A resident with diagnoses including osteomyelitis, bacteremia, MRSA infection, type 1 DM, and psychoactive substance abuse was assessed as needing assisted smoking and supervision while smoking. His care plan stated he would not smoke without supervision and that tobacco supplies were stored in the smoking box, yet surveyors observed a nicotine vape in his possession during an interview. An LPN said vaping was not allowed in the building and should be stored with smoking supplies, and the DON was unaware the resident had the vape.
Failure to Supervise Residents at Risk for Elopement: Two residents who were at risk for wandering or elopement left the facility without proper supervision. One resident with moderate cognitive impairment left in an Uber and later called his daughter because he did not know how to get back, and another resident who required supervised LOA left unaccompanied and was reported missing until he returned on his own. Records showed missing or unclear elopement assessments and no care plan for one resident, and no care plan or progress notes for the other.
A resident with Parkinson's disease, paranoid schizophrenia, and dementia, and known elopement risk with a wander guard, exited the building after staff failed to coordinate alarm monitoring and communicate with one another. RNs silenced the alarm after each assumed the other was watching the camera feed, and an LPN later turned off the front door alarm after assuming it was triggered by a hospice CNA. Police found the resident about 1.5 hours later two miles away with bruising and a reported fall.
A resident with COPD, morbid obesity, weakness, and severe mobility impairment required 2-person total assist for transfers and brief changes, but during peri care the resident used a grab bar, rolled out of bed, and landed on her knees. Staff found a laceration with exposed adipose tissue, bruising, swelling, extreme pain, and the resident was sent to the ED with a femur fracture and laceration.
A resident with severely impaired cognition accessed an unlocked, unattended med cart, removed multiple blister packs, self-administered medications, and later developed AMS and hyponatremia requiring EMS transfer and MICU care. The facility also documented repeated falls for residents with severe cognitive impairment and mobility issues, but the responses were often limited to repeating the same care plan interventions, reviewing the plan, or noting that no new interventions were found after subsequent falls.
A resident with COPD and other diagnoses was observed smoking in the designated smoking area without staff present and without wearing oxygen. Staff stated the resident had been smoking for 1 to 2 weeks, but she was not listed as a smoker in the smoking book and had not yet had the required smoking safety evaluation to determine whether she could smoke safely or needed supervision.
A resident with paraplegia and no sensation below the chest sustained an abdominal burn after a CNA placed a heated item, wrapped in plastic and a T-shirt, on his stomach for spasms and discomfort. The resident did not realize it was too hot until the next day, when the burn and blisters were discovered.
Improper one-person Hoyer lift transfers: A resident with brain tumor, altered mental status, repeated falls, and hospice services required a Hoyer lift and was documented as a 2-person assist. On two observations, a hospice aide transferred the resident alone while closing the door, and the aide stated she usually got the resident out of bed on her own. CNAs, the DON, and the ADM confirmed that two staff members should be present for Hoyer transfers, including hospice staff.
A resident with paraplegia and other significant diagnoses sustained a buttock shearing injury during a Hoyer lift transfer when a CNA improperly removed the sling from under the resident. The resident reported that a newer sling had sharper edges and caused the cut, and the IDT determined the injury was related to friction and shearing from incorrect sling removal.
Inadequate supervision and elopement prevention: One resident with dementia and multiple other diagnoses was repeatedly observed with the call light out of reach, the walker away from the bed, and the room door shut, despite a history of 15 falls and prior wandering. The record showed several falls with limited or no new interventions, and staff stated the resident needed close monitoring and reachable assistance devices. A second resident assessed as high risk for elopement wandered the unit, left the building after an alarm sounded, and was later found by police; the record noted no individualized care plan and no investigation into how the elopement occurred.
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