Two residents at risk for falls and injury did not receive clearly defined or updated safety interventions. One resident with dementia, severe visual impairment, poor balance, and dependence on staff for transfers had documentation indicating the need for two-person assistance, but the Baseline Care Plan and bedside Kardex did not specify the required level of assist. Staff interviews revealed inconsistent practices, including a report of a single staff member performing transfers, and the resident was later found with a dislocated hip. Another resident with severe cognitive impairment, diabetes, impaired mobility, and poor safety insight had two falls in one morning, yet no fall investigation or new interventions were documented in the EHR or Comprehensive Care Plan after these events, despite existing fall-risk care plan entries and facility policy requiring investigation and follow-up.
A resident with repeated falls and moderate cognitive impairment had a care-planned wheelchair anti-rollback brake intervention, but observation showed the wheelchair did not have the device and rolled backward without resistance. The MDSC confirmed the intervention was not in place, and staff were unaware whether it had ever been implemented.
A resident with severe cognitive impairment, total dependence for ADLs, and a documented fall risk with prior falls had a care plan that included Dycem on the wheelchair cushion as a fall-prevention intervention. Policy required staff to ensure appropriate and immediate interventions were implemented after incidents. On multiple observations, including while the resident was in the therapy gym, the wheelchair lacked the care-planned Dycem on or under the cushion. The ADON confirmed the absence of Dycem, resulting in a deficiency for not implementing a prescribed fall intervention.
The facility failed to follow its falls management policy for several residents by not consistently identifying causal factors for falls, not updating or documenting fall-prevention interventions, and not completing required post-fall and neuro assessments. One resident with cognitive impairment and mobility deficits had multiple falls without documented causal analysis or new interventions, and neuro checks were only initiated after one of several unwitnessed falls. Staff did not perform required two-hour checks and allowed this resident to transfer and toilet independently despite care plan requirements for one-person assist and supervision. Another resident with a right femur fracture from a fall remained on an air mattress even though the internal fall investigation identified the air mattress as the root cause and no additional interventions beyond therapy were documented. A third resident with hemiplegia and hemiparesis had a witnessed bathroom fall, but there was no evidence of the required 72-hour post-fall monitoring and documentation, despite staff acknowledging that such monitoring and documentation should occur.
Multiple residents with known fall risks, cognitive impairment, and mobility limitations experienced repeated falls, including unwitnessed falls and falls with major injuries, because staff did not consistently identify fall causes or implement effective interventions. One resident on anticoagulants with delirium and intermittent confusion self-transferred to the bathroom and later self-transferred again, sustaining head and fracture injuries, while a bed alarm cited in the fall investigation was never added to the care plan. Another cognitively impaired resident with dementia and agitation had numerous falls from a w/c and recliner despite dycem and a gel cushion, with fall reports lacking immediate preventive measures and the daily pocket care plan omitting key fall interventions. A third resident with a history of sliding from seating had multiple falls from a w/c and recliner, with inconsistent fall documentation, delayed addition of an intervention that would have required 1:1 supervision, and conflicting care-plan directions about seating after meals. A fourth resident with a BKA and dependence on a mechanical lift had repeated falls from bed and was repeatedly observed sitting on the edge of an elevated bed, while the care-planned low-bed intervention was not included in the pocket care plan or other tools used by NAs and nurses, and staff knowingly did not keep the bed low during meals.
Unsafe Hot Water Temperatures in Resident Areas: Surveyors found multiple resident bathroom sinks and a SCU dining room sink with water temperatures above the facility’s safe limit of 120 degrees Fahrenheit. Affected residents had diagnoses including dementia, Alzheimer’s disease, hemiplegia, and alcohol-related neurologic degeneration, with several showing severe or moderate cognitive impairment and varying levels of independent mobility. Staff interviews and record review showed residents could access these sinks independently at times, and maintenance acknowledged the building’s water was heated by the same water heater.
Surveyors observed that two residents with dementia and/or wandering tendencies had multiple prescribed topical medications, including diclofenac gel, Eucerin cream, miconazole powder, and triamcinolone cream, left unsecured in their shared bathroom. Record review showed no Self Administration of Medication (SAM) authorizations for either resident. The DON and IDON confirmed that all practitioner-prescribed medications, including creams and powders, must be locked and never left out, indicating a failure to keep the area free from accident hazards and to provide adequate supervision to prevent accidents.
Surveyors found that staff did not follow care-planned fall prevention and transfer interventions for three residents at high risk for falls. One resident, fully dependent for transfers and previously injured in a fall, was care-planned for Hoyer lift transfers only but was instead manually transferred from the toilet to a w/c without a gait belt, resulting in a fall and pelvic fracture. Another resident, totally dependent for transfers and toileting with a high fall risk score, was observed in bed without the required fall mat in place and without the fall alarm moved from the w/c to the bed. A third cognitively intact resident, care-planned to be transferred to the bathroom by w/c with a gait belt and to have blue Dycem under the w/c gel cushion, was instead ambulated to the bathroom with a walker, and the Dycem was missing; the NA reported not knowing the resident was to be taken by w/c, and the DON confirmed ambulation should not have occurred.
Surveyors found that the facility failed to protect several residents from falls and injuries by not implementing and not developing effective fall-prevention interventions. One resident with dementia and a history of falls had a care plan requiring close supervision and a reclined Broda chair, yet staff left the resident unattended and previously failed to keep the chair tilted, resulting in a serious head injury and subdural hematoma. Another resident with hemiplegia and a below-knee amputation, care planned and posted as requiring a full Hoyer lift with two staff, was instead pivot-transferred by two aides without the lift and fell, sustaining chest pain that required ER evaluation; required post-fall assessments were not completed. A third resident with stroke-related weakness and a seizure disorder experienced multiple falls linked in documentation to call-light use limitations, lack of non-skid footwear, lighting, and toileting needs, but the care plan did not consistently incorporate interventions addressing these specific root causes. The MDSC and DON acknowledged there was no fall policy and that interventions were not reliably based on identified root causes of falls.
A resident with TBI, mood disorder, history of falls, inattention, disorganized thinking, depression, and documented wandering behaviors was not provided with appropriate elopement or fall prevention interventions. The care plan noted impulsivity, poor redirectability, and a preference for walking outside, yet contained no elopement or wandering interventions, and the resident’s Wanderguard was removed after being assessed as low risk. The resident left the facility multiple times without signing out, and on one occasion staff only realized the resident was gone after finding the resident’s wheelchair outside, leading to a search by staff and law enforcement before the resident was returned with abrasions and complaints of pain. Despite multiple documented falls, the care plan lacked updated fall interventions, and observations showed environmental hazards in the resident’s room, including scattered paper towels, multiple beverage cases and boxes on the floor, and a urinal out of reach, with no fall prevention measures in place.
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