A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer’s dementia and coronary artery disease, had a care plan requiring Hoyer lift transfers with assistance of two staff. However, staff interviews revealed that CNAs and nursing staff routinely used a sit-to-stand mechanical lift for toileting without a corresponding medical order, while the ADL care plan did not specify equipment for toileting. The RN, DON, and a family member all confirmed that the resident was care planned as a Hoyer lift transfer, and the DON acknowledged there was no current order authorizing the use of the sit-to-stand lift, despite its ongoing use for toileting.
A resident with multiple comorbidities and intact cognition, care planned for substantial/maximal ADL assistance and at risk for falls, was documented by PT as requiring a two-person Hoyer lift for all transfers, with a PT communication sheet confirming dependence on a mechanical lift. Despite this, staff continued to use a sit-to-stand lift and later a two-person stand-pivot transfer, contrary to PT’s determination that the resident was not appropriate for sit-to-stand and could not safely bear weight. The resident reported fear of these transfers and often refused to get out of bed. The care plan and CNA guidance listed only “weight bearing assistance” rather than Hoyer use, and interviews with CNA, ADON, PT, PTA, and DON showed that therapy staff consistently considered the resident a Hoyer-only transfer while nursing leadership acknowledged that PT-recommended transfer changes were not promptly reflected in the care plan or CNA task lists, and that the resident was not identified in the facility’s transfer audit.
A resident with severe cognitive impairment, right‑sided hemiplegia, incontinence, and high fall‑risk score was care‑planned only to have staff "anticipate and meet needs," despite the facility’s fall‑prevention program requiring more detailed interventions for high‑risk residents. The admission MDS documented dependence for rolling in bed, while an ADL care plan simultaneously described the resident as using enabler bars and an unspecified assistive device for bed mobility; these devices were not actually present on the bed at the time of the incident. The resident was on an air mattress and anticoagulants, and the air mattress was later identified as a predisposing factor but was not added to the care plan until after the fall. During care, the resident rolled or fell from the bed and was found on the floor; hospital records documented that the resident had been rolled for hygiene and subsequently sustained a brain bleed. Surveyors determined that the facility did not adequately assess and care‑plan the resident’s multiple fall‑risk factors or implement appropriate fall‑prevention interventions before the fall with major injury.
The facility failed to provide adequate supervision, assistance devices, and thorough post-incident investigations for multiple residents at high risk for falls and other accidents. One resident with Parkinson’s disease, orthostatic hypotension, recent severe functional decline, and a documented high fall-risk score was admitted without initiation of a high-risk fall care plan or resident-specific interventions; after seizure-like activity and documented confusion and wandering overnight, the resident was later found on the floor with head trauma, and the facility’s investigation did not establish when the resident was last seen or toileted, nor obtain statements from prior-shift staff. Another cognitively impaired resident with a history of falls and multiple comorbidities, already on a fall care plan, slid from a chair while fidgeting after an activity; the original fall investigation omitted key details such as last toileting and reasons for the fidgeting, and the post-fall evaluation’s contributing factors were left blank until a later addendum, while observations showed that several care-planned fall interventions (e.g., bilateral floor mats, body pillow, bed pillows) were not in place. Additional residents experienced a burn from hot soup without a prior hot-liquid assessment and falls without thorough root-cause analysis, and were observed without their care-planned fall or accident-prevention interventions, demonstrating repeated failures to follow the facility’s own fall mitigation program and to consistently implement and investigate safety measures.
A resident with dementia, anxiety, depression, and severe cognitive impairment was assessed as at risk for elopement, with a plan for a WanderGuard device and a physician order to check its function and placement every shift. Facility policy required at-risk residents to have elopement precautions such as a WanderGuard, with regular testing and documentation. Although the resident was observed wearing a WanderGuard, review of the Treatment Administration Record showed a gap of several months with no WanderGuard check order or documentation. An RN and the DON both stated that WanderGuard checks should be documented in the TAR every shift but were unable to locate any such documentation for this resident, and the DON acknowledged entering the physician order with an incorrect future start date, resulting in the lack of ongoing monitoring records.
Two residents with dysphagia and cognitive/vision impairments were not provided their prescribed adaptive drinking and dining equipment during meals, contrary to facility policy and care plans. One resident with MS, early-onset Alzheimer’s disease, and moderate cognitive impairment was served hot, thickened coffee in an uncovered cup and, while attempting to pour it into a personal thermal mug without supervision, spilled it into the lap, causing bilateral thigh burns with blistering. Another legally blind resident with vascular dementia and dysphagia was served lunch with an open coffee cup and a blue plate instead of the ordered lidded cup and white divided plate, and was observed searching for utensils until staff intervened. Staff interviews showed reliance on care plans/Kardex at the nurses’ station to identify adaptive equipment, incomplete dysphagia cards, and delayed delivery of the adaptive equipment bin, while a coffee sample from the same cart was measured at a temperature capable of causing severe burns within seconds.
A resident with Alzheimer’s disease, dementia, and severe cognitive impairment, who had a known history of sexually inappropriate behavior, was care planned for paired cares with staff but not for preventing contact with other residents. Despite a prior incident of the resident touching another resident’s breast in the dining area, staff continued to seat this resident within arm’s reach of female residents, and some CNAs were unaware of any restriction on such seating. During observation, the resident repeatedly touched a CNA’s leg and then touched another cognitively impaired resident seated next to them, continuing to touch the resident’s arm and blanket after the CNA left, causing visible discomfort. The same resident also attempted to pull a surveyor closer and reached toward the surveyor’s chest, demonstrating ongoing inappropriate touching in the setting of inadequate supervision and incomplete care plan interventions.
A resident with paraplegia and multiple comorbidities, who was cognitively intact and frequently transported by facility van, was taken to an appointment in a wheelchair without being secured by wheelchair tie-downs or a seat belt, contrary to facility policy requiring both. The van driver, a maintenance staff member who reported limited training and discomfort with transporting residents, drove slowly but made an abrupt stop, causing the unsecured resident to slide in the wheelchair, strike objects on the van floor, and later report rib, back, leg pain, and bruising to the knee. Nursing and physician documentation confirmed post-incident pain, stiffness, and bruising, and the driver acknowledged both the lack of restraints during transport and the need to physically reposition the resident despite policy that non-certified staff should not lift or transfer residents.
A resident with moderately impaired cognition, multiple medical conditions, and a Wanderguard bracelet for known wandering risk exited through an unalarmed, coded employees-only door after apparently observing staff enter the code. Night shift CNAs last saw the resident in the early morning hours but did not detect the absence until a therapist went to the room and found the resident missing, by which time the resident had already left the building. The resident traveled over a mile to a former apartment, where police later found the resident in bed, with the wheelchair and a foot pedal located on a stairwell. After return and subsequent evaluation, the resident was found to have sustained a fractured finger, which the resident reported occurred while slipping on the stairs en route to the apartment.
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