A resident with muscular dystrophy, paraplegia, and severe mobility dependence was transferred with a Hoyer lift using a blue sling sized for much heavier residents than her documented weight. During a shower transfer with 2 CNAs, she slipped through the sling, fell to the floor, and sustained a hematoma to the back of her head; EMS was called and a CT later showed a small scalp hematoma.
A resident with severe cognitive impairment, confusion, and repeated exit-seeking behavior successfully eloped from the facility and was found outside on the sidewalk near an active highway before staff realized he was missing. Records showed he had diagnoses including cerebral infarction and traumatic subdural hemorrhage, with a BIMS score of 0 and documented disorganized thinking, while staff notes described him as combative, difficult to redirect, and insisting on going home. Interviews confirmed staff did not know he had left until another resident alerted them.
Uncovered Damaged Wall in Resident Room: Staff failed to keep a resident’s room free of an accident hazard when a heavily scraped wall at the head of the bed remained uncovered for a time. The resident had severe cognitive impairment and a documented history of putting non-food items in her mouth, and CNA staff said she would peel and eat paint from the wall while several LPNs, the DON, and the Administrator were unaware of the behavior or had not been informed.
Incomplete fall investigation and lack of new interventions after resident fall: A resident with hemiplegia, hemiparesis, generalized weakness, and severe cognitive impairment was found on the floor beside the bed. Nursing documented assessment, notification of the NP, supervisor, and family, and initiation of an incident report, but the IDT fall record was left incomplete with no root cause, no immediate or additional interventions, and no care plan update. Interviews with the LPN, LPN/UM, DON, and Administrator confirmed the fall had not been fully reviewed by the IDT at the time of survey.
A resident with severe vascular dementia, a very low BIMS score, and a diagnosis of wandering was observed self-propelling in a wheelchair in the hallway and was later found missing when a nurse attempted to administer medication. The resident, who had been assessed as low elopement risk and did not have a WanderGuard or daily elopement alarm in use, exited the building and crossed the street before being located by staff between nearby medical offices and returned without distress. Staff interviews and record review showed that, although the facility had an elopement policy and a process for assessing and care planning high-risk residents, this resident had not previously been identified as an elopement risk, and adequate supervision and preventive measures were not in place at the time of the elopement, leading to a cited deficiency under F689 for failure to prevent accidents and hazards.
Failure to Investigate Potential Unwitnessed Fall: A resident with a history of falls and high fall risk was found crawling on the floor toward the door, but the facility did not complete a root cause analysis or identify why the resident was on the floor. Staff stated no fall investigation was done because the behavior was considered typical for the resident and was not treated as a fall.
A resident with dementia, severe cognitive impairment, wandering behavior, and documented elopement risk eloped after staff failed to adequately respond to an exit-door alarm and did not promptly recognize the resident was missing. The resident, who required close supervision and was on 30-minute checks for wandering, was last seen ambulating in the facility before a dining room/fire exit alarm sounded; dietary staff briefly checked, saw no one, silenced the alarm, and returned to work without initiating a facility-wide missing-resident response. Later, when the resident did not appear for dinner, staff began searching and learned from a staff member driving home that someone resembling the resident was seen near a nearby store. Police, responding to a report of a suspicious person with a hospital bracelet, found the resident disoriented at a nearby intersection and arranged EMS transport to a hospital. Interviews showed that some CNAs lacked elopement training, one CNA was newly assigned to 1:1 care, and leadership acknowledged uncertainty about how long the alarm had been sounding and how the resident exited, supporting the finding of inadequate supervision and failure to prevent elopement.
A resident with traumatic brain injury, moderate cognitive impairment, wheelchair dependence, and documented wandering behaviors eloped from the facility after being able to exit through a door without an active alarm. Despite physician orders and a care plan requiring wander guard checks every shift, MAR/TAR review showed these checks were largely undocumented prior to the incident. Staff notes described frequent redirection needs, room-to-room wandering, and impulsive behavior, yet the resident was still able to leave the building and was later found in the parking lot. The State Agency determined this failure to supervise and to implement ordered wander guard monitoring constituted Immediate Jeopardy under F689 (Quality of Care).
Unsecured Sharps Containers in Resident Rooms: The facility failed to keep in-room sharps containers securely locked in 3 of 4 halls observed. One resident with severe cognitive impairment had an open container with no lock, another resident’s container would not latch even though a lock was present, and a third resident’s container was held shut with duct tape and had no lock. Staff interviews confirmed broken or missing locks and inconsistent reporting to maintenance.
A resident with severe cognitive impairment, a history of falls, and documented need for a gait belt and walker during transfers was ambulated from the bathroom by a CNA without a gait belt in place. The CNA reported holding the resident’s pants while walking, during which the resident’s feet became twisted and she fell in her room. Facility documentation showed the resident had been assessed as requiring a gait belt, but gait belt use was not included in physician orders or the care plan and was instead communicated via door name tags. The resident sustained a left hip fracture requiring surgical repair and was later readmitted for rehab and strengthening.
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