A resident with fractures, multiple falls, obesity, and moderate cognitive impairment was dependent on 2 staff and a hoyer lift for transfers and toileting, but staff moved her to the toilet without the hoyer when she was trying to get up urgently. During the return transfer, her legs gave out and she was lowered to the floor; the event was not promptly documented or reported, and she later developed new left lower-extremity fractures confirmed by x-ray and hospital evaluation.
A resident with cognitive impairment, stroke-related weakness, dementia, and anticoagulant use fell from an elevated bed while a CNA stepped away to get more towels during care. The resident was left on her side, was later found on the floor bleeding from the head and in pain, and sustained a forehead hematoma and facial laceration requiring hospital evaluation.
A resident with dysphagia, legal blindness, and a pureed diet order choked while being fed by an aide who was unfamiliar with the resident’s needs. Staff observed the resident coughing and choking, and interviews showed the meal served appeared to be mechanical soft or regular texture instead of pureed. The record also reflected a prior choking episode and conflicting staff understanding about who was responsible for verifying the tray ticket against the meal.
A resident with myocardial infarction and moderate cognitive impairment was assessed as at risk for elopement and had a care plan that included structured activities, reorientation, and a Wander Alert bracelet. Staff reported the resident repeatedly removed the alarm device, so a 1:1 sitter was used. During supervision, one CNA left the resident unattended to assist another resident, an alarm sounded, and the resident eloped from the facility; the DON acknowledged the resident required continuous supervision.
A resident with cognitive impairment, weakness, obesity, and prior femur fracture was injured during a toilet transfer when a CNA used a sit-to-stand lift without securing the torso and lower leg straps. The resident slipped partly off the platform, developed pain and bruising, and was later found to have a displaced distal femur fracture requiring surgical repair.
Unsafe wheelchair transport led to a resident’s leg slipping under the chair when a footrest/leg rest moved out of place. The resident told the CNA to slow down, but the chair kept moving, causing a loud snap, severe pain, and a hospital transfer that confirmed a distal femur fracture. Staff interviews described the footrest as broken or not latched, and the resident later remained bedbound with ongoing pain and loss of mobility.
A resident with depression and anxiety exited through the main entrance without staff, and a second resident with Alzheimer’s disease exited unsupervised through a fire exit door after alarms sounded and a door was found unlatched. The facility also failed to fully investigate a fall for a resident with severe cervical spinal stenosis; the incident report lacked a witness statement, management and family notification were not documented, and no root cause analysis was found in the record.
Failure to prevent resident elopement: A cognitively intact resident with schizophrenia, HTN, and hyperlipidemia left the facility after exiting through a dining room/cafeteria door. Staff responded to the alarm by silencing it instead of immediately searching or alerting others, and the resident was later found off the premises near a residence with a small foot cut. The investigation noted the resident wanted to go home and had previously been deemed incompetent with a guardian in place.
Failure to protect a resident from repeated elopement attempts and unsafe exit-seeking behavior. A resident with dementia and severe cognitive impairment, who wore a wander guard, repeatedly tried to leave through multiple doors, asked to go home and find her car, packed her belongings, and even encouraged another resident to use the exit door. Staff repeatedly redirected her, but she still exited the building on several occasions and was later noted to have bruising from pushing against the doors.
A resident with repeated falls and serious injuries was not adequately supervised when a motion sensor alarm was placed and later found positioned incorrectly, with staff reporting they did not hear it or know how it was being monitored. In addition, two CNAs performed unsafe full-body lift transfers on another resident by moving him before he was fully suspended, failing to verify sling loop placement and not opening the lift base legs as required; staff said they were unaware of the lift safety requirements.
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