Two residents were involved in a deficiency related to supervision and wander alert safety. One resident with severe cognitive impairment and known elopement risk exited the facility unnoticed through unsecured doors and was found miles away by police. A second resident’s wander alert bracelet failed to alarm during an elevator transfer, and staff later found the bracelet battery was dead. Leadership and nursing staff stated there was no policy for door checks or for the current wander alert system.
Failure to respond appropriately to an alleged sexual abuse incident: a resident with intact cognition alleged a CNA raped them during incontinence care, but the resident remained in the facility for hours without a documented medical or psychosocial assessment. The CNA said they provided care and applied ointment to the resident’s groin and vaginal area, while video showed the CNA in the room for 36 minutes. The resident was later tearful, fearful, and distrustful of staff, and the DON and admin did not report the allegation to DOH because the resident later described rough handling.
Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
Delayed reporting of resident-on-resident sexual abuse allowed continued nonconsensual sexual contact. A resident with schizophrenia and moderate cognitive impairment reported that his roommate kissed, touched, and sexually assaulted him without consent, while the roommate admitted to sexual contact. A nurse aide heard the allegation but did not report it right away, and the unit manager later confirmed the delay.
A resident with dementia and a history of aggression assaulted another resident in a hallway, pushing him from a chair onto the floor and then attempting to strike him with a chair while a third resident was nearby. Staff on constant observation and another observer did not intervene until after the resident had already been pushed down, despite the resident being on enhanced supervision for prior resident-to-resident altercations. Both residents had severe cognitive impairment, and interviews showed the assigned aide did not understand the urgency of the constant observation role.
Failure to Supervise Resident at Risk for Elopement: A resident with severe cognitive impairment and known exit-seeking behavior was not accurately assessed or care planned for elopement risk. Staff observed the resident in another resident’s room, then an exit alarm sounded; an LPN closed the door and reset the alarm without checking outside, and staff later could not locate the resident. The resident was found outside the secured unit in cold weather with injuries and confusion, while video showed the resident leaving the building and staff not stepping outside to verify whether anyone had eloped.
The facility failed to timely escalate a resident with signs of sepsis, respiratory distress, hypoxia, hypotension, and acute decline for hospital transfer despite NP and telehealth recommendations for immediate ED evaluation; the resident was later admitted with sepsis, obstructing kidney stone, and hypoxic respiratory failure. The facility also missed documentation for ordered wound care for one resident and administered PRN hydrocodone-acetaminophen to another resident without documenting the required pain level.
A resident with intact cognition, multiple medical diagnoses, and documented full code status was found unresponsive, pulseless, and nonbreathing while receiving care. An RN believed Hospice enrollment changed the code status to DNR and did not start CPR or call a code blue, despite the resident’s full code order being documented in the chart.
Failure to Prevent and Treat Pressure Ulcers: A resident with impaired cognition, total ADL dependence, incontinence, and high Braden risk developed worsening sacral and heel pressure injuries after staff did not consistently implement wound prevention measures or recognize the change in condition when sacral redness was first noted. The wound progressed to an infected stage IV sacral ulcer with foul odor, drainage, altered mental status, and hospital transfer; interviews and records also showed the wound was not consistently tracked or care planned, and the resident’s skin breakdown was not promptly escalated.
A resident with dementia and major depressive disorder was identified as high risk for elopement and had interventions in place, including a wander guard and door alarms. Staff verified the device earlier in the evening, but the resident removed it, traveled to the elevator, rode to the lobby, and exited through the front door when the alarm was not heard or responded to. The facility failed to provide adequate supervision and safety measures to prevent the elopement, resulting in Immediate Jeopardy.
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