Inadequate supervision and poorly documented behavior interventions allowed a resident with repeated agitation, wandering, and room-entry behaviors to enter another resident’s room and engage in a struggle over an iPad. The other resident fell and sustained a subarachnoid hemorrhage and subdural hematoma. Staff and the DON reported that redirection was often ineffective, behavior monitoring was not in place, and the care plan had not been meaningfully updated to address resident-to-resident behaviors.
An unlocked treatment cart was observed unattended in the 200 hallway, and an RN confirmed it should be locked when staff are not present. The cart contained wound care cleansers and creams that the RN said could be hazardous to residents. The ADON stated the facility had no written policy for locking the treatment cart.
Unsecured hazardous items and unlocked carts/doors: A resident had a spray bottle of disinfectant/cleaner on a bedside dresser, and housekeeping staff confirmed it was in the room. Surveyors also observed an unlocked, unattended HK cart near the DR, an unlocked door in the service hall, and an unlocked, unattended treatment cart near the resident lounge while residents were moving through the area; staff verified these items and doors should have been locked.
An LPN left a med cart unattended and unlocked in the 200 hall while getting ice for the cart. A surveyor was able to open the top drawer, and another employee then closed and locked the cart until the nurse returned. The Facility Administrator acknowledged the cart had been left unlocked.
A resident had two Renvela pills left in a 30 mL medication cup at the bedside, unsecured and unattended, making the medication accessible to wandering residents, unauthorized staff, or visitors. An LPN confirmed the pills should not have been left out in the room, and the resident did not have a physician order for self-administration.
A resident was observed accessing an unlocked courtyard storage bench and removing pruning shears, and the bench also contained a pointed metal shovel, a rounded shovel, and a small rake. Another resident’s wheelchair had rips and tears in the seat pad and a screw protruding through the left arm pad; the resident reported the screw scratched her arms and the metal wheels bumped her knuckles, and the DON confirmed the issue.
A facility failed to keep resident areas free from accident hazards. An LPN found a resident’s fall mat improperly placed despite care plan and MD orders specifying its location, and a resident in a second-story room reported that screws had been removed so the windows could open fully. Staff also identified multiple wanderers and elopement-risk residents on the same hallway, including residents with very low BIMS scores.
A resident with a smoking safety evaluation requiring a smoking apron and supervision was observed in the smoking area and allowed to start smoking without the apron. The Corporate RN confirmed the evaluation required the apron for safety, and a CNA verified it was not used.
An unlocked and unattended med cart was observed in a hallway while an RN was administering meds in another resident's room, and the RN confirmed she had not locked it. In another room, a resident's sink area had cracked, loose caulk and a loose countertop/sink that the resident said had been noticed as loose and was concerning when washing hands; the Administrator verified it was loose and could cause injury.
An unlocked medication cart was observed unattended near the nursing station, and the assigned RN confirmed she had given her keys to another nurse. In a resident room, three tubes of Bio-Freeze ointment were found on a resident’s bedside shelf in sight and within reach; the DON confirmed the ointment could not be left in the room.
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Citations used to create this checklist
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