The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
Staff failed to use a gait belt while assisting a resident who was ambulating with a rolling walker and on supplemental O2, then turned away from the resident, resulting in a backward fall and a skin tear with tendon exposure to a finger. The same resident had multiple additional unwitnessed falls and a near miss related to ambulation and oxygen tubing. Two other residents with repeated unwitnessed falls, including one with Parkinson-related freezing and another with weakness, confusion, tremors, and sepsis onset, had numerous fall events discussed in weekly fall meetings, but their fall care plans were not updated to reflect the interventions identified. Staff interviews confirmed expectations for gait belt use and individualized gait belts, and revealed that care plans were not being revised after fall meetings despite a facility fall-prevention policy allowing addition of interventions to care plans.
Two residents experienced serious harm due to failures in accident prevention and pain assessment. One terminally ill, dependent resident with severe pain and non-verbal behaviors was known by staff to frequently swing her legs off the bed and onto a nearby baseboard heater, yet no care plan addressed this behavior, repositioning was poorly documented, and room checks were infrequent despite policies requiring regular monitoring. She was later found unresponsive with her leg and foot on or wedged in the heater, sustaining extensive second-degree burns to the calf, toes, heel, and entire plantar surface, while heater surface temperatures in multiple rooms were measured at 190–200°F and above. Another cognitively impaired resident suffered two choking episodes requiring the Heimlich maneuver and then reported persistent right rib pain over several days, with documented pain scores up to 8/10; staff largely relied on the resident’s refusals for hospital evaluation despite severe cognitive impairment, did not obtain diagnostic imaging, inconsistently documented pain assessments, and provided limited PRN analgesia, until a later ER visit for a fall revealed nondisplaced right rib fractures and a complex pelvic fracture.
A resident with dementia, cognitive decline, osteopenia, and a recent iliac fracture experienced three falls, including unwitnessed falls that resulted in bruising, a facial laceration, hematoma, skin tear, decreased LOC, and hospital transfer. Staff reported that IDT post-fall assessments were normally done within 24 hours to identify root causes and interventions, but acknowledged that this resident’s IDT reviews were not timely. The IDT post-fall note for the first fall, completed much later, identified issues with walker use and short-term memory and listed interventions such as increased visual checks, cueing, walker evaluation, and focused OT/PT, yet these interventions were not documented in the EHR or added to the care plan before the subsequent falls, contrary to the facility’s fall management policy.
Fall Prevention Interventions Not Consistently Implemented: A resident with prior falls and poor safety awareness was repeatedly observed with the call light clipped to the foot of the bed or mattress and out of reach, and no floor mat was seen in the room. The resident stated he could not reach his call button or the urinal and did not know how to use the bed remote. Records showed multiple falls with poor bed mobility, confusion, illness, and tangled blankets, while the care plan called for the call light within reach, a low bed, and a floor mat at bedside.
Failure to fully investigate resident burn from hot soup: A resident spilled hot soup on himself and sustained burns, but the facility could not determine who provided the soup, whether a visitor accessed the locked nourishment room, or how the soup was heated. Video footage reviewed showed only a tall male visitor handing the resident a container, and no additional investigative documentation was found. The resident was later seen for follow-up for the burn wound, but the cause and supervision at the time of the incident were not clearly established.
Surveyors found that the facility failed to enforce its smoking policy and accident-prevention measures for multiple smokers, including a resident on O2 who used an open-flame lighter near oxygen equipment and smoked in an outdoor area while wearing a nasal cannula and having a portable O2 tank attached to a wheelchair. The outdoor smoking area lacked required signage and staff supervision, and residents reported that smokers went outside unsupervised. Another resident with a history of marijuana-related incidents kept cigarettes and a lighter accessible in her room despite a care plan and smoking safety screen requiring the lighter to be stored at the nurse’s station. Additional smokers and vape users were not consistently identified on the smoking list or addressed in care plans, and one resident was observed rolling cigarettes in his room with multiple lighters present. These conditions led to an Immediate Jeopardy citation under F689 for accidents and hazards.
A resident with severe cognitive impairment had repeated falls, including unsafe transfers and use of a bedside table as a walker, while the care plan lacked daily direct-care interventions and was not updated after recent falls. Staff also left the call light out of reach and the resident’s walker was removed. Another high fall risk resident reported delayed response to the call light and was observed self-transferring and wheeling herself to the bathroom while staff nearby continued other tasks.
Missing Smoking Safety Assessment and Care Plan: The facility failed to complete a smoking safety assessment and smoking care plan for a resident who smoked and sometimes went out with family or with other residents during supervised smoking times. Staff could not provide the required documentation, and the resident’s cigarettes and lighter were kept locked in the med cart. The facility’s smoking policy required an admission smoking evaluation, a Safe Smoking Evaluation, and care plan documentation for smoking-related privileges and restrictions.
Failure to Complete Post-Fall Assessment: A resident who had recent surgery and multiple falls was found on the floor after pressing the call light, then assisted by CNA and RN staff. Although a note stated no injury was noted and neuro, pain, and physical assessments were performed, the EMR did not show a completed fall assessment or the requested neuro checks and risk assessment for the fall.
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