Failure to Ensure Resident Safety in Smoking Practices
Summary
The facility failed to ensure the safety and well-being of a resident who was reviewed for smoking. The resident, who had a medical history of dementia, delirium, and nicotine dependence, was admitted to the facility and was identified as a smoker. Despite the resident's severe cognitive impairment, the facility did not implement adequate interventions to ensure the resident's safety and compliance with the smoking policy. The resident continued to smoke unsupervised, refused to turn in their lighter, and smoked used cigarettes found on the ground, which posed a significant safety risk. The facility's smoking policy required that residents who smoked be assessed for their ability to smoke safely and that any smoking-related privileges, restrictions, and concerns be noted on the care plan. However, the facility failed to enforce these policies effectively. The resident's care plan included interventions such as applying a protective apron during smoking and keeping the resident's cigarettes and lighter, but these interventions were not adequately implemented. The resident was observed smoking outside designated times and areas, and staff failed to remove the lighter or provide necessary supervision. Interviews with facility staff revealed a lack of consistent communication and documentation regarding the resident's smoking behavior and the necessary interventions. The Director of Nursing and other staff members were aware of the resident's non-compliance with the smoking policy, but additional interventions were not implemented in a timely manner. The facility's failure to address the resident's smoking behavior and ensure compliance with the smoking policy resulted in a situation that was likely to cause serious harm to the resident and others.
Removal Plan
- Immediate Smoking Assessments: All identified residents who smoke were assessed for safety risks, including cognitive impairment and ability to handle smoking materials safely. Residents were identified based on their current desire to smoke. The resident smoking assessment titled, Resident Smoking Initial Assessment, was completed for the identified residents. The assessments were completed, and the residents' care plans were updated accordingly.
- The active smoker list was updated to include Resident #37.
- All residents were previously assessed on admission for a desire to smoke. All new residents will be assessed on admission if they have a desire to smoke. This will be completed by admitting nurse.
- All identified residents were re-educated on the risk vs benefit of following the smoking policy.
- All other necessary interventions including supervised smoking, appropriate storage of smoking materials, smoking in designated areas, and offering of aprons were implemented immediately.
- Immediate Supervision Implementation: The smoking program was reviewed for resident safety by the interdisciplinary team including the Administrator, Activities Director, Director of Nursing, Medical Records Director, Director of Staff Development, Social Services, and the Medical Director.
- Staff were educated by the Director of Staff Development. Staff education included nurses, nurse assistants, activity assistants, department heads, dietary, administration, and housekeeping. Education included how to ensure smoking activities occur in designated, supervised areas to prevent unsupervised smoking and reduce fire hazards. Additionally, staff were trained on the importance of supervision and monitoring of smoking residents, including the prevention of unsafe practices. Education will be ongoing with an expected completion of all staff. Education will be conducted by the Director of Staff Development or designee. Any additional staff or new staff will be given a one on one education prior to start of shift.
- Training on the importance of supervision and monitoring of smoking residents, including the prevention of unsafe practices will be provided for all new hires by Director of Staff Development as part of the orientation process.
- Restriction of Smoking Materials: Any potentially dangerous items, including lighters or cigarettes, have been removed from residents' rooms.
- A lighter was removed from Resident #37's room by CNA.
- All rooms were visually inspected, and residents were asked for any smoking paraphernalia. There was no additional smoking paraphernalia.
- The Activities Director will conduct a monthly sweep visually inspecting all resident rooms and asking for smoking paraphernalia. The Activity Director was educated to this responsibility by the Administrator and Director of Nursing.
- All Staff including nurses, nurse assistants, activity assistants, department heads, dietary, administration, and housekeeping educated by the Director of Staff Development that staff who identify smoking paraphernalia should report it to Administrator or designee. All staff off site were educated via phone by department heads, administrator or designee.
