A resident with intact cognition and multiple medical conditions, including septicemia, DM, and cellulitis, was care planned as dependent for all ADLs and transfers. Observation showed a CNA transferring the resident from a wheelchair to bed using a full-body mechanical lift without a second staff member, contrary to facility policy requiring two staff for mechanical lift transfers. The resident reported not getting into the wheelchair on some days due to insufficient staff. The DON confirmed the two-person requirement for mechanical lift use, and the administrator stated he was unaware that residents were remaining in bed because of staffing and described the issue as related to teamwork.
A resident with severe cognitive impairment, multiple comorbidities, and total dependence for transfers was care planned as a high fall risk with a required floor mat intervention when in bed. The resident was later found face down on the floor next to the bed without the floor mat in place, and subsequently reported pain multiple times and was hospitalized with pneumonia, a displaced proximal humerus fracture, and multiple rib fractures before later being pronounced deceased. The DON confirmed the mat was not present at the time of the fall, and although a PIP required tracking and auditing of falls and interventions, the related audit forms were blank and leadership acknowledged there was no evidence the audits had been completed, contrary to the facility’s fall management policy.
A resident who was cognitively intact but dependent for transfers and required a full body mechanical lift was being moved from bed to a recliner by two aides when a sling shoulder strap detached from the lift, causing a fall. Staff and witness statements confirmed that the lift in use lacked safety clips on the spreader bar, despite manufacturer instructions requiring safety clips to be present and properly used. The DON acknowledged that safety clips had been removed from the lifts because they were viewed as ineffective. The resident sustained a cervical fracture and subsequently went into cardiac arrest with death pronounced the same day, and the situation was determined to be immediate jeopardy.
The facility failed to prevent accident hazards and provide adequate supervision related to hot beverage service. A resident with moderate cognitive impairment, stroke, hemiplegia, contractures, and dysphagia, who was care-planned to receive hot liquids only in a Kennedy cup and at non-scalding temperatures, was instead given hot coffee in a Styrofoam cup without a lid and left unsupervised, resulting in burns to the thighs requiring ED treatment. Surveyors also observed multiple residents independently dispensing very hot coffee or water directly from a machine into open cups, then ambulating with walkers while carrying these beverages, sometimes spilling them. Staff interviews confirmed that machine water was not supposed to be served directly to residents, that dining room staffing was often below the intended level, and that there were no clear interventions to prevent residents from independently accessing the hot beverage machine, leading to an immediate jeopardy finding.
A resident with moderate cognitive impairment, dementia diagnoses, depressive symptoms, and on antipsychotic medication repeatedly stated an intent to leave and became angry when told by their POA and family they could not go home. Throughout the day, the resident declined evening medications, talked about leaving, packed two bags of clothing, and walked toward the lobby stating they were going home, yet the medical record showed no evidence that additional supervision was implemented in response to these behaviors. The facility’s elopement policy required adequate supervision and monitoring for residents at risk, but the DON later reported uncertainty about whether the resident had a wanderguard, and the resident ultimately eloped and was later found off-site.
A resident with moderately impaired cognition, dementia, depression, cancer, identified fall risk, and risk for skin breakdown was care planned to have the call light kept within reach, but surveyors observed the resident seated in a recliner with the call light out of reach on multiple occasions. The resident did not know where the call light was, had a wet brief, and could not request assistance, which was also confirmed by the resident’s representative, who noted the resident was covered with a blanket and not wearing pants underneath. A guest ultimately activated the call light, after which a CNA responded and removed soiled linens. The DON stated staff are expected to ensure residents have access to the call light and needed items when left alone, while the NHA acknowledged there was no facility policy on call light use.
A resident with multiple physical limitations who used an electric wheelchair sustained a fractured leg after getting caught in a doorway and later suffered a large bruise from bumping into a bed. Despite these incidents, no wheelchair safety assessments were completed, and the care plan was not updated with additional interventions. Staff interviews confirmed that safety assessments should have been performed for residents using power wheelchairs.
A resident with moderate cognitive impairment and mobility needs fell in the bathroom after waiting an extended period for staff assistance, as the emergency call light was not answered for over 30 minutes. The resident sustained a head injury and later died from a subdural hematoma. Staff interviews and records indicated previous delays in call light response, and the call light system did not distinguish between emergency and regular calls, contributing to the delayed response.
A resident with moderate cognitive impairment and multiple comorbidities fell from a mechanical lift during transfer due to a wet brief, despite proper sling placement. Staff failed to document the incident, update the care plan, or notify the nurse practitioner, and required post-fall procedures were not followed according to facility policy.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility without staff knowledge on two occasions, despite being identified as a high elopement risk. The resident was found outside the facility by staff and law enforcement after each incident. The facility did not provide adequate supervision or ensure the environment was free from accident hazards, resulting in a deficiency.
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