Aspiration precautions were not followed when an LPN fed a resident with dysphagia, dementia, and significant cognitive impairment. The resident’s care plan and ST recommendations called for small bites, alternating bites and sips, no straws, and slow feeding, but the LPN used overfilled spoonfuls, did not offer fluids between bites, and gave cola through a straw while the resident coughed during the meal.
A resident assessed as an unsafe smoker with hemiplegia, COPD, polyneuropathy, and PVD was observed smoking without his required smoking apron. Staff present stated they were not supervising residents while they smoked, and the apron was found beside the resident in his wheelchair. The MDS coordinator confirmed he should have been supervised and wearing the apron, while the ADON/Tx Nurse said she had been assigned to supervise him but did not have time to ensure compliance.
Failure to supervise a resident with aspiration risk during meals: A resident with myasthenia gravis, weakness, cognitive impairment, aphasia, and dysphagia was observed eating breakfast in bed without staff supervision, despite signage and ST documentation indicating he needed to be upright in a chair for meals. The resident stated he should be positioned upright to avoid choking, and staff including a CNA, LPN, DON, ADON, and corporate nurse acknowledged he should have been assisted and supervised during meals.
Failure to assess needed staff assistance for safe in-bed care: A resident with functional quadriplegia, severe cognitive impairment, ventilator dependence, and a history of falls was totally dependent for mobility and ADLs, yet the facility had no documented assessment for the number of staff needed for safe bed mobility and in-bed care. Staff said the CNA assigned to the resident decided on the amount of help needed, and the resident fell from the bed while a CNA was turning her alone for care.
A resident with OA, dementia, and fall risk needed supervision and assistance for toileting, but a CNA left her alone in the bathroom during a nighttime toileting episode. The resident fell while trying to sit on the toilet, was later found on the floor with hip pain, and hospital records showed a left impacted femoral neck fracture requiring surgical fixation. Staff interviews confirmed the resident was unsteady and should have remained under supervision during toileting.
Failure to supervise a cognitively impaired resident during toileting led to a fall-related injury. The resident had dementia, a hx of falls, and needed assistance with toileting and transfers, but staff reported she often tried to stand or walk without help and was difficult to redirect. A CNA left the resident unattended on the toilet, and the resident was later found in the bathtub with a hematoma to the back of the head and a headache, requiring hospital evaluation.
Failure to Supervise a Known Elopement Risk: A resident with dementia, severely impaired cognition, and a documented wander risk exited through the front door behind visitors while staff did not notice he had left. He was later found by police walking on an interstate highway and returned to the facility uninjured. Interviews showed staff were unaware of the elopement until the resident was brought back.
Unsafe Smoking Supervision: A resident with cerebrovascular disease, quadriplegia, muscle wasting and atrophy, and diffuse traumatic brain injury was documented as unable to safely hold a cigarette, with care plan instructions stating the cigarette must be lit and held by staff. However, staff were observed lighting the cigarette and allowing the resident to hold it herself while smoking, and staff interviews confirmed this practice despite the resident being identified as an unsafe smoker.
The facility failed to complete fall risk assessments and update individualized fall prevention interventions after repeated resident falls. A resident with stroke and seizures had an unwitnessed fall with no documented fall assessment or care plan update, and two other residents with cognitive and mobility-related diagnoses had multiple falls without required reassessment or new interventions. Staff interviews confirmed the fall assessments were not completed as required and that care plans were not updated after the falls.
Unsafe smoker left unsupervised while smoking: A resident with severely impaired cognition, hemiplegia, and substance-related diagnoses was identified as needing 1:1 supervision for smoking. Staff wheeled him to the smoking patio and left him there without supervision, and he was later observed with a lit cigarette. An ADON confirmed he was smoking unsupervised, and the RN confirmed he had left the resident alone despite knowing supervision was required.
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