Failure to Provide Necessary Care and Services for Two Residents
Summary
Facility staff failed to provide necessary care and services to ensure the highest practicable physical, mental, and psychosocial well-being for two residents. For one resident with multiple complex diagnoses, including severe dementia, traumatic brain injury, and a history of behavioral issues, staff did not recognize the resident as an individual or provide a safe and supportive environment during a behavioral incident. The resident became physically aggressive, and an LPN intervened in a manner described by multiple witnesses as aggressive, including grabbing the resident's arms, pushing the resident in a wheelchair, and tilting the wheelchair onto two wheels. This resulted in the resident falling backward and sustaining a head injury. Documentation and witness statements indicated that the LPN's actions escalated the situation, and the resident was subsequently sent to the emergency room for evaluation of a scalp hematoma. The incident was further complicated by inconsistent accounts from staff and a lack of immediate provision of medications by the facility nurse, despite the hospice nurse's request. The resident's daughter was notified, and the resident was described as calm during transport and at the hospital. Upon return from the hospital, the resident was found in soiled clothing and bedding, indicating a lack of attention to personal care needs. The facility's own investigation and staff statements confirmed the aggressive handling of the resident by the LPN, and the facility's policy on abuse, neglect, and exploitation was reviewed as part of the survey. For another resident with spastic quadriplegic cerebral palsy and intellectual disabilities, the facility failed to ensure attendance at a scheduled day support program. Despite a care plan specifying participation in day support three times a week, the resident was not ready for transport when the day support staff arrived, due to incomplete morning care and medication administration. The day support staff were unable to wait, and the resident remained at the facility, missing the program. Interviews with the resident, family, and staff confirmed the resident's enjoyment of and desire to attend the program, and that the failure to send the resident was due to the facility's inability to prepare the resident in time.
Penalty
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The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
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