A resident who required total assistance and had significant neurologic and mobility impairments was injured after being turned in bed by only one CNA instead of the two-person assistance specified in the care plan. The resident rolled off the bed during care, was sent to the hospital, and was found to have a small acute frontal subdural hematoma after the fall.
A resident with severe cognitive impairment and a history of dementia with exit-seeking behavior exited through a back door that did not alarm because it had not completely closed. Staff found the resident at the bottom of the steps after the resident had already left the unit, and maintenance staff stated the door was not routinely checked for proper functioning.
Inaccurate fall assessments and inadequate supervision led to repeated falls and injury. One resident with severe cognitive impairment, Parkinson’s disease, and syncopal episodes was repeatedly scored as low fall risk because staff omitted balance findings and key diagnoses, and the resident sustained multiple falls, including a chip fracture. Another resident with dementia, a recent humerus fracture, and multiple medications affecting fall risk was also assessed incompletely, later ordered for 1:1 supervision, but the record did not show true 1:1 monitoring was provided.
A resident with severe dementia and an identified elopement risk repeatedly stated a desire to go home, paced the facility, and was seen trying the front door before later eloping from the building. Staff found the resident walking on a nearby road with a member of the public, and the investigation identified that an exit door on the 600 hall was not secured properly and did not alarm when first opened.
A resident with severe cognitive impairment, anxiety, and visual hallucinations wandered the memory care unit and became agitated, then struck one resident in the face and later hit another resident in the face. Staff interviews confirmed the resident frequently wandered and was agitated, but there were no updated wandering/elopement assessments after room changes and no changes to the behavior plan after the incidents.
A resident with a history of behavioral disturbances and an order for 1:1 supervision was left unsupervised when the assigned GNA stepped away to handle a pizza delivery. During that time, the resident entered another resident’s room and exposed his groin area to the resident and a visiting family member.
Failure to use ordered mechanical lift during transfer: A dependent resident reported knee pain after being transferred by two staff members without a Hoyer lift. Records showed the resident was care planned for transfer with a mechanical lift and 2-person assist, and the MDS coded the resident as dependent for transfers. The DON confirmed the transfer was done by standing and pivoting rather than using the Hoyer lift, despite the resident's TASK record indicating the transfer method.
Inadequate supervision of a wandering resident occurred when a resident with a wander guard and severe cognitive impairment was able to leave a secured HC unit via the elevator and reach the lobby. Facility records showed the wander guard alarm activated at the elevator area and again at the first-floor exit door, but staff manually cleared the alarm without following the expected response process, including a resident head count.
Failure to supervise a resident during an elopement attempt led to the resident being found in the PT room using a [NAME] to cut the fence and strike an RN several times. The resident had bruises and a skin tear at admission, then sustained additional bruises and a skin tear during the incident. The DON stated staff did not know how the resident accessed the pliers, and no elopement risk reassessment was completed after the event.
A dependent resident with MS who required a mechanical lift and two staff for transfers was struck above the eye by a Hoyer lift when a GNA brought the equipment into the room and the lift swung forward during the transfer process. The resident and spouse reported the aide was rushing and rough, and facility interviews confirmed the aide later acknowledged the lift bumped the resident while she was not being careful.
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