Failure to follow a resident’s care plan for transport and mobility led to a fall during a dental appointment. The resident had stroke, dementia, and severe cognitive impairment, and the care plan required one-person assist in a wheelchair and use of a tilt-back wheelchair or stretcher for all transportation. Instead, the resident was taken to the appointment in a standard wheelchair, slid out onto the floor, and was sent to the ER; the RNCM confirmed the appropriate mobility device and transport services were not arranged.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
Aspiration precautions were not followed for two residents with swallowing and aspiration risk concerns. One resident with dysphagia and confusion had conflicting aspiration instructions, and fluids were left within reach at the bedside despite 1:1 supervision being documented. Another resident with pneumonia and moderate cognitive impairment was ordered for 1:1 supervision for all eating and drinking, yet cups of juice and water were observed within reach in the room, and staff gave inconsistent awareness of the supervision and bedside fluid restrictions.
A resident with DM, a foot ulcer, and chronic pain was sent for foot surgery and received post-anesthesia instructions not to stay alone and to have a responsible person present. Staff accompanied the resident to the appointment, but the CNA was later picked up and no staff member waited to assist the resident back to the facility after surgery; the resident, CNA, SS coordinator, and Admin all confirmed the resident returned without staff escort.
A resident with severe cognitive impairment and multiple medical conditions was left unsupervised off the facility premises in a busy street area after staff were told not to assist the resident back, and the resident was later found lost by police. The facility also failed to update care plans for two other residents with repeated elopement and fall events, including a resident who repeatedly tried to go to the bank and later fell from a wheelchair, and another resident with severe cognitive impairment who fell after being left alone during a fire drill.
A resident with dysphagia and aspiration precautions was given a meat sandwich without staff checking the current diet order, and the resident choked until a nearby employee performed the Heimlich maneuver. Another resident with stroke-related swallowing issues and a no-straw precaution was observed with a straw in a juice cup despite staff recognizing the resident was an aspiration risk. The incidents involved failure to follow ordered diet texture and aspiration precautions, including supervision and no-straw restrictions.
A resident with esophageal obstruction was ordered NPO and on tube feeding, but a CNA served orange juice during fluid pass before breakfast. The resident consumed a small amount before it was removed, and staff documented that the physician orders and care plan were not followed.
A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
Staff did not follow a resident’s smoking safety care plan or another resident’s ordered liquid consistency. One resident with a history of tobacco use and vaping was supposed to be supervised when smoking, but staff gave conflicting reports about the resident’s smoking status and continued indoor vaping was noted. Another resident with dysphagia and an order for mildly thick liquids was observed with thin water and other thin liquids, and staff provided ice water without thickening it even though the resident had aspirated on thin liquids and had not been assessed to self-thicken.
Failure to keep a high fall risk resident’s call light within reach. A resident with a stroke, femur fx, and cognitive impairment had a care plan for 1-person assist with transfers and call light access, but was observed multiple times with the call light draped over the bed and out of reach. The resident had two unwitnessed falls related to attempts to self-transfer, and staff acknowledged the resident was forgetful and that it was not safe to ambulate in a wheelchair around the bed to reach the call light.
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