Accident hazards and inadequate supervision were identified when sharps containers were found over the fill line in resident rooms and on treatment carts, a resident using a tilt-in-space wheelchair lacked a required safety device assessment, and a resident with dementia and recent falls had no new fall CP interventions after repeated falls. Staff also found smoking materials were not secured for an active smoker, and two residents with elopement risk were not adequately supervised, including one who exited the facility unsupervised and another who was found outside smoking while the wander guard failed to alert staff.
A resident with stroke-related weakness, ataxia, and delusional disorders was involved in a verbal altercation with one resident while alone in the dining room and later a physical altercation with another resident near the resident’s room. Staff reported no one was monitoring the dining room incident, and staff were unsure whether care plan interventions existed for supervision or prevention of resident-to-resident altercations. The other resident involved in the physical incident had dementia, severe cognitive impairment, and needed supervision/maximum assistance with ADLs.
A resident with quadriplegia and a neck fracture fell from bed during incontinent care and sling placement when an NA was in the room alone and did not follow the care plan requiring two-person assistance for bed mobility. The resident rolled off the bed while being turned, and the NA stated they had not reviewed the resident’s Kardex and was unsure of the required level of assistance.
Failure to Follow Fall and Elopement Care Plans: The facility did not consistently assess, supervise, or update care plans for residents with cognitive impairment, mobility limits, repeated falls, and exit-seeking behavior. A resident with confusion and poor safety awareness eloped through an unlocked patio door, another resident with severe cognitive impairment repeatedly exited without the planned escort, and two residents with repeated falls had supervision and care plan interventions that were not consistently followed or revised. Staff documentation showed missed or delayed updates, incomplete investigations, and instances where required 1:1 supervision was not maintained.
Failure to Prevent Elopement for a Cognitively Impaired Resident: A resident with impaired cognition and documented elopement risk left the facility after a security guard did not review the updated elopement binder and inadvertently assisted the resident in exiting the building. The resident had a low BIMS score, wandering history, and active exit-seeking behaviors, and was later found at a hospital several blocks away.
Elopement Supervision Failure: A resident with dementia, severe cognitive impairment, and exit-seeking behavior was found by police walking disoriented about 0.4 miles from the facility after staff failed to provide adequate supervision. The resident had a wander guard and an elopement care plan, but 15-minute checks were not documented for several hours, and staff interviews confirmed the resident should not have left unattended.
Failure to supervise residents and follow care plan interventions led to a resident-to-resident altercation in the dining room. One resident with Down Syndrome, PTSD, anxiety, and moderately impaired cognition had a history of prior dining room altercations and a care plan intervention for staff to help with a clothing protector, while another resident with Alzheimer’s disease, dementia, and severely impaired cognition was observed passing out clothing protectors and other items to residents without staff present. Staff stated the care needs were not visible on the Kardex and the dining room was not adequately supervised.
Failure to develop and timely implement fall interventions and provide adequate supervision for residents with fall risk. A resident with dementia and another resident with diabetes, spinal stenosis, fibromyalgia, and cognitive impairment had repeated unwitnessed falls, including one resident being left unattended in the shower and another lacking a posted reminder sign during observation. A third resident with ESRD, DM, and dementia had multiple falls, and the record showed interventions were not timely added after some of the falls.
A resident with severe cognitive impairment, garbled speech, wheelchair use, and dependence for transfers was sent to a medical appointment without an escort. Staff said there was no formal assessment or care plan process for escort needs and the transportation scheduler relied on prior appointment notes; the resident’s escort need was not listed, so no escort was sent until the clinic called for one.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
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