A resident with poor safety awareness and limited mobility was not adequately supervised while in the courtyard during extreme heat. He independently accessed the courtyard, remained outside in direct sunlight, and was later found unresponsive, sweaty, and difficult to arouse. He was sent to the hospital with an elevated temperature and second-degree burns to both thighs. Review of video, interviews, and records showed staff did not accompany him when he entered the courtyard on the final occasion, and the resident required assistance with mobility and did not ambulate independently.
Unlocked Bed Brakes During Transfer Led to Resident Fall and Fracture: A resident with a history of right shoulder injury and a care plan for two-person dependent transfers fell during a wheelchair-to-bed transfer when the bed brakes were not locked. The resident was sent to the hospital and found to have a displaced proximal humerus fracture. Staff stated that transfer safety required locked bed and chair brakes and use of a gait belt, but the brakes were not checked during the transfer.
A resident with dementia, severe cognitive impairment, osteoporosis, epilepsy, and a history of falls was identified as high fall risk and unsafe to ambulate independently. After a witnessed hallway fall while being led to dinner, staff did not immediately notify the nurse or obtain prompt assessment and monitoring. Hours later, the resident was found in significant pain with a shortened, externally rotated leg, was sent to the hospital, and was diagnosed with an acute displaced right hip fracture requiring surgical repair.
Failure to Prevent Resident Elopement: A resident with severe cognitive impairment and multiple medical conditions was not identified as an elopement risk on assessment, then exited through a therapy room door and reached the sidewalk near the street without the alarm sounding. Staff later found the resident in a wheelchair and escorted him back inside; the DON and other staff acknowledged the event was an elopement and that the resident had left the premises unsupervised.
A resident with a PICC line, substance abuse history, and a BIMS score of 15 was observed entering another resident’s room and then could not be located when staff attempted to check vitals. Staff searched the facility, found an open window, and later documented that the resident left without notifying staff and left AMA, while police and APS were notified. Record review did not show that the resident told staff she intended to leave before exiting, and staff gave conflicting accounts of whether the event was elopement or AMA.
A resident with acute respiratory failure, pulmonary edema, weakness, dysphagia, and moderate cognitive impairment had two vitamin C tablets left in a cup on the bedside table. The resident said the nurse gave the tablets and that he had been taking meds independently, but there was no physician order authorizing self-administration at the time, and the care plan initially lacked documentation for self-administration. The DON stated staff prepared the meds, left them with the resident, and later returned to verify they were taken, despite the facility policy requiring meds to be given only per written orders and not set up in advance.
Failure to Prevent Elopement for Two Residents: Two residents with documented dementia, cognitive impairment, and wandering or exit-seeking behaviors were identified as elopement risks and had Wander Guards in place, yet each was found outside the facility unsupervised. One resident was located near a gas station after leaving without an alarm sounding, and another was reported by a community member walking along a road before staff found and returned the resident.
A resident with a BIMS of 15, walker use, and continuous O2 was injured when her wheelchair tipped backward during van transport. The driver failed to secure the wheelchair’s front clamps, and the resident reported hitting her head and sustaining a skin tear to her upper arm after the chair flipped and struck items in the van.
A resident with aphasia and moderate cognitive impairment eloped from the facility without signing out or notifying staff. Staff later discovered the resident was missing during a med pass, searched the building and grounds, and learned from family that she had been taken to the hospital. EMS found her next to her motorized scooter, agitated and confused, and the ER documented encephalopathy and presumed heat stroke. Interviews showed the facility expected residents to notify the nurse and sign out when leaving, but the resident had no prior elopement history and was not located until after she had already been transported to the hospital.
A resident with a prior elopement history, moderate cognitive impairment, and use of a motorized wheelchair was allowed limited independent travel and had inconsistent care plan documentation regarding a wander-guard and supervision needs. The resident signed out to the portico, was later found missing, and was located at home about 24 miles away after a code pink was called. Staff interviews and the record showed the resident was not accompanied as planned and a staff member who saw him leaving did not stop him or notify others.
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