Failure to Prevent Heater Burns and Address Post-Heimlich Rib Pain
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and assessment, resulting in serious injuries to two residents. For the first resident, who was actively dying on hospice with lung cancer, poor skin integrity, lethargy, severe pain, and non-verbal pain behaviors, staff did not adequately identify and address the risk posed by a baseboard heater located directly next to the bed. Multiple staff reported that this resident frequently swung or placed her legs off the bed and onto the heater, yet there was no care plan addressing burn risk from the heater prior to the incident. On the night of the burn, documentation showed the resident was to be turned and repositioned every two hours, but the Treatment Administration Record reflected only four documented repositioning times out of 24 opportunities over two days, and surveillance video from midnight to 5:30 a.m. showed only four very brief room entries before the burn was discovered, contradicting staff statements that checks occurred every 30 minutes or every two hours. In the early morning, the resident was found in bed with her left leg hanging off the side and on top of the baseboard heater, with her foot wedged in the heater according to one staff account. Staff described the burn as a significant second-degree burn from the toes to the heel, covering the entire bottom of the left foot, with additional second-degree burns on the left calf and toes, and with substantial fluid and blood drainage. At the time she was found, the resident was not responsive to verbal or physical stimuli and could not report pain. Staff applied cool, wet cloths to the leg and foot. Witnesses reported that the bandage on the burn appeared new when hospice arrived later, despite the burn having occurred earlier that morning, and one staff member stated the leg did not get wrapped until after the resident passed away. The Skin Observation Tool documenting the second-degree burns and identifying the baseboard heater as the cause was not signed until eleven days after the event. The physical environment also contributed to the hazard. The maintenance staff member reported that wall heating units had been damaged over the years, with missing parts and sharp metal edges, and that he relied on floor staff to notify him of damage; several damaged heat registers had not been reported and had no work orders. He stated that room temperatures should be 72–82°F and heat registers 140–150°F, but temperature checks performed with a facility temperature gun in multiple rooms showed heater surface temperatures ranging from 190°F to over 200°F and described as very warm to the touch, with one resident and family member complaining that it was too hot. Maintenance also acknowledged that no heater temperature checks had been completed since the burn incident. These conditions, combined with the resident’s known behavior of placing her legs on the heater, her dependence for repositioning, and the lack of documented frequent monitoring and a specific care plan for heater-related burn risk, led to the resident sustaining extensive second-degree burns. For the second resident, the deficiency centers on the facility’s failure to adequately assess and respond to ongoing rib pain following two choking incidents in which the Heimlich maneuver was performed. This resident had severe cognitive impairment, as evidenced by Brief Interview for Mental Status (BIMS) scores of 4 and later 0, and a history of serious injuries including complex pelvic and rib fractures identified after a later fall. During the first choking incident, staff performed the Heimlich maneuver while the resident remained seated in a chair. Nursing progress notes documented that shortly afterward the resident complained of soreness and then persistent right lower rib pain, with pain levels reported up to 7/10 and later 8/10. The notes show repeated complaints of right rib pain over several days, with the resident sometimes declining hospital evaluation and PRN Tylenol, and at other times accepting Tylenol, which made the pain tolerable but did not resolve it. Despite the resident’s severe cognitive impairment, the facility relied on his stated preference not to go to the hospital and did not consistently re-engage the responsible party after the initial contact, nor did they obtain diagnostic evaluation for the rib pain. Nursing documentation shows that after the first choking event, the resident’s pain complaints continued daily, and a second choking incident occurred a few days later, again requiring the Heimlich maneuver. The provider ordered monitoring for pain after the second choking event, but there were no X-rays or other diagnostic tests ordered in response to the ongoing rib pain. Vital sign records show incomplete documentation of pain scores on several days when progress notes indicated the resident was in pain. The resident’s care plan was later found to be missing from the EHR, and there was no speech/swallow evaluation because the usual hospital-based speech therapist position was vacant. When the resident subsequently fell and was sent to the ER for hip pain, hospital records identified a complex pelvic fracture and nondisplaced fractures of the right 6th and 7th ribs, confirming rib fractures that had not been previously evaluated despite days of documented rib pain following the Heimlich maneuvers. Facility leadership stated they did not further review the rib fractures as a concern because the resident was on hospice and they focused on overall pain management, but the record shows limited use of PRN analgesics and no escalation of assessment in response to persistent pain complaints. Facility policies in place at the time required frequent monitoring of terminal residents, a structured and documented repositioning program for residents in bed at least every two hours, and reassessment of acute or significantly worsened pain every 30–60 minutes until relief was obtained. The documented practices for both residents deviated from these expectations. For the first resident, there was inadequate documentation of repositioning and monitoring, no pre-incident care plan addressing known heater-related behaviors, and environmental heater temperatures far exceeding the stated range. For the second resident, there was incomplete pain assessment documentation, reliance on the expressed wishes of a severely cognitively impaired resident without consistent involvement of the responsible party, absence of diagnostic evaluation despite persistent rib pain after forceful abdominal thrusts, and a missing care plan in the EHR. These actions and inactions led surveyors to cite the facility under F689 for accidents and hazards, with an Immediate Jeopardy determination related to the first resident’s heater burns.
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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