Sunrise of Cuyahoga Falls

Based on medical record review, review of a police report, review of a facility self-reported incident, review of hospice reports, review of death certificate, review of coroner's report, observation of video camera footage, interviews with staff, review of facility policy, and review of manufacturer guidelines, the facility failed to ensure Resident #60 had the right to adequate and appropriate nursing care to prevent an incident of entrapment and subsequent death by asphyxiation. Prior to the incident, the facility failed to ensure Resident #60 was assessed and ongoing monitoring was in place related to the use of an electric bed with a bed mobility device (Halo Safety Ring) and bed remote cord. This resulted in Real and Present Danger, serious life-threatening harm and the death of Resident #60 when on 09/10/24 at 3:52 A.M. Resident #60, who required staff assistance for bed mobility and repositioning, was observed via video surveillance provided by family sliding from her bed and was found by staff at 4:41 A.M. unresponsive with her lower body on the floor next to her bed and her head hanging from the bed remote cord that was looped around the Halo Safety Ring attached to the side of her bed. In addition, the facility failed to ensure staff were knowledgeable and had the necessary skill sets to respond appropriately upon finding Resident #60 unresponsive. This affected one resident (#60) of three residents reviewed for resident safety/accident hazards.

On 11/14/24 at 1:49 P.M. the Executive Director (ED) was notified Real and Present Danger began on 09/10/24 at 3:52 A.M. when Resident #60 was observed via video surveillance footage sliding from the right side of her bed with her head becoming entrapped between the mattress/bed frame and against the Halo Safety Ring. Video footage at 4:19 A.M. showed Resident #60 with the bed remote control cord under her neck and her head hanging from the bed remote cord. Resident #60 could be heard gasping/moaning over the sound of a television. Licensed Practical Nurse (LPN) #803 was observed entering Resident #60's room at 4:42 A.M. finding Resident #60 with her lower body on the floor next to her bed and her head hanging from the bed remote cord that was looped around a Halo Safety Ring resulting in her death.

The Real and Present Danger was abated on 11/21/24 when the facility implemented the following corrective actions:

On 09/10/24, during standard staff communication venues which included shift to shift crossover meetings, messages in the care communication dashboard in Point Click Care (PCC), and during reviews of individual service plans, the Care Managers and Wellness Team (all Registered Nurses [RNs], LPNs, Caregivers, and Managers) were reminded to check call pendants and bed control cords to confirm that breakaway lanyards were in use and cords were not wrapped around Halo Safety Rings. These reminders were issued by the ED, the Resident Care Director (RCD) and/or the Maintenance Coordinator (MC). The Team Members were instructed to communicate any issues identified to the ED, Maintenance Coordinator, or the Community Leader on duty. The Community on-call leader information was posted for team member reference on PCC dashboard and sent via an on-shift text message weekly. No issues were identified on 9/10/24.

On 09/10/24, the MC completed an audit to confirm Halo documentation was complete including physician orders and resident and responsible party consents. The MC tracked these orders and consents for Halos as part of the preventative/safety management program. The MC confirmed that these documents were executed before he installed a Halo Safety Ring. No issues were identified during the documentation review.

In addition, on 9/10/24, the ED and MC completed visual bed checks in resident rooms to confirm approved devices were installed, equipment was correctly installed, and appropriate call/bed cord positioning. Per the visual bed checks on 9/10/24, no unapproved devices were installed, equipment/Halos were installed correctly, and call/bed cords were positioned appropriately.

The MC would continue to complete monthly Halo Safety Ring checks which was a component of the preventative maintenance/safety program, and this would be confirmed as completed by the ED during monthly preventative maintenance reviews with the MC. For Residents with specialty mattresses, the MC would continue to refer to and adhere to the facility's policy regarding Assistive Devices and Bed Safety Program. The Assistive Devices and Bed Safety Program policy included coordinating with vendors to install assistive devices to a qualifying bed using manufacturer instructions/recommendations and testing the bed for entrapment risks using the bed entrapment measuring tool; team members immediately reporting to the ED any death, or serious injuries injury resulting from an issue with a bed or equipment and related equipment including the bed frame, assistive device, and mattress; the ED ensuring reports were made to required State and Federal agencies, and the ED/RCD monitoring, evaluating, tracking and trending use of assistive devices within the community and including in Quality Improvement process.

On 09/10/24, an investigation of the event was immediately launched by the ED and a Self- Reported Incident (SRI) was initiated for an injury of unknown origin.

Between 09/10/24 and 09/13/24 there was ongoing communication and training with Care Managers and Wellness Nurse Team Members conducted by the ED and MC regarding responding to medical emergencies including a discussion of the Responding to Medical Emergencies policy and procedure. The Responding to Medical Emergencies policy and procedure included action steps, notification guidelines, and documentation to be provided to emergency medical personnel.

On 09/26/24 the Wellness Nurses received comprehensive refresher training conducted by the ED regarding bed safety and their specific responsibilities in responding to medical emergencies.

