Personal hygiene items were found in the rooms and bathrooms of several residents with severe cognitive impairment, including body wash, perineal cleanser, shaving cream, mouthwash, shampoo/body wash, and lotion. Staff and the DON acknowledged that these items were not supposed to be left in the rooms, but they were observed on tables and in bathrooms despite residents’ dementia and confusion. Some residents stated they knew how to use the items, while staff noted that residents could become confused and use or ingest them incorrectly.
Improper Gait Belt Use During Resident Transfer: A resident with severe cognitive impairment, debility, immobility, and transfer dependence was observed being prepared for a wheelchair-to-bed transfer by two CNAs. The gait belt was initially placed over the resident's upper back and breasts instead of just above the hips, and the surveyor stopped the transfer. The CNAs then repositioned the belt and completed the transfer, while staff stated they had not been recently trained on gait belt use and the facility lacked a current gait belt policy.
Jagged shelving edges were observed on the east hall and west hall where shelving had been attached directly to the wall. The Maintenance Supervisor said he had placed the shelves but had not sanded the rough edges, and the ADON, DON, and Administrator all acknowledged the shelving had jagged edges and had not been finished as expected. Staff stated the condition could cause skin tears, splinters, or cuts for staff, visitors, or residents.
A resident with dementia-related cognitive impairment and a low elopement score left through an open patio gate and was missing for about 30 to 40 minutes before being found several blocks away and returned by a staff member. Staff later noted sunburn to his scalp, face, arms, and legs. The DON, MD, and NP stated he had no prior exit-seeking history and had been assessed as low risk.
Unsafe Resident Transfer Without Gait Belt: A resident with dementia, Alzheimer’s disease, Parkinson’s disease, and moderate cognitive impairment was transferred from bed to w/c without a gait belt. A CNA attempted the transfer, the resident’s knees buckled, and the CNA grabbed the resident by the brief, torso, and under the arms before lowering her to the floor. Staff later assisted the resident from the floor to the bed and then to the w/c by pulling under the arms and on clothing, despite the care plan and facility policies calling for safe handling and gait belt use when appropriate.
A resident with dementia, Alzheimer’s disease, anxiety, severe cognitive impairment, and high fall risk was observed eating dinner in the secured unit with a large puddle of liquid under his chair. Staff were busy assisting others, and an LPN initially did not notice the spill, then covered it with a towel; the ADON also did not see it. Staff acknowledged the resident was unsteady and could slip and fall if he stepped on the liquid.
A resident with severe cognitive impairment and extensive transfer needs and another resident requiring 2-person transfers were both lifted from wheelchair to bed by CNA A and CNA B without gait belts. Staff lifted the residents under the arms, and in one case also grabbed the back of the resident's pants, despite care plans calling for assisted transfers and a gait belt being available in the room for one resident. Interviews confirmed staff knew underarm lifting was not appropriate and that gait belts were expected.
A resident with intact cognition and a smoking history was documented as safe to smoke with supervision, yet was observed going to the smoking area with cigarettes in hand and smoking without staff present. He stated he was allowed to keep his cigarettes and lighter on him, while the DON and ADM said his smoking supplies should have been controlled and he was supposed to be supervised.
A resident with stroke, aphasia, severe cognitive impairment, and poor safety awareness was found on the floor and was lifted into a wheelchair by two CNAs who hooked their arms under his arms instead of using a gait belt. The nurse was not notified when he was found on the floor, despite facility policy and DON expectations for immediate nurse assessment and safe transfer procedures.
Hazardous Items Found in Resident Rooms: Staff observed germicidal wipes in one resident’s room and scissors in another resident’s possession. Both residents had dementia and required assistance with care and supervision, and staff interviews confirmed that such items should not be kept in resident rooms. The Administrator removed the scissors after the resident said his daughter had given them to him, and the facility policy stated that medications, chemicals, cleaning supplies, and other hazardous materials must be kept locked or secure.
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