Failure to Adequately Supervise High-Fall-Risk Resident and Safe Handling by Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices to prevent accidents for a resident with an unsteady gait and high fall risk. The resident had diagnoses including non-Alzheimer’s dementia, muscle weakness, and difficulty walking, and a quarterly MDS documented severely impaired cognition. The MDS also showed the resident required partial/moderate assistance for walking 50 feet and for transfers from sitting to standing, and that the resident used a wheelchair for locomotion. The resident’s fall care plan included interventions such as keeping rooms and hallways well-lit, clean, and clutter free, ensuring the call bell was within reach, encouraging and reminding the resident to call for assistance, providing properly fitted footwear and gripper socks at night, and providing assistance with ADL care as needed. On the date of the incident, surveillance video from the unit showed that at approximately 4:38 PM the resident got up from their wheelchair and ambulated up the hallway with an unsteady gait while holding onto the handrails. The resident then walked across the hallway to a cart stocked with personal protective equipment and rolled the cart into two residents’ rooms. During this time, staff were observed going in and out of residents’ rooms, and there were three CNAs and one LPN assigned to that side of the unit. Staff interviews indicated that one CNA was monitoring residents in the dining room, another CNA was taking residents to their rooms for incontinence care before dinner, and the LPN was administering medications while also monitoring residents sitting in the hallway. The video further showed that when one CNA observed the resident entering a room with the cart, the CNA stopped, went into the room behind the resident, and rolled the cart back into the hallway. The CNA was then seen standing in the doorway pulling the resident by the arm, pulling the resident into the hallway, and holding the resident under the left armpit while pulling the resident up the hallway toward the wheelchair as the resident resisted. The CNA then placed the resident on the edge of the wheelchair; as the resident resisted sitting, the CNA held the resident under the armpit and by the pants and dragged the resident back into the wheelchair. The CNA pushed the resident’s upper body forward while their right hand moved back and forth at the resident’s lower back, appearing to hit the resident on the buttock, and the resident’s body jerked forward. Interviews with CNAs, the LPN, the RN Supervisor, and the DON confirmed that staff were expected to monitor residents in the hallway and dining room and that the resident was on hourly visual monitoring, but the resident was nonetheless able to ambulate unassisted and manipulate the cart in the hallway and other residents’ rooms.
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