A resident with altered mental status and moderately impaired cognition fell from a bedside commode after a CNA turned her back to help the roommate with a blanket, despite the care plan requiring supervision while on the commode. The resident sustained a rib contusion, and the CNA stated the fall could have been prevented if she had not turned away or if another staff member had been present.
A resident with moderate cognitive impairment and documented wandering/exit-seeking behaviors eloped from the facility in a wheelchair and was found outside near the back entrance roadway without staff awareness or supervision. The resident had a WanderGuard bracelet, but staff interviews and the facility investigation showed door alarms were not always immediately responded to, the alarm code was known by residents, and a prior exit attempt had occurred earlier the same evening without increased monitoring.
Failure to Provide Required Transfer Assistance Led to Resident Injury: A resident with stroke-related weakness and moderate cognitive impairment was care planned for two-person assist with all transfers, but a CNA transferred the resident alone and lowered the resident to the floor when the resident’s legs gave out. The incident was not promptly reported, and the resident later developed bruising, swelling, pain, and an acute distal tibia fracture. The record did not document a root cause for the fall.
An unsecured gray tote containing 36 medication cards with pills was found on the floor outside the locked med storage area, while other boxes nearby contained only empty cards. RN stated she did not know why the meds were in the tote, and the DON acknowledged the meds should not have been left unsecured; the Administrator said the tote should have been returned to the pharmacy immediately.
A resident with Parkinson’s disease, moderate cognitive impairment, and a history of repeated falls sustained multiple falls in the room while trying to toilet, reach items, or self-ambulate. After one fall, nursing documentation was incomplete and the resident developed worsening pain, swelling, and inability to bear weight before a femur fracture was identified and the resident was transferred to the hospital. Falls continued after surgery, and observations showed the resident in bed with the alarm not sounding, items out of reach, and the room cluttered.
A resident with morbid obesity and bilateral foot drop, whose care plan called for two staff for bed mobility and incontinence care, slid off the edge of the bed during perineal care and sustained abrasions and skin discoloration. The resident stated an SRNA rolled them too far while the SRNA was on the opposite side of the bed, and staff interviews confirmed the SRNA performed the care alone instead of waiting for another staff member. The ADON and DON stated the resident should have had two staff assist with the care.
A resident with dementia, osteoporosis, and a right artificial hip joint, assessed as severely cognitively impaired and dependent for bed mobility, toileting, and transfers, had a care plan and Kardex requiring a two-person assist for these ADLs. An SRNA, despite knowing this requirement, began perineal care alone and rolled the resident onto her side, causing the resident to roll out of bed onto the floor. The incident report and IDT identified the root cause as failure to follow the Kardex, with contributing factors including the resident’s weakness and history of falls. An LPN and unit manager found the resident on the floor, obtained stat x-rays that revealed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where imaging confirmed a comminuted, moderately displaced femoral fracture and an ORIF procedure was performed. Staff interviews confirmed that the resident had long required a two-person assist and that only one staff member was present at the time of the incident, and also revealed that nurses and managers had not routinely spot checked SRNAs for adherence to the care plan/Kardex prior to the event.
The facility failed to provide adequate supervision and a hazard-free environment for three residents, resulting in two falls and unsafe medication handling. One resident, cognitively intact but requiring two-person assistance and supervision for toileting, was transferred to the bathroom by a single aide and left alone on the commode, where the resident was later found on the floor. Another resident with severe cognitive impairment and high fall risk, care planned for two-person transfers but without specific supervision interventions for time spent in a common area, sustained an unwitnessed fall from a chair in the TV area, resulting in facial injuries and a nasal fracture. A third resident with severe cognitive impairment, not assessed to self-administer medications, was observed with a cup of crushed medications in pudding left unattended at the bedside, contrary to facility policies requiring direct observation of medication administration and secure storage.
Failure to provide required two-person assistance during transfers. A resident with type 2 DM, neuropathy, and a prior stroke was cognitively intact but needed substantial to maximum help with mobility and was care planned for two staff during transfers and personal care. During observation, a SRNA assisted the resident alone, including moving her to the bedside and then transferring her to the toilet without another staff member present, even though staff interviews confirmed she had left-sided weakness and required two-person assistance.
A resident with dementia, impaired mobility, and dependence for transfers was care planned and assigned to be transferred with a total mechanical lift, green sling, and assistance of two staff, as documented in the MDS, care plan, device assessment, and assignment sheets. Despite this, a CNA independently transferred the resident from wheelchair to bed without using the mechanical lift, during which the resident’s leg struck the iron bed frame, causing a full-thickness laceration that required hospital evaluation and suturing. Staff interviews confirmed that the resident was known to require a total lift and that assignment sheets clearly indicated the required lift, sling color, and two-person assist.
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