A resident with severe cognitive impairment, wandering behavior, and a known elopement risk exited through an alarmed kitchen door after staff cleared the alarm without checking the outside area. Staff later found the resident outside near another entrance and returned the resident inside. The resident had diagnoses including dementia, was care planned for wandering, and had orders and assessments documenting high risk for elopement.
A resident with ESRD, DM with CKD, dialysis dependence, and bilateral LE amputations was transported in a facility van when the wheelchair flipped backwards because the front secure straps were not attached. The CNA secured only the rear straps, then drove away and the resident fell backward in the wheelchair after the van accelerated from a stop. The resident had a bump on the forearm and reported chest and lower back discomfort.
A resident with multiple chronic conditions and dependence on staff for transfers fell during a mechanical lift transfer when staff used an oversized bariatric sling instead of the correct medium sling. The resident slid out of the sling and onto the floor, and the record and interviews showed staff knew the sling was too large but used it anyway. The DON and Administrator stated the facility had not known there were different sling sizes at the time, and the sling instructions required the correct size to be selected based on the resident's assessment.
A resident with neuropathy, non‑weight‑bearing status on one leg, multiple comorbidities, and a known history of falls was care planned as high fall risk and required two‑person assistance with a gait belt for all transfers. After prior incidents where the resident’s legs had given out during transfers, two staff attempted a wheelchair‑to‑toilet transfer by standing and pivoting the resident using the stronger leg while the resident held grab bars, but they did so without a gait belt. The resident’s legs collapsed, the resident went down to the knees, and an abrasion to the knee occurred. Staff and leadership interviews, along with policies and job descriptions, confirmed that a gait belt was required for all assisted transfers and that staff were expected to follow this procedure, but the involved staff admitted they forgot to use the gait belt during this transfer.
A resident with severe cognitive impairment, a left femur fracture, and dependence for toileting hygiene required extensive 2-person assistance for toileting per the care plan. A CNA instead changed the resident while standing in the room, and the resident lost balance and fell. Interviews showed staff were trained to use safer toileting and transfer methods, including changing residents in the bathroom with support and using another CNA or nurse when needed, but the resident’s person-centered interventions were not followed.
A cognitively impaired resident with dementia, altered mental status, impaired mobility, and documented elopement risk repeatedly roamed the halls and was reported by CNAs to the assigned LPN, but no enhanced supervision was implemented. Late at night, the resident accessed an alarmed dining room exit door, held it open, and exited into an unsecured outdoor area, where the resident fell and then continued on foot to a nearby hotel. The door’s egress alarm sounded, but the LPN, despite prior training on alarm response, assumed it was related to trash removal, did not immediately investigate, later silenced the alarm, briefly looked through the door, and failed to go outside or verify resident safety. The resident’s absence was only discovered during later rounds, and a search was initiated after the resident had already been found at the hotel by emergency responders, demonstrating a failure to maintain a hazard-free environment and provide adequate supervision to prevent elopement.
A resident with dementia, bone density disorder, and major mobility dependence was transferred from bed to wheelchair by one CNA without the required mechanical lift or two-person assistance. The resident’s care plan called for two staff members and a mechanical lift for transfers, but the transfer was done without following those instructions, and the resident sustained an acute distal femur fracture.
A resident with hemiplegia, hemiparesis, a below-knee amputation, moderate cognitive impairment, and wheelchair dependence was transported in a facility van by a CNA who had previously been in-serviced and skills-checked on van safety. During the trip, the CNA secured only three of the four required wheelchair floor locks, and a hold-down device had been removed from the van and not replaced. As the CNA drove over a road irregularity and braked, the incompletely secured wheelchair tilted backward, causing the resident to fall onto the van floor and report head pain with a nodule at the base of the skull. Facility policy required an environment free from accident hazards and staff competency in preventing avoidable accidents, but the missing tie-down and failure to fully secure the wheelchair led to this transport-related fall.
Unsafe handling of a resident during a behavioral incident led to a fall and femur fracture. An RN entered the resident’s room to give medication, the resident became agitated and chased the RN, and a laundry cart was placed between them in the hallway. Staff accounts differed, but multiple witnesses described the RN and resident pushing the cart back and forth before the resident fell to the floor. The resident had multiple diagnoses including PTSD, dementia, schizophrenia, gait instability, and a recent hip replacement revision.
A resident with traumatic brain injury, altered mental status, and a history of wandering was housed on a locked unit with a care plan identifying elopement risk but focused mainly on therapeutic activities and medication monitoring. After returning from a home visit, the resident exhibited escalating behaviors over several days, including being up all night walking halls, entering other residents’ rooms, standing at locked exits, following staff out locked doors, voicing a desire to leave, and stating a plan to escape through a window. On the night of the incident, camera footage showed the resident moving between the room, day room, and bathroom until entering the room and not re-emerging, while the CNA on duty did not perform checks, reported that staff did not usually re-check the resident once in the room, and admitted to dozing off. The resident broke the bedroom window with furniture, left the building unnoticed, and was later found by police nearly two miles away after a citizen reported almost hitting the resident with a car, demonstrating that the facility failed to provide adequate supervision and monitoring during a period of increased exit-seeking.
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