Beds and resident belongings were found too close to baseboard heaters in 7 of 7 sampled rooms, including beds against heater units, a walker with clothing against a heater, and dressers, cords, and curtains placed against heaters. An LPN stated beds should be kept at least 4 inches away from the heaters and noted the Fire Dept had warned the facility that items touching the heaters was a fire hazard, while another staff member said she did not know of any requirement for keeping items away from the heaters.
A staff member failed to promptly notify nursing staff after a resident fell from his wheelchair, delaying the nurse’s immediate assessment of the resident’s condition and any injuries. The resident later required RN assessment, neuro checks, vital signs, Hoyer transfer, and ER transfer after hitting his head; hospital records showed acute on chronic anemia and a closed head injury, and the resident returned with facial and stump abrasions. Interviews showed the fall occurred around shift change and was not immediately reported by the CNA team, contrary to the facility’s fall protocol.
Failure to prevent resident elopement: A resident who had been identified as an elopement risk exited through an alarmed door and walked several blocks away before staff located him and returned him uninjured. Staff found another resident at the exit door wearing a Wanderguard, checked outside, and did not see the missing resident until the family reported he was off-site. The resident had decreased cognition, poor safety awareness, and a history of trying to leave the facility unattended.
A resident at high risk for elopement with severe cognitive impairment exited the facility unattended and was later found by police and sent to the hospital for evaluation with no injuries. Surveyors later found multiple exit door alarm problems, including alarms that were too quiet, not sounding, or turned off, and staff interviews showed confusion about WanderGuard monitoring and alarm checks.
A resident being transported from a hospital for admission fell from her wheelchair when the van had to brake abruptly because she was not properly secured with wheelchair tie-downs or seat belts. She sustained a left ankle fracture, required hospitalization and surgery, and said the wheelchair had been moving around during transport after her hip surgery.
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.
A resident with dementia and memory problems had a documented history of trying to go outside alone and checking bird feeders, with a wander guard placed on the walker to alert staff. However, direct care staff interviewed did not recognize the resident as a wander risk, and one staff member stated the resident went outside when the weather was nice with activities staff, while another could not explain why the care plan did not reflect those outings or why staff were unaware of the risk.
The facility failed to keep beds in safe positions, complete fall investigations, and supervise a resident who was smoking on facility property. A resident with quadriplegia fell from a high bed and sustained a hip fx, another resident had a closed head injury after a fall from bed, and a third resident had a laceration above the eye after a fall that was not fully investigated, including no interview of the roommate. The facility also observed a resident repeatedly leaving unattended to smoke by a dumpster, despite being a non-smoking facility, with no smoking-related orders, care plan interventions, or assessments documented.
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.
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