A resident with dementia, metabolic encephalopathy, and severely impaired decision making was dependent for transfers and had therapy documentation indicating the need for a mechanical lift with two staff members. The care plan and EMR profile did not include the mechanical lift requirement, and a CNA transferred the resident from bed to a shower chair alone by lifting under the arms. The resident was later found to have a swollen, deformed left arm, and hospital imaging confirmed an acute displaced distal humerus fracture.
Failure to provide adequate supervision for a cognitively impaired resident with a high fall risk. The resident had severe cognitive impairment, hydrocephalus, restlessness, agitation, and difficulty walking, and required assistance with toileting and other ADLs. The resident had multiple unwitnessed falls and floor incidents, including being found on the floor in the room, in bathrooms, and in a hallway, with one event causing a head laceration and eyebrow hematoma. Staff notes and fall investigations showed the resident was impulsive, moved quickly, and at times was left unattended during toileting or was found away from the assigned room.
Failure to report and investigate discharge with IV access in place: A resident with intact cognition and a midline for IV antibiotics was discharged after completing treatment, but the discharge record did not include an order to keep or remove the line. Staff later learned the resident had gone home with the midline still in place, and interviews showed the nurse who discharged the resident did not know it was present. Facility leaders stated the event warranted an IR, but none was completed.
A resident with macular degeneration, heart failure, hearing loss, moderate cognitive impairment, and a history of falls was identified as high risk for falls, but the care plan did not clearly retain the resident’s actual falls. Although progress notes documented multiple falls and the RN and DON acknowledged the falls should be reflected in the care plan, the actual fall entries were not readily visible because they had been resolved in the EMR.
A resident with impaired cognition, poor safety awareness, and elopement/fall risk was allowed to leave the elevator area and enter a courtyard without documented supervision. The resident later had an unwitnessed fall with facial injuries and reported dizziness. Surveyors also found that another resident had access to the elevator code and could deactivate the alarm system, allowing the at-risk resident to ride the elevator without staff escort.
Failure to prevent elopement of a cognitively impaired resident: A resident with severe cognitive impairment and documented elopement risk exited a secured unit after a visitor used the keypad code to leave the unit. The resident followed the visitor to the lobby and then left the facility when the receptionist opened the front door, assuming both were visitors and not checking the elopement-risk photos posted at the desk. Police later found the resident disoriented about 1 mile away and returned the resident to the facility.
Failure to Investigate Reported Fall Injury: A resident with impaired cognition, an unsteady gait, and fall risk had bruising around the eye initially documented as an injury of unknown origin. Later PN showed the resident reported the injury came from a fall, and staff interviews confirmed awareness of the fall report, but the event was not documented as a fall or thoroughly investigated per facility policy.
A resident with severe cognitive impairment and a prior fall injury was observed in a low bed without the floor mat that remained listed in the care plan, despite staff acknowledging the intervention should have been in place. In a separate finding, a resident with dementia and Alzheimer’s disease who was at risk for elopement had a Wander Guard with blank eTAR checks, an expired device date listed on the order, and no PN documenting replacement after staff found the device was not on the resident.
Bilateral floor mats were not kept in place for two residents with fall risk. One resident with repeated falls and gait impairment was observed with a floor mat leaning against the wall instead of on both sides of the bed, and another resident with hemiplegia and a recent fall was observed with only one mat at bedside while the other side had none. The UM and DON stated that ordered bilateral mats should be on the floor on both sides of the bed while the resident is in bed.
A resident with moderately impaired cognition and diagnoses including cellulitis, atelectasis, and muscle weakness was care planned as an elopement risk with a WanderGuard bracelet and interventions such as accompaniment to meals, frequent rounding, and redirection. Despite this, the resident, known to wander and whose photo was posted throughout the facility, was able to leave the building after a WanderGuard alarm sounded at the lobby exit. Surveillance showed the receptionist manually deactivated the alarm without identifying its source, and the resident, dressed in a jacket and carrying envelopes, walked behind the receptionist and exited, appearing as a visitor. Staff interviews revealed that clinical staff believed alarms should not be turned off until the resident was located, while the receptionist reported she had been trained to silence the alarm by entering a code and then visually checking from the desk, contributing to the resident’s undetected elopement.
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