A resident with severe vascular dementia, a very low BIMS score, and a diagnosis of wandering was observed self-propelling in a wheelchair in the hallway and was later found missing when a nurse attempted to administer medication. The resident, who had been assessed as low elopement risk and did not have a WanderGuard or daily elopement alarm in use, exited the building and crossed the street before being located by staff between nearby medical offices and returned without distress. Staff interviews and record review showed that, although the facility had an elopement policy and a process for assessing and care planning high-risk residents, this resident had not previously been identified as an elopement risk, and adequate supervision and preventive measures were not in place at the time of the elopement, leading to a cited deficiency under F689 for failure to prevent accidents and hazards.
A resident with dementia, severe cognitive impairment, wandering behavior, and documented elopement risk eloped after staff failed to adequately respond to an exit-door alarm and did not promptly recognize the resident was missing. The resident, who required close supervision and was on 30-minute checks for wandering, was last seen ambulating in the facility before a dining room/fire exit alarm sounded; dietary staff briefly checked, saw no one, silenced the alarm, and returned to work without initiating a facility-wide missing-resident response. Later, when the resident did not appear for dinner, staff began searching and learned from a staff member driving home that someone resembling the resident was seen near a nearby store. Police, responding to a report of a suspicious person with a hospital bracelet, found the resident disoriented at a nearby intersection and arranged EMS transport to a hospital. Interviews showed that some CNAs lacked elopement training, one CNA was newly assigned to 1:1 care, and leadership acknowledged uncertainty about how long the alarm had been sounding and how the resident exited, supporting the finding of inadequate supervision and failure to prevent elopement.
A resident with traumatic brain injury, moderate cognitive impairment, wheelchair dependence, and documented wandering behaviors eloped from the facility after being able to exit through a door without an active alarm. Despite physician orders and a care plan requiring wander guard checks every shift, MAR/TAR review showed these checks were largely undocumented prior to the incident. Staff notes described frequent redirection needs, room-to-room wandering, and impulsive behavior, yet the resident was still able to leave the building and was later found in the parking lot. The State Agency determined this failure to supervise and to implement ordered wander guard monitoring constituted Immediate Jeopardy under F689 (Quality of Care).
A resident with severe cognitive impairment, a history of falls, and documented need for a gait belt and walker during transfers was ambulated from the bathroom by a CNA without a gait belt in place. The CNA reported holding the resident’s pants while walking, during which the resident’s feet became twisted and she fell in her room. Facility documentation showed the resident had been assessed as requiring a gait belt, but gait belt use was not included in physician orders or the care plan and was instead communicated via door name tags. The resident sustained a left hip fracture requiring surgical repair and was later readmitted for rehab and strengthening.
A resident with multiple medical conditions and decreased ability to perform ADLs was found with two white tablets in a medication cup on the bedside table, which the resident identified as Imodium saved from a prior medication pass. Facility policy requires staff to remain with residents until oral medications are swallowed and prohibits leaving medications in a room without a self-administration order. Record review confirmed there was no such order for this resident. An LPN verified that medications had been left at the bedside contrary to policy, and the DON stated that nurses are not to leave medications at the bedside and must observe residents swallowing medications.
A resident with dysphagia, functional quadriplegia, memory problems, and an active NPO order, dependent on enteral nutrition, was able to receive and consume a cereal bar and water provided by visiting church members. A CNA and an LPN later found the resident with part of the cereal bar in the mouth and an empty cup, and the resident could not identify who had given the items. After ingestion, the resident developed vomiting, sweating, clamminess, and gurgling, with critically elevated BP, and was sent to the hospital, where records documented vomiting, intubation for airway protection, and suspected aspiration pneumonia. Surveyors determined this lack of supervision and control over outside food and drink constituted Immediate Jeopardy related to accident hazards and supervision requirements.
A resident with severe cognitive impairment, muscle weakness, and dependence for transfers was identified as high risk for falls and had a care plan that included keeping the call light within reach, anticipating needs, and offering assistance to bed after dinner following a prior fall from a recliner. On a later evening, the resident was again left in a recliner after dinner and attempted to get up without assistance, resulting in an unwitnessed fall and a right rib fracture. Interviews showed that CNAs relied on nurse report for fall interventions, an LPN did not access care plans and believed only frequent checks were in place, and there was inconsistent understanding of how care plan updates and Kardex information were communicated to direct-care staff, leading to the fall-prevention intervention of assisting the resident to bed after dinner not being implemented.
A resident with severe dementia and high fall risk was taken outside by an LPN, left without direct staff supervision, and positioned near an unsecured gate with wheelchair brakes unlocked. While the receptionist was occupied with other duties, the resident rolled down a sloped walkway, fell from the wheelchair, and sustained a left femoral neck fracture and skin tears. In separate incidents, two other severely cognitively impaired, high fall-risk residents who were care planned and ordered for chair sensor alarms were found with their alarms switched off: one resident stood and fell in a common area, lost consciousness, and was later diagnosed with a nondisplaced pelvic fracture, and another was observed seated in a scoot chair with the alarm box in the off position, leaving the intervention ineffective.
A resident with severe dementia, daily wandering, and a high fall risk experienced multiple falls with serious injuries over several months, while care plan interventions remained limited to basic measures such as nonskid strips, clothing adjustments, and redirection. The resident’s room was located near an exit and away from the nurse’s station, and the resident was known by CNAs to be impulsive and ambulatory, often attempting to walk without assistance. On one occasion, staff left a large rolling trash can in the hallway near the resident’s room, despite training that it should be stored in the shower room; the resident attempted to use it for support, it rolled away, and the resident fell, sustaining a right femur fracture. This sequence of events reflects the facility’s failure to identify and remove an environmental hazard for a resident with a known history of falls.
A resident with severe cognitive impairment, right AKA, hemiplegia, and dependence for mobility and ADLs had a prior unwitnessed fall from bed with head involvement and was subsequently identified as high risk for falls, with the care plan directing staff to keep the bed in the lowest position. Surveyors later observed on multiple occasions that the resident’s bed was elevated rather than kept low, including after a CNA entered and exited the room without adjusting the bed. In interviews, an RN acknowledged the bed was not in the lowest position despite the fall risk, the CNA stated she only learned that day the resident was a fall risk and should have lowered the bed, and an LPN confirmed the bed should be kept low and that staff do not document bed position each shift.
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