On 11/14/24 refresher instructions were placed in the PCC Care Communication Board by the ED reminding Care Managers to continue checking and confirming on their shifts that bed control cords were not attached or wrapped around Halo Safety Rings. The Team Members were re-instructed to communicate any issues identified during these checks to the ED, MC, or the Community Leader on duty information which was posted for team member reference on reference on PCC dashboard and sent via an on-shift text message weekly.

On 11/18/24, an issue was identified by the ED that a Halo Safety Ring appeared to be loose. It was removed immediately. This Halo Ring was installed by a durable medical equipment (DME) provider and ordered by the hospice provider. Following total removal of the Halo, it appeared the installation was not completed correctly by the DME provider. The DME provider and hospice were notified of the issue and incidents filed with their corporate offices.

On 11/18/24 HEALTHPRO therapy began training Wellness Nurses, caregiver staff and the RCD on the process and steps for checking and confirming appropriate use of Halo Safety Rings and bed control cords on resident beds. As a component of this training, the staff were educated on how to complete a skill return demonstration with residents. A resident return demonstration would be completed to confirm resident understanding and use of Halo Safety Rings and/or bed control cords.

Beginning 11/18/24, the RCD or Wellness Nurse would meet with each resident monthly for 90 days, to do a visual observation of the Halo Safety Ring and bed remote, and request that the resident complete a return demonstration. Following the 90-day meetings, the RCD or Wellness Nurse will meet with residents who experienced a change in condition and/or during re-assessments.

On 11/19/24, the ED instructed the MC to immediately complete comprehensive checks of Halo Safety Rings, including bolt checks on third party supplied and installed Halo Safety Rings. As part of the 11/19/24 third party comprehensive checks, the MC identified another pair of Halo Safety Rings installed by the same DME provider and ordered by a different hospice provider that also had bolt/washer issues. These bilateral Halo Safety Rings were immediately removed. The DME provider and the hospice provider were then notified, and incidents filed with their company corporate offices. Moving forward, the DME provider was no longer allowed to install Halo Safety Rings until the ED and MC could be assured that the installation was sound and complete, and a meeting occurred with the DME provider operations director.

On 11/19/24, communication occurred with the facility's key therapy, hospice, and durable medical equipment providers to reinforce the facility's expectations regarding equipment delivery and installation. The ED initiated this communication via in person contact and phone calls.

A HEALTHPRO therapy training and return demonstration was completed by 11/21/24 for those residents on their caseload and receiving services. By 11/21/24, a Wellness Nurse or RCD that had been trained by HEALTHPRO therapy staff completed the checks and return demonstrations for residents not receiving HEALTHPRO services. If a resident currently using equipment was deemed unable to use a Halo Safety Ring or bed remote safely, their physician would be consulted by the RCD and an order for discontinuation of the Halo Safety Ring requested.

Beginning 11/21/24, a resident who received a physician order (proposed by therapy, hospice, or the facility's Wellness Team) for a Halo Safety Ring or other assistive device would be assessed prior to installation for their ability to safely use a Halo Safety Ring or other assistive device by the RCD or Wellness Nurse. Per the facility's Bed Safety Program, if a resident was deemed to be able to safely use the equipment, the resident and/or responsible party would be educated by the RCD or Wellness Nurse during the Halo consent signing process regarding the risks and benefits of using a Halo Safety Ring. If a bed remote could not be used/stored safely by a resident, alternatives would be developed and incorporated into the service plan.

Newly hired staff would be trained on maintaining a restraint free environment during their initial orientation. Halo Safety Rings would be discussed including what they looked like and how they were installed. The ED or designee would bring up online pictures of properly installed Halos and show how they hooked to the bed frame and how they looked when accurately installed. This had been and would continue to be a key component of the on-boarding process.

Although the Real and Present Danger was abated on 11/21/24, the violation remained as the facility was in the process of implementing the corrective action plan and analyzing the plan for effectiveness.

Findings include:

Review of the medical record for Resident #60 revealed an admission date of 03/29/24 with diagnoses including progressive supranuclear ophthalmoplegia (a condition where the brain sends and receives faulty information from the nerves that control eye movement), post-laminectomy syndrome, polyosteoarthritis (a type of arthritis that causes joint pain, stiffness and impaired movement), vertebrogenic low back pain, motor neuron disease, repeated falls, and diabetes mellitus. Resident #60 was on hospice services.

Review of the physician order dated 03/29/24 revealed Resident #60 had a Do Not Resuscitate - Comfort Care (DNR-CC) order and Resident #60 was admitted to Hospice services for supranuclear ophthalmoplegia.

