Failure to Follow Fall Interventions: A resident with dementia, ESRD on dialysis, impaired mobility, and a history of falls was observed ambulating and self-transferring in her room and bathroom without staff assistance, despite orders and a care plan requiring one-person assist with a walker, call light use, frequent safety checks, and skid strips by the bed. Staff interviews confirmed the resident was transferring independently and that the skid strips were not in place as documented.
A resident with severe cognitive impairment and mobility problems fell during PT gait training when staff ambulated the resident without the ordered safety supports, and the resident sustained a rib fracture. Another resident was escorted to meals without the ordered gait belt despite PT instructions for SBA/CGA with a FWW and gait belt. In addition, a resident reported a wheelchair brake problem that had been known to staff before a fall, but the equipment concern was not addressed promptly through the facility’s maintenance process.
The facility failed to maintain adequate safety checks and supervision for two residents with serious psychiatric histories and suicidal ideation. One resident had repeated plans to starve, ingest eye drops, jump off a bridge, and poison self, yet room checks and other protections were not consistently documented or maintained, and monitoring was later reduced before the resident ingested Visine and Tylenol in suicide attempts. A second resident, who had been care planned for community supervision due to suicidal ideation, eloped multiple times and was not adequately supervised.
A resident slipped and fell on a freshly mopped wet floor in her room after no wet floor sign was in place, striking her head on the concrete floor and sustaining a laceration that required ER evaluation and staples. The record also showed a separate failure involving another resident with severe cognitive impairment and dependence for transfers, when an NA completed a transfer without the two-person assist specified in the care plan.
A resident with severe cognitive impairment and a history of wandering into other residents’ rooms was found naked on another resident’s bed after staff had not completed a comprehensive assessment of his wandering behavior or evaluated whether existing interventions were effective. Staff interviews confirmed he was expected to be kept in sight and engaged in the common area, but they did not know how long he had been in the room and did not receive retraining after the incident. The DON stated the facility did not complete a root cause analysis or document evaluation of the interventions in place.
A resident with severe cognitive impairment, dementia, and a high fall risk was found in bed with the call light out of reach while his wheelchair was across the room. He stated he was unsure how to get help and was not sure he should get up on his own. Staff later confirmed he needed the call light close by, that he sometimes ambulated or toileted independently, and that they were expected to ensure he had access to it to help prevent falls.
Incorrect Lift Sling Use and Incomplete Fall Analysis: Staff transferred a resident with dementia and severe cognitive impairment using a total body mechanical lift with the wrong manufacturer sling, despite the care plan and lift manual requiring the correct sling for that specific lift. The facility also failed to complete a comprehensive root cause analysis for a resident with spinal cord disease and neuromuscular dysfunction who had multiple unwitnessed falls, and the fall care plan was not updated until after several falls had already occurred.
Failure to Implement Fall Interventions: A resident with stroke, dementia, impaired cognition, and a history of falls was identified as a fall risk with care plan interventions including proper footwear and walker use. Observations showed the resident barefoot or wearing plain socks without grips while getting up, walking in the hallway, and lying in bed, and staff interviews confirmed grip socks should have been in place and that no refusal was documented.
Failure to supervise a resident at risk for elopement. A severely cognitively impaired resident with a history of wandering, a wander/elopement alarm, and prior successful attempts to leave the unit was routinely escorted from a semi-locked area to visit another resident on an unlocked unit. After one visit, she left unaccompanied, exited the building without staff knowledge, and was found in the parking lot heading toward a busy avenue. Staff had no clear plan for her return to the semi-locked unit after the visit.
A facility failed to keep a furnace room free of fire hazards when a hospital bed mattress and board were found leaning against the gas furnace and gas water heater, and leadership was unaware of the unsafe storage. The facility also failed to complete required follow-up after a cognitively intact resident with schizoaffective disorder and psychotic disturbances left the building, became lost, and fell while getting into a car service, with no incident report, post-fall observations, care plan, or new interventions documented.
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