A resident with dementia and impaired cognition left the facility unsupervised after being seen near the exit door, with no staff nearby. Staff searched for the resident, who was later found by a neighbor and returned via EMS. After the resident reported a fall, staff noted a bruised arm and a knot above the eye, and the resident was sent to the hospital with a hematoma to the R forearm.
A resident with severe dementia, a BIMS score of 3/15, and a high elopement risk exited through an emergency door after setting off an alarm. A housekeeper turned off the alarm without checking outside, and staff did not initiate the missing resident protocol. The resident was later found outside lying on the ground next to a wheelchair and sustained a facial hematoma and abrasions after falling from the wheelchair.
Failure to supervise a resident with dementia who repeatedly wandered into other residents’ rooms and slept in their beds. The resident had a BIMS score of 8/15, was identified as a wandering/elopement risk, and was observed lying in another resident’s bed; the other resident reported it happened again later, and staff said the resident commonly wandered the hall and entered other rooms. The care plan, progress notes, Kardex, and elopement book did not reflect the behavior.
A resident who required a 2-person assist fell during bed care after only one CNA assisted and the resident reported sliding off the bed, later requiring surgery for a leg fracture. Another cognitively impaired resident with a wander risk exited the building despite a wander guard, and the investigation lacked a clear timeline and consistent account of how long he was unaccounted for. A third resident was injured when staff performed a Hoyer transfer to a shower bed in a way the DON described as not safe, and the lift tipped over onto the resident.
A CNA was providing peri-care and turning a cognitively intact resident with significant weakness and a history of falls when the resident slid out of bed and was injured. The resident and roommate stated the CNA kept rolling the resident despite repeated statements that they were falling, and the bed did not appear to be locked. The resident later reported head and leg pain, and the resident was hospitalized with a thoracic compression fracture.
A resident who was totally dependent for transfers and required a mechanical lift with two staff was transferred by only one CNA. During the transfer, the sling slipped off a hook and the resident fell headfirst to the floor, sustaining a head laceration that required five staples after hospital evaluation.
A facility failed to ensure residents who required two-person transfers were assisted by two staff at all times. CNAs reported not enough help was available, especially during breaks and early mornings, and residents said mechanical lift or sit-to-stand transfers were often done by only one person. A resident with COPD and depression, a resident with cord compression and morbid obesity, a resident with PVD and an above-knee amputation, and a cognitively intact resident dependent for transfers were all affected.
Failure to Follow Transfer Status During Toileting Assistance: A resident with dementia, moderate cognitive impairment, and high fall risk was supposed to use a Sara Steady/sit-to-stand lift for transfers and toileting, but a CNA assisted the resident with a walker and no gait belt, stepped away during the transfer, and the resident fell. The resident sustained multiple fractures, a forehead hematoma, and pain, and the record also showed staff were not consistently aware of the resident’s current transfer status and gait belts were not available in the resident rooms as expected.
Failure to Identify and Assess Elopement Risk: A resident with dementia, impaired cognition, and repeated exit-seeking behaviors was not effectively assessed for elopement risk or included in a care plan with individualized interventions. The resident later exited the facility unsupervised during a fire alarm, and staff reported the resident had shown exit-seeking behavior since admission while the NHA and DON relied on clinical judgment and did not add elopement interventions unless the resident repeatedly tried to leave.
Failure to Supervise Resident with Dementia and Prevent Elopement: A resident with dementia, severe cognitive impairment, and repeated wandering and exit-seeking behaviors left the facility unnoticed while wearing a monitoring device. Staff did not realize the resident was missing until family called, and camera footage showed the resident moving toward the front door before leaving the building. Family later reported that a stranger picked the resident up and transported her away from the facility.
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