Review of care plans initiated on 03/27/24 (prior to Resident #60's admission) revealed Resident #60 was on hospice services and interventions included to adjust personal care needs according to changing abilities. Resident #60 had impaired cognitive functioning and interventions included to provide supervision as needed to ensure safety was not compromised. Resident #60 had mobility concerns and interventions included special hand railings to assist with mobility and physical assistance of one staff member with mobility. Resident #60 had transferring concerns and interventions included providing physical assistance of two staff members with transfers. Resident #60 had bladder incontinence with interventions including if resident could not tolerate transfer overnight check and change every two hours. Resident #60 was at risk for falls and interventions included due to inability to use recliner remote appropriately safely tuck the remote in a side pocket on recliner chair, remind resident to use call pendant for assistance, reminder signs in room for fall precautions, evaluate and assess for physical/cognitive/environmental factors that could contribute to falls, inform resident and caregivers about safety reminders and what to do if a fall occurred, educate resident and caregivers of potential fall hazards, and remind and assist resident with using the bathroom at frequent intervals. Resident #60 had actual falls and interventions included to evaluate post fall, report any change in condition or status, after fall and before moving the resident evaluate for changes in range of motion, provide first aide as appropriate, obtain emergency medical services as appropriate, evaluate environment post fall for contributing factors, record and report vital signs after falls, review medications post fall, and check on resident at frequent intervals at least two to four times per shift to offer assistance and reassurance. The care plan included Resident #60 required assistive devices and interventions included hospital bed with bilateral Halo bars (Halo Safety Rings) to encourage bed mobility.

Review of the Acknowledgement and Consent for the Use of a Transfer Assistive Device dated 03/31/24 revealed Resident #60's family signed the consent for use of the Halo Safety Rings. The form identified potential risks as entrapment of head or limb, strangulation, suffocation, head injury, orthopedic injury, fall with injury, bruises, skin tears, and death. The consent also indicated an increase in gap or entrapment opening could appear if the bed was moved with security pole or grab bar.

However, an interdisciplinary note dated 04/11/24 timed 12:19 P.M. revealed Resident #60 was pending hospital bed with Halo delivery. An interdisciplinary note dated 04/17/24 timed 1:10 P.M. revealed Resident #60 was denied a hospital bed. The interdisciplinary team (IDT) discussed with family there could be no Halo mobility bars applied to current bed, and they would need private pay for the Halo mobility bars. The note revealed staff were to check Resident #60 frequently for any incontinent episodes.

Review of a Fall Progress Note dated 04/21/24 timed 10:33 A.M. revealed Resident #60 had an unwitnessed fall. Resident #60 had rolled out of bed hitting her head on the side table. Resident #60 sustained bruising and swelling to the left side of her face, a blood shot eye, a skin tear to left elbow, and skin tear to left knee. Resident #60's son was notified, and the note indicated he requested a hospital bed with Halo mobility bars.

Review of the Health Status Note dated 04/21/24 timed 10:02 P.M. revealed Resident #60 had a fall in bedroom and was sent to hospital. Resident #60 returned to facility. Resident #60 had a new hospital bed and Halo Safety Rings upon return. There was no evidence Resident #60 was assessed for safety or use of the Halo Safety Rings and hospital bed at that time.

Review of a physician order dated 04/23/24 revealed Resident #60 had bilateral Halo Safety Rings for independence with bed mobility.

Review of the Health Status Note dated 05/05/24 timed 12:03 P.M. revealed Resident #60 had an unwitnessed fall in bedroom. Resident #60 lost her balance and was having trouble seeing. A new care plan intervention was added to check on Resident #60 every one to two hours.

Review of the Health Status Note dated 05/28/24 timed 11:31 A.M. revealed Resident #60's son reported complaints of Resident #60's mattress being very uncomfortable. Hospice was notified and the note revealed they would deliver a low air loss mattress.

Review of Nurse Practitioner (NP) visit progress note dated 06/04/24 revealed staff reported Resident #60's condition was getting worse, and she was less interactive. Resident #60 was only able to wheel herself in the wheelchair about four feet before asking for help.

Review of the Health Status Note dated 06/05/24 timed 11:15 A.M. revealed Resident #60 found the new air mattress to be uncomfortable. The settings on the mattress were checked and firmness was increased. There was no evidence Resident #60 was assessed for safety or use of the Halo Safety Rings and hospital bed at that time.

Review of the Hospice Physician Narrative dated 06/12/24 revealed Resident #60 was sleeping 16-18 hours per day, was dependent (on staff) for most activities of daily living, had progressive visual impairment, and was alert to person and place. Resident #60 was noted to be newly incontinent of bowel and bladder. Resident #60 was no longer able to walk and required two staff assist to transfer to a standard wheelchair. It was noted Resident #60 had several falls during her admission.

Review of the Health Status Note dated 06/12/24 timed 10:03 A.M. revealed Resident #60's care plan was updated to check and change resident in bed overnight due inability to rise at night for incontinence care.

Review of the Interdisciplinary Note dated 06/19/24 timed 12:50 P.M. revealed Resident #60 had a fall on 06/18/24 and there was now a camera in room for safety. There were noted unspecified behavioral and anxiety concerns.

Review of the Health Status Note dated 06/22/24 timed 8:06 A.M. revealed Resident #60 was refusing to sleep in bed and preferred to be in recliner. Resident #60 was noted to take control for chair lift and lift self out of chair.

Review of the NP visit progress note dated 08/06/24 revealed Resident #60 was on hospice services for supranuclear palsy (a rare brain disease that affects walking, balance, eye movements and swallowing) and had a slow decline in cognitive and physical abilities. Resident #60 was noted to have a history of frequent falls and was using a wheelchair for mobility. Resident #60 was slow to respond to questions during visit per her baseline. There was no evidence Resident #60 was assessed for safety or use of the Halo Safety Rings and hospital bed at that time.

