Inadequate Staff Training Leads to Resident Elopement
Summary
The facility failed to provide sufficient nursing staff with the necessary knowledge, training, and skills to address the behavioral healthcare needs of a resident diagnosed with dementia and assessed at high risk for elopement. The resident, who had a history of elopement and was known to exhibit wandering behavior, was not adequately monitored or assisted according to their care plan. On the evening of 11/27/2024, the resident became agitated and refused to re-enter the facility after being out on pass with a family member. Despite the resident's care plan indicating the need for frequent monitoring and intervention in cases of behavioral problems, the staff did not take appropriate action to address the situation. The Registered Nurse (RN) on duty failed to implement the resident's care plan, which included interventions such as speaking in a calm manner, diverting attention, and removing the resident from the situation to an alternate location if necessary. Instead, the RN instructed the family member to follow the resident and contact law enforcement, rather than sending facility staff to intervene. As a result, the resident was missing for two and a half hours before being found by local law enforcement and subsequently placed on a 72-hour hold due to being a danger to themselves. Interviews with facility staff revealed a lack of awareness and training regarding the resident's elopement risk and behavioral needs. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) were not fully informed of the resident's high elopement risk, and the Director of Nursing (DON) acknowledged that the facility did not have a competency checklist for dementia care. The facility's policy and procedures indicated that staff should be trained to support residents in distress, but the deficiency in staff training and intervention contributed to the resident's elopement and subsequent hospitalization.
Penalty
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A resident with paraplegia and a history of trauma was involved in an incident where an LPN physically restrained him by blocking his wheelchair, leading to the resident punching the LPN. The resident had grabbed his medication and attempted to leave, contrary to physician orders. This action violated the facility's Resident Rights policy, which ensures residents are free from restraints. The incident was witnessed by staff, and authorities were notified.
The facility failed to ensure sufficient staffing to meet the behavioral health needs of residents, affecting two residents and potentially impacting all 31 residents on a nursing unit. The inadequate staffing led to delays in care and supervision, resulting in falls and hospitalizations for residents with complex behavioral health needs.
Failure to Ensure Resident Rights and Appropriate Behavioral Health Management
Penalty
Summary
The facility failed to ensure appropriate nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of Resident #115, particularly in relation to mobility and behavioral health needs. Resident #115, who had diagnoses including paraplegia and a chronic ulcer, was cognitively intact and required varying levels of assistance for daily activities. The care plan highlighted the resident's risk for impaired psychosocial well-being due to a history of trauma, emphasizing the need for respectful and compassionate communication. However, an incident occurred where the resident grabbed his crushed pain medication from the medication cart and attempted to leave, leading to a confrontation with LPN #402. During the incident, LPN #402 blocked the resident's path and physically restrained him by placing her foot in the wheel of his wheelchair, as the resident was required to take his medication in front of the nurse. This action led to the resident punching the LPN in the hands. The facility's Resident Rights policy, which states that residents have the right to be free from restraints, was not adhered to in this situation. The incident was witnessed by other staff members, and the police, DON, and Administrator were notified. This deficiency highlights a failure in ensuring the resident's rights and appropriate handling of behavioral health needs.
Insufficient Staffing for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the behavioral health needs of the residents, specifically affecting two residents and potentially impacting all 31 residents on the Rosepointe B nursing unit. Resident #101, who had vascular dementia, hemiplegia, hemiparesis, and schizophrenia, exhibited socially inappropriate behaviors and required substantial assistance for daily activities. On multiple occasions, Resident #101 was found on the floor or attempting to remove his incontinence brief and clothing, indicating a need for constant supervision. The staffing on the unit was insufficient, with only two STNAs assigned to care for 31 residents, leading to delays in care and supervision for Resident #101, who eventually fell and was sent to the hospital for evaluation. The staff, including the RN and STNAs, reported difficulties in managing their workload and ensuring timely care for all residents due to the inadequate staffing levels. Resident #76, who had vascular dementia, psychotic disturbance, and other cognitive impairments, also required significant assistance and supervision. This resident frequently removed his incontinence brief and consumed feces, necessitating constant monitoring and care. On one occasion, Resident #76 was found on the floor next to his bed and was later admitted to the hospital for a possible cranial bleed. The staff reported that the unit was challenging to manage with only two STNAs, as many residents required mechanical lifts for transfers and had complex behavioral health needs. The lack of sufficient staff led to delays in providing care and addressing the residents' needs promptly. Interviews with the nursing staff revealed that the workload was overwhelming, and they often had to forgo breaks to ensure residents received care. The DON and Administrator determined the staffing levels, but the assigned staff was not adequate to meet the needs of the residents on the Rosepointe B unit. The staff's inability to provide timely and appropriate care due to insufficient staffing levels directly contributed to the deficiencies observed in the care of Residents #101 and #76.
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