Failure to Use Gait Belt During Assisted Ambulation: A CNA assisted a resident with a walker to the bathroom without using a gait belt, and the resident lost balance and fell, sustaining an elbow abrasion and a fractured femur requiring surgery. The resident had COPD, dementia, repeated falls, and a history of TBI, and her care plan called for one staff member to assist with toileting and transfers using a gait belt, wheelchair, or sit-to-stand lift as needed. Interviews showed staff relied on the care plan or Kardex for assistance needs, while the facility policy stated gait belts should be used with assisted ambulation unless medically contraindicated.
A resident with dementia and a care plan for two-person full body mechanical lift transfers was pivot-transferred from his wheelchair to bed without a gait belt after staff found no sling under him. An LPN directed the transfer despite knowing the care plan, and the resident’s leg was caught on a bed frame with a missing cover plug, causing a large skin tear and puncture that required ER repair with staples and stitches.
A cognitively impaired resident with dementia, anxiety, and delusional disorder was identified as an elopement risk due to increased confusion and repeated wandering/exit-seeking. While seated near the front entrance, she slipped out when the receptionist opened the door for a visitor and then looked away, allowing the resident to exit unnoticed. She was later found more than two blocks away walking on the sidewalk and said she was going to her parents’ home.
A resident with severe cognitive impairment and total dependence on staff was found on the floor after not being checked for about four hours, with her bed left elevated. She sustained a bleeding hand laceration that required sutures and a splint in the ER. Interviews and record review showed staff were expected to complete hourly visual safety checks, but the resident was last seen hours earlier and the facility did not explain why she was not monitored or why the bed was raised.
A resident with impaired cognition, repeated elopement-risk findings, and a wander guard left through the front entrance after visitors entered and a CNA/MA deactivated the alarm. He was found about 1.5 blocks away after falling with his walker and sustained abrasions and bruising; hospital records later noted cellulitis, altered mental status, AKI, and multiple bruises. Interviews showed staff were unclear on elopement procedures and who was at risk.
A facility failed to assess multiple beds, side rails/grab bars, and mattresses for entrapment hazards. Surveyors found loose or unsecured rails and mattresses on several residents’ beds, including one resident with an improperly used rail secured with a zip tie and another with a five-inch gap between the mattress and headboard. The DON said she was unaware these items needed entrapment assessment, and the CEO could not produce documentation showing when the rails were installed or inspected.
A resident with moderately impaired cognition fell forward from his wheelchair when a CNA pushed him to the dining room without attaching the wheelchair foot pedals, despite a known history of putting his feet down while moving. He hit his face and sustained a forehead lump, nasal abrasions, and a small hand skin tear; staff interviews and the incident report confirmed the CNA had been trained on the pedal requirement and did not follow it.
A resident with hemiplegia after a stroke fell from the toilet after a CNA left him in the bathroom without his call light within reach. He reported that the stand aid was left in front of him with the brakes not locked, and when he reached for the call light cord, the device moved and he fell, hitting his head and sustaining a laceration to his arm. Staff interviews showed inconsistent practices for leaving the stand aid in the bathroom and ensuring the call light was accessible.
A resident spilled coffee that had been served too hot, and two other residents were observed drinking coffee without the lid precautions identified in their hot liquid safety evaluations and care plans. In a separate incident, a CNA left a resident alone in the shower despite a care plan requiring supervision/touching assistance, and the resident fell and bruised his knees.
A resident with moderate cognitive impairment, autism, and visual impairment was left unsupervised outside his room after it had been mopped and the floor was still wet. A CNA told him to wait, then walked away, while a Caution Wet Floor sign was posted at the entrance and environmental services said the floor had to be completely dry before re-entry. The resident later entered the room despite the wet floor.
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