A resident with COPD, lack of coordination, and anxiety disorder had a prior fall with a care plan intervention for nonskid strips at the bedside. The facility later failed to keep that intervention in place, and the resident was found on the floor beside the bed after hollering for help, resulting in a left hip fracture and surgical repair. Surveyors observed the nonskid strips were not at the bedside, and the DON, ADM, LPN, and RD confirmed they were missing.
A resident with dementia, seizure disorder, repeated falls, and high fall risk was care-planned for a low bed with brakes locked, a fall mat, and call light within reach, and was totally dependent on staff for transfers and bed positioning. Despite this, staff accounts indicated the bed was often kept at about waist height, and several staff reported not seeing a fall mat at the bedside. The resident was later found supine on the floor with her head and torso under the bed, the bed frame resting on her chest and head, and the corded bed remote under her back, requiring staff to raise the bed to remove her. A detective observed that a fall alert device on the bed was not plugged in and that the call light was tucked behind the nightstand, out of the resident’s reach, though it worked when tested. EMS and police documented compression marks on the resident’s torso and face consistent with the bed frame and piston. The facility’s own safety policy required implementation of interventions to reduce accident risks, but records showed no care-plan revision with additional bed-related safety measures after prior falls and no documentation that existing interventions were consistently implemented, leading surveyors to cite a deficiency for failure to prevent accidents and maintain a hazard-free environment.
Incomplete Smoking Assessments for Tobacco-Using Residents: The facility failed to complete smoking assessments with each quarterly or comprehensive MDS for several residents who used tobacco. Records showed that residents with diagnoses including HTN, AKF, dysphagia, epilepsy, heart disease, nicotine dependence, MDD, anxiety, COPD, and DM2 had prior smoking evaluations, but later quarterly MDS assessments either did not assess tobacco use or lacked updated smoking documentation. The DON stated smoking assessments should be completed on admit, quarterly, and with a change of condition.
Unsecured razors were found unattended on the back of a shared sink in the room of two cognitively intact residents. One resident had COPD, HF, depression, HTN, and antiplatelet therapy, while the other had DVT, pneumonia, malnutrition, asthma, and an apixaban order. Facility policy required sharps to be placed in appropriate containers at the point of use, and both the LPN and DON stated the razors should not have been left unsecured in the room.
A resident with Alzheimer's disease, moderate cognitive impairment, and an Eliquis order fell while being changed and hit her head, causing a forehead bruise/hematoma and a skin tear to the elbow. The SBAR note showed the provider was not notified at the time of the incident, and an LPN later stated she called the resident's son but did not notify the physician or NP. The NP learned of the fall later during facility rounding, noted the resident's head injury and hip pain, and sent the resident to the ED for further evaluation.
Hot water temperatures were not monitored in several resident bathrooms, with sink readings of 132 to 134 degrees F found in multiple occupied rooms. The facility had an Accident and Hazard Prevention Policy and a Maintenance Director role requiring regular safety inspections, but no documentation showed temperature monitoring for months before the survey. Interviews with the DON, ED/Maintenance Supervisor, and Administrator showed inconsistent understanding of how often checks were done, while several residents were dependent on staff for hygiene or did not routinely use their bathrooms.
A resident with severe cognitive impairment, documented wandering and exit-seeking behaviors, and a high elopement risk score was not care planned for wandering or exit seeking despite policy requiring such interventions. Nursing notes and an elopement risk assessment identified the resident as an active exit seeker with a physician’s order for a wander guard bracelet, yet the care plan only addressed general behavior issues and did not include specific elopement precautions. On one morning, the resident followed a visitor through the lobby, passed the receptionist and a housekeeper, and exited through the front doors without staff knowledge or assistance while the wander guard system at the entrance failed to alarm. The resident walked off the premises in freezing, icy conditions, was later transported by a private vehicle to a family home, fell on an icy surface while exiting the vehicle, and was ultimately found to have sustained an acute intertrochanteric hip fracture, leading surveyors to cite Immediate Jeopardy at F689 for failure to provide a safe environment and adequate supervision.
Unsecured medications were found in a resident’s room despite no order for self-administration. The resident had dementia and severe cognitive impairment, and surveyors observed eye drops, gas relief tablets, antacid chews, and antifungal powder left unsecured in the room; an RN confirmed the resident did not self-administer medications and that the medications were unsecured.
Staff failed to follow the individualized transfer care plan for a resident with significant mobility limitations and a history of falls, resulting in two separate incidents where the resident was manually transferred without the required mechanical lift. These actions led to the resident sustaining a right tibia fracture and a right lower femur fracture requiring surgery. The failure to adhere to the care plan and facility policies placed the resident and others at risk for serious harm.
A resident with severe cognitive impairment and known exit-seeking behaviors eloped from the facility through a window that lacked a safety stop, remaining missing for an extended period before being found miles away. The resident's care plan was not updated after repeated exit-seeking incidents, and staff failed to provide adequate monitoring or conduct regular safety checks, particularly during overnight shifts. The facility also had a history of complaints about staff not providing care or responding to call lights at night, and management did not provide sufficient oversight or auditing during these hours.
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