A resident with intact cognition and multiple medical conditions, including septicemia, DM, and cellulitis, was care planned as dependent for all ADLs and transfers. Observation showed a CNA transferring the resident from a wheelchair to bed using a full-body mechanical lift without a second staff member, contrary to facility policy requiring two staff for mechanical lift transfers. The resident reported not getting into the wheelchair on some days due to insufficient staff. The DON confirmed the two-person requirement for mechanical lift use, and the administrator stated he was unaware that residents were remaining in bed because of staffing and described the issue as related to teamwork.
A resident with severe cognitive impairment, multiple comorbidities, and total dependence for transfers was care planned as a high fall risk with a required floor mat intervention when in bed. The resident was later found face down on the floor next to the bed without the floor mat in place, and subsequently reported pain multiple times and was hospitalized with pneumonia, a displaced proximal humerus fracture, and multiple rib fractures before later being pronounced deceased. The DON confirmed the mat was not present at the time of the fall, and although a PIP required tracking and auditing of falls and interventions, the related audit forms were blank and leadership acknowledged there was no evidence the audits had been completed, contrary to the facility’s fall management policy.
Unsafe resident supervision, wheelchair securement, and water temperatures: A resident with severe cognitive impairment tripped and fell outside after exiting without the expected supervision, sustaining a laceration above the eye. Another resident with repeated falls slid out of a wheelchair during van transport when the resident was not properly secured and the van braked abruptly; staff noted the seatbelt setup did not prevent movement. Surveyors also found shower rooms and multiple resident bathroom sinks with water temperatures well above safe levels, including readings up to 143.2 degrees F.
A resident who was cognitively intact but dependent for transfers and required a full body mechanical lift was being moved from bed to a recliner by two aides when a sling shoulder strap detached from the lift, causing a fall. Staff and witness statements confirmed that the lift in use lacked safety clips on the spreader bar, despite manufacturer instructions requiring safety clips to be present and properly used. The DON acknowledged that safety clips had been removed from the lifts because they were viewed as ineffective. The resident sustained a cervical fracture and subsequently went into cardiac arrest with death pronounced the same day, and the situation was determined to be immediate jeopardy.
A resident with severe cognitive impairment, Alzheimer's Disease, and dementia had a care plan identifying fall risk and poor safety awareness, yet staff interviews and record review showed the resident fell in the dining room after trying to climb over a chair arm when unable to move the chair back. The resident also had prior falls while attempting to ambulate on his/her own, including one with an untied shoelace and another unwitnessed fall in the dining room.
The facility failed to prevent accident hazards and provide adequate supervision related to hot beverage service. A resident with moderate cognitive impairment, stroke, hemiplegia, contractures, and dysphagia, who was care-planned to receive hot liquids only in a Kennedy cup and at non-scalding temperatures, was instead given hot coffee in a Styrofoam cup without a lid and left unsupervised, resulting in burns to the thighs requiring ED treatment. Surveyors also observed multiple residents independently dispensing very hot coffee or water directly from a machine into open cups, then ambulating with walkers while carrying these beverages, sometimes spilling them. Staff interviews confirmed that machine water was not supposed to be served directly to residents, that dining room staffing was often below the intended level, and that there were no clear interventions to prevent residents from independently accessing the hot beverage machine, leading to an immediate jeopardy finding.
Failure to provide adequate supervision to prevent resident injury. A resident with dementia, memory impairment, and wandering was found on the floor near a plant after staff heard a crashing sound, but no staff witnessed the fall. Staff reported residents were being assisted out of the dining room at the time, and the resident representative said the fall involved a head strike on a planter. The resident later returned from the hospital with a facial fracture and bruising.
Improper Use of Hoyer Lift Castor Brakes During Resident Transfers: Staff were observed locking the castor brakes on a Maxi Move hoyer lift while transferring a resident who was wheelchair dependent, had moderate cognitive impairment, and required a mechanical lift for ADL care. Two CNAs and an NA were seen locking the wheels during lifting and lowering, despite the manufacturer instructions stating the brakes should not be used when a patient is supported by a sling.
A resident with moderate cognitive impairment, dementia diagnoses, depressive symptoms, and on antipsychotic medication repeatedly stated an intent to leave and became angry when told by their POA and family they could not go home. Throughout the day, the resident declined evening medications, talked about leaving, packed two bags of clothing, and walked toward the lobby stating they were going home, yet the medical record showed no evidence that additional supervision was implemented in response to these behaviors. The facility’s elopement policy required adequate supervision and monitoring for residents at risk, but the DON later reported uncertainty about whether the resident had a wanderguard, and the resident ultimately eloped and was later found off-site.
A resident with moderately impaired cognition, dementia, depression, cancer, identified fall risk, and risk for skin breakdown was care planned to have the call light kept within reach, but surveyors observed the resident seated in a recliner with the call light out of reach on multiple occasions. The resident did not know where the call light was, had a wet brief, and could not request assistance, which was also confirmed by the resident’s representative, who noted the resident was covered with a blanket and not wearing pants underneath. A guest ultimately activated the call light, after which a CNA responded and removed soiled linens. The DON stated staff are expected to ensure residents have access to the call light and needed items when left alone, while the NHA acknowledged there was no facility policy on call light use.
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