The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
Staff failed to use a gait belt while assisting a resident who was ambulating with a rolling walker and on supplemental O2, then turned away from the resident, resulting in a backward fall and a skin tear with tendon exposure to a finger. The same resident had multiple additional unwitnessed falls and a near miss related to ambulation and oxygen tubing. Two other residents with repeated unwitnessed falls, including one with Parkinson-related freezing and another with weakness, confusion, tremors, and sepsis onset, had numerous fall events discussed in weekly fall meetings, but their fall care plans were not updated to reflect the interventions identified. Staff interviews confirmed expectations for gait belt use and individualized gait belts, and revealed that care plans were not being revised after fall meetings despite a facility fall-prevention policy allowing addition of interventions to care plans.
Two residents experienced serious harm due to failures in accident prevention and pain assessment. One terminally ill, dependent resident with severe pain and non-verbal behaviors was known by staff to frequently swing her legs off the bed and onto a nearby baseboard heater, yet no care plan addressed this behavior, repositioning was poorly documented, and room checks were infrequent despite policies requiring regular monitoring. She was later found unresponsive with her leg and foot on or wedged in the heater, sustaining extensive second-degree burns to the calf, toes, heel, and entire plantar surface, while heater surface temperatures in multiple rooms were measured at 190–200°F and above. Another cognitively impaired resident suffered two choking episodes requiring the Heimlich maneuver and then reported persistent right rib pain over several days, with documented pain scores up to 8/10; staff largely relied on the resident’s refusals for hospital evaluation despite severe cognitive impairment, did not obtain diagnostic imaging, inconsistently documented pain assessments, and provided limited PRN analgesia, until a later ER visit for a fall revealed nondisplaced right rib fractures and a complex pelvic fracture.
A resident with dementia, cognitive decline, osteopenia, and a recent iliac fracture experienced three falls, including unwitnessed falls that resulted in bruising, a facial laceration, hematoma, skin tear, decreased LOC, and hospital transfer. Staff reported that IDT post-fall assessments were normally done within 24 hours to identify root causes and interventions, but acknowledged that this resident’s IDT reviews were not timely. The IDT post-fall note for the first fall, completed much later, identified issues with walker use and short-term memory and listed interventions such as increased visual checks, cueing, walker evaluation, and focused OT/PT, yet these interventions were not documented in the EHR or added to the care plan before the subsequent falls, contrary to the facility’s fall management policy.
Surveyors found that the facility failed to enforce its smoking policy and accident-prevention measures for multiple smokers, including a resident on O2 who used an open-flame lighter near oxygen equipment and smoked in an outdoor area while wearing a nasal cannula and having a portable O2 tank attached to a wheelchair. The outdoor smoking area lacked required signage and staff supervision, and residents reported that smokers went outside unsupervised. Another resident with a history of marijuana-related incidents kept cigarettes and a lighter accessible in her room despite a care plan and smoking safety screen requiring the lighter to be stored at the nurse’s station. Additional smokers and vape users were not consistently identified on the smoking list or addressed in care plans, and one resident was observed rolling cigarettes in his room with multiple lighters present. These conditions led to an Immediate Jeopardy citation under F689 for accidents and hazards.
A resident with mental health issues, impaired decision-making, and a documented elopement risk repeatedly expressed a desire to leave, including plans to travel out of state, yet the facility did not individualize the care plan to include family-discussed interventions such as supervised walks, supervised medical appointments, or measures tied to medication refusal and increased elopement risk. Behavior monitoring for wandering and exit-seeking was not implemented despite documented nighttime pacing and an attempted self-discharge. During transport to a dental appointment, a staff member who knew the resident was an elopement risk left the resident unsupervised at the clinic, contrary to expectations noted on the appointment schedule, allowing the resident to leave by taxi to a relative’s home. The facility did not complete a documented IDT after-action investigation, did not promptly perform a post-elopement evaluation, and only maintained largely generic elopement care plan interventions after the resident’s return.
A resident with severe dementia and a history of falls was not provided with adequate supervision or individualized interventions to address her wandering and behavioral risks. Despite multiple injuries, including a compression fracture and a fractured hip, the care plan lacked specific strategies for fall prevention and behavioral management. Staff interviews and documentation revealed inconsistent monitoring, insufficient staffing, and a lack of effective interventions, resulting in repeated accidents and injuries.
Staff failed to maintain adequate supervision and follow safe handling protocols, resulting in a resident being left unsupervised and sustaining a hip fracture after being pulled from a wheelchair by another resident, and in a separate incident, two residents engaged in a physical altercation due to lack of supervision.
Multiple residents experienced falls resulting in injuries such as fractures and lacerations due to the facility's failure to implement an effective fall prevention program. Staff did not consistently complete required fall checklists, update care plans, or conduct thorough post-fall assessments. Communication about fall risk was inadequate, and staff training on fall prevention interventions was lacking, leading to repeated incidents and insufficient individualized interventions.
A resident suffered a large hematoma and swelling to the left lower extremity after staff performed a manual stand pivot transfer instead of using a hoyer lift as required. The incident was caused by lack of updated care plan information, poor communication between therapy and nursing staff, and failure to ensure the proper transfer equipment was in place.
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