Failure to Supervise and Individualize Fall Prevention for a Resident with Repeated Falls: A resident with dementia, anxiety, PTSD, weakness, and impaired decision-making had multiple falls and repeated attempts to stand from her wheelchair, but the record did not show consistent review of fall causes, updated care plan interventions, or reliable implementation of individualized measures. Therapy and pharmacy identified several fall-related concerns, including medication effects and possible vision issues, yet staff observations showed the resident was often left without close supervision or redirection when she tried to rise in the common area.
A resident with cerebrovascular disease, traumatic brain injury, repeated falls, severe mobility limitations, moderate cognitive impairment, and high fall risk was care planned and ordered to use a mechanical (hoyer) lift for all transfers. Policy required two CNAs and proper use of mechanical lifts. Surveyors observed that after being wheeled to her room, the resident was transferred from wheelchair to bed by a single CNA without a mechanical lift present. The CNA later acknowledged that the transfer after lunch was done as a two-person transfer without the lift, and staff interviews revealed inconsistent understanding of the resident’s transfer requirements despite documented orders and therapy recommendations for mechanical lift use for all transfers.
A resident with sepsis, Alzheimer’s disease, repeated falls, and documented need for at least contact guard or stand‑by assist with a walker was allowed to ambulate outside unaccompanied. The care plan identified fall risk and general fall precautions but did not specify the required supervision level for ambulation, and therapy notes showed the resident was not cleared for independent ambulation, especially on uneven surfaces or outdoors. Staff interviews revealed inconsistent understanding of the resident’s mobility status, incomplete special instructions regarding fall risk and assistance needs, and conflicting statements about whether the resident was considered safe to walk alone. The resident went outside alone, was later found on the ground near the parking lot with a newspaper and her walker nearby, reported tripping and falling, and was noted to have oral bleeding and pain with movement; hospital imaging confirmed facial bone and coccyx fractures.
Fall interventions were not consistently implemented for two residents. One resident with dementia, muscle weakness, and a history of falls was repeatedly observed without a fall mat by the bed and wearing regular socks instead of non-skid socks, despite a care plan calling for both interventions; records also showed multiple unwitnessed falls. Another resident with severe cognitive impairment, heart disease, COPD, and a T11-T12 fracture was observed several times in bed without the fall mat on the floor by the bed, and staff noted they were not aware the mat needed to be placed there.
A resident with stroke history, AFib, and Eliquis use was transported in a van for a swallow study when her wheelchair was not fully secured. During the trip, the wheelchair shifted and her head struck the van interior, resulting in an ED transfer and a CT-confirmed subdural hematoma with ICU monitoring.
The deficiency centers on failures in transportation safety and fall management that led to serious resident injuries. A resident with dementia and bilateral lower extremity impairments was transported in a wheelchair without foot pedals, seated on a blanket and Hoyer sling, and improperly restrained when the driver misapplied the lap and shoulder belt to avoid disturbing an ostomy bag. During the trip the resident slid forward, struck both legs on a step in the vehicle, and was later found to have bilateral tibial fractures with significant bruising, swelling, and pain. The driver’s training had been informal, passed down from another staff member without documented competencies, van‑specific procedures, or clear emergency protocols, and leadership acknowledged they had not investigated the admitted misuse of the seat belt. Separately, two residents at high risk for falls experienced multiple falls, including one with a facial laceration and maxillary sinus fracture, while care‑planned fall interventions such as scheduled toileting, prompted voiding, monitoring, and assisted transfers were not consistently implemented, and IDT reviews and implementation of recommended interventions were not always timely.
A resident with Parkinson’s disease, chronic respiratory failure, MI, AFib, and anticoagulant use was transferred with confusion between a Sara Steady and a Hoyer lift, despite staff records not matching her transfer needs. She reported that a CNA used the sit-to-stand incorrectly, causing pain and bruising across her back and side, and nursing later changed her to a Hoyer lift. The record also showed therapy was not timely notified to review the transfer concern after the bruising occurred.
A resident with a hx of falls, gait/mobility impairment, and severe cognitive impairment had a care plan calling for the bed to remain in the lowest position, but staff repeatedly observed the bed left in the highest position. The resident had previously fallen during a shower when a hospice CNA could not catch the fall and the resident hit the back of his head. RN and ADON interviews confirmed the fall interventions were not being followed as written.
A resident with cognitive impairment and documented visual deficits requested very hot tea, which a PTA dispensed from a hot beverage machine and then further heated in a microwave, contrary to facility policy prohibiting reheating of facility-provided drinks. The PTA secured a lid on the cup and placed it at the bedside. Due to visual impairment, the resident could not locate the drinking opening, attempted to remove the lid independently, and spilled the hot liquid onto an arm and thigh, sustaining second-degree partial thickness burns over approximately 6% TBSA. Nursing and NP assessments documented bright red, blanchable burns with blistering and subsequent healing, and staff interviews confirmed that the beverage had been overheated and that the resident’s visual impairment and lack of appropriate supervision and adaptive equipment contributed to the accident.
A resident with sepsis, pneumonia, weakness, and high fall risk required substantial assistance with ADLs and had a care plan that included two-person assistance for incontinence care. During incontinence care, a CNA assisted the resident alone, during which the resident rolled out of bed and sustained right shoulder pain, multiple toe skin tears, and a knee abrasion. The resident later reported that the CNA repeatedly pushed her to roll and that she was pulled up from the floor by her painful arm. The ADL care plan did not clearly specify bed mobility assistance needs, staff understanding of required assistance was inconsistent with the care plan, and there were no nursing progress notes documenting the fall in the EMR on the day of the incident.
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