A resident with renal dialysis dependence, muscle weakness, and CVA history was being transported in a wheelchair when a driver started the van before fully securing the wheelchair securement system. While traveling uphill, the wheelchair fell backward, causing a T1 fracture and subdural hematoma. The DON initiated CPR, EMTs transported the resident to the ED, and the resident later died from anoxic brain injury after cardiac arrest.
A resident with severe cognitive impairment, Alzheimer’s disease, and behavioral issues was involved in an incident where the resident threw water on an LPN. Video showed the LPN following the resident, taking a cup from the resident’s hands, and pouring the cup’s contents onto the resident’s head while other staff watched. Interviews also showed staff knew the resident became upset when items were removed from the room in the resident’s presence, and one CNA did not report the incident because they were unsure it needed to be reported.
A CNA and a resident engaged in a verbal confrontation after the resident shouted at the CNA and called her lazy. The CNA responded by telling the resident to shut up and calling the resident racist, while another CNA and an LPN observed the yelling and arguing. The resident had diagnoses including dementia, depression, and mood disorder, and the facility policy stated residents have the right to be free from verbal abuse.
Improper Mechanical Lift Transfer Resulted in Resident Fall: A resident with a history of right hip fracture, weakness, and unsteadiness fell during a mechanical lift transfer after two lift pads were placed under the resident. CNAs used the lift while the resident had two slings/pads under them, causing the pads to separate and the resident to fall to the floor, hit their head on the lift, and land on their right side. The resident was later sent to the ER and hospital records showed a closed right hip fracture.
Failure to report witnessed abuse incident: A resident with severe cognitive impairment and a history of behavioral issues threw water at an LPN, and video later showed the LPN following the resident, taking cups from the resident, and pouring liquid on the resident's head while other staff watched. CNAs who witnessed the event did not report it, and the DON later discovered the incident during video review.
A resident with a history of fractures, falls, neuropathy, and gait impairment was injured after a CNA performed a one-person transfer instead of the required mechanical lift transfer. The resident reported a cracking sound and severe leg pain, but an LPN did not promptly assess the change in condition or notify the provider when pain remained unresolved after PRN medication. Later, two CNAs again transferred the resident without the required lift, despite knowing the care plan, and the resident was ultimately found to have an impacted supracondylar fracture of the distal femur.
A resident with moderate cognitive impairment, wheelchair dependence, and a care plan for two staff and a mechanical lift for all transfers was moved by a CNA using a one-person pivot transfer instead. The resident reported leg pain and heard a cracking sound when weight was placed on the leg, and imaging later showed an acute fracture of the thigh bone just above the knee. Interviews confirmed the CNA did not follow the resident’s care plan and performed the transfer without the required lift.
Kitchen staff failed to maintain sanitary food prep practices and proper food storage. Observations showed debris on the refrigerator floor, an undated container of peaches, and uncovered frozen food with frost. Staff were seen touching cooked food and prep surfaces with contaminated hands or gloves, failing to perform hand hygiene between tasks, improperly cleaning and using a thermometer, handling plates with hands touching the food surface, and having loose hair outside hair nets. Interviews and prior in-services confirmed expectations for handwashing, thermometer sanitation, and hair containment.
An LPN failed to perform hand hygiene before, after, and between medication administrations while passing medications to multiple residents. The LPN was observed handling resident medication cups, assisting a resident with medications, and touching a hallway trash can lid before returning to the med cart without cleaning hands. Facility interviews and policy review confirmed that hand hygiene is required before and after resident contact, between residents, and after contact with contaminated items.
A resident with severe cognitive and physical impairment developed a serious fracture after returning from a family outing, and staff observed swelling and pain but could not determine how the injury occurred. The DON, LPNs, CNAs, MD, and Radiology Director all noted uncertainty about the cause, yet the Administrator decided the fracture was pathological and did not report the injury of unknown origin to OLTC as required.
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