A resident with heart disease, muscle weakness, abnormal gait, a fall history, and documented need for extensive two-person transfer assistance was transferred by only one aide. During the transfer, the resident lost balance, was lowered to the floor, and struck the face on a windowsill, causing a skin tear and bruising. The resident and roommate both stated only one staff member was present, and the DON confirmed the resident was supposed to be transferred with two staff members.
A resident with dementia and major depressive disorder was identified as high risk for elopement and had interventions in place, including a wander guard and door alarms. Staff verified the device earlier in the evening, but the resident removed it, traveled to the elevator, rode to the lobby, and exited through the front door when the alarm was not heard or responded to. The facility failed to provide adequate supervision and safety measures to prevent the elopement, resulting in Immediate Jeopardy.
A resident with moderate cognitive impairment, anxiety, and a history of substance use disorder repeatedly expressed a desire to leave, packed belongings, and was frequently unable to be redirected. Staff relied mainly on a Wander guard device and routine redirection even as the resident continued using other residents’ wheelchairs and had a prior missing device incident. Video and staff statements showed the resident used the facility wheelchair to exit through the main door while an ambulance attendant entered, then reached the parking lot with a cigarette in the mouth before being returned by staff.
A resident with severe cognitive impairment, diabetes, HTN, neurogenic bladder, and an absent upper limb was not adequately supervised to prevent elopement. He had prior exit-seeking behavior, but his elopement risk was not consistently identified, and he later exited through the front door in his power wheelchair, was found off the facility grounds near a road, and was observed waving a flashlight at passing cars while saying he was trying to go to Youngwood. Staff statements noted increasing confusion and prior issues with an SCD.
A resident with anxiety, depression, and moderate cognitive impairment had a care plan and physician order for a Wander Guard on the left ankle, but surveyors observed no device on the resident and the LPN could not locate it. In a separate finding, a severely cognitively impaired resident with cerebral infarction and hemiplegia had zinc oxide and A and D ointment left at the bedside in a cup and spoon without an order for either cream; the DON confirmed staff should not leave medicated cream at the bedside.
A resident with neurocognitive disorder with Lewy Bodies and insomnia was repeatedly documented wandering the halls, entering other residents’ rooms, taking food and belongings, and trying to get into other residents’ beds. Nursing notes and facility documentation also described the resident taking items from carts and sustaining a laceration under the eye after wandering. Another resident reported that the resident frequently entered her room, ate her food, and laid in her bed.
A resident with vascular dementia, anxiety, and impaired safety awareness was identified as an elopement risk, but the care plan was not shown as updated after repeated exit-seeking behavior. The resident attempted to leave through a side door, later became yelling and physically aggressive, opened an emergency exit door, and crossed outside onto the sidewalk before staff brought her back in. Staff interviews and incident records confirmed the resident was known to be at risk and was supposed to receive 15-minute checks and redirection.
Inadequate 1:1 supervision for a resident with psychosis, dementia, and behavioral disturbances led to repeated wandering into another resident’s room. The resident had a history of anxiety, pacing, non-compliance with redirection, and unwanted sexual behaviors, and was found in another resident’s room while 1:1 supervision was still ordered. An NA admitted leaving the resident unattended near the nursing station to use the bathroom, and the DON confirmed the supervision failure.
A resident with severe cognitive impairment and diagnoses including Alzheimer's Disease sustained a second degree burn after hot coffee was spilled on the thigh. A CNA obtained the coffee from the employee breakroom in a Styrofoam cup after asking the resident if he/she wanted coffee, and the resident was unable to explain exactly what happened. The record documented redness, blistering, and a broken blister on the left thigh, and the facility failed to ensure the coffee was served from the main kitchen, in an appropriate container, and with proper supervision.
A resident with paraplegia, diabetes, confusion, and wandering behavior was identified as an elopement risk, yet was found in an enclosed courtyard area without the facility’s knowledge after being last seen near the nurse’s station. Staff statements confirmed the resident had accessed the courtyard and became stuck in a wheelchair, and the DON later confirmed the facility failed to ensure adequate supervision.
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