A facility failed to provide required supervision and assistance during transfers and bed mobility for two residents. One resident who was completely dependent and required a Hoyer lift with assist of 2 fell when a CNA used the wrong sling and did not have a second staff member present, resulting in head trauma, brain bleeds, and skull fractures. Another resident who required assist of 2 for bed mobility fell from the bed during toileting care when one CNA worked alone.
Failure to Report Allegation of Neglect Involving Improper Hoyer Lift Transfer: A resident with dementia, stroke, and ESRD who was fully dependent for transfers slipped out of a Hoyer lift during a transfer and sustained a head injury. The incident was reported to the State as a fall with injury, but the DON knew the CNA used the wrong sling for the wrong lift and did not have a second staff member present, and the report did not identify the event as an allegation of neglect.
Improper Hoyer lift use during a transfer led to a resident falling onto the floor when two CNAs attempted to move the resident from a chair to a bed. The lift tipped over after the base was partially closed to maneuver around another resident’s recliner, and the resident reported back and R knee pain. The resident was sent to the hospital, where x-ray showed no acute fracture or dislocation.
Failure to supervise a resident at risk for elopement: A newly admitted resident with baseline confusion, poor safety awareness, and a low BIMS score was identified as a wander risk and placed on a Wanderguard, yet the resident exited through double doors without staff knowledge. Video showed the resident walking unattended along a busy roadway while the wander system did not alarm, and the resident was later found by a staff member and returned.
A resident with severe cognitive impairment, fall risk, and need for assistance to roll fell from the bed during in-bed care when a CNA instructed the resident to roll and the resident rolled the opposite way. The resident was found face down beside the bed with facial bleeding and skin tears, was sent to the ER, and later returned with stitches to the cheek. The facility’s investigation noted positioning near the bed edge, insufficient guarding, a bed that was not wide enough, and no floor mat in use during care.
An LPN documented a resident's unwitnessed fall, baseline and subsequent neurochecks, and a nursing note, but the record lacked evidence that an RN completed the required initial post-fall assessment and documentation. The resident was on Eliquis for aFib and was sent to the ER after being found on his knees with his head resting on the bedside table.
A dependent resident had a physician order for showers twice weekly, but the order was discontinued when the resident was sent to the hospital and was not re-entered after readmission. As a result, the facility did not ensure the resident was bathed at least two times per week.
The facility failed to follow a physician order to trend a resident’s weights. The resident had CHF, the care plan included weight monitoring, and the provider ordered weights twice weekly, but several ordered weights were not obtained. E4 confirmed the finding during interview.
A resident with osteoporosis, a prior lower leg amputation, and impaired cognition and mobility reported right ankle pain during PT/OT. Therapy noted the ankle looked more everted than baseline and immediately informed nursing, but the LPN gave Tylenol and did not assess the pain or notify the provider at that time. The provider was not notified until about 8 hours later, after which a STAT x-ray showed an acute distal fibular fracture.
Failure to post required staffing information. Surveyors observed that the staffing posting at the nursing station did not include the total worked hours per shift for each discipline, including RN, LPN, and CNA. The Scheduler stated that the postings had not included nurse and CNA hours since she joined the company under the previous ownership, and the finding was discussed with the ED, DON, and ADON.
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