Three residents who were dependent on staff for bed mobility and transfers did not receive adequate supervision and safe handling during care and transfers, resulting in serious injuries. A resident who was totally dependent for bed mobility slid from the bed to the floor while a CNA focused on gathering supplies during care, later being found to have an ankle fracture. Another resident with a prior brain bleed, craniotomy, and left-sided paralysis, requiring a mechanical lift with two staff, sustained a head injury when a Hoyer lift was improperly positioned or controlled during transfer from a shower bed to a wheelchair, causing the lift bar to strike the top of the head and leading to ongoing head and neck pain. A third resident needing extensive assistance fell between a shower bed and her regular bed when a CNA attempted to transfer her without locking the shower bed wheels, resulting in acute L2–L3 compression fractures confirmed by CT.
A resident with cerebrovascular disease, hemiplegia, gait abnormalities, and a history of falls, who was totally dependent for ADLs and care planned for two-person Hoyer lift transfers, was transferred by a CNA using a Hoyer lift without the required second staff member. During the transfer from bed to a shower stretcher, the CNA had to repeatedly reposition the lift while the resident swung in the lift sheet and held onto the lift with one arm. An LPN later stated the resident was care planned for two-person assistance and had assumed another staff member was present, while the CNA admitted she knew two-person assistance was required but proceeded alone because other staff were busy.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with severe cognitive impairment, an unsteady gait, and elopement risk left the unit through an emergency door after staff lost sight of the resident, and the resident was later found outside in the employee parking lot. In a separate incident, a CNA transferred another resident alone without the required Hoyer lift or two-person assist, despite the resident’s care plan requiring both.
Multiple residents with documented upper extremity impairments, balance problems, poor vision, seizure history, and unsafe smoking behaviors were allowed to keep cigarettes and lighters and to smoke without direct supervision, despite care plans and smoking safety evaluations identifying significant risks. One resident with quadriplegia and severely contracted fingers independently retrieved and lit cigarettes from a cross‑body bag while staff left him alone in the smoking area. Other residents with stroke, epilepsy, neuropathy, and vascular dementia were observed smoking outside without staff present, declining smoking aprons, and disposing of cigarettes in non‑fire‑safe metal cans, while the smoking areas lacked fire extinguishers, fire blankets, and properly assembled safety ashtrays. A resident who used oxygen via nasal cannula with an oxygen concentrator in the room kept a cigarette lighter in the room, even though staff acknowledged this should not occur for someone on oxygen. Facility leadership confirmed that certain smoking areas were not supervised, residents were permitted to retain smoking materials if care planned, and there were no smoking blankets available, contributing to the identified deficiency.
A resident with traumatic brain injury, dementia with agitation, and a high fall-risk score experienced multiple unwitnessed falls, including one causing a hip fracture, due to the facility’s failure to consistently implement care-planned fall-prevention interventions and supervision. The care plan and therapy notes called for close supervision and keeping the resident in a Broda chair within staff line of sight, but MARs, TARs, and CNA documentation showed no monitoring entries, and monitoring was not listed as an intervention. Surveyors repeatedly observed the resident in a Broda chair in hallways, common areas, and an office, sometimes restless and attempting to stand, without staff present. Staff and leadership acknowledged that the resident was supposed to remain in direct view when up, yet incident reports documented numerous unwitnessed falls from the wheelchair/Broda chair and in hallways, demonstrating inconsistent adherence to the facility’s fall prevention policy.
A resident with severe cognitive impairment and a history of falls was left unsupervised during care, resulting in a fall, head laceration, and a fractured femur, after which comfort care was initiated and the resident expired. Additionally, broken glass was left unaddressed in another resident's restroom on a dementia unit, despite staff awareness, creating a hazard for residents, including those who wander. Facility policy requiring hazard identification and adequate supervision was not followed in both cases.
A resident with significant mobility impairments was transferred using a mechanical lift by only one staff member, contrary to facility policy requiring two staff for such transfers. During the transfer, the lift made contact with a chair base, causing the resident to be lowered to the floor and resulting in pain and an emergency department visit. Staff interviews confirmed the transfer was not performed according to established procedures.
A resident who was completely dependent and required two-person assistance for bed mobility and transfers was left unsupervised by a single CNA during incontinence care. The CNA, unaware of the care plan requirements, attempted to turn the resident alone, resulting in the resident falling from the bed and sustaining multiple serious injuries.
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