A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
A non‑ambulatory, non‑weight‑bearing resident with dementia, hemiplegia, osteoporosis, and severe cognitive impairment had a care plan requiring two‑person assistance and a mechanical lift for all transfers. One CNA reported properly using a mechanical lift with another staff member earlier in the day, with no bruising noted at that time. Later, another CNA, who was assigned to the resident overnight, admitted to the UM, DON, and assistant administrator that she transferred the resident alone using a stand‑pivot transfer without a mechanical lift, despite other CNAs on the unit confirming they were not asked to assist and were aware the resident required a lift and two staff. The next morning, two CNAs discovered bruising on the resident’s left ankle and forehead, and imaging confirmed multiple left ankle fractures consistent with twisting or stand‑pivot motion, with no documented falls or combative behaviors involving the lower extremities during the relevant period.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with Alzheimer’s, dementia, a history of falls, and severe cognitive impairment had an MD order and care plan for a wander guard device on a walker, with nightly function checks required on the 11 P.M.–7 A.M. shift using a universal tester. On the day of the incident, the TAR showed no documentation that the required wander guard check was completed, and the assigned nurse later stated she did not test the device because she did not want to wake the resident, despite facility policy requiring such checks. The device was not functioning, allowing the resident to leave the unit, use the elevator, and exit to an outdoor courtyard without triggering the wander guard alarm system, where the resident was later found outside with the walker nearby.
Failure to use required smoking apron: A resident with moderate cognitive impairment and a documented need for a smoking apron was observed smoking without the apron while supervised by the Housekeeping Supervisor. The resident’s care plan and annual assessment identified the apron as a smoking safety intervention, but the supervisor stated the resident did not need one, while the UM later confirmed the apron should have been used and the DON noted there was no process to inform non-CNA/non-nursing staff of smoking safety changes.
A resident with severe cognitive impairment and osteoarthritis, who required substantial staff assistance for transfers and ADLs, was weighed in a wheelchair‑accessible platform scale whose access was obstructed on three sides by walls and a large shower bed. A CNA, confined behind the wheelchair due to the room setup, could only use one accessible ramp and had limited ability to maneuver around the resident. As the CNA attempted to roll the wheelchair off the scale, the resident suddenly put a foot down and leaned forward; because of the obstructions, the CNA could not move to the front in time to adequately assist, and the resident fell forward to the floor, sustaining a forehead laceration that required sutures. The DON later reported being unaware that the shower bed was stored in that room in a way that restricted safe access to the scale.
Meal Supervision and Choking Hazard Failures: A resident with severe cognitive impairment and a hospital 1:1 feeding order was allowed to eat alone in the room despite a therapy screen recommending supervision; the resident choked, required the Heimlich maneuver, was transferred to the hospital, intubated, and had chicken removed from the airway. A second resident with severe cognitive impairment and stroke-related deficits was repeatedly observed eating in bed without staff present even though the care plan and Kardex called for continual supervision with meals.
A resident with dementia, intrusive and rummaging behaviors, and a care plan requiring supervision while eating was assisted with a meal in their room by a CNA, who then moved the tray across the room, reported removing all food wrappings, and left the resident alone to assist another person. Shortly afterward, staff found the resident unresponsive on the floor with vomit present, initiated a Code Blue, and transferred the resident to the hospital, where EMS removed a piece of plastic wrap containing food from the resident’s airway during attempted intubation. The DON later reported the source and timing of the resident’s access to the plastic wrap could not be determined, despite policies requiring an environment free from accident hazards and adequate supervision during meals for cognitively impaired residents.
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