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.
Failure to Report Injury of Unknown Origin: A resident had multiple skin tears, bruises, discolorations, and redness documented on admission and again on a later skin assessment, including bruising to the face, chest, extremities, abdomen, and feet. An LPN stated new skin areas should trigger documentation, risk management, treatment, and notification of management, but the ADON confirmed no internal risk management report was initiated, and the facility lacked evidence that the injury of unknown origin was reported to the State Agency.
Failure to develop a person-centered care plan addressed a resident with stroke, GERD, and dysphagia who had documented aspiration risk and swallowing precautions from SLP. The resident reported trouble tolerating meds, pills getting stuck, and better tolerance when upright in a WC with water, but staff said they were unaware of the swallow precautions and the CNA task did not include specific instructions to monitor unsafe eating behaviors or use the identified strategies.
Admission Assessment Completed by LPN Without RN Oversight: An LPN completed a resident’s admission assessment and documented multiple skin findings, including skin tears, redness, and discolorations on several body areas. An RN stated that the full admission assessment, including skin, pain, fall risk, Braden, and oral assessments, is the responsibility of the nurse assigned to the resident’s room and that an LPN cannot complete the admission assessment without RN oversight.
Failure to protect residents from abuse. A resident with severe cognitive impairment physically assaulted a roommate while the roommate was asleep, and staff observed the attack. Another resident with severe cognitive impairment sexually grabbed a female resident, while the care plan had not been updated for years despite prior sexually inappropriate behavior. A third resident with intact cognition reported verbal mistreatment and being forcefully grabbed by a CNA at the nurse’s station.
Failure to report resident abuse, sexual misconduct, and injuries of unknown origin: Staff documented multiple resident-to-resident physical abuse incidents involving a resident with dementia and repeated sexual inappropriate behaviors by another resident, but the incidents were not reported to the Administrator or reflected on the reportable log. Staff interviews showed some events were observed but not escalated. The facility also documented bruises and other injuries of unknown origin for a severely cognitively impaired resident, but the Administrator confirmed the injuries were not reported to the SSA.
Failure to Investigate Resident Abuse, Unknown Injury, and Possible Neglect: The facility did not investigate multiple resident-to-resident physical and sexual abuse incidents involving a resident with severe cognitive impairment, nor did it investigate sexual inappropriate behavior affecting another resident. The facility also did not thoroughly investigate an injury/possible neglect event involving a severely cognitively impaired resident found on the floor after care, as the investigation omitted staff names and did not review the care plan requiring 2-person assistance.
Failure to care plan TLSO brace use. A resident admitted with a lumbar fracture had care plans initiated, but the record lacked an individualized plan for the TLSO brace. Notes documented the brace was to be worn to support the lumbar spine, that it was very wide and went up to the chest, and that the resident was not strong enough to apply it tightly. POC documentation stated the brace was to be applied at all times, and the DON confirmed there was no care plan addressing brace application, positioning, or tightness.
A resident hospitalized for depression returned with discharge instructions to continue fluoxetine 20 mg daily, but the facility transcribed the order as 10 mg daily. The resident received multiple doses at the lower dose before psychiatry later documented depression/anxiety and the dose was increased to 20 mg; the DON confirmed the initial transcription error resulted in 17 undermedicated doses.
Two residents missed ordered doses after admission because pharmacy services were delayed. One resident with anxiety did not receive clonazepam on multiple scheduled doses because staff were waiting for pharmacy clearance, a valid prescription, and medication availability. Another resident with major depressive disorder and mood disorder missed quetiapine doses because the medication had not yet been delivered. Staff confirmed that newly admitted residents sometimes do not have all medications available and that pharmacy delivery can take 24 to 48 hours.
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