A resident with CVA with hemiparesis, epilepsy, and TBI fell forward from a shower chair after bathing when he was left alone while the aide stepped out of the room. Records showed the resident had a history of falls and required max assist for transfers, but the care plan did not include standby assistance at all times before the fall. The facility’s investigation found the bathing supervision and transfer assistance did not match the resident’s assessed needs or care plan.
A resident with dementia, osteoporosis, vertebral compression fx, chronic pain, and a hx of falls was assisted to a recliner without the required gait belt and without continuous physical support. When the CNA stepped away to adjust a chair pad, the resident lost balance and fell backward onto her buttocks. The resident later developed worsening pain, required ED eval, and was transitioned to palliative care for comfort-focused pain mgmt.
Unsafe van transport and inadequate driver training led to two residents falling during abrupt stops. One resident with a hx of diffuse TBI and wheelchair dependence fell when her lap belt was not secured, and another resident slid to the floor after releasing her seat belt while a staff member driving alone with two residents said she had not been trained on restraint use or resident monitoring. Interviews and records showed inconsistent knowledge about who was responsible for securing residents and no clear facility-wide competency sign-off for van drivers.
A resident with moderate cognitive impairment and wandering/exit-seeking behaviors was placed on a wander guard alarm, but the record lacked a documented risk-benefit assessment and informed consent. Staff also failed to fully respond when a door alarm sounded, as the area outside the door was not checked for an exiting resident even though staff knew residents had used that door before and policy required a visual scan of the surroundings.
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.
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