A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with dementia, severe cognitive impairment, and known elopement risk was monitored with wanderguards and 15‑minute safety checks but had been restless and attempting to exit shortly before eloping. Earlier that day, a malfunctioning wanderguard door alarm was reset by a facilities staff member, who relied on a green indicator light and did not manually test the system with a probe as required by protocol. The resident then exited through the front door without triggering an alarm, was observed outside by the DON, and was ultimately redirected back inside by an RN and CNA after having walked a significant distance away from the entrance; the NHA later identified the failure to manually test the system after service as the root cause of the elopement.
Surveyors found that the facility did not follow care-planned fall prevention interventions for two residents with severe cognitive impairment and extensive fall risk factors. One resident with Alzheimer’s disease and significant ADL dependence was repeatedly observed in a high bed without floor mats in place, despite a care plan requiring the bed in the lowest position and mats on the floor. Another resident with dementia, multiple fractures, and a documented history of a serious fall with injuries was observed in an elevated bed with a regular mattress, the call light on the floor and out of reach, and the floor mat folded against the closet instead of next to the bed, even though the care plan called for a low bed, perimeter mattress, and mats on the floor. The assigned nurse stated this resident was not considered a fall risk and was unaware of the perimeter mattress intervention, while the DON later stated staff should be aware of the resident’s fall risk and required interventions.
A resident with paraplegia, blindness, muscle weakness, and moderately impaired cognition, who was on Eliquis and care planned for a two-person assist with bed mobility and ADLs, was being changed in bed by a single CNA. The CNA rolled the resident to the far side of the bed, removed her hands, and walked around to the other side, during which the resident rolled off the bed. The CNA acknowledged that the Kardex required a two-person assist and that the resident should have been rolled toward, not away. The resident was hospitalized with a closed head injury, abdominal hematoma, and a closed femur fracture, with ED records documenting a rollover fall from bed during clothing change and subsequent treatment including blood transfusion and pain management.
A resident with cognitive impairment, abnormal gait, and mobility limitations had a care plan requiring a two-person assist for transfers, but was transferred by a single CNA for ADL care. During the transfer, the resident’s legs gave way while turning, he slid, let go of the CNA, and fell to the floor, striking his leg and back and later reporting bruising and scratches. The CNA involved stated she had been informed the resident was a one-person extensive assist and this was her first time caring for him, while another CNA identified the resident as a two-person stand assist and the DON confirmed the resident was a two-person assist at the time of the incident.
Failure to Prevent Avoidable Falls During Transfers and Wheelchair Use: A resident with dementia, ataxia, falls, and TBI had three avoidable falls. Staff left the resident seated on the edge of the bed while retrieving a WC, used a sit-to-stand lift without an order or care plan indication, and later the resident slid out of a WC when the anti-rollback device was loose and not functioning properly.
A resident with dementia, weakness, and impaired mobility was found on the floor yelling in pain and repeatedly stating that her leg was broken, with significant right hip and knee pain and a large skin tear on her arm. Staff moved her from the floor to a wheelchair, later stood her for a more thorough skin check, and then used a stand-and-pivot transfer to bed while she continued to yell out and refused to bear weight on her leg. Facility policy required a licensed nurse to complete a full post-fall assessment, including pain and range-of-motion evaluation and determining the need for emergency treatment, before moving a resident, and specified that the resident should not be moved until this initial evaluation was completed. This assessment was not completed prior to moving the resident, resulting in the cited deficiency.
A resident with left hemiplegia, foot drop, orthostatic hypotension, and a history of falls was awakened in the early morning by a CNA, at an LPN’s direction, to obtain a weight. Despite care plan and therapy documentation that the resident required a left AFO and a gait belt to stand, the CNA transferred the resident barefoot and without the AFO or gait belt to a wheelchair platform scale in a small weight room with only one handrail. The resident was stood on the scale, began to black out, and fell backward to the floor, later reporting left leg and knee pain and bleeding from the left great toe. The CNA acknowledged not using the AFO or gait belt and that the resident had no socks on, while the LPN reported believing the resident had gripper socks and documented that he lost his footing on the scale. The DON stated she did not interview the CNA or the resident and obtained no witness statements, relying only on the nurse’s account, despite the facility’s fall policy requiring identification of interventions based on resident-specific risks.
A resident with cerebral infarction, lymphedema, and polyarthritis, who had a physician order for transfers using a mechanical lift with 2-person assist, was initially moved from bed to wheelchair with the lift. After repositioning in the wheelchair caused the sling to slip out of place, two CNAs were unable to use the sling for the return transfer and instead manually transferred the resident by lifting and attempting to stand them, contrary to the ordered transfer method. The resident reported experiencing pain during this manual transfer and later informed the DON, who acknowledged that the CNAs were expected to follow the resident’s plan of care. A requested transfer policy was not provided to surveyors.
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