A resident with documented elopement risk, a guardian, and a Wander Guard was not physically checked when staff realized the resident was missing, and the resident was later found by police lying in a road with seizures and altered mental status after leaving the facility unnoticed. Another resident with wandering and cognitive concerns was observed near a busy roadway after leaving unsupervised, with incomplete sign-out documentation and no elopement reassessment. The facility also failed to control smoking safety for a resident with a history of arson and fire-setting and for another resident who smoked in a room with a blind roommate, despite policies requiring supervised smoking and secure control of smoking materials.
Failure to Manage Unsafe Behaviors and Behavioral Health Needs: A resident with dementia, schizophrenia, and a history of fire-setting repeatedly smoked in undesignated areas and in the building, while another resident with mood disorder, nicotine dependence, and TBI repeatedly smoked in the room and bathroom and kept smoking paraphernalia in the room. The facility also failed to monitor residents with elopement risk, allowing one resident to wander unsupervised and elope, another to leave the building unsupervised multiple times and nearly be struck by a vehicle, and a third resident with a history of aggression to physically assault other residents.
A resident with moderate cognitive impairment and a care plan addressing refusals of care was forcibly held down by an RN and CNA after refusing incontinent care multiple times. During the interaction, the resident became physically aggressive, but staff continued the care, with witness statements describing the RN directing that the resident had to be changed. The resident later reported being held down, having arms grabbed, clothing ripped off, and being washed with a cold rag; bruising, wrist redness, hand discoloration, soreness, and emotional distress were documented.
Failure to Assess and Treat Worsening Pressure Injuries: Two residents with high pressure injury risk had new skin breakdown that was not promptly assessed or treated by the treatment nurse. One resident’s buttocks/sacral excoriation progressed to an unstageable wound with foul odor, drainage, and necrotic tissue, while another resident’s buttocks and sacral open areas were not evaluated or placed on treatment until they later became unstageable and then stage III/IV pressure injuries. Staff interviews confirmed the wounds should have been documented, measured, and monitored earlier.
Staff did not follow the posted lunch menu for a puree entree and fruit side. A Dietary Manager used a #12 scoop for Puree Beef Stroganoff and stated the puree version did not include noodles, even though the recipe called for the dish to be served over rice or noodles and the diet guide listed a 6 oz portion. Staff also used a #16 scoop for Sliced Strawberries instead of the 1/2 cup portion listed on the diet guide. The RD confirmed the menu was not being followed and that the portions served were incorrect.
Failure to Protect Residents from Resident-on-Resident Physical Abuse: A resident with documented aggressive behavior repeatedly assaulted other residents after wheelchair contact in the dining room and hallway. The resident yelled, cursed, grabbed hair and clothing, hit residents in the face and head, and pulled one resident from a wheelchair, causing scratches, discoloration, and other minor injuries. Facility records described a pattern of monthly physical altercations, but no effective supervision or behavior-management approaches were included in the care plan.
Hot puree lunch items were served at an improper temperature during trayline service. A test tray showed that Puree Beef Stroganoff and Puree [NAME] Beans were not hot, and the CDM agreed the items did not melt butter/margarine. Prior Resident Council minutes and a grievance also documented complaints that food was cold on the halls and that chili came out cold and was not heated up.
The facility failed to develop and implement policies and procedures for residents independently signing themselves out and leaving without supervision. The CQA Director stated nurses ask the resident’s expected return time, check the elopement book, and may send medication, but she was unaware of a specific policy for assessing whether a resident could sign out independently or with supervision. She also stated the decision would rely on resident rights, the MDS, the elopement assessment, and BIMS, and that a refusal to sign out could be treated as AMA if the BIMS score was high enough.
QAPI failed to identify all causal factors related to two elopements and smoking noncompliance involving two residents. The committee did not determine all contributing factors or what actions were needed to prevent further resident safety concerns. The facility’s policy required systematic analysis and root cause review, but the investigation showed the events involved a resident accessing clippers and cutting a screen, a window that was not properly secured, and smoking concerns tied to the absence of a locked container for smoking materials.
A resident with CHF and HTN, who was cognitively intact and care planned for fragile skin, was held on his/her side by two CNAs during ADL care after repeatedly saying not to touch him/her. One CNA reported the resident was combative and tried to kick and hit staff, while the other said the resident said, “Don’t touch me,” as she held the resident’s shoulder and leg and blocked hits. The resident’s rep later reported bruising to both hands, and the resident said the prior attempt at care hurt.
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