Failure to Use Gait Belts, Lifts, and Adequate Supervision Resulting in Resident Falls With Fractures
Summary
The deficiency involves the facility’s failure to provide adequate supervision, follow its own transfer and ambulation policies, and use appropriate assistive devices to prevent accidents for multiple residents. For one resident with diabetes, stroke, heart failure, severe cognitive impairment (BIMS 3), muscle weakness, and limited ROM, the MDS showed she did not walk 10 feet due to medical/safety concerns and normally used a manual wheelchair. Her care plan identified a brain injury, impulsivity, and non‑compliance with directions, and directed staff to assist her to ambulate with a gait belt and front‑wheeled walker and to transfer using a non‑mechanical lift. She was not on a restorative program, and staff interviews indicated she was mostly in bed, required significant assistance, and had not been ambulating to the bathroom for some time, with CNAs typically changing her in bed and transferring her to a recliner with assistance of two and a gait belt. On the date of the fall, an incident report and nursing progress notes documented that a CNA reported the resident lost her balance and fell while ambulating to the bathroom, and that the resident was found on the floor on her right side, screaming in pain, without a gait belt, with her walker tipped over nearby and her wheelchair by the bathroom wall. The RN and CNA assisted her back to bed without using a mechanical lift, despite her inability to bear weight, by grabbing her pants and sliding and lifting her into bed. EMS documentation and ED records described that EMS found her after a fall from her wheelchair with severe right shoulder pain, and the ED history stated she fell when trying to use her wheelchair for support while getting out of the shower. Imaging revealed an impacted right humeral fracture and a comminuted olecranon fracture with elbow effusion, and she was admitted for trauma management. The resident’s daughter reported that her mother had been mostly bedbound, could not walk during prior visits, and that she was told by the RN that the CNA had followed the resident with a wheelchair as she walked to the bathroom, which conflicted with her understanding of her mother’s abilities. Staff interviews revealed inconsistent accounts of the event and failures to follow policy and care plan directions. The RN stated the resident had not gotten up by herself in a long time, that she was found on the floor without a gait belt, and that a mechanical lift was not used to get her off the floor, contrary to facility policy for non‑weight‑bearing or extensive‑assist residents. The CNA involved gave differing versions of the incident, at one point stating the resident was assisted up from the recliner with a gait belt and walker and that a mechanical lift was used to get her into bed, which was contradicted by another CNA who entered the room and observed the resident being placed in bed without a gait belt and without a mechanical lift present. Investigative notes documented that the resident was impulsive, did not always follow directions or wait for staff, and had been caught ambulating on her own, yet the facility’s own documentation also stated she had not been ambulating and required significant assistance, indicating a lack of consistent implementation of care plan interventions and safe transfer policies. A second resident with weakness, unsteadiness on feet, and intact cognition required one‑person assistance with ambulation and maximal assistance for hygiene and toileting. Her care plan directed staff to assist with ambulation and transfers with moderate assistance of one staff using a gait belt and front‑wheeled walker. On the day of her incident, she walked to the bathroom with her walker, used the toilet, and activated the call light to request staff assistance for peri care. She reported that she waited a long time for help, that when the CNA arrived and began assisting her, she felt herself slipping and told the CNA, who responded "I've got you" but did not prevent her from sliding to the floor. She stated the CNA held her by the arm rather than using a gait belt, and that a second agency CNA came in and both attempted to get her into the wheelchair by her arms while she was unable to stand due to right leg pain, before the nurse arrived. Facility documentation of this fall described that the resident’s legs became weak during peri care and she was lowered to the floor, and that she was later found in the bathroom in a wheelchair with a gait belt on. The NP’s progress note, however, recorded the resident’s description that she slid down between the toilet and wheelchair when the caregiver did not use a gait belt despite her warnings that she was slipping. X‑rays revealed an acute trimalleolar fracture of the right ankle, and she required hospital evaluation, pain management with Fentanyl, and stabilization with a soft cast. The facility’s fall report and physician form characterized the event as a fall during transfer from toilet to wheelchair with legs becoming weak, but did not reconcile the resident’s account that a gait belt was not used and that she was lifted by her arms by two agency CNAs. Interviews with the agency CNAs involved in this second resident’s care showed that they were new to the facility, had not been oriented to the electronic record (PCC), did not know resident‑specific information, and were unfamiliar with the facility’s equipment and procedures. One agency CNA described the day as hectic, with staff sick and leaving, and stated that she answered a bathroom call light for a resident she did not know, assisted with peri care, and the resident started to fall. She called another agency CNA for help, and together they struggled to get the resident into the wheelchair before a nurse arrived; she reported that no one asked her what happened and she was not contacted afterward. The second agency CNA similarly described the shift as chaotic, stated she had no idea how to operate the facility’s mechanical lifts, and reported that she found the first CNA with the resident on the floor in front of the toilet, called for a nurse, and helped get the resident up. Nursing and administrative staff interviews acknowledged that agency CNAs were working with minimal orientation, that the ADON and DON were not directly overseeing their onboarding, and that there was uncertainty about how agency staff accessed care plans and fall‑prevention information, contributing to failures to use gait belts and appropriate transfer methods as required by facility policy. Facility policies on fall occurrences, gait belts, mechanical lifts, and non‑mechanical transfers specified that gait belts should be used when a patient is weak but can bear some weight and is a fall risk, and that mechanical lifts should be used for non‑weight‑bearing or total/extensive assist transfers, while non‑mechanical lifts are appropriate only when a patient can bear partial weight and follow commands. In both residents’ cases, the documented conditions (weakness, impaired balance, need for significant assistance, and in one case inability to bear weight after the fall) and the care plan directions were not consistently followed. Staff failed to use gait belts during transfers and ambulation, did not use mechanical lifts when residents could not safely bear weight, and did not ensure that agency CNAs were adequately oriented to resident needs and facility safety policies, leading to falls with significant injuries for the residents involved.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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