A resident with dementia and a documented assist-of-1 toileting plan was left alone on a toilet commode without a gait belt, stood up before the aide returned, and fell with wrist pain. Another resident with vertigo and syncope was ambulated at night without the required gait belt, lost balance during a bathroom return, fell, and sustained head and arm injuries requiring ER evaluation and stitches.
Failure to follow a resident’s no-Styrofoam dietary order. A resident with dementia and other behavioral diagnoses had a care plan and MD order for no Styrofoam, after the SLP observed the resident chewing on Styrofoam. During dining observations, the resident was served meals in Styrofoam containers and plates, while dietary staff reported the dishwasher had been broken and meals were being served in disposable Styrofoam containers. The DON/Dietary Services confirmed the resident was served in Styrofoam despite the order.
Failure to Maintain Hands-On Toileting Assistance: A resident with high fall risk, impaired balance, and a need for one-person physical assistance with toileting fell while being assisted at an off-site restroom. An NA positioned the resident at a urinal, then turned away to provide privacy and was not giving hands-on support when the resident fell and struck the head, resulting in scalp staples. Records showed the resident had prior falls, subdural hematomas, and documented needs for direct observation and physical support during toileting.
Failure to Supervise Resident and Follow Elopement Procedures: A resident with dementia, cognitive impairment, and other diagnoses required 24-hour supervision and did not have approval for an independent LOA, yet staff allowed the resident to sit outside unsupervised and did not complete the required elopement risk process. Staff were unclear about supervision responsibilities, documentation incorrectly stated the resident returned from an LOA, and the resident was later reported missing. Police found the resident at a hotel after surveillance showed the resident leaving the facility and spending time outside without staff monitoring.
A resident with dementia, impaired balance, fatigue, and dependence on staff for transfers had repeated documentation of forward-leaning wheelchair posture and evening transfer difficulty. After earlier falls and PT concerns about poor sitting posture and fatigue, the resident was being pushed in a wheelchair by an NA when the resident fell forward, struck the head, and was later found to have cervical spine fractures. Interviews confirmed the resident leaned forward most afternoons and that leg rests were not used during transport.
A resident with dementia, severe cognitive impairment, and dependence for all care required two staff for bed mobility, but one NA rolled the resident alone during sheet changes. While the NA pulled the sheet, the resident slid off the bed and fell to the floor, later resulting in an acute R tibia fracture. Interviews with PT and the DON confirmed the resident needed two staff for bed mobility and that rolling the resident away from the staff member was not the safest technique.
A resident with dementia and moderately impaired cognition was care planned for two-person transfer assistance, but a NA transferred the resident alone without a gait belt. The resident stood up quickly, turned during the transfer, caught a foot on the wheelchair, and fell, resulting in a head laceration, abrasions, headache, and hospital transfer.
Elopement Risk Assessment Not Completed Timely: A resident with schizoaffective disorder, Wernicke's encephalopathy, DM, and epilepsy left the facility without staff knowledge after telling a staff member a friend was picking him/her up and they were going to a diner. Staff watched the resident briefly from the receptionist desk, then the resident was found walking toward the road and was returned without injury. The resident had not had a documented elopement risk assessment for more than a year before the incident, despite care plan concerns for impaired thought processes and the DON stating assessments are completed on admission, readmission, and with a change in condition.
A resident with dementia, chronic pain, right-sided hemiplegia, and a fall history had increasing transfer weakness and fatigue that were observed by NA and RN staff but not reported or reflected in the care plan. During a toileting transfer, the resident could not bear weight, the transfer was continued anyway, and the resident fell, striking the face. After the fall, the NA left the resident on the floor unattended, and later transfers required four staff while the resident grimaced, clenched the jaw, and complained of severe pain. The resident was later found to have an acute intertrochanteric femur fracture requiring ORIF.
The facility failed to supervise smoking activity, maintain shower equipment, and ensure wheelchair footrests were in place. A resident with severe cognitive impairment fell when a shower chair collapsed and sustained a skin tear, while another resident with nicotine dependence was found with cigarettes and a lighter and had repeated smoking-related incidents without documented A&I follow-up. A third resident who depended on staff for wheelchair mobility slid from a wheelchair when the leg rests were not in place, and staff confirmed the resident needed the supports while seated and transported.
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