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.
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.
Fall Prevention and Unsafe Water Temperatures: The DON and surveyors found that one resident with moderate cognitive impairment lacked a complete fall care plan after a head-strike fall, and another resident with severe cognitive impairment had repeated falls with inconsistent documentation of toileting status, alarms, call light use, and root-cause analysis. Surveyors also measured several resident room sinks at 122 to 129 degrees F, above the safe range noted in facility policy and CPSC guidance, while residents reported the water was very hot.
A resident with legal blindness, diabetes, ESRD, and cognitive intactness sustained a second-degree abdominal burn after hot noodles spilled on him. The resident said he had been eating ramen noodles prepared by staff when the cup tipped and spilled, and survey observations later found him eating while lying in bed with the tray table over him and limited ability to position himself safely. Records and staff interviews showed the blister was not initially recognized by the CNA, and the resident’s burn was later treated as a wound.
A resident with MS and dependence for transfers was injured during a Hoyer lift transfer when a sling loop came undone and he fell, striking his head on the lift and floor. Earlier, staff had also used the wrong size lift for his weight during another transfer, and the resident began to fall and was lowered to the ground. The resident was sent to the ER with a head injury and reported ongoing head and neck pain afterward.
A resident with COPD, heart failure, diabetes, and moderate cognitive impairment rolled off an elevated bed during incontinence care after a CNA repositioned her onto her side. The care plan required two staff members to be present when entering the room, but the resident was cared for by one CNA. After the fall, the resident had a change in LOC, reported head pain, was transferred to the hospital, and died shortly after arrival.
Unsafe transfers and wheelchair transport resulted in resident injuries. One resident who depended on a sit-to-stand lift fell when staff transferred her with the device, and the record did not show an RN assessment, physician/representative notification, incident report, or PT/OT re-evaluation after the fall. Another resident with cognitive impairment sustained a left forearm skin tear when a CNA moved her wheelchair too quickly and her arm struck a dining room table.
A resident who required a Hoyer lift for transfers fell when a sling strap came unhooked during a bed-to-shower-chair transfer. The resident struck the head, sustained visible injuries, and was sent to the hospital, where an acute parafalcine subdural hematoma was diagnosed. Records and staff interviews confirmed the resident was dependent on staff for transfers and had diagnoses including CVA, DM, and cognitive impairment.
Failure to Supervise and Individualize Fall Prevention for a Resident with Repeated Falls: A resident with dementia, anxiety, PTSD, weakness, and impaired decision-making had multiple falls and repeated attempts to stand from her wheelchair, but the record did not show consistent review of fall causes, updated care plan interventions, or reliable implementation of individualized measures. Therapy and pharmacy identified several fall-related concerns, including medication effects and possible vision issues, yet staff observations showed the resident was often left without close supervision or redirection when she tried to rise in the common area.
A resident with dementia, weakness, and prior unwitnessed falls was not adequately supervised during showering and fell while standing to wash his groin. The resident slipped on the wet surface, hit his head, and sustained a skin tear and abrasion. Staff interviews and the record showed the CNA left the bathroom to retrieve items, and the resident’s fall risk was not reassessed after prior falls.
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