Failure to Maintain Accurate Resident Identification Wristbands
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective resident identification system, resulting in residents either wearing incorrect identification wristbands or having no identification at all. During an abbreviated survey, observations on the dementia unit showed multiple residents, including Residents #2 and #5, without identification wristbands despite a facility policy requiring a resident identification system to support the provision of medical and nursing care. Staff interviews confirmed that identification wristbands are the primary method used by CNAs and other personnel, especially when residents cannot state their names or when staff float to unfamiliar units. Resident #5, a newly admitted resident with diagnoses including dementia, myocardial infarction, and peripheral vascular disease, had a recent Comprehensive MDS documenting severely impaired cognition. On observation, this resident had no identification wristband, name tag, or any other identifier in place. When the surveyor asked CNA #1, who was assigned to this resident, to identify them, CNA #1 was unable to do so and stated that residents are supposed to wear identification wristbands and that they could not identify the resident because the resident was new and had no band. The RN Unit Manager acknowledged that identification wristbands are expected to be applied upon admission and that they did not complete this admission and could not explain why the band was not applied. Resident #2, admitted with anxiety disorder, intracardiac thrombosis, and major depressive disorder, had an MDS indicating intact cognition. This resident reported an incident in which they were issued and wore another resident’s identification wristband belonging to a resident with a similar last name. The resident stated that when the podiatrist came to provide routine podiatry services, the podiatrist addressed them by the incorrect name shown on the wristband. The RN Unit Manager and the DON both confirmed that Resident #2 had been found wearing an incorrect identification wristband, but they could not identify which staff member applied it or how long it had been in place. Leadership interviews further revealed that identification wristbands may fall off or break and are not always promptly replaced, and no alternate process was described to ensure resident identification when wristbands are missing or incorrect.
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