A resident with a prior stroke, obesity, and weakness required 2-person assist for bed mobility and turning/repositioning, but only one NA provided care during morning care. While being turned on the bed, the resident rolled off the bed and fell to the floor, sustaining a right tibia/fibula fracture that required ED evaluation and pain management.
Unsafe water temperatures were found at resident-accessible sinks and bathrooms across multiple floors, with readings above the safe range and a mixing valve set too high; staff were unsure of safe bathing temperatures, and water temperature logs had not been completed for months. In a separate event, a resident with dementia and a traumatic subdural hemorrhage was found prone on the floor bleeding from the face after an unwitnessed fall, then lifted back into bed despite the facility fall policy requiring a full head-to-toe assessment and minimal movement unless there was a life-threatening concern.
Failure to complete quarterly smoking assessments for two residents who smoked. One resident with COPD had an admission smoking screen showing the need for assistance and supervision, but no smoking care plan or required quarterly reassessments were found. Another resident with COPD, dementia, weakness, and worsening tremors had a supervised-smoker care plan, but quarterly reassessments were missing for an extended period; during observation, the resident dropped a lit cigarette twice and later required supervision and a smoking apron for safety.
A resident with dementia, muscle weakness, and total dependence for transfers was not transferred according to the PT’s recommendation for a mechanical lift after a decline in mobility. Staff continued manual transfers without a gait belt, including lifting the resident under the arm and elbow area. The resident then developed swelling, extensive bruising, and pain to the upper extremity, requiring NP assessment, imaging, medication changes, and ongoing monitoring.
Failure to ensure adequate supervision for residents at elopement risk was cited for three residents with dementia-related diagnoses. Two residents were observed ambulating independently on a secured unit while wearing wander management devices, and one resident was documented packing belongings and running down the hall after a family member while stating a desire to go home. The record showed missing physician orders or missing implementation for daily device functionality checks, and the DON acknowledged the orders were not in place.
A resident with dementia, severe cognitive impairment (BIMS 3/15), poor safety awareness, and high elopement risk, who self-propelled rapidly in a wheelchair and wore a wander guard, was inadequately supervised on a secured unit. The resident wheeled to a stairwell exit door, held the fire bar until it released, exited into the stairwell, and fell down a flight of stairs while in the wheelchair. The stairwell door alarm sounded but was not loud enough to be heard by staff in common work areas such as the shower room, dining room, and a nearby office, and individuals in an adjacent medical office, rather than facility staff, reported hearing the alarm and subsequent noise. The resident was found on the stairwell landing with a head injury and was later diagnosed via CT with a subdural hematoma and subarachnoid hemorrhage, demonstrating a breakdown in elopement prevention and supervision systems.
A resident with dementia and elopement risk had a wanderguard noted on the walker during surveyor observations, but the record lacked a physician order for the device and orders for shift placement checks and weekly functionality checks. The chart also did not show documentation that the wanderguard was being monitored per policy, and the RN UM and DON acknowledged the missing orders.
A cognitively impaired resident with dementia and severe BIMS impairment, care planned and ordered to wear a wander guard with regular placement and function checks, eloped from the facility after being last seen in an activity room with a visitor. Staff later could not locate the resident for dinner, and searches were initiated while the resident’s whereabouts were unknown for several hours. Witnesses, including the Activities Director, Receptionist, another resident’s family member, and the visitor, reported that the resident and visitor exited through the main entrance without a wander guard alarm sounding and without use of a door code. The visitor admitted driving the resident to the spouse’s home without notifying staff. EMS and hospital records documented that the resident had been missing for several hours, was confused, could not recall events, and reported severe throat and chest pain, arriving at the hospital with an ankle monitoring device in place. Upon the resident’s return, the facility discarded the original wander guard without testing its functionality and could not provide evidence of consistent monitoring per policy and physician orders, resulting in an Immediate Jeopardy situation.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, documented exit-seeking behavior, and a care plan identifying high elopement risk and the use of a wander guard was inadequately supervised. Earlier in the day, an LPN observed the resident attempting to open an exit door and redirected the resident, who was later last seen in their room. The resident subsequently exited a secured unit through a stairwell door that only briefly alarmed and was not connected to the wander guard system, descended to a basement level, and left through an exterior door. Because wander guard sensors were only placed at elevators and not at exit doors or stairwells, the resident’s departure went undetected until a Code Orange was called and the elopement protocol initiated, after which staff located the resident off premises and returned the resident to the facility.
A resident with hemiplegia, partial foot amputation, vascular dementia, and total dependence for transfers experienced multiple incidents while using a stand aid, including sliding to the floor, falling backward, and being lowered to the floor when knees buckled. Despite facility policy requiring post-fall rehab screens, no rehab screens were documented after several of these falls, and the rehab director was unaware of the events and the resident’s non-compliance and knee buckling. Later, rehab formally recommended use of a full-body Hoyer lift with two staff for all transfers, but nursing did not update the care plan or the NA assignment sheet, which continued to direct use of a stand aid, and leadership acknowledged that the resident’s changed transfer status was not clearly communicated to caregivers.
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