F0689

G

Failure to Provide Adequate Supervision and Maintain Fall-Prevention Measures

Seneca, South Carolina Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to keep the environment free of accident hazards and to provide adequate supervision and fall-prevention interventions for multiple residents at high risk for accidents. One resident with vascular dementia, severe cognitive impairment (BIMS score 0), gait and balance problems, muscle weakness, vision/hearing impairment, and benign essential tremors was care planned and assessed as high risk for falls. On the day of the incident, this resident was taken from the second floor to an outdoor area by an LPN who was not the assigned nurse, along with two cognitively intact residents who had requested to go outside. The LPN left all three residents outside and returned to the unit without confirming supervision arrangements with the assigned nurse and without locking the cognitively impaired resident’s wheelchair brakes. The gate that helped secure the patio area was not latched, and the facility did not routinely use the padlock on the gate except during high windstorms.

While the residents were outside, the receptionist was at the front desk answering phones and assisting visitors and did not continuously monitor the residents. After approximately 15–20 minutes, one of the other residents stood up from their wheelchair and began yelling for help after observing the cognitively impaired resident roll down a sloped walkway toward a gazebo. Staff responding to the receptionist’s call for help found the resident lying on their left side on the sidewalk with the wheelchair flipped on top of them, approximately 30–55 feet from the front door. The resident was screaming in pain, had skin tears on the left arm and finger, an externally rotated left leg, and complained of pain in the buttocks and left hip. Emergency medical services transported the resident to the hospital, where imaging showed an impacted left femoral neck fracture. Interviews with the DON, nurse practitioners, and the resident’s responsible party confirmed that this resident was not appropriate to be outside without direct staff supervision and that the facility had no policy defining which residents could go outdoors alone or criteria for levels of supervision.

The facility also failed to implement and maintain fall-prevention interventions for two additional residents with severe cognitive impairment and high fall risk. One resident with aphasia, dementia, muscle weakness, gait abnormalities, unsteadiness, and a history of frequent falls was care planned for a wheelchair sensor alarm per family request, and the fall risk evaluation identified the resident as high risk. During supper, this resident was found on the floor in the common area, unconscious, after staff heard a loud bang and a verbal cue telling the resident to sit down. The resident had hit their head, lost consciousness, developed a large bruise on the left forehead, and later complained of left hip pain; hospital records documented a nondisplaced pubic body fracture. Post-fall checks by CNAs and the RN revealed the resident’s chair alarm box was in the off position and had not been turned back on after toileting.

Another resident with Parkinson’s disease, dementia, lack of coordination, muscle weakness, unsteadiness, and gait abnormalities had severe cognitive impairment (BIMS score 2) and was care planned and ordered to have sensor pads in bed and wheelchair every shift for safety. The MDS documented daily use of a chair alarm. During surveyor observation, this resident was seated in a scoot chair in a common area with a sensor chair pad in place, but the alarm box switch was in the off position, rendering the alarm ineffective. The assigned LPN and the DON confirmed that the alarm in the off position would not alert staff when the resident shifted weight or attempted to get up, and that staff were expected to follow all care-planned interventions. These findings show that for three high-risk residents, the facility did not ensure appropriate supervision, secure environmental controls, or consistent use of ordered fall-prevention devices, resulting in accidents and injuries for two of the residents.