Failure to Identify Causes and Individualize Fall Interventions: A resident with severe cognitive impairment, incontinence, and multiple psychoactive meds had repeated falls in the room and bathroom area. The facility often documented no causal factors or used limited interventions such as a reminder sign, med review, video monitoring, and alarms, while not addressing issues noted in the events such as toileting needs, feces in the bathroom, poor lighting, and refusal to wear gripper socks or shoes.
Failure to Implement Elopement Protections: The facility did not consistently implement elopement safeguards for multiple residents with cognitive impairment and wandering or exit-seeking behaviors. One resident with Alzheimer’s disease eloped and was returned by police, while overnight 15-minute checks for several residents were not documented as completed. Another resident with stroke-related cognitive deficits was identified as at risk after trying to leave, but the record showed no elopement interventions in place before the attempt, no wander guard on the resident or wheelchair, and no protected list with photos and descriptions.
Inconsistent process for residents who did not return from leave. Two cognitively intact residents signed out of the facility without clear return times, and staff responses varied when they failed to return as expected. For one resident, the ADM and SSD made repeated contact attempts and searched areas the resident frequented, but APS notification was delayed. For the other resident, staff attempted calls to the resident and ex-wife, but there was no evidence that APS, police, or the physician/NP were notified when contact could not be made.
A facility failed to identify the causes of repeated falls and to base interventions on those causes for two high-fall-risk residents. One resident had dementia, hemiplegia, aphasia, incontinence, wandering, and multiple falls, but the documented interventions included 15-minute checks, reminders not to get up alone, and a bed-positioning cue that did not match the fall causes. Another resident had severe cognitive impairment, Alzheimer’s disease, and hospice services, with falls related to confusion, weakness, pain, toileting, and wandering, yet the interventions were 1:1 supervision and close observation, which the DON said were not measurable and did not address the identified causes.
Failure to Prevent Hot Liquid Burns: Two residents were involved in hot coffee incidents after the facility left coffee accessible at nurse stations without a consistent monitoring system or resident hot-liquid safety assessments. One resident with cognitive impairment, Parkinson’s disease, dysphagia, and weakness spilled coffee on self and sustained burns with blisters to the chest, abdomen, and thigh. Another resident with stroke-related deficits, dysphagia, and dependence for most ADLs was later observed with an uncovered cup of coffee at the nurse’s station and spilled coffee on clothing. Staff and the Administrator confirmed there was no process in place before the incidents to prevent residents from getting hot coffee themselves.
Failure to ensure Wanderguard monitoring for residents at risk for elopement. Three residents with dementia-related diagnoses were identified as elopement risks and had Wanderguard interventions in their care plans, but MARs showed repeated missed checks because the checker or test machine was unavailable. Staff gave conflicting accounts about who checked the doors and bands, and there was no documented schedule for testing the door system. One resident later eloped, and the note stated the Wanderguard did not alarm on exit or entry.
Failure to Supervise Elopement Risk and Complete Post-Fall Monitoring: A resident with moderate cognitive impairment, a history of wandering, falls, and multiple head injuries was repeatedly allowed to leave unsupervised without elopement interventions in the care plan, and neuro checks after unwitnessed falls were missing or incomplete. The resident was found outside or in the parking lot on multiple occasions after falls, including one event with a subdural hematoma and midline shift. The facility also delayed reporting another resident missing after an unsupervised leave, despite the resident having severe cognitive impairment, ESRD, severe visual impairment, and delirium-related behaviors.
Failure to Identify Fall Causes and Implement Effective Fall Interventions: The facility did not consistently identify the causal factors behind repeated falls or ensure fall interventions matched the residents’ actual needs. Residents with dementia, impaired memory, wandering, incontinence, gait imbalance, and prior falls were found on the floor in multiple incidents, including after sliding from bed, falling from a chair, falling in the bathroom when a shoe came off, and sliding from a wheelchair during toileting. Documentation showed missing or incomplete assessment of factors such as alarm use, walker location, pain, mental status, environmental conditions, and incontinence, and several interventions were not aligned with the circumstances described in the fall reports.
Failure to Document Fall Causative Factors: A resident had two documented falls, one found on the floor by a wheelchair and another found lying in front of the wheelchair with the pedals on. Although the events were recorded and no injury was noted, the chart and progress notes did not identify a causative factor for either fall. The MDSC confirmed the documentation did not reveal what caused the falls.
Failure to protect a resident from sunburn injury. A resident with stroke-related hemiplegia/hemiparesis, wheelchair dependence, and need for staff assistance was taken outside and left in the sun without documented monitoring or a reachable call light. Staff gave conflicting accounts of how long the resident was outside, and the resident reported being left out too long. The resident later had redness and pain on both thighs, the physician documented a sunburn, and the DON confirmed no sunscreen had been available before the incident and no prevention interventions had been added to the care plan.
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