The facility failed to disinfect a shared glucometer between resident uses, with an LPN using the same meter for two residents without proper cleaning and disinfection. It also failed to use enteric precautions for a resident with suspected and later confirmed C. difficile while stool testing was pending, and staff did not consistently perform hand hygiene, glove changes, or gown use during personal care and transfers for residents on EBP, including a resident with a catheter and another receiving a bed bath.
A facility failed to protect two residents with severe cognitive impairment from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent after repeated sexual encounters were discovered. Staff found the residents together in bed or in the bathroom, often unclothed, and allowed privacy based on their behavior without documenting a structured consent assessment. The facility also did not fully investigate unexplained bruising and reported vaginal bleeding for one resident in the setting of the known relationship, and the MD was not notified of the incidents or injuries.
A resident with dementia, cleft palate, and dysphagia was ordered an IDDSI Level 6 soft and bite-sized diet, but marshmallows were left in the room and later eaten, leading to a choking episode with cyanosis, pulselessness, apnea, and hospitalization. Staff also served a meal tray with a whole Salisbury steak patty and other foods not prepared into bite-sized pieces, and interviews showed staff were not consistently educated on the resident’s diet restrictions or IDDSI requirements.
Failure to Notify MD of Worsening Wound: A resident with multiple comorbidities and a pressure injury had a right gluteal abrasion that progressively worsened from an open wound to a stage IV ulcer with drainage, odor, slough, and exposed tissue. Staff documented the decline in skin assessments and notes, but there was no reproducible evidence that the MD was notified when the wound first deteriorated. The wound later became infected and required hospital transfer for surgical debridement.
Failure to supervise a resident during bathing, address fall risks, and use wheelchair foot pedals. A resident who needed help with bathing was left alone in an unlocked shower room after a CNA assisted with shaving; he slipped, struck his chin, later developed nausea and vomiting, and was diagnosed with an SDH, required a ventilator, returned on hospice, and died in the facility. The facility also did not identify fall causes or add fall-prevention interventions for one resident after a fall, and staff were observed pushing another resident in a wheelchair without foot pedals.
Failure to supervise a cognitively impaired resident at high risk for wandering led to an elopement from an unsecured smoking area. While a CNA was assisting another resident, the resident walked out of the parking lot smoking area, passed the front entrance, and was not recognized as missing until lunch tray pickup. Staff later found him about 0.8 miles away after he had crossed busy streets and railroad tracks; he returned without injury.
A resident with stroke-related dysphagia, GERD, aphasia, and documented impulsive eating was not given consistent supervision or documented swallow precautions despite repeated SLP notes calling for slow pace, small bites, alternating solids and liquids, and upright positioning. Staff interviews showed that some CNAs and nurses were unaware of the resident’s choking risk and specific instructions. The resident was left alone eating breakfast in bed, became unresponsive, and EMS found severe airway obstruction by food; the resident died from food bolus airway obstruction.
A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident with a table, and used profanities toward the resident. The RN supervisor and DON did not initiate an immediate abuse investigation, did not complete a resident assessment or incident documentation, did not notify the provider, and did not remove the accused CNA from access to the resident. The resident had dementia with moderately impaired cognition and a care plan noting potential for abuse related to resistance of care, verbal aggression, and physical aggression.
A resident with impaired cognition, stroke-related deficits, and constipation was subjected to manual stool removal by an LPN after a suppository did not work. Staff interviews and the resident’s statements indicated she said stop and begged the LPN to stop while he continued the procedure, and she later described the care as painful, violating, and demeaning. The LPN said he manually removed the stool in the bathroom, did not complete an abdominal assessment, and did not contact the provider for further direction.
A resident with a seizure disorder did not receive the ordered bedtime phenytoin dose after admission because the order was not entered into the system, and the MARs reflected only the once-daily dose. The resident later had a seizure and was transferred to the hospital, where records documented status epilepticus, a subtherapeutic phenytoin level, and active infection. Interviews confirmed the missed order and that the resident had been receiving only one daily dose.
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