Unlocked bed wheels were observed for two residents while the beds were in use. One resident with muscle weakness, impaired gait, chronic pain, burns with skin graft, and right foot drop had a fall after the bed shifted, and the resident reported the bed had slid on other occasions because the wheels were unlocked. A CNA stated bed brakes should be relocked after cleaning, an RN stated unlocked wheels could contribute to falls, and the DON stated the beds should be locked at all times when in use.
A resident who was dependent for transfers was observed being moved with a Hoyer lift by an Activities Assistant without the required second staff member. The resident’s care plan directed mechanical lift transfers by two CNAs with nurse monitoring, and the AA later acknowledged she knew it was wrong and unsafe to use the lift alone. The DON stated a Hoyer lift requires two staff members for the safest transfer.
Improper Transfer Without Required Hoyer Lift: A resident with stroke history, pelvic/lumbosacral fractures, RA, failure to thrive, and hospice status was ordered to be transferred with a Hoyer lift and 2 staff using a divided-leg sling. Instead, 2 CNAs transferred the resident to and from a shower chair without the lift, including lifting under the arms, and the resident sustained a skin tear and bruising to the chest and forearms.
Staff left a computer cart with a drink, a chair, and a backpack unattended in the doorway of a room, blocking entry, and separately left another unattended computer cart and chair with personal belongings in a hallway between two rooms, obstructing access to handrails and room entrances. No staff were present near these items. In an interview, the ADM stated that leaving computer carts, drinks, purses, bags, or other personal items in hallways or in front of doorways was not acceptable and that such items should be stored in designated staff areas.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
A resident with impaired physical functioning and a left AKA, care-planned for two-person substantial/max assist and Hoyer lift transfers, was being repositioned by one CNA while the bed was left in the highest position and the resident was instructed to hold the bedrails, leading to a witnessed fall from the bed. After the fall, the resident repeatedly reported severe back and knee pain, with documented edema, bruising, and pain behaviors, while initial imaging was read as negative and the resident was not immediately sent to the ER. Persistent severe pain led to repeat imaging that revealed a right femur fracture, and subsequent hospital evaluation also identified lumbar compression fractures, confirming that the unsafe bed position and inadequate supervision contributed to a serious injury event.
A resident with a history of CVA, falls, poor safety awareness, and cognitive impairment, whose care plan called for frequent observation and supervised placement when out of bed, was transported alone to a follow-up medical appointment and left unattended. Family members reported that the physician’s office called them expressing concern about the resident’s safety and that the resident was found sitting in a wheelchair without having been seen by the doctor. Transport staff stated they were trained that drivers only provide transportation and no patient care, and that they rely on the DON’s notation on the appointment sheet to know if an escort is needed. An LPN reported that not all residents go to appointments with escorts and that the scheduler would know if an escort was required, and she was unaware that this resident had been left alone.
A resident with multiple comorbidities and generalized muscle weakness had a care plan requiring two-person assistance for ADLs, including bathing and bed mobility. During a bed bath provided by one CNA, who reported being unaware of the two-person assist requirement, the CNA remained on one side of the bed while the resident rolled toward the opposite side and fell from the bed to the floor. The resident sustained a laceration to a finger, reported pain in the arm, leg, and hip, and was later found to have a displaced distal femur fracture and a displaced fracture of the fifth finger, requiring surgical repair.
Surveyors found that a resident room had multiple strips of floor tape that were worn, curling, and leaving sticky, uneven residue near the bedside area, and that a hallway near the dining room had a hose connected to a wall-mounted water source by an ice machine that was not properly secured in its protective case, causing water to drip and form a puddle on the floor. The Maintenance Supervisor and the ADM acknowledged that floor tape should remain flat and that the hose should be secured to prevent tripping and slipping hazards for residents.
Surveyors found a portable electric space heater plugged in and operating on the floor of a common hallway near a vending machine, in an area accessible to residents. The heater’s placement and operation in this location created an accident hazard, particularly for residents with dementia or limited safety awareness, as acknowledged by the substitute Administrator and the Maintenance Director during interviews.
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