A resident who required two-person assistance was transferred by one CNA and fell to the floor during the transfer. Another resident who required supervision and a fire-resistant smoking apron was observed smoking without the apron in place, and an LPN stated they did not normally supervise smoke breaks or know which residents needed an apron. The facility also left an electrical room door unlocked, with paint, power tools, insect spray, electrical cords, and enabler bars inside.
Improper One-Person Mechanical Lift Transfer: A resident with dementia, a history of falls, and a care plan requiring a full-body mechanical lift for transfers was transferred from a geriatric chair to bed by one CNA alone. The facility policy required two nursing assistants for mechanical lift transfers, and staff reported short staffing and being told to complete lift transfers without another aide available. The DON stated two staff members were absolutely required for mechanical lift use.
Failure to supervise a resident during a nebulizer treatment. A resident with dementia and severe cognitive impairment was receiving ordered inhaled sodium chloride for congestion, but an LPN left the room during the treatment more than once. While unattended, the resident removed the mask and turned off the machine. The ADON and DON stated a nurse was required to stay with the resident during breathing treatments, and the resident had no assessment showing ability to self-administer.
Failure to supervise a resident at risk for elopement: A resident with dementia and severe cognitive impairment was identified as an elopement risk, but was found by a visitor sitting in the south parking lot in a wheelchair after leaving the front lobby unsupervised. Staff brought the resident back inside, assessed the resident, and the DON stated the activity director had been away from the lobby for about 10-15 minutes when the resident disappeared.
Smoking Safety and Supervision Failures: The facility did not complete or update smoking safety assessments correctly, allowed a resident on O2 to be in the smoking area without proper reassessment, did not assess another resident who smoked independently and kept cigarettes in the room, and failed to supervise an unsafe smoker as required by the smoking assessment. Staff interviews showed inconsistent awareness of who smoked, who needed supervision, and how smoking materials were controlled, while observations confirmed residents in the smoking area without staff oversight.
A resident on supervised smoking with oxygen therapy was observed with cigarettes and a lighter left in the room despite staff stating smoking materials should be secured, and another resident with dementia and severe cognitive impairment eloped from the facility and was found in a nearby grocery store parking lot. Staff reported the exit doors were secured, rounds were done every two hours, and the resident was walking independently at the time of the elopement.
Failure to implement hourly toileting after a resident's fall. A resident with heart failure, urinary and bowel incontinence, and a history of falls was found on the floor after attempting to stand and said they needed to use the bathroom. Although the incident report stated an hourly toileting intervention was ordered after the fall, the MAR, TAR, and CNA task list showed no documentation that the intervention was carried out, and staff interviews confirmed the resident was being toileted every two hours instead.
Resident Eloped From Facility Without Adequate Supervision: A resident with moderately impaired cognition was assessed as not at risk for wandering or elopement, yet later eloped from the facility and walked to an apartment on adjoining property before staff located and returned the resident. An LPN reported seeing an unidentified person leave the building without staff following, and the incident report contained an incorrect date.
A resident with a history of exit-seeking and wandering eloped from the facility after staff failed to recognize the resident had left until law enforcement called from a neighborhood three blocks away. The resident had a high elopement risk score, dementia, and repeated documented attempts to leave. In a separate event, two residents with wandering behaviors were observed near an open, unattended kitchen with hot food, knives, chemicals, and an unlocked exterior door, while kitchen staff were away on break.
Failure to supervise a resident at high risk for wandering led to an elopement event. The resident had dementia, delirium, and head injury, with moderate cognitive impairment and later documentation showing a high wandering risk. Nursing notes described the resident as confused, pacing, and easily redirected, and the resident exited the facility and was found at a fast food restaurant after crossing a busy four-lane highway.
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