Review of the Wellness Visit dated 08/18/24 timed 9:59 A.M. revealed Resident #60 continued on hospice services, had increased confusion, was too weak and unsteady to ambulate, was using only a wheelchair, and required two staff assistance for transfers. Resident #60 was noted to have been declining and hospice indicated she would need a Hoyer (mechanical) lift soon for transfers. There was no evidence Resident #60 was assessed for safety or use of the Halo Safety Rings and hospital bed at that time.

Review of the Ohio 3.0 Service Evaluation and Health Assessment (SEHA) dated 08/28/24 revealed Resident #60 had bilaterally poor vision, was able to communicate verbally, was alert to person and place with forgetfulness or short attention span and had difficulty finding the right words. Resident #60 required physical assistance by one staff member for mobility, dressing, bathing, and assistance to bathroom. Resident #60 required physical assistance by two staff members for transfers, had diminished or absent sensation to bilateral lower extremities related to numbness, and had limited range of motion to upper and lower extremities with decreased strength. Resident #60 had assistive devices including handrails for mobility. Resident #60 was at risk for falls and was occasionally incontinent of bladder. Review of the assessment revealed there was no evidence Resident #60 was assessed for safety or use of the Halo Safety Rings and hospital bed at that time.

Review of Resident #60's Brief Interview for Mental Status (BIMS) assessment dated 08/30/24 revealed a score of 9.0 indicating the resident had moderately impaired cognition.

Review of the progress note dated 09/02/24 timed 8:26 A.M. revealed Resident #60 attempted to rise from chair/ambulate/climb out of bed without assistance. There was no evidence Resident #60 was assessed for safety or use of the Halo Safety Rings and hospital bed at that time.

Review of the progress note dated 09/10/24 timed 5:48 A.M. authored by LPN #803 revealed Resident #60 had a change in condition and was noted to be deceased. Resident #60 was absent of vitals and hospice was called. The hospice nurse contacted family and primary physician and notified the coroner.

Review of police Case Report dated 09/10/24 revealed officers arrived at the facility at 6:49 A.M. and were notified by the medical examiner Resident #60 had fallen out of bed and got a cord wrapped around her neck. Resident #60's son was on scene and had video footage of Resident #60's fall and subsequent death. Officers viewed the video footage and noted Resident #60 was last seen alive at 3:52 A.M., at 4:00 A.M. Resident #60 slipped further onto the ground and the cord was around her neck, at 4:46 A.M. a staff member entered Resident #60's room and it was unclear if Resident #60's vitals were checked, and at 5:30 A.M. Resident #60 was pronounced deceased by hospice nurse. Resident #60's son indicated due to Resident #60's conditions including progressive supranuclear palsy and motor neuron disease Resident #60 would not have been able to lift herself up after a fall.

Review of the progress note dated 09/10/24 timed 1:29 P.M. authored by the Resident Care Director revealed during routine checks Resident #60 was found on the floor on the side of her bed unresponsive. Staff were unable to obtain a pulse. There was no documentation of the manner in which Resident #60 had fallen or that she was found with her head hanging from the bed remote cord, upper body suspended off the floor, and her lower body on the floor.

Review of progress note dated 09/10/24 at 6:19 P.M. authored by the ED revealed the ED met with Resident #60's brother and his wife around 10:45 A.M. Resident #60's brother requested all hospice equipment be removed from suite, none of her laundry was to be washed, and the door was to be locked. The medical equipment company arrived shortly after to pick up hospice equipment.

Review of a facility Self-Reported Incident (SRI) form dated 09/10/24 revealed Resident #60 had an injury of unknown source. The SRI included during routine checks Resident #60 was observed on floor deceased. Resident #60 was on hospice services. It was noted Resident #60 was slouched on floor next to her bed during routine rounds. The coroner was involved due to suspected fall and initially released the body. When the family viewed video footage from the camera in the resident's room, the coroner was asked for an autopsy due to the location of the resident's bed control for the high low bed and staff moving the resident from floor to bed. The SRI indicated family would not provide the facility with the video footage at the time to investigate further. The family reported concerns about staff reporting the fall. Hospice had notified Resident #60's family of her death. Camera footage was provided to the police department by Resident #60's family. The facility concluded that the allegation/suspicion was unsubstantiated due to inconclusive evidence. The facility created an addendum to the SRI on 11/07/24 and noted the resident's death was ruled as accidental asphyxiation by coroner. There was no evidence that the SRI investigation was reopened by the facility at that time due to the additional information obtained.

Review of the hospice Client Activity Report dated 09/10/24 revealed at 4:55 A.M. Licensed Practical Nurse (LPN) #803 called to report the death of Resident #60. LPN #803 stated Resident #60 was last checked at 2:06 A.M. LPN #803 further stated that around 4:00 A.M. Resident #60 had an unwitnessed fall and was on floor. Staff attempted to get Resident #60 off floor and Resident #60 was determined to be deceased. An on-call Registered Nurse (RN) was notified by triage team for an as needed (PRN) visit.

