A resident with impaired mobility, weakness, and a prior wrist fracture required supervision and touching assistance for showering and bathing, but a CRCA left her alone in the shower room. The resident fell in the bathroom and sustained a comminuted, intra-articular distal radius fracture of the right arm; witness statements and the facility investigation confirmed staff did not stay with her during the shower.
A resident with dementia, anxiety disorder, and a history of intracerebral hemorrhage had a fall risk care plan that included keeping the call light in reach. Surveyors observed the resident’s touch pad call light on the floor under the room divider curtain on two occasions, including while the resident was in bed, and an LPN confirmed it was not within reach.
Fall interventions were not implemented for a resident with severe cognitive impairment, repeated falls, dementia, and an unsteady gait. The care plan and MD order required the bed to remain in the lowest position and a floor mat to be placed beside the bed, but after an unwitnessed fall while the resident was trying to get out of bed, the post-fall review and staff statements showed the bed had been left high and the mat was not at bedside. An LPN and CNAs confirmed the bed and mat were not set as ordered when the fall occurred.
Failure to Maintain Safe Bed Position for a Dependent Resident: A resident with intact cognition but dependence for bed mobility and transfers, high fall risk, and a history of falls was found on the floor after sliding out of bed. Staff and the fall investigation identified that the bed had been left raised too high after assistance into bed, and the resident was on anticoagulant therapy and sent to the ED for evaluation.
Failure to complete fall risk and post-fall assessments: A resident with COPD, adult failure to thrive, repeated falls, and dependence for transfers and toileting was identified as a fall risk, but the facility did not complete required 90-day fall risk evaluations. After an unwitnessed fall, an RN checked VS and orientation but did not perform ROM before moving the resident, and no neuro checks or post-fall assessment were documented. The DON verified the resident was not assessed appropriately after the fall, which was linked to recent narcotic medication changes and acute confusion.
A resident with a history of stroke, aphasia, and high fall risk sustained repeated falls despite multiple care plan changes, including placement near the nurse’s station, low bed positioning, diversionary activities, and a dump wheelchair. The record showed no effective individualized fall/safety plan or root cause analysis for the ongoing falls, and the resident later suffered a head injury with hematoma and an unwitnessed wheelchair fall that resulted in intracranial hemorrhage and a C7 fracture, requiring hospital transfer.
A resident with schizophrenia and a court-appointed guardian was allowed to leave on an independent LOA without an assessment of appropriateness or guardian permission, and staff later found the resident missing for an extended period. In a separate incident, a resident with hemiplegia and hemiparesis was care planned for two-person mechanical lift transfers, but a CNA transferred the resident alone several times and reported that the second helper sometimes left during the lift.
A facility failed to ensure safe smoking supervision and that residents smoked only in designated areas. One resident with bipolar disorder and other diagnoses was observed smoking in front of the facility after signing out, with no staff outside, despite being directed to smoke in designated areas. Another resident with COPD and tobacco use was observed smoking alone in the smoking area even though the smoking assessment required supervision; the DON confirmed staff should have been supervising, but the resident was not visible to staff.
The facility failed to implement fall prevention interventions for two residents and failed to complete required smoking assessments for two residents. One resident with multiple neurologic and psychiatric diagnoses was transferred without the ordered dycem and without the reminder sign, while another resident with CHF, dementia, and CKD did not have the ordered bed mats in place. In addition, one resident listed as a smoker had incorrect smoking evaluations, and another resident began smoking after admission but had no smoking assessment completed until the quarterly review; the DON confirmed the gap.
Smoking materials were found in resident rooms and on residents’ persons despite policy prohibiting residents from keeping cigarettes, lighters, vapes, and other smoking articles. Surveyors observed a resident using a vape in her room, and several other residents had cigarettes and lighters stored in pockets or drawers, with staff confirming the materials were kept in rooms and that one resident had been allowed to vape unattended.
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