A resident with Alzheimer’s disease, dementia, severe cognitive impairment, and dependence for transfers was care planned for a total lift, but staff used a sit to stand lift instead. The CNA acknowledged not following the Kardex and care plan, another CNA assisted without checking the transfer instructions, and the NP, LPN, and DON confirmed the resident could not consistently follow commands and should not have been transferred with a sit to stand lift.
Failure to Apply Required Shoulder Restraint During Van Transport: A resident with intact cognition was transported in a facility van using a wheelchair securement system and lap belt, but the shoulder restraint was not applied. The resident reported feeling unsafe and said the restraint was requested but not used. The Activities Director confirmed the omission, and the DON/Administrator acknowledged that staff were expected to follow the manufacturer’s wheelchair tie-down guidelines requiring both lap and shoulder restraints.
A resident with anoxic brain damage and a persistent vegetative state fell during ADL care when a side rail was not fully secured. CNA care involved repositioning the resident while the rails were raised, but the resident slid over the left side of the bed and was found on the floor with a scalp laceration and bleeding; the RN later noted the top left rail was down and the resident had a head injury.
Failure to supervise allowed two residents with severe cognitive impairment and dementia to follow a transportation employee out the front entrance and remain outside unattended for about 11 minutes. Staff did not realize the residents had exited until a dietary aide and a family member spotted them in the parking lot and alerted the facility. The residents were ambulatory with walkers and were later brought back inside.
Failure to supervise a resident with swallowing precautions during meals. A resident with CVA, dysphagia, and severe cognitive impairment had ST recommendations for close supervision, small bites and sips, and upright posture while eating. Staff were aware of the resident’s choking risk and prior choking episode, but during lunch an LPN and CNAs stepped away and no one remained at the table with the resident. The resident began choking, required emergency intervention, was transferred to the hospital, and later died after being removed from the ventilator.
Failure to analyze falls and implement new interventions: Two residents had falls in their rooms, including one resident with severely impaired cognition and hemiplegia/hemiparesis and another resident with moderately impaired cognition after surgical aftercare. In both cases, the fall documentation did not identify measures to reduce hazards or risks, did not determine a root cause, and did not develop an intervention to prevent recurrence. Interviews with the DON and Administrator confirmed that no new interventions were put into place after the falls.
A resident with dementia and severely impaired cognition exited behind a visitor and remained outside unattended for about two minutes before a social worker redirected him back inside. Front desk staff were distracted by computer issues and did not observe the exit, and the resident had been assessed as not at risk for wandering or elopement.
Failure to investigate an initial fall and maintain a resident’s bed in a low position led to repeated falls for a resident with metabolic encephalopathy and severely impaired cognition. Staff found the resident on the floor in the morning, but no fall investigation was completed for that event. Later, after the resident returned from the hospital, the resident was found on the floor again within minutes while the bed was elevated and bedrails were raised.
Incorrect Sling Used During Mechanical Lift Transfer: A resident who required a Hoyer total lift and a specific small red sling fell from a lift when staff used an inappropriate black sling that was already under the resident in the wheelchair. The resident, who had hemiplegia, a right above-knee amputation, and was on Eliquis for atrial fibrillation, struck her head on the lift and sustained a head laceration and a subarachnoid hemorrhage.
A cognitively impaired resident with a history of cerebral infarction, right-sided hemiplegia, and a documented moderate risk for wandering was able to leave a supervised front porch area without staff awareness, propel a wheelchair down the facility driveway, and cross a heavily trafficked road into an area with a steep ditch and wooded terrain. Staff interviews showed that the resident was usually outside with other residents and staff present, but on the day of the incident a CNA last saw the resident on the porch and was unsure how the resident exited unsupervised. The resident was ultimately discovered by a CNA who had been alerted by a pest control worker, by which time the resident had already crossed the roadway, demonstrating a failure to provide adequate supervision and prevent elopement for a cognitively impaired individual.
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