Review of the hospice Visit Note Report dated 09/10/24 revealed Hospice RN #809 arrived at the facility at 5:30 A.M. and Resident #60 was found to be deceased. Postmortem care was provided, and the hospice physician, coroner, and funeral home were notified. It was noted Resident #60 passed peacefully in her sleep with no signs of pain or discomfort. The hospice physician was to sign the death certificate. An addendum was added on 09/10/24 timed 10:54 A.M. indicating LPN #803 had reported an unwitnessed fall to on-call triage team. Hospice RN #809 called the corner and reported fall with no apparent physical injury and that Resident #60 had expired. The coroner released Resident #60's body to the funeral home. After notifying family of Resident #60's unwitnessed fall when they arrived the family reviewed the camera footage from camera set up in Resident #60's room. The camera displayed Resident #60 slid out of bed and the bed cord caught her in the neck area. Hospice RN #809 contacted the coroner again at 6:15 A.M. and reported the new information. The corner withdrew the release of body to funeral home and arrived on site at 6:45 A.M. The coroner spoke with the police and made a report. The coroner transport collected Resident #60's body at 8:05 A.M. The hospice physician was notified of the events.

Review of the Certificate of Death dated 09/18/24 revealed Resident #60's cause of death was asphyxia due to hanging on 09/10/24.

Review of the medical examiner Report of Investigation dated 10/29/24 revealed on 09/10/24 at 5:58 A.M. the medical examiner's office was notified of the apparent natural death of Resident #60 by Hospice RN #809. On the morning of 09/10/24 Hospice RN #809 was notified by facility staff Resident #60 had been found unresponsive on the floor next to her low bed and she had been placed back into her bed. No resuscitation was performed due to hospice status. Hospice RN #809 responded to the facility and found Resident #60 in bed with no apparent trauma. Resident #60 was pronounced deceased at 5:30 A.M. Resident #60 was released to funeral home. At 6:12 A.M. Hospice RN #809 called the medical examiner's office and reported family had video of Resident #60 rolling out of bed and being strangled by the call button cord. The staff did not report this aspect of Resident #60's death. The medical examiner investigator arrived on scene at 6:38 A.M. and observed Resident #60. Resident #60 was observed in bed and a call button with a cord was on the floor next to the bed. There was bruising on the right side of the resident's face and mouth and an abrasion to right shin. The video footage was reviewed by the investigator. At 3:52 A.M. Resident #60 was observed supine (lying on back with face upward) in bed sleeping with blankets pulled up to neck. Resident #60 then slid/rolled out of bed to her right and her head became wedged between the bed and a circular metal handrail at top of bed. A call button with cord was looped through handrail. The video at 4:19 A.M. showed Resident #60 prone on floor next to bed with back arched upwards. Resident #60's upper torso was suspended by call button cord on the front of her neck and a small plastic waste basket. Resident #60 was not moving at that time. At 4:41 A.M. Resident #60 was found by staff and at 4:51 A.M. Resident #60 was put back to bed by three staff members.

Review of the Report of Autopsy dated 10/29/24 revealed a partial autopsy for Resident #60 was completed on 09/10/24 at 11:42 A.M. The report indicated the resident's cause of death was asphyxia due to hanging and the manner of death was accidental when Resident #60 rolled out of bed with neck compressed by call button cord. There were noted florid petechial hemorrhages of the face, lips, and conjunctiva, a 7.5-inch ligature impression mark began on left side of neck extending to right anterior midline, a curvilinear impression/contusion angles across right upper arm onto right breast, and a triangular area of impression/abrasion marks extended from the jawline up alongside nose on right side of face. Resident #60 had died from an asphyxial hanging event when her neck became entrapped by cord looped on bedside rail after rolling out of bed. The event was documented on video taken in room. In the video Resident #60 could be seen sliding from bed with legs to floor and head leaning against bedside rail and later showed Resident #60 had rolled prone with neck suspended by cord looped onto side rail. Resident #60 was later placed back in bed by staff.

Review of the Performance Counseling and Improvement Plan for Corrective Action dated 09/19/24 revealed LPN #803 was given written termination for failure of appropriate knowledge in assignments and failed to show appropriate nursing judgement related to incident on 09/10/24.

Observation of video surveillance footage provided by Resident #60's family as part of the complaint investigation revealed the following.

A two-minute and two second video dated 09/10/24 timed 12:28 A.M. revealed LPN #803 was in the room with Resident #60 providing incontinence care while Resident #60 was in bed.

A two minute and 23 second video dated 09/10/24 timed 12:32 A.M. revealed LPN #803 lowered Resident #60's bed and left room after incontinence care was provided. LPN #804 closed the door; Resident #60 was in bed with her eyes closed. The television was on and Resident #60 had blankets pulled up to her chin. The bed control cord was observed wrapped around the Halo Safety Ring on Resident #60's right side. Resident #60's body was angled towards the right side of bed under her blankets. The head of bed was in the raised position.