- Revised Smoking Policy and Agreement Enforcement: A smoking agreement has been reintroduced and enforced for all residents who smoke, with clear guidelines about safe smoking practices, supervision, and the need to follow all facility policies. The smoking agreement was revised to better match the facility's smoking policy and procedure. A revision was made indicating that aprons are offered and strongly encouraged based on assessment, instead of requiring an apron to be eligible for the smoking program.
- Residents have the right to refuse smoking apron. Staff will continue to offer and encourage the apron. In the event of a refusal, the resident will be educated on the risk vs. benefit of the apron use. The resident will be provided supervision during smoking by Activity aide or designee during smoke break. Fire blanket and fire extinguisher are available in smoking area.
- Staff assisting residents who refuse to wear apron will notify the Activity Director or designee. Activity aides were trained by Activity Director. The Activity Director or designee will bring this to the attention to the interdisciplinary team during the interdisciplinary team meeting. This will then be care planned by nursing during the interdisciplinary team meeting.
- Residents who refuse to sign the agreement will have their smoking materials stored securely and will only be allowed to smoke under direct supervision. Residents who refuse to sign will be asked to turn in any smoking paraphernalia. If resident refuses to voluntarily give up paraphernalia the interdisciplinary team including the administrator, director of nursing, activity director, medical record director, director of staff development, infection preventionist, social services or other designee, will confiscate smoking materials as per our policy or discharge the resident.
- Residents who refuse to sign will be placed on every shift visual monitoring for smoking paraphernalia. Monitoring will be done by licensed nurses. Licensed nurses were trained by Director of Staff Development and Director of Nursing.
- Staff Education and Training: Facility staff, including nurses, nurse assistants, activity assistants, department heads, dietary, administration and housekeeping, have been immediately educated on the updated smoking policy, the importance of smoking assessments, and how to ensure that all smoking activities are managed safely. The education was conducted by the Director of Staff Development.
- Environmental Safety Measures: Fire safety training was given by fire training vendor.
- Additionally, fire safety training was done by the Director of Staff Development. Staff educated included nurses, nurse assistants, activity assistants, department heads, dietary, administration and housekeeping. Training was completed, and additional fire safety measures, such as fire extinguishers and fire blankets near designated smoking areas, have been implemented. Staff not currently in facility were called and educated by the Director of Staff Development via phone.
- Safe smoking area training was done for the Activities Director and activity assistants. Training was done by the Director of Staff Development and Administrator.
- Activities and or designee will do a check after each smoke break to ensure that smoking areas are safe and free from hazards such as loose smoke buds. Aides will verify receptacle is in working order, fire extinguisher is in place and fire blanket is in present. Activity aides were trained by activity director and administrator.
- Activity aides will supervise that all cigarettes will be extinguished and disposed in proper receptacle of after each smoking break. Activity aides were trained by activity director and administrator.
- A weekly scheduled audit conducted by the Medical Records Director or designee to review and monitor compliance with safety procedures.
- Compliance of audits conducted by the Medical Records Director will be monitored for three months and will be added to the Medical Record Director's portion (or designee) for our QAPI meeting, quarterly thereafter.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with Huntington’s disease, dementia, and known fall risk fell from a low bed onto a floor mat after shaking, and staff did not respond until alerted by a surveyor. The resident was assisted back to bed with a two-person assist, but no immediate assessment or VS were obtained, and there was no same-day nursing documentation of the fall. An LPN stated that staff typically did not complete fall assessments or obtain VS when a resident was found on a floor mat or observed getting out of bed, and facility leadership confirmed this practice, despite a written falls protocol requiring assessment and documentation of all falls, including VS, injury and neuro assessment, pain evaluation, and timely identification of causes and contributing factors.
