Failure to supervise a resident with severe dementia, impaired safety awareness, and a high fall risk led to an unwitnessed fall in a dayroom away from the nurses’ station. An RA placed the resident there after a shower and left the resident unattended while caring for another resident; the resident was later found on the floor with the arm twisted backward and was sent to the ED with a closed distal humerus fracture.
Unattended Housekeeping Carts Left Unlocked in Resident Lounge: Two housekeeping carts were observed unattended and unlocked in a resident lounge while residents were present. The carts contained bleach-smelling liquid in a mop bucket and multiple cleaning products, including air freshener sprays, germicidal spray, glass cleaner, and liquid soap. The HA staff confirmed the carts were left in a resident area, and the Housekeeping Director, DON, and Administrator stated carts should be locked or stored out on the dock when not in use.
Improper Transfer Resulted in Arm Fracture: A resident with osteoporosis, impaired mobility, and severe cognitive impairment required a Hoyer lift and two staff for transfers, but a CNA performed a stand-pivot/manual transfer instead. During the transfer, the resident’s arm and hand were caught between the chair armrest and the resident’s body, and the resident later complained of left arm pain. The resident was diagnosed with a closed fracture of the left humeral shaft, and staff interviews confirmed the transfer did not follow the resident’s care plan.
Failure to Supervise a Resident at Risk for Elopement: A resident with severe cognitive impairment, dementia, and a documented elopement risk exited through secured doors without a WanderGuard and was later found outside on the ground with her wheelchair on top of her near the back dock/loading dock area. Staff reported she had been seen earlier near the nurses’ station, a search was started after she could not be located, and she sustained forehead abrasions and a bruised elbow before being sent out for evaluation.
A resident with severe cognitive impairment and an order for bed bolsters to define the bed perimeter for safety was observed with a fitted sheet placed over the perimeter mattress cover, flattening the wedge-shaped foam bolsters. The MM, SDC, CNAs, LPN, and DON all stated staff were trained not to cover the mattress perimeter device with a fitted sheet because it caused the bolsters to flatten and defeated the purpose of the intervention.
Missed Fall Risk Assessment for Resident After Falls: A resident with COPD, CHF, type 2 DM, and hallucinations had a fall risk evaluation showing high fall risk, but the required quarterly reassessment was not completed. The resident later had a fall with a closed femur fracture and another fall without injury. The DON gave inconsistent statements about when fall risk evaluations are done, and the MDS Coordinator said she did not know how the assessment was missed.
A resident with severe cognitive impairment, hospice services, and a history of major falls was injured when a single hospice CNA was providing bed bath and linen change care despite documentation indicating the resident required a total lift and two staff for turning and repositioning. While the CNA was loosening sheets, the resident rolled off the bed and sustained bilateral distal femur fractures.
A cognitively impaired resident with dementia and a nonfunctioning Wander Guard exited through an unlocked front door without staff knowledge and was later found at a nearby school attempting to enter the building. Records showed high elopement risk, inconsistent q15 documentation, and no routine Wander Guard checks as ordered, while staff initially believed the resident was still in her room.
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.
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