A one minute and 14 second video dated 09/10/24 timed 3:18 A.M. revealed Resident #60 sleeping in bed. The television could be heard. Resident #60 was lying on her back and her legs appeared to be hanging over the edge of the bed on her right side. There were two round metal Halo Safety Rings/ mobility bars on each side of the bed near the head of the bed. There was a bedside table with personal items and a trash bin on Resident #60's right, next to the bed. The bed was pushed up to the wall on Resident #60's left side.

A one minute and 26 second video dated 09/10/24 timed 3:52 A.M. revealed Resident #60 was sliding from the right side of her bed. The video showed Resident #60 attempting to adjust herself unsuccessfully. Resident #60's body continued to slide off the bed and her head became trapped against the metal Halo Safety Ring/mobility bar and the mattress. Resident #60's full body turned at the neck with her head trapped against the Halo Safety Ring/mobility bar. Resident #60 tried to reach out towards the bedside table. Resident #60 could be heard gasping/heavily breathing over the sounds of the television. Resident #60's legs could be seen shifting at times during the video. Resident #60's head was trapped against the Halo Safety Ring/mobility bar until the end of video with her body resting on the floor. The bed was noted to be raised at the head and at the knees. There were blankets tangled around her legs on the floor and a disposable incontinence pad partially pulled off the bed.

A one minute and 13 second video dated 09/10/24 timed 4:19 A.M. revealed Resident #60 lying face down with no body parts on the bed. There was a taut cord wrapped from the Halo Safety Ring/mobility bar extending to Resident #60's neck area. Resident #60's upper body was hanging above the ground from the taut cord and the trash can was not visible beneath her. Resident #60 was heard gasping/moaning over the sound of the television. Resident #60 remained face down with the taut cord extending towards and under her neck with her upper body suspended until end of video.

A one minute and 50 second video dated 09/10/24 timed 4:41 A.M. revealed Resident #60 lying face down with a taut cord wrapped around the Halo Safety Ring/mobility bar extending towards and under her neck. Resident #60's upper body was elevated off the ground. Resident #60 was no longer moving or making any noises at this time. LPN #803 entered the room and reached for a phone attached to her pant leg while standing over Resident #60, dialed the phone. LPN #803 then asked Resident #60 how she had fallen then returned the phone to her pant leg. LPN #803 reached down and touched the cord extending towards and under Resident #60's neck. LPN #803 then reached out and touched Resident #60's shoulder and tapped her several times. LPN #803 then pulled up Resident #60's incontinence brief which had slipped below her hips and left the room.

A two minute and nine second video dated 09/10/24 at 4:46 A.M. revealed Resident #60 lying face down on the ground with her upper body over the trash can. The cord was no longer seen in the video and Resident #60's bed appeared to be arranged with new incontinence pads. LPN #803 and Care Manager (CM) #804 entered the room. The two staff members reached beneath Resident #60's arms and attempted to pull Resident #60 off the floor. Resident #60 was completely limp, and the staff could not lift her and lowered her to the floor. The staff were heard telling Resident #60 they were going to stand her up. Resident #60 did not respond. The two staff attempted to stand Resident #60 up again without success. The staff lowered Resident #60 to her knees. It appeared LPN #803 reached down to check Resident #60's pulse at her neck. The staff made a third attempt to stand Resident #60 however she remained limp and unresponsive. The video ended with Resident #60 on her knees and the two staff supporting her upright.

A two minute and 54 second video dated 09/10/24 timed 4:50 A.M. revealed CM #805 entering the room and standing in front of Resident #60 who was on her knees supported by LPN #803 and CM #804. The three staff hoisted Resident #60 up by her upper body and pushed her towards the bed. Resident #60's arms were limp and dangling during the transfer. The three staff toppled over Resident #60 as she came to rest on the bed. LPN #803 positioned Resident #60 to her back and covered her with a blanket. CM #805 is heard asking if Resident #60 fell out of the chair and LPN #803 stated no, she fell out of her bed. LPN #803, CM #804, and CM #805 readjusted Resident #60 to the middle of the bed and then left the room. An assessment of Resident #60 was not completed at any time during the video recording. The bed remote control cord was observed on the floor under the bed.

Interview on 11/13/24 at 9:43 A.M. with Care Manager (CM) #804 via telephone revealed on 09/10/24 she was asked by the nurse to help get Resident #60 off the floor. CM #804 indicated when she entered Resident #60's room she saw Resident #60 lying on the floor on her stomach with her head on the trash can beside the bed. CM #804 indicated Resident #60 was not moving or making any noises. CM #804 attempted to help LPN #803 get Resident #60 off the floor, but Resident #60 was too heavy, so they had to get a third person to help. CM #804 was unable to confirm if LPN #803 had assessed Resident #60 for a pulse, breathing, or injury. CM #804 indicated she could see Resident #60 was deceased when they got her up onto the bed. CM #804 saw the bed remote cord near the trash can when she went into Resident #60's room but she did not see the cord wrapped around Resident #60. CM #804 indicated the bed remote cord was usually attached to the Halo Safety Ring. After getting Resident #60 off the floor CM #804 went back to her assignment and did not have further interaction with the resident.

