Two residents were involved in a deficiency related to supervision and wander alert safety. One resident with severe cognitive impairment and known elopement risk exited the facility unnoticed through unsecured doors and was found miles away by police. A second resident’s wander alert bracelet failed to alarm during an elevator transfer, and staff later found the bracelet battery was dead. Leadership and nursing staff stated there was no policy for door checks or for the current wander alert system.
Failure to protect a resident with severe cognitive impairment and elopement risk from window exit. The resident had a history of wandering and prior exit-seeking, was placed on a secure unit with a wander guard, and later broke a window lock, exited through a room window, and fell to a lower patio roof, sustaining multiple fractures. After hospital return, the elopement assessment and care plan were not updated for window safety, and staff said they did not routinely check room windows during hourly rounds.
A facility failed to provide adequate supervision and/or elopement protection for two residents assessed as elopement risks. One resident refused a wander guard and was monitored with hourly head counts, but the resident later left the building without being detected and was found at the representative’s home overnight. Another resident had a physician order for a right wrist wander guard, but was observed in the dayroom without the device in place, and staff reported the resident sometimes removed it.
Failure to Supervise a Resident With Suicidal Ideation History: A resident with a history of suicidal ideation, psychosis, and prior self-harm-related behaviors expressed distress, became agitated, and repeatedly accessed a TV room window area where staff had to remove vases after the resident grabbed them and struck the window. The resident was not placed on frequent checks and was later found unresponsive with a cord wrapped around the neck; CPR was started, EMS transported the resident to the hospital, and the resident was pronounced deceased.
A resident with schizophrenia, mild cognitive impairment, and an elopement risk removed a wander guard and exited the building unsupervised. The care plan did not include documented supervision interventions for the resident, and the record did not show consistent evidence that ordered 15-minute monitoring was carried out after the elopement. Staff later found the resident outside, returned the resident to the unit, and documented no injuries.
A resident with dysphagia and a puree diet was given an egg salad sandwich after requesting an alternate meal, then choked, became cyanotic, and required the Heimlich maneuver. In addition, bedside meds were left unattended for multiple residents who were not approved to self-administer, including Nystatin powder and OTC diphenhydramine, despite assessments and care plans indicating they could not keep meds at the bedside.
A resident with myotonic muscular dystrophy, PVD, and DM2 sustained a right calf laceration when bed hardware protruding from the frame caught the leg during an RN-assisted transfer into bed. The resident had profuse bleeding and was sent to the hospital, where 16 staples were placed. Interviews and observation showed the bolt/screw at the foot of the bed was the source of the injury, and similar bolts were still present in other rooms at the time of survey.
A resident with dementia, Alzheimer’s disease, anxiety, severely impaired cognition, and a history of agitation during care sustained a head laceration when a CNA shaved the resident’s head with a razor and the resident became combative and moved during the procedure. The resident required ER transfer and four staples. The record states staff were not supposed to shave residents’ heads, and the DON and Medical Director said head shaving is generally done by a barber and should not be done when a resident is combative or moving.
A resident with anoxic brain damage, quadriplegia, and seizure disorder was dependent on staff for bed mobility and personal care and required two staff for turning and hygiene. A CNA provided toileting care alone while the resident was in bed, despite the care plan, and the resident slipped out of bed during the turn. The resident was sent to the hospital with a right tibia and fibula fracture, and staff interviews confirmed the CNA did not follow the resident’s plan of care.
A facility failed to provide required supervision for two residents. One resident who needed 2-person assist for bed mobility was turned by a CNA with only 1 staff present, slid from the bed, and sustained a femur fracture. Another resident with severe cognitive impairment and a care plan for close supervision ambulated alone, fell in a hallway, and fractured a hip. Interviews showed staff and rehab personnel knew the resident should not have been walking alone, but the resident was not monitored at the time of the fall.
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