Failure to investigate multiple skin tears for a resident with dementia, hemiplegia/hemiparesis, and a hx of falls. Facility records showed treatment orders and notes that the sponsor was notified of new skin tears, but there was no evidence identifying how the injuries occurred. The facility policy classified skin tears as incidents requiring an incident/accident report, investigation, and witness statements, yet the TX nurse and ADM could not confirm an investigation had been completed, and the event summary report showed none.
A resident with documented elopement risk, a guardian, and a Wander Guard was not physically checked when staff realized the resident was missing, and the resident was later found by police lying in a road with seizures and altered mental status after leaving the facility unnoticed. Another resident with wandering and cognitive concerns was observed near a busy roadway after leaving unsupervised, with incomplete sign-out documentation and no elopement reassessment. The facility also failed to control smoking safety for a resident with a history of arson and fire-setting and for another resident who smoked in a room with a blind roommate, despite policies requiring supervised smoking and secure control of smoking materials.
Failure to Supervise Residents at Risk for Elopement and Falls: The facility did not keep track of residents at risk for wandering or elopement and did not maintain safe supervision near exits and outdoor areas. A resident with dementia and a wander guard left through the front door while the receptionist was away and was later found by police near an interstate ditch after the alarm did not sound. Other residents using wheelchairs were left unsupervised during smoking breaks or on the porch, then were found near a store or on a busy highway after staff failed to notice they were missing. Another agitated resident voiced wanting to leave and was later found at a restaurant after being assisted out the door by another resident.
A resident’s family reported that the resident had fallen and developed a new bruise on the left side of the face. An LPN, an RN/unit manager, the DON, the ADON, and the Administrator all became aware of the alleged unwitnessed fall and observed or were informed of the facial bruise, with nursing staff documenting findings such as a raised bruised knot and a light purple bruise extending from the cheek to the eyebrow. Despite a facility policy requiring prompt investigation and completion of an incident/accident report for all resident accidents or incidents, no incident report was completed by any of the involved staff, even though several acknowledged that one should have been done and that they were responsible for doing so.
Staff did not follow the care plan and facility policy requiring a mechanical lift with two-person assistance for a resident with severe mobility and cognitive impairments. Instead, a staff member performed a lift alone in the morning, and later, two staff members completed a manual transfer without the lift. These actions resulted in the resident sustaining a large bruise and experiencing significant pain, necessitating pain medication.
The facility failed to complete thorough RCA for two residents who fell and sustained fractures. One resident with dementia and severe cognitive impairment was found on the floor with a right trochanter fracture, and the RCA documented the injury and transfer to the ER but did not investigate how the fall occurred. Another resident with multiple mobility and neurologic diagnoses was found on the floor with hip and elbow pain and later a left hip fracture; the RCA repeated the event details but did not identify a cause or include witness statements, and the DON confirmed the cause was not determined.
Failure to Report Resident Injury and Swelling A CNA heard a resident say someone ran over his/her foot with a wheelchair and observed swelling, but did not report it to nursing staff. The resident, who had severe cognitive impairment and multiple chronic conditions, was not assessed until several days later when CNAs noticed bruising and swelling to the leg and knee; x-ray then showed an acute proximal tibia fracture. Interviews confirmed the LPNs, RNS, RNUM, CRNP, and DON were not informed when the complaint and swelling were first observed, despite the facility policy requiring accidents and incidents to be promptly reported and investigated.
A resident with moderate cognitive impairment and multiple psychiatric and neurologic diagnoses repeatedly vaped in bed and in the room despite the facility’s vaping policy limiting use to designated areas. Staff and the NP observed the resident vaping in the room, and multiple staff reported the resident hid vape devices and family members brought in replacements after devices were removed. The report also found another resident had smokeless tobacco at the bedside without the required assessment or a care plan focus for tobacco use.
A resident with dementia and a history of falls did not consistently receive prescribed fall prevention interventions, as only one fall mat was placed and the bed was not kept in the lowest position over several days, despite staff awareness and care plan documentation.
The facility did not keep an area free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors. Staff did not implement sufficient monitoring or protective measures to address environmental risks.
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