A resident with bipolar disorder, schizoaffective disorder, and schizophrenia, who was legally deemed incompetent and had a guardian over person, was repeatedly allowed to sign out and leave on unsupervised LOAs despite the guardian’s explicit requests to the DON and Administrator to prohibit such leave. Over several months, the resident went out unsupervised 159 times. The care plan identified elopement risk, dissatisfaction with guardian placement, and intent to leave, and called for guardian guidance/consent. The guardian reported seeing the resident in the community punching people and confirmed she had told facility leadership not to allow unsupervised LOAs. The RDCO, Administrator, and DON acknowledged they continued to permit daily unsupervised LOAs based on the resident’s BIMS score of 15 and their view of resident rights, despite the guardian’s objections.
The facility failed to provide adequate supervision and ensure safe use of assistive devices during care and transfers, resulting in accidents for two residents. One resident with morbid obesity, chronic respiratory failure, and complete dependence for bed mobility and ADLs was provided incontinent care by a single CNA, despite requiring two-person assistance for transfers; during care, the resident rolled, grabbed the bed rail, and fell from the bed to the floor, later being found to have a painful right-leg contusion. Another resident with post-stroke hemiplegia, multiple comorbidities, and dependence on staff for ADLs and transfers was being moved from wheelchair to bed with a mechanical lift when she slid from the lift pad to the floor because the pad was not fully positioned under her buttocks and could not be adequately adjusted by staff.
The facility failed to complete thorough fall investigations and post-fall monitoring for two residents at risk for falls due to deconditioning and multiple comorbidities. In one case, a cognitively intact resident with vascular disease, diabetes, CHF, and foot ulcers was found on the floor after sliding from a recliner; the incident report lacked documentation of environmental, situational, and physiological factors, neurological checks for the unwitnessed fall were not initiated, required 72-hour monitoring was missed on night shifts, and the fall risk assessment was not updated until several days later. In another case, a cognitively intact, wheelchair-dependent resident with dementia, DVT, and general weakness was found on the floor with the wheelchair tipped over after an unwitnessed fall, and the neurological check section on the post-fall form was crossed off with no monitoring documented, despite facility expectations and policy requiring such assessments after unwitnessed falls.
A resident with dementia, severe cognitive impairment, a history of multiple prior falls, and documented need for substantial assistance and 24-hour supervision with ADLs and toileting was left unattended on the toilet by a CNA who left the room to obtain linens and an adult brief. Despite care plan and fall risk assessments indicating the resident required one to two staff for transfers, ambulation, and toileting, and was unsteady and only able to stabilize with assistance, the CNA exited the bathroom and bedroom. While unsupervised, the resident got off the toilet and was attempting to leave the bathroom when she fell backwards, striking her back and head on the sink. An LPN responding to the incident found the resident on the bathroom floor with a back bruise and a goose egg on her head, and hospital evaluation later confirmed multiple rib fractures, a small hemopneumothorax, an acute T9 transverse process fracture, and hematomas, all associated with this fall. Facility documentation and interviews confirmed that the resident was known to frequently get up without assistance and was generally not left alone on the toilet, but on this occasion the established supervision and assistance requirements were not followed, leading to the fall and injuries.
A resident with dementia, Alzheimer’s disease, and multiple comorbidities was identified as high risk for falls and care planned for safety, including non-skid footwear and supervision in common areas, yet experienced multiple falls resulting in serious injuries over time. The facility repeatedly failed to provide or document comprehensive fall investigations, did not substantiate its claim that orthostatic hypotension caused one fall, and did not demonstrate that key interventions such as proper footwear and ordered safety checks were in place at the time of several falls. The resident fell in her room, while on C. diff isolation, near the nurses’ station, and in the secured unit dining room, sustaining an L3 compression fracture, head laceration requiring staples, a right hip fracture, and later multiple rib and wrist fractures and facial laceration. Staff interviews revealed gaps in supervision, incomplete communication about the resident’s restlessness and agitation, and lack of clear determination of fall causes, while the facility withheld fall investigations as QAPI and could not show that fall risks and behaviors were adequately assessed and addressed.
