Inadequate supervision and elopement prevention: One resident with dementia and multiple other diagnoses was repeatedly observed with the call light out of reach, the walker away from the bed, and the room door shut, despite a history of 15 falls and prior wandering. The record showed several falls with limited or no new interventions, and staff stated the resident needed close monitoring and reachable assistance devices. A second resident assessed as high risk for elopement wandered the unit, left the building after an alarm sounded, and was later found by police; the record noted no individualized care plan and no investigation into how the elopement occurred.
A deficiency occurred when a resident’s wheelchair was not secured during van transport between buildings on a medical campus. A resident reported, and video confirmed, that another resident’s wheelchair was not anchored to the van floor; instead, the driver was seen driving while holding the wheelchair base with one hand, and the resident was holding the back of the driver’s seat. The driver later admitted he did not apply the wheelchair straps because the distance was short and he was in a hurry, while the DON and ADM confirmed that the resident had not been properly secured despite usual practice of securing residents during transport.
A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs when a sling strap snapped, causing the resident to fall and strike the back of the head. The resident sustained an abrasion, a 1 cm scalp laceration with bleeding, and severe back pain rated 9/10, and was sent to the hospital for evaluation. Manufacturer instructions required staff to inspect slings and straps for wear before each use, but there was no evidence the specific sling used in this transfer had been inspected for integrity, and the Administrator acknowledged that the strap breakage led to the resident’s fall and injury.
A resident with cognitive impairment, neurological conditions, and substance-related diagnoses was assessed as being at risk for elopement and documented as having poor safety awareness, poor judgment, and wandering behavior requiring frequent redirection. Nursing staff observed the resident wandering in the hall and behind the nurse’s station and communicated during shift report that a WanderGuard was recommended, but no device was applied because staff did not know where to obtain one. The resident later left the building through the front door, was not immediately detected as missing, and was ultimately found by a medication technician about a mile away walking on a sidewalk near a restaurant, demonstrating a failure to provide adequate supervision and timely elopement interventions.
A resident with multiple comorbidities and an above-knee amputation requested that staff heat prepackaged ramen soup in a microwave at the nutrition station; staff followed package directions and returned the hot soup, which the resident, who used a motorized wheelchair and insisted on carrying items independently, then spilled while turning, causing a third-degree burn to the palmar side of the left wrist. Staff interviews showed that, before this incident, CNAs and an LPN heated food based on package instructions and judged safety by touch without thermometers, and the DON confirmed that no thermometers were available and that staff relied on touch to determine if food was safe to serve.
A resident with multiple medical conditions was transported in a facility van when the wheelchair was only secured with rear straps and the front straps were not attached, causing the chair to tip backward and the resident to strike her head on the vehicle. The driver repositioned and fully secured the wheelchair and continued to the appointment without calling EMS. The resident later reported the incident at an urgent care visit and was diagnosed with a closed head injury. Facility interviews confirmed that the van used required manual attachment of front straps and that these had been forgotten, and the incident was not documented in the resident’s medical record, although neuro checks were completed afterward.
A resident with weakness and orthostatic hypotension fell and hit his head after being left alone in the shower, despite needing supervision or more assistance with bathing. Another resident with paraplegia was injured in a van crash when the wheelchair seatbelt was not secured properly, and the driver had no documented training on safely transporting residents. Surveyors also found multiple room sinks with water temperatures above 120 degrees, including readings up to 130.2 degrees.
A resident with stage 4 CKD, a distal femur fracture, and a non–weight-bearing order for the left leg was being transferred from bed to a bedside commode using a walker and gait belt when the assisting CNA left mid-transfer to answer other call lights, leaving the resident unattended. The resident, who was on Eliquis and had oxygen tubing in place, attempted to reposition the walker and sit further back on the commode, became tangled, and fell forward to the floor, sustaining a nasal abrasion and a minimally impacted nasal bone fracture confirmed by CT.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite having a wander guard alarm in place. Staff failed to respond appropriately to the alarm, did not verify the resident's location, and turned off the alarm without notifying others, resulting in the resident being unsupervised outside the facility for several hours.
A resident with multiple sclerosis and paraplegia, who was at high risk for falls and used an air mattress, was not provided with two-person assistance during a brief change. During care, the resident lost control and fell from the bed, resulting in bilateral femur fractures. Staff interviews revealed inconsistent understanding of assistance requirements for residents on air mattresses, and the care plan did not specify two-person assist for bed mobility at the time of the incident.
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