments including vital signs.