Failure to Assess and Document Resident Fall per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to timely assess and document a fall for a resident identified as being at risk for falls. The resident, admitted with diagnoses including Huntington’s disease, hypothyroidism, constipation, and dementia, had a care plan identifying fall risk related to increased need for assistance with bed mobility and transfers, Huntington’s disease, overactive bladder, and a history of falls. Interventions included use of a low bed, floor mat, bolsters, dycem to the wheelchair, nonskid footwear, and supervision with staff remaining with the resident in the bathroom. During observation, the resident began to shake and fell out of bed onto a floor mat, landing on her back, while the bed was in the low position. Staff did not immediately respond until alerted by the surveyor, and two staff members then used a two-person assist to return the resident to bed. Following the fall, the resident was not immediately assessed on the floor or after being returned to bed, and vital signs were not obtained at that time. An LPN later stated that the resident had increased shaking over the past week, confirmed that a two-person assist was used to return the resident to bed, and acknowledged that no vital signs had been taken immediately after the fall and still had not been completed at the time of the interview. The LPN also stated that staff typically did not complete a fall assessment if the resident was found on the floor mat next to the bed. Review of the nurse’s notes showed no documentation of the fall on the day it occurred, and a later note documented the resident as found lying next to the bed with no injury noted and normal range of motion, with the resident denying pain. The Administrator and Regional Nurse reported that the resident frequently got out of bed and this was considered a behavior, and that staff would not complete a fall assessment or obtain vital signs if they observed the resident getting out of bed or found on the fall mat, even if the fall was unwitnessed. This practice was inconsistent with the facility’s Falls - Clinical Protocol policy, which required assessment and documentation of all falls, including vital signs, injury assessment, neurological status, pain, changes in condition, identification of possible causes within 24 hours, documentation of contributing factors, and monitoring and follow-up.
Failure to Honor Guardian Restrictions on Unsupervised Leave of Absence
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to follow a resident’s legal guardian’s request to prohibit unsupervised Leaves of Absence (LOAs). The resident had been admitted with bipolar disorder, current manic episode with psychotic features, anxiety disorder, and schizoaffective disorder. An Annual MDS showed the resident was cognitively intact with a BIMS score of 15. The resident’s care plan documented risk for injury related to elopement, dissatisfaction with guardian placement, intent to leave the facility, and schizophrenia, with interventions including updating boundaries, mental status, and guardian guidance/consent, and noting that the guardian sometimes gave permission for the resident to sign herself out. Amended Letters of Guardianship from probate court showed the resident was deemed incompetent and had a legal guardian over person only. Record review showed that over a several‑month period the resident signed herself out and went on unsupervised LOAs 159 times. The resident’s guardian reported she had repeatedly asked the DON and Administrator for months not to allow the resident to leave unsupervised because of the resident’s schizophrenia and non‑adherence with medications, and stated she had personally seen the resident downtown at a bus stop punching people and at a bread store. The Regional Director of Clinical Operations confirmed the facility allowed the resident to leave unsupervised on a daily basis because she had a BIMS of 15 and “has rights,” despite knowing the guardian did not want the resident to go on LOAs. The Administrator and DON also confirmed they allowed the resident to leave unsupervised daily, citing resident rights and the resident’s intact cognition, even though the guardian had informed the facility not to let the resident leave.
