An unsecured portable oxygen cylinder was observed standing on the floor in a resident’s room, first while the resident was present and later while the resident was out of the room. Staff, including a CNA, an LPN, and the ADON, stated the tank should be secured in a cart, holder, or on the wheelchair, and the facility’s oxygen administration policy required portable cylinders to be secured to an O2 cart or wheelchair.
A facility failed to keep a shared resident room free of accident hazards when a roach-like insect was seen near a resident’s belongings and bottled water. A Maintenance Assistant sprayed Talstar Professional Insecticide in the room while the residents were present, even though the DON later confirmed the residents should not have been in the room during application until the solution dried.
Inadequate Fall Supervision and Intervention: A resident with dementia, hemiplegia, weakness, impaired cognition, and a history of falls had repeated unwitnessed falls and one witnessed fall, with injuries including a forehead bruise, reopened knee skin tear, and eye swelling. Survey review found incomplete fall investigations, missing or inconsistent neuro checks, unclear documentation of the resident’s position and last observation before several falls, and no individualized fall interventions documented for multiple events.
Failure to supervise a wandering resident resulted in two residents being found together in one resident’s bed while both were fully unclothed. The resident involved had severe dementia-related wandering and needed increased supervision, while the other resident had moderate cognitive impairment and a history of sexually inappropriate behaviors. Staff described frequent wandering, room entry, and attempts to get into other residents’ beds, and the DON and NHA confirmed they did not know who was supervising the residents at the time of the incident.
A resident with dementia, weakness, poor coordination, and dependent transfer status was transferred alone by a CNA despite care plan and order requirements for 2-person assist and a prior PT recommendation for a full-body mechanical lift. During the transfer, the resident complained of foot pain, and staff later noted swelling and warmth; x-ray confirmed a nondisplaced calcaneus fracture. Interviews confirmed the CNA was alone and was not aware of the resident’s required transfer assistance.
Unsafe Supervision of Resident Smoking Materials: A resident with hemiplegia, epilepsy, nicotine dependence, and moderate cognitive impairment was observed smoking in the designated area while removing a lighter from his pocket. Staff stated that residents were not permitted to keep lighters and that smoking materials were supposed to be secured at the nursing station, but the staff member did not know how the resident obtained the lighter. The resident’s assessment and care plan both required supervision while smoking and storage of cigarettes and lighters by staff.
A resident with severe cognitive impairment and multiple fall risk factors had six falls over a short period, but only four were logged. Nursing notes and IDT reviews were missing for several falls, and the record did not consistently show the required fall investigations or care plan review. The resident’s care plan included fall precautions such as call light use, low bed positioning, non-skid footwear, orientation, and PT, yet the documentation did not consistently reflect the circumstances of each fall or interdisciplinary follow-up.
Failure to Reassess Fall Interventions After Repeated Unwitnessed Falls: A resident with encephalopathy, schizophrenia, bipolar disorder, and a history of subarachnoid hemorrhage had repeated unwitnessed falls with head bleeding. Although the care plan identified fall risk and included multiple interventions, the record did not show updates after the first fall, and staff later confirmed the earlier fall was not reviewed when the resident fell again and required 911 transfer for further evaluation.
Unsafe Storage of Sharp Objects in Resident Areas: A resident’s room contained two knives on an overbed table in a plastic container, and an open unattended shower room had a razor on the sink. The resident had Type 2 DM with diabetic neuropathy, a BIMS score of 13, and used a walker/wheelchair. Staff and the DON acknowledged that sharp objects and razors in these areas were safety issues.
A resident was served the wrong lunch tray and initially received an alternate meal that included an ingredient she was allergic to, rather than the primary meal she expected. She reported repeated problems with meal delivery, including missing meals and incorrect items, and staff could not explain why the tray mismatch occurred. The resident later received the primary meal, and records showed an egg allergy, an EpiPen order, and an order to check trays against meal tickets before delivery.
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