Interview on 11/13/24 at 10:48 A.M. with LPN #803 via telephone revealed she had recently had a resident who fell and passed away. LPN #803 stated (at the time of the incident) she did not know what steps to take, and stated she was clueless in that situation. LPN #803 also voiced concerns with completing her (work) assignment. LPN #803 then confirmed the resident who fell and passed away was Resident #60. LPN #803 stated that on 09/10/24 she first checked Resident 60 on the night shift during 12:00 A.M. rounds. LPN #803 stated she completed incontinence care and Resident #60 mentioned being very tired. LPN #803 stated she checked on Resident #60 again at approximately 2:00 A.M. although stated she only checked on the resident from the doorway and she did not enter the room. LPN #803 stated she rounded again at approximately 4:00 A.M. and said Resident #60 was one of the last check and changes to complete. When LPN #803 entered Resident #60's room she found Resident #60 face down on her belly with her head propped up on the trash can. LPN #803 noted some blood dripping down the trash can. LPN #803 attempted to use the facility mobile phone to call for help but stated the batteries had died. LPN #803 stated she then tapped Resident #60's shoulder and called her name but Resident #60 was unresponsive. LPN #803 left the room to find staff to help. LPN #803 stated Resident #60 had Halo bars attached to the hospital bed and the corded bed control remote was always wrapped around the Halo bar. LPN #803 stated when she entered the room, she observed the bed control cord wrapped around Resident #60's face from her chin to her ear. LPN #803 stated she unwrapped the cord from the Halo bar to free Resident #60. LPN #803 stated CM #804 was in another room providing incontinence care and when she was done, they went to Resident #60's room. LPN #803 stated Resident #60 had fallen out from the right side of the bed and her call light pendant was around her neck. LPN #803 indicated Resident #60 had slid out of bed with all the bed covers and the disposable incontinence pads that were under her. LPN #803 stated CM #804 attempted to help get Resident #60 off the floor, but they were unable to lift her. LPN #803 stated they made several attempts to get Resident #60 off the floor and it was not pretty. LPN #803 stated she checked for pulse and did not find a pulse. LPN #803 indicated she knew Resident #60 was on hospice services, so she decided to get Resident #60 into bed, positioned, and cleaned up to preserve her dignity. LPN #803 then went out of the room and called hospice. LPN #803 told the hospice nurse about the fall but stated the hospice nurse cut her off before she could provide a description of the fall. LPN #803 stated the hospice nurse told her not to worry about any documentation. LPN #803 confirmed she entered a progress note prior to hospice arriving. LPN #803 stated she had viewed the family's video footage of the incident and confirmed the video footage was an accurate timeline of events. LPN #803 stated the incident was chaos and she was just worried about getting Resident #60 off the floor.

Interview on 11/13/24 at 12:05 P.M. with the ED revealed the facility had created a Self-Reported Incident (SRI) because the family stated Resident #60 had a fall that went unreported. The ED reported the hospice nurse had initially called the family and let them know Resident #60 had passed away peacefully in her sleep. Resident #60's son was later notified of the fall and watched the video camera footage. The ED stated they did not know the events leading up to Resident #60's death until the video footage was reviewed. The hospice nurse had to make an addendum to the report to include the fall later that day.

Interview on 11/13/24 at 1:43 P.M. with Hospice Administrator #810 via telephone revealed they received a call on 09/10/24 at 4:55 A.M. and were notified by LPN #803 Resident #60 had an unwitnessed fall and when staff attempted to get her off the floor Resident #60 was found to be deceased. Hospice Administrator #810 indicated Hospice RN #809 arrived on scene on 09/10/24 at 5:21 A.M. and pronounced Resident #60 as deceased at 5:30 A.M. Hospice Administrator #810 stated it was initially documented Resident #60 had passed away peacefully; however, information obtained from Resident #60's family revealed Resident #60 had slipped from her bed and was caught in the cord of the bed. This information was shared with the coroner who arrived to view the body at approximately 6:45 A.M. Hospice Administrator #810 stated the police were notified and a report was made.

Interview on 11/13/24 at 2:11 P.M. with Hospice RN #809 via telephone revealed himself and Resident #60's son had arrived at the facility at about 5:30 A.M. on 09/10/24. Hospice RN #809 stated he went straight to Resident #60's room to pronounce her deceased then went to talk with LPN #803. LPN #803 told Hospice RN #809 Resident #60 had fallen and was noted to be deceased when they got her up. Hospice RN #809 did not see any signs of injury upon assessment. Hospice RN #809 notified Resident #60's son of the fall and they viewed the video camera footage. Hospice RN #809 confirmed it appeared Resident #60 was tangled in a cord, so he notified the coroner of the fall circumstances. Hospice RN #809 stated LPN #803 did not report the manner in which Resident #60 fell or was found. Hospice RN #809 stated LPN #803 did not report finding a cord around Resident #60.