Inadequate Supervision and Improper Use of Assistive Devices During Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and ensure the safe use of assistive devices during care and transfers, resulting in accidents for two residents. One resident with chronic respiratory failure, ventilator dependence, heart failure, morbid obesity (weight 557.8 pounds), bilateral lower-extremity range-of-motion limitations, and complete dependence for bed mobility and ADLs was identified as at risk for falls and skin integrity issues. Her care plan included protective and preventative skin care and monitoring during daily care, and the MDS documented she was dependent on staff for bed mobility and always incontinent of bowel and bladder. Despite this, the facility’s staff and regional nurse continued to assert that only one staff member was required for ADL care, even though the resident required a two-person assist with a mechanical lift for transfers and was completely dependent for bed mobility. On the date of the incident, a single CNA provided incontinent care to this resident in bed. During care, the resident rolled onto her side toward the door, grabbed the bed rail, attempted to reposition her legs, and continued rolling until she fell from the bed to the floor. The CNA’s witness statement indicated she was on one side of the bed, saw the resident roll and fall, then moved to the other side to check on her before leaving the room to get assistance. The resident was later documented as having severe pain in the right leg, with hospital evaluation revealing tenderness and a contusion of the right lower extremity, though no fracture was found. The investigation and interviews confirmed that the resident’s size, dependence for bed mobility, and need for two-person assistance for transfers were not translated into a requirement for two-person assistance during bed mobility and incontinent care. The second resident involved had a history of hemiplegia and hemiparesis following a stroke, hypertension, dysphagia, dysarthria, acute and chronic respiratory failure, heart failure, and type II diabetes mellitus. Her care plans identified her as a fall risk and documented dependence on staff for ADLs and transfers, with interventions including use of a mechanical lift for chair-to-bed and bed-to-chair transfers. During a two-staff transfer from wheelchair to bed using a mechanical lift, the resident slid from the lift pad to the floor. Staff statements and the facility’s fall/skin incident report documented that the mechanical lift pad was not positioned fully under the resident’s buttocks, and staff attempted to adjust it but were unsuccessful, resulting in the resident slipping out of the pad. This event demonstrated improper pad placement and unsafe use of the mechanical lift during the transfer.
Incomplete Fall Investigations and Missed Post-Fall Neurological Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and thorough fall investigations and post-fall monitoring for two residents. One resident with diagnoses including peripheral vascular disease, diabetes with foot ulcers, CHF, hypertension, and a non-pressure chronic ulcer of the right heel and midfoot was cognitively intact and care planned for fall risk due to deconditioning, with interventions such as anticipating needs, ensuring call light and appropriate footwear, and following fall protocol. After this resident was found sitting on the floor in front of a recliner, having reportedly slid from the chair and denying injury, the incident report for the fall was left incomplete, with no documentation in the sections for predisposing environmental, situational, or physiological factors, and only vital signs, a brief statement of findings, and notifications recorded. For this same resident, the Post Fall Monitoring Form showed that the section for initiation of neurological checks following the unwitnessed fall was crossed off, and there was no documentation of immediate neurological monitoring. The required 72-hour post-fall monitoring, to be completed every eight hours for six shifts, was not done on the midnight shifts on two specified dates. Additionally, the resident’s fall risk assessment, which facility policy required to be completed after any fall, was not updated until eight days after the fall. Interviews with the DON and Regional Clinical Nurse confirmed that neurological checks should have been implemented for this unwitnessed fall, that the incident report was not fully completed, that post-fall assessments were missed on specified shifts, and that the fall risk assessment should have been completed immediately after the fall. A second resident, with diagnoses including difficulty in walking, DVT of the right lower leg, dementia, general weakness, diabetes, and wheelchair dependence, was also cognitively intact and care planned for falls due to deconditioning, with interventions such as Dycem to the chair, appropriate footwear, call light in reach, items within reach, and a custom wheelchair. This resident experienced an unwitnessed fall in which the resident was found sitting upright on the floor, leaning against the bed with shoes on, and the wheelchair tipped over on its side. The Post Fall Monitoring Form again showed the neurological check section crossed off with no documentation of immediate neurological monitoring. Interviews with the Administrator confirmed that the facility’s expectation was to initiate neurological checks for any unwitnessed fall, that this resident’s fall was unwitnessed, and that neurological checks were not completed despite this expectation. Facility policies on falls and fall prevention required assessment after any fall, monitoring for 72 hours, and detailed documentation and review, which were not followed in these cases.
