A resident with chronic fatigue syndrome, a prior R humerus fracture, OA, repeated falls, and substantial transfer assistance needs fell while ambulating with a walker. Staff found the resident on the floor in the tub room with severe pain, and the facility determined that a CNA had transferred the resident without using the required gait belt during the assisted transfer.
Standing water was not promptly cleaned from a central hallway and near the Dakota Dining Room, with water observed trailing across the floor and dripping from a ceiling AC unit into a bucket that created a puddle extending into the doorway threshold. The water remained in place for extended periods, and a yellow caution sign was later placed over the area while the puddle continued to grow. An MNT supervisor stated staff are expected to monitor for water and other safety hazards and clean them up promptly.
A resident with dementia, cleft palate, and dysphagia was ordered an IDDSI Level 6 soft and bite-sized diet, but marshmallows were left in the room and later eaten, leading to a choking episode with cyanosis, pulselessness, apnea, and hospitalization. Staff also served a meal tray with a whole Salisbury steak patty and other foods not prepared into bite-sized pieces, and interviews showed staff were not consistently educated on the resident’s diet restrictions or IDDSI requirements.
Failure to use wheelchair footrests for a resident seated in a wheelchair. A CNA transported the resident back to his room to assist with dressing, but did not place the footrests on the wheelchair or cue the resident to raise his legs and feet, and the resident's legs and feet bounced along the floor.
Improper Use of Mechanical Sit-to-Stand Lift During Resident Transfers: Staff failed to properly use a mechanical sit-to-stand lift during transfers for multiple residents. One resident was transferred without removing heel boots as directed, another was left hanging in the lift after letting go of the handlebars while the CNA continued care, and two CNAs completed a transfer without securing the sling around a resident’s abdomen.
Inadequate supervision during a sit-to-stand lift transfer resulted in a resident’s hand being bumped against a bathroom door frame, causing a skin tear to the back of the R hand. The resident had fragile skin, diabetes, immobility, and required assist of 1 staff with a PAL lift for transfers.
Improper Sit-to-Stand Lift Transfer: Two CNAs assisted a resident with left-sided weakness, paralysis, and a history of falls during a PAL transfer. The resident was raised to standing while the abdominal strap buckle and leg straps were not secured, and morning care was provided while the resident remained connected to the lift.
A resident with Parkinson’s disease, muscle weakness, unsteadiness on feet, and gait/mobility abnormalities had a care plan requiring a stand-pivot transfer with two staff and a gait belt. During an observed toileting transfer, two CNAs assisted the resident, who showed visible shakiness and an unsteady gait, but one CNA placed her hands around the resident’s ribcage to move the resident back to the wheelchair instead of using a gait belt as required. The CNA later acknowledged not using a gait belt, and administrative staff confirmed their expectation that gait belts be used during transfers per the care plan.
A resident with Parkinson’s disease and Alzheimer’s disease, who was non-verbal, non-ambulatory, and unable to self-transfer, had a care plan requiring substantial assistance by two staff and use of a sit-to-stand lift for transfers after 5 p.m. Facility policy also required use of mechanical lifts as a safer alternative and mandated two staff for mechanical lift transfers. Despite these requirements, a CNA did not follow the care plan during a transfer, and the resident was later found with a head lump, facial and hand lacerations, and blood on the floor. An investigation concluded the injuries likely occurred during or shortly after this improper transfer, in which the required lift and two-person assistance were not used.
A resident with Alzheimer’s disease and dysphagia, ordered a pureed diet, accessed a brownie from an unattended snack cart while agitated and independently moving about the unit. Staff attempted to intervene, but the resident shoved the brownie into his mouth and choked; EMS later pronounced the resident deceased. The snack cart had food items openly displayed, and a CNA acknowledged leaving it unattended and knowing the brownie was not consistent with the resident’s diet order.
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