Failure to Prevent Fall Injury and Control Hot-Liquid Burn Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and individualized interventions to prevent accidents for a cognitively impaired resident and across multiple resident-use floors. One resident with diagnoses including Alzheimer’s disease, epilepsy, and hypertension had a Minimum Data Set showing severely impaired cognition and a need for supervision or touching assistance when walking. The resident’s comprehensive care plan, last revised in February 2026, identified a high risk for falls related to dementia and impaired mobility, with interventions such as following the facility fall protocol, staff awareness of the resident’s location in common areas, supervision with a four-wheeled walker, and ensuring needs were anticipated and met. However, on an evening in January 2026, the resident was found sitting on the floor in the doorway between two lounges with a large hematoma on the left forehead and redness and soreness of the left kneecap, requiring transfer to the emergency department for further evaluation. The LPN who discovered the resident reported that the only care provided prior to the incident was medication assistance and that no toileting or ambulation assistance had been given. The incident documentation identified predisposing factors such as ambulating without assistance and non-compliance with safety recommendations, but there was no documentation of staff supervision, monitoring, or the resident’s location prior to the fall. The incident report did not include additional staff or CNA witness statements or a documented timeline indicating when the resident was last observed before being found on the floor. Although an intervention to complete routine safety checks was noted in the incident report, it was not incorporated into the comprehensive care plan, and there was no documented evidence that routine safety checks were implemented following the incident or upon the resident’s return from the hospital. Additionally, the deficiency extended across three resident-use floors where hot liquids at temperatures capable of causing burns were accessible to residents, including those with cognitive impairment requiring supervision, indicating that the environment on those floors was not kept as free of accident hazards as possible.
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