A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
The facility failed to ensure a safe environment and adequate supervision for several residents, including one cognitively intact smoker on continuous O2 who repeatedly smoked in their room and entered the smoking area while still on oxygen, without effective intervention by the assigned smoking monitor or documented increases in safety checks or reassessment. Room searches of identified smokers revealed multiple residents with smoking materials and lighters, including residents on continuous O2, yet there was no documented evidence of follow-up smoking safety reassessments. Additionally, a severely cognitively impaired, high fall-risk resident experienced multiple falls with injuries over several months, while incident reports repeatedly recommended increased supervision and frequent checks that were not incorporated into the care plan or consistently documented in CNA task records, and nursing leadership acknowledged that supervision interventions and root cause analysis were lacking.
Two residents were exposed to accident hazards when staff did not follow facility policies for medication administration and smoking safety. For one resident with mild dementia, diabetes, COPD, and dysphagia, an LPN prepared multiple oral and inhaled medications and left them unattended at the bedside, despite no assessment or MD order for self-administration and policies requiring an IDT determination before bedside medications are allowed. For another resident with hemiplegia, hemiparesis, and dementia, the required interdisciplinary Smoking/Tobacco Safety Screen was incomplete, even though the care plan called for it and a prior note documented the resident leaving the building early in the morning to smoke and having half-smoked cigarettes on the room floor. Surveyors later observed a cigarette on the floor of this resident’s room, and the resident reported keeping cigarettes and a lighter in the room and going outside to smoke, while the OT and DON confirmed the smoking safety assessment had not been fully completed.
A comatose, fully dependent resident with chronic respiratory failure, prior intracerebral hemorrhage, and HTN had a care plan and Closet Care Plan requiring two-person assistance for overall rolling and bed mobility. Despite this, a CNA provided personal/incontinent care and rolled the resident in bed without a second staff member present, even though the CNA knew two-person assistance was required. During this one-person transfer, the resident rolled out of bed, fell to the floor, struck the head, and was later found on CT to have bilateral acute post-traumatic subdural hematomas, resulting in hospital admission to a trauma ICU.
A resident with dementia, syncope, gait abnormalities, severe cognitive impairment, and a history of multiple falls, who required substantial/maximal assistance for transfers, was placed in a wheelchair in a hallway and left without direct supervision while staff provided morning care to others. The resident’s fall care plan, initiated years earlier and later updated only to add a chair tab alarm, was not revised with new interventions despite repeated falls, and there was no documented fall risk assessment or monitoring schedule in place. Staff interviews showed reliance on the chair alarm for supervision and lack of awareness among CNAs of the resident’s fall history or specific fall-prevention measures. The resident was later found on the floor after staff heard an alarm or loud thump, and facility video review showed the resident leaning forward from the wheelchair to reach for something on the floor before falling, resulting in a head laceration and cervical fracture.
Surveyors found that the facility did not keep resident environments free from accident hazards when medications and supplements were left unsecured in resident rooms and fall-prevention equipment was used improperly. One resident had a cup with cream and crushed medication left at the bedside, while another had collagen peptides, alpha lipoic acid, and topical cream accessible in the room, even though the DON stated no residents self-administered medications and the Administrator indicated such items should be locked. A third resident, admitted with a femur fracture, acute respiratory failure, and HTN and care-planned for fall risk, had two thick floor mats stacked on one side of the bed, contrary to the care plan and staff expectations for mat placement, and staff acknowledged that this configuration could increase fall and tripping risk as the resident ambulated more independently.
Two residents did not receive adequate supervision to prevent accidents. One resident with dementia, severe cognitive impairment, gait problems, and a known elopement risk exited through an alarmed fire door while staff on the unit did not promptly respond to the sounding alarm; the resident was later found outside on the ground with facial and extremity abrasions. Another high fall-risk resident with renal failure, on dialysis, and with a history of multiple recent falls was seated in the dining room, care planned to remain in view of staff, while a CNA who had agreed to supervise sat at a distance looking at their phone and out the window; the resident repeatedly leaned forward and ultimately fell from the wheelchair, sustaining a large bump to the forehead.
A resident with obesity, paraplegia, generalized weakness, and dependence for bed mobility had a rehab assessment and physician order for a left enabler bar to aid in turning and positioning, but the care plan lacked specific goals and interventions for its use and documentation did not show that the device was in place during care. While a CNA was providing peri care and turning the resident, the resident slipped or rolled off the bed and fell to the floor, later being found to have a right intertrochanteric hip fracture requiring surgical repair. Staff interviews revealed uncertainty or lack of recall about the presence or position of the enabler bar, and the resident reported that they did not have enablers before the fall and that they were pushed over too far during turning.
The facility failed to ensure safe and consistent use of mechanical lift slings, resulting in one resident falling from a lift and sustaining a head laceration requiring staples, and placing several other residents at risk. One resident with stroke-related hemiplegia and impaired cognition, fully dependent for transfers, did not have lift use reflected in the care plan, and staff reported the sling was not properly positioned before the lift was moved. For other residents dependent on full-body lifts, sling sizes were not documented, and staff selected sling sizes based on visual inspection, experience, or availability rather than weight and manufacturer guidelines. In separate observations, two CNAs prepared to use an extra-large sling instead of the required medium sling because it was the only one available, another resident care-planned for an extra-large sling was found in a large sling, and a disposable sling marked as unsafe for use was observed on a wheelchair with a CNA stating it was intended for reuse. Multiple CNAs, LPNs, and an RN Manager confirmed uncertainty or lack of documentation regarding sling sizing, while the DON acknowledged problems with sling availability and the use of disposable slings in place of reusable ones.
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