Failure to Order Wound Consult and Treatment for New Buttock Blister: An RN observed an open blister on a resident’s right buttock during incontinent care and documented that the MD was notified and a wound consult and Xeroform treatment were obtained, but the orders were not found in the chart. Staff did not document use of the facility’s skin assessment tool or follow the pressure ulcer/injury policy, and within days the blister was documented as a Stage 3 pressure injury.
Incomplete investigation of missing controlled medication: Facility staff did not complete a thorough investigation of a missing Tramadol bubble pack belonging to a resident with a PEG tube, Stage 4 pressure ulcer, anoxic brain damage, epilepsy, and muscle weakness. The FRI and final report noted the nurse involved was interviewed, but there was no documented evidence that the nurse was off duty during the investigation period or that staff investigated inconsistencies between the controlled drug record and the physician’s order.
Care Plan Not Updated for New Skin Abrasions: A resident with a stage 3 sacral PI, surgical wound, and high Braden risk developed new right knee and left medial lower leg abrasions, but the care plan was not revised to include goals and interventions for those new skin issues. The record showed the abrasions were later noted as slowly improving, and the DON acknowledged that the care plan had not been updated.
A resident with cerebral infarction, muscle weakness, and Stage 3 and Stage 4 pressure ulcers was found with wet, stained gown and linens and dry stool on his thigh, while staff gave conflicting accounts of when care was last provided. The resident’s daughter said she often found him needing care, and a CNA said he was not repositioned when first seen in the morning and was only turned after ADL care began later, despite a care plan calling for repositioning at least every 2 hours.
A resident with a tracheostomy, chronic respiratory failure, aphasia, and severe ADL dependence was sent to a podiatry appointment without a nurse or trach supplies. Records, family report, and staff interview showed the resident traveled with transportation only, while the podiatry office was not notified and was unprepared to manage suctioning needs if needed.
A CNA provided wound care outside his scope for a resident with cerebral infarction, muscle weakness, and stage 3/4 pressure ulcers. The CNA reportedly used the same gloves to clean fecal matter and remove a soiled sacral dressing, then pulled on stuck packing without moistening it, sprayed wound cleanser on it, and caused bleeding. Staff stated wound care was not within CNA scope, and the complainant reported the CNA had changed the sacral dressing on multiple occasions.
Improper Storage of Open Ozempic Pen: Staff failed to ensure proper storage of a resident's Ozempic multi-use pen. Surveyors found an opened pen in the med refrigerator that had been kept beyond the manufacturer's 56-day use period, and an LPN acknowledged she was unsure how long the pen could be used after opening.
Facility staff did not provide required Notices of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare Part A services for two Medicare beneficiaries. In one case, the resident’s representative received the NOMNC by email only one day before rehab services ended. In the other case, a resident signed the NOMNC on the last covered day of Part A services. During interview, the social worker confirmed that NOMNCs for these residents were not issued 48 hours in advance of the termination of covered services.
Surveyors found that the facility did not ensure required monthly medication regimen reviews were consistently documented and that physician responses to pharmacist recommendations were obtained. For one resident with dementia, diabetes, hypertension, and chronic kidney disease who was receiving PRN oxycodone for severe pain, there was no documented monthly medication review for a specific month despite facility policy requiring monthly pharmacist review. For another resident with COPD, dementia with mood disturbance, depression, and multiple psychotropic and related medications, the consultant pharmacist documented concerns about psychotropic polypharmacy and recommended a psychiatric consult and consideration of gradual dose reductions, but the record contained no documented physician or prescriber response. The RN/Clinical Nurse Manager described a process for routing MRRs to physicians but could not locate a response for this resident’s review or explain how missed MRRs were prevented.
Staff failed to maintain sanitary conditions in food storage, preparation, and dishwashing areas, including undated opened shredded cheese, expired milk with settled contents, condensation leaking onto frozen food, and significant food residue on equipment and floors. A kitchen manager checked tuna salad temperature before handwashing, a dishwashing employee used a towel to dry sanitized kitchenware, and mold and limescale were present in the dishwashing area. Pest control reports had previously cited food debris and inadequate cleaning under and behind kitchen equipment and drains. During a follow-up visit, employee personal belongings were stored on racks in the dry storage room, creating potential cross contamination with food and food-contact surfaces.
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