Failure to Supervise a Resident at Risk for Elopement: A resident with dementia, TBI, and chronic respiratory failure had escalating exit-seeking behavior and impaired judgment, yet was able to elope from a secured courtyard gate and later through an office window without staff awareness. After the first elopement, the resident was missing for days before being found by EMS on a highway and was treated for a hip fx, elbow fx, pneumonia, and other medical issues. The record also shows a later elopement after repeated attempts to leave the building.
Improper wheelchair restraint during van transport: A resident with ESRD on dialysis, B/L BKA, and a wheelchair fell onto the van floor when the van braked because the passenger restraint belt was not properly applied. The resident later reported pain and swelling in the lower leg area, and the facility’s investigation confirmed the transport event involved incorrect use of the restraint system.
A resident with cerebral palsy, scoliosis, osteoporosis, and total transfer dependence fell during a Hoyer lift transfer when a sling loop came undone from the lift bar. RN and CNA staff heard a popping sound, the resident struck her head, and she developed a hematoma, bruising, pain, and a traumatic head injury requiring ER evaluation. Staff later reported the sling may not have been the correct size or type and that the lift used did not have safety latches.
Hazardous Room Conditions and Unimplemented Fall Interventions: A resident with a history of falls, pain, limited mobility, and a prior spine fracture was observed walking without a walker, with no grip strips in place, no fall mat at the bedside, and the bed not in the lowest position despite care plan interventions. The resident also placed incontinence pads on the floor, which staff acknowledged were a fall hazard. Another cognitively intact resident’s room remained cluttered with boxes, oxygen tanks, and miscellaneous items blocking the pathway between the bed, bathroom, and exit door, and staff reported the resident refused help moving his belongings.
A resident with dementia and a known elopement risk followed a dietary aide through a secured door after the aide used a keypad to disable the alarm and did not redirect the resident. The resident exited the building, wandered in the community for about a half hour, and was found about 0.4 miles away without injury.
Incomplete neurological monitoring after a resident’s unwitnessed fall with head injury. A resident with dementia and other chronic conditions fell beside the bed, developed a forehead hematoma and facial bruising, and later reported head pain. Required neuro checks were missing across multiple shifts, and when the resident refused parts of the assessment, there was no documentation that the MD was notified.
The facility failed to prevent unsafe smoking behavior and to maintain an appropriate smoking care plan for two residents. One resident was observed vaping in the dining room near other residents, including one on O2, despite a policy limiting smoking and e-cigarette use to designated outdoor areas. Another resident had a history of smoking marijuana and was identified as a smoker, but her smoking evaluation and care plan were not in place until the survey, even though staff described her as an independent smoker and noted she needed help with lighter use due to hemiplegia.
Failure to Monitor Air Mattress for a Resident with a Pressure Ulcer: A resident with dementia, dependence for ADLs, and a stage 3 pressure ulcer was observed on an air mattress that was on and set to alternate, but the EMR did not document the mattress settings. The care plan did not include the air mattress as an intervention, the CPO lacked orders for the settings, and the MAR/TAR did not show regular checks of the mattress function. Staff interviews showed nurses were expected to monitor the mattress, but there was no set schedule, and a nursing note linked a new lower-back pressure injury to air mattress failure.
Delayed and inconsistent wander guard assessment for an elopement-risk resident. A resident with cognitive impairment, hallucinations, and poor safety awareness had documented wandering and exit-seeking behavior, yet the EMR showed consent, the physician order, and the wander guard evaluation were not completed or entered in a timely and consistent manner. The care plan said the resident was to continue using a wander guard and staff were to ensure proper placement and functionality, but the chart also contained conflicting elopement and fall documentation. Staff reported the resident wandered throughout the building and had been using the bracelet for some time.
Failure to provide adequate supervision and person-centered fall prevention led to repeated falls for two residents. One resident with stroke-related weakness, anxiety, and worsening cognitive impairment repeatedly attempted self-transfers to the bathroom, was not consistently supported with toileting assistance or purposeful rounding, and sustained a head injury with intracranial bleeding. Another resident with Alzheimer's disease, poor memory, and impulsive behavior had multiple unwitnessed falls, including one that resulted in a right elbow fracture, while staff did not update the fall care plan or consistently provide the cueing and supervision identified in the plan.
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