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.
A resident with severe cognitive impairment and total dependence for transfers was supposed to use a Hoyer lift for all transfers per the care plan, PT, physician orders, and STNA Kardex. Staff instead used a sit-to-stand lift during a transfer, and the resident slid out of the chair onto the floor. Family and staff stated the wrong lift was used, while the DON and Administrator stated staff were expected to follow the Hoyer lift orders.
Unsecured insulin and supplies were left on top of a medication cart outside a resident room, including insulin pens, Lantus insulin, an insulin syringe, lancets, alcohol pads, and a glucometer. The cart was not within sight of a nurse, and RN stated she had gone to the nurse’s station to get papers and should have taken the insulin and supplies with her. The ADON, DON, and Administrator stated medications and related supplies were to be stored or locked when not in use.
A cognitively impaired, exit-seeking resident with dementia and severe cognitive deficits, identified as a moderate elopement risk and care planned to reside on a secure memory unit with supervision and diversional activities, was placed in a room adjacent to an alarmed exit door. In the days before the incident, staff documented and observed escalating behaviors, including repeated statements about wanting to go home, pushing on exit doors, packing a suitcase, and being non-redirectable, yet at the time of the event, one LPN and two CNAs on the unit were occupied with other residents. When the exit door alarm sounded, staff briefly checked the courtyard and rooms, turned off the alarm, and returned to their tasks, while a deteriorated wooden gate in the courtyard fence allowed the resident to push through and leave the property. The resident walked to a nearby park and was found by citizens who called 911; law enforcement then notified facility staff, who had been unaware the resident had left, demonstrating a failure to provide adequate supervision and maintain secure egress controls for an identified elopement risk.
A resident with severe cognitive impairment and a history of psychiatric conditions was able to leave the facility unsupervised by exploiting a faulty lock and a gap in a poorly maintained fence. The resident, known to be at risk for elopement, was not immediately noticed missing, and facility checks of exits were incomplete and not performed on weekends. The resident was later found outside a nearby store and returned without injury.
A resident with ESRD, DM, and depression had a care plan requiring a mechanical lift with two staff for transfers, but staff left the resident suspended in a Hoyer lift while one aide went to get help. The resident reported being left in the air, a CNA saw the resident in the lift, and the DON stated the investigation determined two CNAs walked out of the room while the resident was still in the lift.
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