A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Failure to Investigate and Document a Resident Fall: A resident with ataxia, vascular parkinsonism, dementia, and severe cognitive impairment was observed with both knees on the floor mat beside the bed and later had bruising to the eye and a leg abrasion. OT staff and an RN described the resident slipping off the bed, but no incident report was completed at the time and the fall care plan was not updated. A later fall incident report documented the resident found on the floor, and the DON stated the event should have been treated as a fall.
A CNA attempted to transfer a resident using a manual pivot instead of the resident’s required Hoyer lift with two staff assist. The resident’s weight shifted during the transfer, she was lowered to the floor, and she later reported that she was dropped and fell with her leg caught underneath her. The resident, who had cerebral palsy and was dependent for transfers, was later found to have fractures of the lower R femur and patella. An LPN nearby heard the CNA call for help, and the CNA did not report the fall.
A resident with stroke, severe vascular dementia, vision loss, weakness, gait impairment, and a history of falls was not adequately supervised, and multiple unwitnessed falls were documented without corresponding nursing notes. The resident was later outside with another resident in a wheelchair, tripped and fell onto the other resident, and sustained a major left shoulder fracture requiring hospital transfer. Interviews with the DON, NHA, and LPN confirmed the resident’s declining cognition, prior falls, and that the incident occurred on a weekend when no supervisory staff were at the front desk.
A resident with MS, paraplegia, and total dependence for care fell during a shower after a CNA transferred her alone despite a care plan requiring a Hoyer Lift and 2-person assist. The resident reported the shower chair felt unstable and that she warned the CNA she was slipping before falling to the bathroom floor. Staff later confirmed the care plan was not followed, the shower chair appeared damaged, and the resident sustained a left hip fracture requiring hospital transfer and surgery.
Surveyors found that the facility failed to keep the environment free of accident hazards when a resident’s room contained an unattended shaving razor on the sink and additional razors in a nightstand, despite leadership stating razors were not permitted in resident rooms. An LPN disposed of unused lancets in regular trash instead of a sharps container, contrary to acknowledged policy. On two occasions, an unattended housekeeping cart on an upper floor had germicidal wipes left on top and easily accessible, even though housekeeping leadership and staff stated that chemicals and disinfectant wipes were to be kept locked in the cart for safety.
A resident with dementia, weakness, and fall risk was allowed to sit on the seat of his rollator while an untrained SSD pushed him during a community outing. The walker caught on a gap in the sidewalk, the resident fell backwards and struck his head, and he was later hospitalized with a subarachnoid hemorrhage requiring ICU monitoring. Interviews showed non-clinical staff had not been trained on safe mobility assistance, and staff reported there was no clear policy or pre-outing coordination for resident supervision and walker use.
Unsafe sit-to-stand transfer with inadequate supervision. A resident who required 2-person assist and a mechanical lift was transferred by a CNA without another staff member present and without securing the lower leg straps on the lift. The resident slid from the sling during a long-distance move, reported severe shoulder pain, and was later hospitalized with a closed femur fracture and shoulder dislocation. Staff said the CNA had not been properly shown how to secure the straps and believed using the lift alone was standard practice.
Unlocked AC unit rooms were found on the 4th and 2nd floors during a tour, and both doors could be locked from the inside. No staff were observed nearby. The Maintenance Director stated the rooms are mechanical rooms that should be kept locked, and Corporate Maintenance said the doors had been left open for housekeeping to clean.
Failure to supervise a resident with a known wandering history led to an elopement when the resident left the facility unsupervised and was missing for 10 hours. The resident had moderate cognitive impairment, a Wanderguard order, and prior exit-seeking behavior, but the care plan was not in place and staff did not recognize the resident as at risk. A receptionist confused the resident for a visitor, silenced the alarm, and let him out without notifying nursing staff.
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