Unsupervised Toileting of High-Risk Resident Resulting in Serious Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance with toileting for a resident with a known high risk of falls, resulting in a serious fall and injuries. The resident had dementia, a history of falls, periprosthetic fracture around an internal prosthetic of the left hip joint, a fracture of the neck of the left femur, age-related macular degeneration, and osteoarthritis. Her care plan, initiated and revised prior to the incident, identified her as at risk for falls due to dementia, decreased mobility, increased weakness, unsteady gait, and a history of multiple prior falls when attempting to stand, transfer, or ambulate without assistance. The care plan and fall risk evaluation documented that she required assistance from one to two staff for all transfers, ambulation, and toileting, had severely impaired cognition, and needed substantial or maximal assistance with toileting hygiene and transfers, as well as 24-hour supervision and assistance during ADLs and transfers. In the months preceding the incident, the resident experienced multiple falls, including events on 10/12/25, 10/29/25, 11/07/25, 12/02/25, and 12/25/25, each occurring when she attempted to stand, transfer, or ambulate without assistance. A fall risk evaluation dated 12/25/25 further documented that she was cognitively impaired, unable or unwilling to follow directions, and displayed behaviors such as restlessness, wandering, resisting care, and altered safety awareness. She was unsteady and only able to stabilize with assistance when moving from seated to standing, walking, moving on and off the toilet, and transferring between surfaces. Occupational therapy records indicated she required maximum assistance of one staff member for transfers from various surfaces and multimodal cues to increase ADL performance, reinforcing that she required continuous supervision and assistance during ADLs and transfers. On 03/21/26, despite these documented risks and needs, the resident was left unattended on the toilet by a CNA who was unfamiliar with her and her fall risks. According to the progress note and fall investigation, the CNA placed the resident on the toilet and then left the bathroom and bedroom to obtain new bedding and an adult brief from the hallway linen closet. While the CNA was away, the resident got herself off the toilet. When the CNA returned, she observed the resident coming out of the bathroom door and saw her fall backwards, striking her back and head on the sink. Initial documentation and the fall questionnaire indicated the CNA found the resident standing and that the resident became startled and fell back, with no mention that the CNA assisted her to the floor. The LPN who responded to the incident found the resident on the bathroom floor with a bruise on her back and a goose egg on the back of her head and documented that the CNA reported seeing the resident fall and being unable to reach her in time to assist. Subsequent hospital evaluation documented multiple rib fractures, a small hemopneumothorax, an acute T9 transverse process fracture, and hematomas, which were associated with this fall. The facility’s own investigation noted that the resident had been left alone in the bathroom and added an intervention for staff to remain in the bathroom until the resident finished toileting, underscoring that the lack of supervision during toileting led to the fall and resulting injuries. Additional interviews supported that residents with similar cognitive impairment and toileting needs were generally not left alone on the toilet and required frequent checks, with staff often remaining in or just outside the bathroom to monitor them. The LPN confirmed that this resident was known to frequently get up without assistance and, for that reason, was not typically left alone on the toilet. The administrator acknowledged that staff from other buildings, who were unfamiliar with residents and their risks and were unlikely to review care plans, were being used at the time of the incident. The facility’s fall management policy required ongoing review of care plans and use of fall risk evaluations to identify individualized fall risk factors, but in this case, the CNA did not follow the resident’s established need for continuous supervision and assistance during toileting, directly leading to the unsupervised toileting event and subsequent fall. The hospital records following the incident documented that the resident presented after a mechanical fall with chest wall pain and visible bruising to the left side. Imaging and physician notes identified left-sided rib fractures (seventh through eleventh ribs), a small left hemopneumothorax, an acute left T9 transverse process fracture, and hematomas of the left chest wall, retroperitoneum, and right iliacus muscle. The records stated it was unknown whether osteopenia or osteoporosis contributed to the fractures and did not characterize the fractures as pathological. The physician noted that the resident was at high risk of falls and had been sent to the emergency room after this fall, confirming that the injuries were associated with the incident in which she was left