Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with impaired cognition, multiple fractures, dementia, and a history of falls had an unwitnessed bathroom fall while attempting to self-transfer. Although an order was entered to keep the walker at the bedside and other fall precautions were noted, the walker was observed out of reach at the end of the bed, and staff gave inconsistent accounts of where the intervention was documented. The care sheet did not include the bedside walker intervention, and staff relied on different records and verbal report for fall precautions.
A resident who was bedbound, non-ambulatory, and high fall risk required two staff for repositioning and other care. A CNA repositioned and changed the resident alone, pushed her too close to the edge of the bed, and the resident fell to the floor, sustaining a femur fracture that required surgery. Interviews confirmed the CNA knew the resident needed two staff but did not obtain assistance, and the facility investigation concluded the care plan was not followed.
Fall interventions identified after resident falls were not added to care plans for three residents. A resident with repeated falls, dementia, and walker use had multiple post-fall interventions documented on accident reports, but they were kept on paper forms or passed by word of mouth instead of being available in the care plan. Two other residents with impaired cognition and fall histories had similar post-fall interventions documented, including equipment changes, medication changes, and supervision-related measures, but staff and the DON confirmed these interventions were not readily available to all staff through the care plan.
Failure to complete fall analysis and implement fall interventions for two residents. One resident with dementia, impulsivity, prior fractures, and repeated falls had inconsistent care plan revisions, incomplete incident analysis, and 15-minute checks that were not documented as required, and later sustained a fracture after a fall. Another resident with severe cognitive impairment and hemiplegia had fall interventions documented in the care plan, but staff observed the resident without the fall mat and body pillow in place as ordered.
A resident with Alzheimer’s disease, severely impaired cognition, a history of wandering, and use of a walker exited the facility without staff awareness and was later found miles away at her previous home. Records showed her wander guard and 15-minute safety checks had been discontinued before the event, despite prior elopement risk documentation and past wandering behaviors. Staff searched after she was seen outside, but she had already traveled through a busy area and was missing for about 2.5 hours.
A resident with dementia, repeated falls, and strict hip precautions was assisted by an RN to the bathroom with a walker despite a care plan that said nursing staff were not to ambulate her. During the transfer, staff heard a popping sound from the hip, and the resident later developed swelling and increased pain; hospital evaluation confirmed a dislocated right hip prosthesis requiring closed reduction. Records and interviews showed the resident had poor safety awareness, self-transferred repeatedly, and required close supervision, alarms, and TTWB/30-lb weight-bearing restrictions.
Unsafe Smoking Practices: A resident with limited dexterity, hand wounds, and a history of burn holes in clothing was allowed to smoke independently despite care plan interventions calling for a cigarette holder and smoking apron. Staff observed repeated burn holes in his clothing, and an LPN and RN confirmed the holes were from cigarette burns and that the resident would not use the safety devices identified for him.
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