Interview on 11/13/24 at 2:43 P.M. with the ED revealed on 09/10/24 at 6:15 A.M. she was notified by Maintenance #806 that police were in the building. The ED stated she was then notified Resident #60 had fallen and passed away. When ED arrived at the facility Resident #60's family had already left. The family came back later and showed her video footage. When the ED saw the videos and heard the family concerns, she stated she began an investigation. The ED noted she had only seen video clips and had not been shown a full video of the situation. The video clips were reviewed with the ED and the ED confirmed she had seen the same video clips. The ED confirmed she had seen Resident #60 slide from her bed and come to rest on the floor with what appeared to be the bed control cord around her. The ED confirmed the clips showed a lack of urgency from LPN #803 but then noted it only took 10 to 12 minutes to get help and stated the clips might not portray that. The ED stated a full physical assessment was not completed because LPN #803 did identify the resident did not have any vital signs. The ED stated LPN #803 was terminated following the incident with Resident #60 for inappropriate knowledge of job assignment. The ED was not notified of the fall for Resident #60 by LPN #803. The ED stated while viewing the clips the manner in which LPN #803, CM #804 and CM #805 got Resident #60 off the floor was inappropriate and not a manner in which she would have tried to get her up. The ED stated staff were educated on using a Hoyer lift and calling the fire department to assist with getting residents up from the floor regardless of resident being on hospice.

Interview on 11/13/24 at 3:26 P.M. with NP #800 via telephone revealed Resident #60 had experienced a physical decline over the last two times she had seen her; Resident #60 was much slower and weaker. NP #800 noted Resident #60 was unable to stand or turn when she visited. Resident #60 was able to hold her head up and slowly responded to questions per her baseline. NP #800 was notified by hospice services Resident #60 had passed. NP #800 was unaware of the fall or the circumstances involving the fall.

Interview on 11/14/24 at 7:17 A.M. with Maintenance #806 revealed on 09/10/24 when he came in the building, he saw Resident #60's family talking in the bistro. Maintenance #806 indicated he thought that was strange as families were not usually in that early. Maintenance #806 stated he went about his rounds and when he was at the front desk, he could hear Resident #60's son yelling and swearing. Maintenance #806 stated he tried to calm Resident #60's son and asked him what was going on. Resident #60's son reported his mother had passed away and it was seen on camera. Resident #60's son asked when the ED would arrive. Maintenance #806 immediately called the ED. Maintenance #806 stated Resident #60's son would not show him the video but stated Resident #60 had choked to death with the bed remote cord. Maintenance #806 stated the police and hospice were on site at that time and he waited for the ED to arrive.

Interview on 11/14/24 at 1:02 P.M. with Maintenance #806 revealed Resident #60 had Halo bars installed through the hospice company. Resident #60 also had a hospital bed with an air mattress. Maintenance #806 indicated when a resident was on an air mattress and had Halo bars the facility did not check for entrapment zones. Maintenance #806 revealed the measurements would not be the same due to air fluctuations in the mattress and the mattress/assistive bars would fail the entrapment testing. Maintenance #806 indicated a failure of entrapment testing was identified by too much space between the mattress and Halo bar. Maintenance #806 reported the only assistance bars used in the facility were the Halo Safety Rings.

Interview on 11/14/24 at 2:26 P.M. with Director of Operations #811 from Galaxy Medical Equipment revealed the Halo Safety Rings were generally considered safe and not an entrapment risk; however, anyone could get hurt with equipment. Director of Operations #811 indicated they often delivered the same set up Resident #60 had (air mattress, hospital bed, and Halo Safety Rings) for residents. Director of Operations #811 stated his staff were not to tie bed control remotes to Halo Safety Rings; the bed remotes were to be stored at the top of the headboard. Director of Operations #811 stated he often saw caregivers store the bed control remote tied to the Halo Safety Rings.

Attempts to interview CM #805 via phone were made on 11/13/24 at 10:27 A.M., 11/14/24 at 8:54 A.M., and on 11/15/24 at 2:38 P.M. CM #805 did not respond to voicemails requesting a return call.

Interview with Resident #60's son, as part of the complaint investigation, revealed concerns that on 9/10/24, his mother became entangled in the cord to her bed remote control. As a result, she was asphyxiated and died. Her entanglement and death were recorded by a video camera placed in her room with the permission of the facility. His mother had resided at the facility and was on hospice. He reported that his mother weighed approximately 200 pounds and was in a bed that the hospice provider had provided, it was an electric bed with a corded bed control. The resident's son stated his mother had no ability to use the bed remote, but it was there for staff convenience. The bed control had been placed under the bed and then brought up and wrapped around what he called a Halo bar. He said this was for staff convenience as well, so they didn't have to bend down to the floor to pick up the remote. The resident's son stated the way the cord was positioned and secured on the Halo bar; it created a loop. On 09/10/24, his mom rolled out of bed and her head became stuck in the loop causing her to be hung ... He said even more alarming was when staff did come in the room, they did not even really check her. There were three of them and they just plopped her back in bed and then covered her up. He said he got a call from the facility and was told she passed away.

Review of the facility policy, Responding to Medical Emergencies