A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
Failure to follow a resident’s transfer care plan led to a fall. The resident had a dx of nondisplaced fx of the R femur, was dependent on staff for transfers, and was ordered to use a ceiling lift; the resident was also only to ambulate with therapy staff. Despite this, a CNA attempted to ambulate the resident with a FWW and gait belt during a transfer, and the resident lost balance and was guided to the ground. An RN later confirmed the care plan was not followed.
Failure to Follow Fall Safety Interventions: A resident with dementia, anxiety disorder, stroke history, and a history of falls was care planned as high fall risk with interventions including no assistive devices at bedside, bed in the lowest position, and a fall mat at bedside. Staff observed the resident in bed with the walker within reach, the bed not in the lowest position, and no fall mat in place, and an RNCM confirmed these were the planned interventions.
A resident with dementia, anxiety, sensory impairments, frequent falls, and documented high elopement risk had care plan interventions for frequent monitoring and staff awareness of wander risk, and was listed in the facility’s elopement records. Progress notes described ongoing exit-seeking behavior and a prior elopement in which the resident left through the front door with belongings and was later found in the community. Despite this, multiple staff members, including CNAs, a CMA, and an RN, reported they did not know the resident was an elopement risk or that elopement interventions were in place, while only an LPN recognized the resident as an exit seeker who dressed neatly and sat near the exit. Observations showed the resident fully dressed, making the bed, cleaning the room, and repeatedly stating an intention to go home, while leadership acknowledged staff were not following the care plan or aware of the elopement risk.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with dementia, behavioral issues, poor safety awareness, and a history of falls was assessed as a wander risk and care planned for assisted transfers and potential one‑on‑one supervision. Despite documented agitation, aggression, pacing without assistance, and unsuccessful behavioral interventions, the resident continued to ambulate and attempt self‑transfers without adequate supervision. On one day, the resident sustained a witnessed fall while attempting to stand without help and later an unwitnessed fall near the bed after reporting having hit the head. Staff reported that the resident required two‑person assistance for safety and needed one‑on‑one supervision, but only one staff member was available and no one‑on‑one could be arranged, leading to the falls and subsequent hospitalization for subdural hematomas.
A dependent resident with diabetes and urinary incontinence, care planned as requiring two-person assistance for all bed mobility and toileting, was being changed in bed by two CNAs when one left the room to obtain barrier cream, leaving the resident on their side with only one CNA present. While the remaining CNA was at the sink wetting a washcloth, the resident stated they were falling and was subsequently found on the floor by the returning CNA and an LPN. The resident was transferred to the hospital and later found to have bilateral femur fractures requiring surgery. Multiple staff, including CNAs, an RN, an LPN care manager, and the DNS, confirmed that the resident was fully dependent, could not roll independently, and should have had two staff present throughout care or been repositioned onto their back before any staff left.
A resident with spinal stenosis and chronic kidney disease, who required partial to moderate assistance with bathing and transfers, was being transported back to their room in a rolling shower chair by a NA student. At the doorway, the chair became stuck on a transition strip; despite the resident stating they were usually taken into the room backwards because of this strip, the NA student attempted to free the chair by lifting on the backrest. The backrest detached, causing the resident to fall backwards to the floor. The resident reported fear and some back pain after the fall, and staff assessment found no major injury. The DNS later confirmed the fall was due to incorrect and unsafe techniques used by the NA student.
Two residents experienced deficiencies in accident prevention when staff did not follow their care plans. One resident with dementia and a history of rolling out of bed was repeatedly observed in bed without a required fall mat properly placed on one side, despite a care plan directing padded mats on both sides whenever the resident was in bed. Another resident with stroke-related weakness, care planned for two-person assistance with transfers using a FWW, was transferred by a single CNA after a shower without reviewing the care plan, during which the resident’s legs weakened and the resident slid or fell to the floor. Staff and leadership later confirmed that both residents were care planned for these specific safety measures and that staff were expected to follow and review care plans.
A resident with severe cognitive impairment and a history of wandering had a care plan and TAR requiring a Wander Guard on the wheelchair and shift-by-shift checks of its placement and function, along with diversional interventions. Surveyors found no documentation that staff performed these required Wander Guard checks. The resident subsequently eloped and was found confused and in a precarious position near a busy street, and staff reported the resident did not have a Wander Guard on the wheelchair at that time. Although 15-minute checks were ordered after the elopement, there was no documentation that these monitoring checks were completed, and the administrator confirmed that no monitoring sheets could be located.
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