A resident with cerebral palsy and dependence for transfers had a care plan requiring a Hoyer lift and two staff for all transfers, but a CNA attempted a manual stand-and-pivot transfer instead. During the transfer, the resident’s weight shifted, she was guided to the floor, and she later reported being dropped and injured. Hospital imaging confirmed fractures of the distal femur and patella, and staff interviews confirmed the resident’s transfer status required a lift with two-person assistance.
A resident with Type 1 DM and a recent DKA history developed worsening hyperglycemia, emesis, confusion, and altered mental status, but critical labs showing glucose 592 and CO2 <5 were not promptly communicated or acted on. Staff documented elevated blood sugars and symptoms, yet provider notification and 911 activation were delayed until the resident was critically ill with suspected DKA and severe metabolic acidosis, requiring EMS transfer to the ER.
A resident with chronic kidney disease, recent digestive surgery aftercare, and a nephrostomy tube, who required maximal assist for transfers and used a wheelchair, was being transported by a CNA-driver for follow-up care and subsequent ER evaluation. Instead of proceeding directly to the ER, the CNA-driver diverted to a personal dental appointment, parked the facility van in an unshaded area, turned the engine off, and left the resident strapped in the wheelchair in the back of the van without supervision. The van’s doors and windows were largely closed, it became very hot inside, and the resident, who remained cognitively intact, called 911 reporting she was locked in and getting warm. Police and Fire Department responders found the non-running van with only a slightly open door and one window down, noted the resident was visibly sweating, and removed her from the vehicle. The facility’s own policies prohibited leaving residents unattended in vehicles and required continuous supervision during transport, but these were not followed, resulting in a finding of neglect and Immediate Jeopardy.
Failure to Provide Diabetic Monitoring and Treatment: An IDT failed to recognize that a resident with type II DM, CKD, and recurrent UTIs needed a diabetic treatment plan after re-admission. Although an abnormal BG was documented, staff did not notify the MD, no diabetic orders were entered, and BG monitoring stopped for weeks. Staff later gave conflicting explanations about hospice status and family wishes, but there was no documentation that the resident or representative declined diabetic care. The resident was ultimately found with severe hypoxia and a BG reading too high for the device, then transferred by 911 with sepsis and HHS requiring ICU care.
The facility failed to enforce its Smoking/Vaping policy for multiple smokers, including oxygen‑dependent residents, allowing them to keep cigarettes and lighters on their person or in their rooms and to smoke inside, including while oxygen was in use. One oxygen‑dependent resident with COPD and intact cognition had a documented history of smoking in his room and bathroom despite prior staff observations and care plan interventions requiring supervised smoking. Staff, including CNAs, an RN, and the DON, were aware of repeated in‑room smoking and residents’ refusal to surrender smoking materials but generally did not confiscate supplies, relying instead on notifying management while rounding remained infrequent. This inaction culminated in an event where a resident’s nasal cannula ignited while he smoked in his room, causing second‑degree facial burns and respiratory distress, and surveyors later observed other smokers, including another oxygen‑dependent resident and a roommate of an oxygen‑dependent resident, leaving the designated smoking area and returning to oxygen‑posted rooms with cigarettes and lighters still in their possession.
Failure to Protect a Vulnerable Resident from Sexual Abuse: A cognitively impaired resident was found in bed with another resident who had a documented hx of sexually inappropriate behavior toward staff and residents. Staff observed thrusting movements and the other resident on top of her, while the resident was later sent to the hospital for rape kit and STD testing as a suspected sexual battery. Records showed the resident had severe cognitive impairment, and the other resident had a care plan for inappropriate sexual behaviors and required 1:1 supervision.
Two residents were involved in a sexual abuse incident when a CNA entered a darkened room and found one resident in a wheelchair at the bedside of another, who was lying in a fetal position with her brief pulled down, while the wheelchair-bound resident had a clenched fist against her genital area and his other hand on his exposed penis. The alleged victim had dementia, a BIMS score indicating significantly impaired cognition, and a documented lack of capacity for sexual consent, with a care plan calling for cueing, reorientation, and supervision. Staff and leadership reported that the alleged perpetrator frequently visited other residents’ rooms and masturbated in his shared room, and a prior inappropriate interaction between the same two residents in the dining room had been redirected but not reported. The resident’s representative also reported multiple prior occasions of finding the male resident in the female resident’s room with the door shut and notifying staff, who stated they would separate and monitor them more closely, indicating a failure to adequately identify, assess, and monitor behaviors that could lead to resident-to-resident sexual abuse.
A resident who was cognitively intact, on hospice, and documented as full code with a tracheostomy and feeding tube was found unresponsive by a CNA, who notified the assigned RN. The RN confirmed the resident had no respirations or vital signs but did not verify code status, assumed the resident was DNR because of hospice enrollment, and did not initiate CPR or call 911, instead contacting the physician and hospice. Another RN later saw on the electronic record that the deceased resident was full code, informed the first RN, but did not report the situation to administration. The facility’s abuse/neglect policy defined neglect as failure to provide necessary services and failure to report suspected neglect, and the failure to perform CPR on a full-code resident and to report the incident was determined to be neglect and Immediate Jeopardy.
A resident with traumatic brain injury, moderate cognitive impairment, and a history of unpredictable behaviors became agitated and physically aggressive during transfer to bed. Despite the resident’s refusals and distress when a mechanical lift was brought in, two CNAs continued care. One CNA was reported to have grabbed the resident’s arm, twisted it, and forcefully slapped the same area of the forearm multiple times while laughing, after the resident kicked and hit staff. The resident later stated that nurses slapped his arm several times, and a family member reported being told that staff repeatedly tapped the resident’s arm while saying not to do that. Multiple staff, including CNAs and LPNs, observed redness and linear marks on the resident’s right forearm, and a provider note documented localized erythema with superficial linear markings consistent with a grab or excoriation-type injury. These events show that the resident was not protected from physical abuse by staff.
A resident with obesity, lymphedema, seizure history, and an intact BIMS score was care planned for 2-person assistance with bed mobility and had a prior documented fall when care was provided by a single CNA. On a later date, a CNA who normally worked in activities was reassigned to the nursing unit, did not review the care plan, and relied on a brief verbal report that did not mention the 2-person bed mobility requirement. While providing incontinent care alone, the CNA turned the resident toward the window as the resident held the side rail; the resident’s heavy legs slipped off the bed, pulling his body to the floor. Nursing notes and an LPN’s account documented that the resident’s lower body was on the floor in a twisted position while he held the side rail, after which he complained of right hip pain. Imaging confirmed an acute proximal femur fracture, and the facility’s abuse/neglect policy defined neglect to include performing 1-person assistance when 2-person assistance is care planned.
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