A resident with severe cognitive impairment, dementia with behavioral disturbances, and fall risk interventions in place was transferred by staff using methods that did not match the care plan and Kardex. Staff used a transfer belt for some transfers, then later used a Hoyer lift from mattresses on the floor to a wheelchair, but used a green sling even though the resident required a yellow sling based on weight. The RN, LPN, DON, and PT verified the resident’s transfer status and sling instructions were not updated to reflect current needs.
A resident with severe cognitive impairment, dementia, a history of falls, and dependence on staff for transfers was observed using a lift reclining chair even though the care plan and physical device review did not identify that device. Therapy staff lowered the chair and placed the remote next to the call light on the resident’s lap, and staff stated they were not aware of any formal assessment for safe use of the lift chair. The DON stated the resident should have had an assessment to determine whether she was safe to have the lift chair.
Code Alert System Failed to Prevent Resident Elopement: The facility failed to keep the code alert system functioning as intended and did not follow the manufacturer’s weekly testing and inspection guidance. Two residents with significant cognitive impairment were able to get through the main doors, and one resident exited the building before staff followed outside. The report also states that multiple residents with code alert devices did not have adequate elopement or wandering assessments and care plan interventions, and several attempts to leave were not documented in the record.
The facility failed to accurately assess and document mechanical lift sling sizes for two residents who required total assistance with transfers using a Hoyer lift. Manufacturer instructions required sling selection based on both height and weight, but staff and the DON described using primarily weight and did not consistently consider height. For one resident with paraplegia and multiple mobility impairments, the care plan and lift assessment specified use of a full lift with two staff but omitted the resident’s height, weight, and sling size. For another resident with lumbar spondylosis, muscle weakness, and spinal stenosis, the lift assessment contained a weight range inconsistent with the MDS and did not identify sling size, and the care plan did not specify sling size or transfer device. Staff interviews showed confusion about who determined sling size and where this information was documented, with no sling size information found in care plans or the NA binder.
A resident with dementia, moderate cognitive impairment, poor vision, unsteady gait, and high fall risk had a care plan requiring staff to toilet her during 4:00 a.m. rounds due to prior falls and need for extensive assistance with toileting and toilet transfers. A CNA checked on the resident during the night but did not offer toileting assistance, stating she was unaware of the toileting intervention because it was not on the Kardex and she had not reviewed the care plan. The resident later attempted to get up to use the bathroom independently, was found on the floor complaining of left leg pain, and was sent to the ED where a closed displaced left femoral neck fracture was diagnosed, requiring a left hip hemiarthroplasty. The NP stated the fall could have been prevented if the care-planned toileting intervention had been followed.
A facility failed to implement and communicate individualized elopement-prevention interventions for three cognitively impaired residents identified as elopement risks. One resident with dementia and suspected Lewy Body Disease repeatedly removed a Wanderguard and continued to wander and make exit-seeking comments, yet no elopement-focused care plan, comprehensive reassessment, or increased supervision was put in place, and hourly safety checks were inconsistently documented. This resident later left the building unsupervised during the night after staff redirected her toward her room but did not verify her return. Two other residents with dementia, one with a history of elopement and one who verbalized a desire to go home and stayed near exits, were assessed as elopement risks, but their care plans and Kardexes lacked clear elopement interventions, triggers, or consistent use of wander alarms, and staff interviews confirmed limited awareness of their elopement status and absence of specific preventive measures.
A resident with severe cognitive impairment, vascular neurocognitive disorder, gait abnormalities, repeated falls, and hemiparesis experienced multiple unwitnessed falls over several weeks. Although the care plan addressed extensive ADL assistance, toileting, repositioning, and behavioral analysis, it did not incorporate a psychiatric recommendation for 24-hour supervision. Documentation showed inconsistent or absent root cause analyses after several falls, and the care plan was not revised to reflect the resident’s ongoing fall pattern or the psychiatric evaluation. Staff interviews revealed that NAs and nurses were unaware of new interventions, had not received education on managing the resident’s repeated falls, and did not know about the psychiatric recommendation, while the DON confirmed that supervision levels and the care plan had not been updated despite the facility’s fall prevention policy requiring comprehensive analysis after multiple falls. A family member reported inconsistent toileting, lack of notification about falls, and finding the resident incontinent and unattended.
A dependent, cognitively impaired resident with hemiplegia and contractures was being transferred by two NAs using a full‑body mechanical lift with a medium sling when the resident fell from the sling, sustaining a scalp laceration with hematoma, a tiny SAH, and a right elbow skin tear with soft tissue swelling. Staff placed the sling with the top several inches below the shoulders and the bottom under the resident’s buttocks, contrary to expectations that it extend from the shoulders to below the tailbone, and one NA reported double‑looping the upper sling straps on the lift bar. Both NAs heard a popping or adjusting sound from the sling during the lift, visually rechecked the loops, then continued the transfer; as the lift was moved away from the bed and the resident’s feet were swung off the mattress, the sling rotated and the resident fell out of the top right side while his legs remained in the sling. Interviews with the DON, RN, and lift manufacturer’s representative confirmed that only one correctly selected loop per side should be attached and that improper sling positioning and/or loop attachment could allow a resident to fall, and the facility’s investigation concluded the cause was inconclusive but may have involved human error.
A resident with stroke, hemiplegia, and dysphagia was care planned for a regular diet with thin liquids, bite-size food, and assist of one with meals, but staff did not follow those interventions. Observations showed meatloaf and coffee cake were served without being cut up, and no staff were present to assist while the resident ate. The cook said food should have been cut into bite-size pieces, while an NA said she was not aware she was assigned to assist with all meals.
A cognitively impaired wheelchair user with multiple neurologic diagnoses was primarily supervised through a remote observation system and alarms, without a care-planned requirement for direct staff supervision. The resident independently exited his room, opened an emergency stairwell door whose delayed-egress alarm and badge lock had been disabled for months, and proceeded into the stairwell without staff intervention until minutes later, when staff responded to a wander guard alarm and found him face down on the stairs with his wheelchair attached and a scalp hematoma. Multiple staff, including nursing, unit, maintenance, and security personnel, knew or later confirmed that the door was unarmed but did not report or correct it, assuming it was intentional, and there were no documented facility policies or routine checks in place to ensure proper functioning of the door alarm, wander guard, or badge systems, while the remote monitoring technician also failed to follow protocol by leaving the monitoring station and not activating the remote alarm when the resident left his room.
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