unattended while toileting. The facility’s documentation of the event, including the fall investigation and questionnaires, consistently indicated that the resident was left alone in the bathroom despite her documented need for assistance and supervision with toileting and transfers. The lack of a contemporaneous witness statement from the CNA and the later, typed statement created over a month after the fall introduced discrepancies about whether the CNA partially assisted the resident to the floor. However, the LPN’s account and initial documentation emphasized that the CNA reported seeing the resident fall and being unable to reach her in time, and that the resident struck her head and back on the sink. These facts, combined with the resident’s known fall risk profile and care plan requirements, form the basis of the deficiency for failing to ensure adequate supervision and assistance to prevent accidents during toileting. The facility’s fall management policy, revised 10/24/25, required that care plans be reviewed throughout treatment to ensure resident-specific fall reduction interventions were incorporated and that fall risk evaluations be completed on admission, after significant changes, quarterly, and as necessary. The resident’s care plan and evaluations had already identified her need for assistance and supervision with toileting and transfers, yet on the day of the incident, these interventions were not followed when the CNA left her unattended on the toilet. This failure to adhere to the resident’s individualized fall prevention measures and to provide adequate supervision in the bathroom directly preceded the resident’s unsupervised attempt to ambulate, her fall, and the serious injuries documented in the hospital records.
Failure to Investigate and Prevent Recurrent Falls in a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly assess and address the causes of repeated falls for a resident at high risk for falls, and to ensure that fall-prevention interventions were consistently implemented. The resident was admitted with Alzheimer’s disease, dementia, anxiety disorder, atrial fibrillation, and other comorbidities, and was care planned early on for safety concerns and fall risk, including use of non-skid footwear and encouragement to stay in common areas while awake. A falls risk assessment identified the resident as at higher risk for falls. Despite this, the facility did not complete or provide comprehensive fall investigations, did not document orthostatic blood pressure assessments when claiming orthostatic hypotension as a cause, and did not demonstrate that existing interventions such as non-skid footwear were in place at the time of multiple falls. On one occasion, the resident was found on the floor in her room after reporting she heard voices in the hall and went to check; the facility later stated the fall was related to orthostatic hypotension, but there was no evidence in the medical record that orthostatic blood pressures were obtained at the time of the fall. The resident was sent to the ER and diagnosed with a closed compression fracture of the L3 vertebra. Subsequent falls occurred when the resident was restless and trying to stand up alone, including while on C. diff isolation, and when she was observed on camera walking around her room, sitting on the arm of a recliner, and falling to the floor. In these instances, the record did not show that the facility verified whether non-skid footwear was in use, and interviews confirmed that at least one fall occurred when the resident had nothing on her feet. The facility’s comprehensive fall investigations and witness statements were withheld as QAPI, and no documentation was provided to show thorough investigation, confirmation that interventions were in place, or determination of root causes. Additional falls included an unwitnessed fall where the resident was found on the floor next to her rollator with a head laceration requiring staples, and another fall near the nursing station where she was found sitting on the floor in front of her wheelchair and later diagnosed with an intertrochanteric right femoral fracture. The facility reported that the resident was last seen 10–20 minutes before some of these falls, but did not provide evidence that ordered safety checks (such as every 15-minute checks during isolation) were actually completed. The final fall occurred in the secured unit dining area, where the resident was assisted to a padded wheelchair in a semi-reclined position and left in the dining room while the LPN passed medications and CNAs provided morning care to other residents. Within approximately 5–15 minutes, the resident was found on the floor with facial injury, multiple fractures, and extensive ecchymosis. Staff interviews indicated the resident had been restless and scooting in her chair the prior day, but this was not communicated in report, and the facility could not identify the cause of the fall. The death certificate later listed the manner of death as accident, with the underlying cause being sequelae of blunt impacts to the head, trunk, and left arm with fractures and soft tissue injuries due to falls.
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