A cognitively impaired resident with a history of cerebral infarction, right-sided hemiplegia, and a documented moderate risk for wandering was able to leave a supervised front porch area without staff awareness, propel a wheelchair down the facility driveway, and cross a heavily trafficked road into an area with a steep ditch and wooded terrain. Staff interviews showed that the resident was usually outside with other residents and staff present, but on the day of the incident a CNA last saw the resident on the porch and was unsure how the resident exited unsupervised. The resident was ultimately discovered by a CNA who had been alerted by a pest control worker, by which time the resident had already crossed the roadway, demonstrating a failure to provide adequate supervision and prevent elopement for a cognitively impaired individual.
Two residents with cognitive impairment and documented fall risk experienced falls when staff did not follow established transfer and alarm orders. One resident, ordered for a total mechanical lift with two-person assist, was instead transferred by a CNA using a sit-to-stand lift after the resident stated she could stand, leading to a fall when the resident released the handles and slid to the floor. Another resident, ordered to have a bed/chair alarm checked each shift and with a care profile specifying a bed alarm, was found on the floor after an unwitnessed fall with head injury when the bed alarm was not engaged and did not sound.
Two ambulatory residents with dementia, severe cognitive deficits, and known wandering behavior, each wearing a wander guard bracelet, were able to exit through a unit door when a visitor held it open, despite the door alarm sounding and prior observations that they frequently walked together and approached doors. An LPN responded to the alarm and, along with other staff, initiated a search when the residents could not be found on the unit; staff ultimately located the residents across a four-lane highway and returned them to the building without injury. The incident occurred despite facility policies requiring use of a security system for residents unable to protect themselves from harm by wandering, and staff and leadership acknowledged that the residents had a history of walking the halls together and going to doors, and that increased monitoring and restricting visitor access to door codes could have prevented the elopement.
A cognitively impaired resident with dementia, agitation, and a history of wandering was previously assessed by the IDT as not being at risk for elopement and did not have elopement precautions in place. On one occasion, a visitor exited through the front door without realizing the resident followed outside, and staff later discovered the resident alone on the front porch after being missing for several minutes. An LPN and CNA participated in locating and returning the resident, and the incident revealed that supervision and elopement risk assessment were insufficient for this resident.
A resident with anoxic brain injury, severe cognitive impairment, and total dependence for bed mobility and toileting had repeated falls from bed during care. Staff knew the resident was high risk and that he flailed, thrashed, and could be combative, but a CNA provided care alone and did not check the care plan for the required level of assistance. The DON confirmed there was no fall review to identify the root cause and no interventions were put in place after the resident rolled off the bed.
A resident who was cognitively intact but required substantial/maximal assistance for rolling in bed, with a documented care plan specifying two-person assistance for turning and repositioning, was being provided an in-bed linen and brief change by a CNA working alone. During the process of rolling the resident and removing soiled linens, the resident rolled too far and fell from the bed despite attempts by both the resident and the CNA to prevent the fall, resulting in a proximal humeral fracture confirmed by X-ray and subsequent hospital transfer.
Improper Oxygen Storage and Missing Cautionary Signage: An oxygen concentrator and oxygen cylinder were observed stored in a resident’s room without required cautionary signage on the door. The resident had unspecified dementia, a BIMS score of 00, no physician order for oxygen therapy, and staff including an LPN, RN, and DON confirmed the equipment was present and the sign was missing.
A resident with COPD, heart failure, rheumatoid arthritis, moderate cognitive impairment (BIMS 9), and wheelchair dependence was transported by facility staff to an outside medical appointment when the wheelchair was not properly secured in the facility van. CNAs reported using the van’s securement system but did not use any checklist to verify correct application; during transit they heard a noise and found the resident on the van floor with the wheelchair on its side and the seatbelt no longer in place. The resident reported hitting the head and having head pain. The facility’s investigation and QAPI review determined that the wheelchair straps had not been appropriately placed to firmly secure the chair, while the maintenance review found the securement equipment itself intact and functioning. The resident was evaluated in a hospital ED for fall and head injury and treated with an over-the-counter analgesic after imaging showed no new diagnoses.
A cognitively impaired resident with dementia and documented wandering and elopement risk exited the facility unnoticed after following a visitor out the front entrance. Nursing staff had last seen the resident walking the halls after lunch, but when the resident was no longer observed, an LPN initiated a missing resident code and staff began searching. The receptionist, who was responsible for monitoring the entrance and using an elopement book with photos and information on at-risk residents, stated she had not been informed that this resident was an elopement risk and did not recognize her as a resident when she followed a visitor outside. The elopement book contained no information on this resident, and the door alarm did not sound when they exited; maintenance and the administrator later confirmed video showed the receptionist turning off the alarm. The resident, who later reported she followed others because she did not want to be left alone, was found by staff in a nearby subdivision after leaving the building.
A resident with paroxysmal atrial fibrillation and intact cognition was transferred using a mechanical lift by a single CNA, contrary to facility policy requiring two staff for all mechanical lift transfers. During the transfer, the lift pad shifted and the resident slipped from the sling, falling to the floor and sustaining a broken fingernail. The CNA reported she was alone because other staff were unavailable and described a facility change in strap placement method that had been in effect at the time. The DON confirmed that the incident involved a solo mechanical lift transfer, that policy requires two staff with one acting as a spotter, and that the CNA had not received follow-up lift training since hire.
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