Failure to supervise a resident at risk for elopement: A resident with hemiplegia, altered mental status, and schizophrenia was assessed as unsafe to leave unsupervised due to exit-seeking behavior, poor compliance with safety instructions, and lack of awareness of safety concerns. Staff later found the resident outside the facility after a CNA saw her on the sidewalk, and records show she eloped, was located hours later, returned refusing assessment, and was sent for an emergency involuntary psych commitment.
Elopement Prevention and Supervision Failure: Two residents with documented wandering and elopement risk left the facility unsupervised. One resident with Parkinson’s disease, cognitive impairment, and repeated exit-seeking behavior exited through a door that did not latch properly and was later found walking on a high-traffic street. Another resident with dementia and Alzheimer’s disease was reported to have followed visitors out and was later found outside the building despite a wander guard and care plan interventions.
A resident who was dependent on staff for bed mobility and repositioning fell out of bed during a bed bath while one staff member was providing care. The resident had encephalopathy, chronic respiratory failure with hypercapnia, and severe obesity, and the care plan and MDS showed the resident required total assistance for bed mobility. The resident slipped off the edge of the bed, landed on the floor, and was later sent for hospital evaluation after complaints of pain and concern for possible head trauma.
Failure to Maintain Safe Environment and Provide Adequate Supervision: Two residents with dementia-related conditions and recurrent falls were not consistently protected from hazards or adequately supervised. One resident had repeated falls from a wheelchair or bed area with reused or nonpreventive interventions, while another resident wandered the locked unit, entered other residents’ rooms, attempted to exit, and was observed without staff present in the hallways or at the nurse’s station.
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 multiple sclerosis, chronic pain, and decreased sensation in her feet was given hot packs after her heated blanket was removed. Staff microwaved the packs but did not determine the temperature before applying them, relying on the CNA’s ability to touch the pack and on the resident to say when it should be removed. The DON was unaware the packs were being heated in the microwave, and the ADM stated the facility did not allow microwave-heated reusable packs because the temperature could not be known before skin contact.
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Citations used to create this checklist
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