F0689

G

Failure to Provide Safe ADL Assistance and Adequate Supervision Resulting in Fall Injuries and Unauthorized Exit

Cleveland, Ohio Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate, safe assistance during ADLs/personal care for a quadriplegic resident and failure to provide sufficient supervision to prevent another cognitively impaired resident from leaving the facility unsupervised. One resident, who was cognitively impaired, quadriplegic, and had multiple contractures, was dependent on staff for toileting, bathing, personal hygiene, bed mobility, and transfers. His care plan identified him as at risk for falls related to immobility and paralytic syndrome and required mechanical lift transfers with assistance of two staff members for transfers and mobility, but it did not specify the number of staff required for bathing, bed mobility, dressing, or incontinence care. Staff interviews, including an RN and LPN, indicated that this resident required two staff members for all care because he was unable to move himself.

On the evening of the incident, a CNA provided personal care to this quadriplegic resident alone. According to the CNA’s written statement, the resident was placed on his right side during care and rolled off the bed. The LPN who responded reported that the CNA told her he had lost his grip on the resident during care. The LPN observed the resident on the floor in a fetal position with his head against equipment, and another CNA later described the resident as wedged between the floor and the nightstand with blood around his mouth. Initial nursing documentation noted shearing to the right knee and a new pain level of 3–4 out of 10 after the fall, and pain medication was administered. The fall investigation documented that the resident rolled from bed during care but did not identify the root cause, did not clarify the level of assistance that should have been used, did not document whether the resident hit his head, and did not show that neurological checks were completed.

Hospital records from the subsequent emergency department visit documented that the resident had sustained a four-foot fall from bed during care and arrived with multiple fractures to the left pelvis and left hand, a hematoma to the left eyebrow, and abrasions to the right knee and left ankle and toes. EMS reported that facility staff were initially hesitant to send the resident to the hospital and that he was transported after family request. The DON later acknowledged being informed that the CNA had provided care unassisted and that the care plan did not specify that two staff were required for ADLs, although it did indicate the resident was total care. The facility’s falls policy required staff to identify risk factors and define possible causes for falls and to identify pertinent interventions to prevent subsequent falls, but the investigation for this event did not fully address these elements.

The second component of the deficiency concerns a resident with vascular dementia, impaired cognition, difficulty walking, and lack of coordination, who required supervision with ambulation and bed mobility. The resident’s care plan identified fall risk and impaired cognition, with interventions to assist with transfers and mobility and to encourage participation in daily decisions, but it did not address wandering or elopement. An elopement assessment rated the resident at low risk for elopement, and there were no physician orders authorizing leave of absence (LOA) privileges during the period reviewed.

On the date of the incident, the resident left the facility without staff awareness or a documented sign-out. Nursing staff, including the assigned LPN and an RN on duty later in the day, reported they were unaware the resident had left until notified by a supervisor or by police. The receptionist recalled seeing the resident earlier in the afternoon but did not recall seeing her leave or having visitors and later received a call from police indicating the resident was at the police station. Hospital documentation stated that the resident had escaped from the facility, was wandering outside looking for her husband, tripped on a curb, fell, and struck her head, resulting in a skin tear to the right elbow and superficial lacerations to multiple digits of the right hand. The DON confirmed that the resident had impaired cognition, that no LOA orders were in place, and that the administrator reported the event to the state as an unauthorized LOA. The facility’s LOA policy required that residents who are not their own responsible party leave only with a responsible party who signs them out at the front desk, but this process was not followed in this case.

The combination of these events—providing one-person assistance during personal care to a quadriplegic, totally dependent resident whose care needs effectively required two staff, and allowing a cognitively impaired resident to leave the building unsupervised without LOA authorization or staff awareness—formed the basis of the cited deficiency for failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assistance to prevent accidents.