Failure to Assess, Monitor, and Respond to Resident Incidents
Penalty
Summary
A resident with severe cognitive impairment, chronic respiratory failure, tracheostomy, and ventilator dependence was not properly assessed or monitored for several significant events. The facility failed to document or investigate a bruise observed on the resident's right upper arm, despite the bruise being pointed out by a family member and the resident making a statement suggesting possible abuse. There was no documentation in the progress notes or weekly skin assessments regarding the bruise, nor evidence of staff-to-resident abuse allegations being investigated, as required by facility policy. Additionally, the resident ingested a wound cleanser spray, an event witnessed by a psychologist and later reported by a family member. There was no documentation that the physician or poison control was notified, nor any evidence of monitoring or follow-up after the ingestion, despite the product label instructing to seek medical attention if swallowed. Interviews with facility staff, including the nurse practitioner, psychologist, and ADON, confirmed a lack of awareness or documentation regarding the ingestion incident. The facility also failed to respond to repeated pulse oximeter alarms while the resident was on a ventilator. Video footage showed the alarm sounding multiple times over several minutes without staff response, and the ADON confirmed that staff should have checked on the resident. The facility was unable to provide policies or procedures related to chemical ingestion or pulse oximeter alarm response, and the DON acknowledged that documentation and follow-up were lacking in these incidents.