Failure to Notify Physician and Family of Resident’s Decline: A resident with multiple chronic conditions developed several days of nausea, vomiting, poor PO intake, weakness, and overall decline, but the record showed no timely MD/NP notification or increased monitoring before an unwitnessed fall. Therapy and nursing notes documented ongoing symptoms, yet only one-time Zofran was given and vital signs were not recorded during the decline. The resident later fell while vomiting, sustained facial and cervical injuries, and was hospitalized with severe electrolyte abnormalities, AKI, aspiration pneumonia/pneumonitis, respiratory failure, septic shock, and prolonged critical illness.
A resident with intact cognition, high fall risk, and multiple mobility and medical issues developed several days of nausea, vomiting, poor intake, weakness, and decline, but the record showed no timely comprehensive assessment, vital sign monitoring, or provider escalation. Nursing and therapy notes documented ongoing symptoms, meal refusals, and limited treatment with ondansetron, yet there was no clear follow-through before the resident had an unwitnessed fall while trying to vomit in the bathroom and was sent to the hospital with serious injuries and severe metabolic abnormalities.
Failure to Protect a Resident from Sexual Abuse: A resident with moderate cognitive impairment and dependence for ADLs was kissed on the mouth by another resident while lying in bed. Staff observed the interaction, removed the other resident, and the resident stated the contact was unwanted and non-consensual and that she could not express no. The other resident admitted to the kissing and minimized the behavior despite knowing the resident could not consent.
A resident with wounds and skin breakdown received perineal care from two CNAs who wore gloves but not gowns, despite EBP criteria being met. One CNA then left the room wearing soiled gloves, carried soiled linen and a brief into the hallway, disposed of them in hallway receptacles, and only then removed the gloves and performed hand hygiene. The resident had diagnoses including pressure ulcers, diabetes, and CKD, and the DON confirmed the resident should have been on EBP.
Expired and damaged food items were found throughout kitchen storage areas, including juice, tortillas, chips, muffin mix, milk, apples, butter, and bacon past their expiration dates. A Dietary Aide was also observed using a dented can of sliced apples in muffins, and another dented can was found on a stockroom shelf. The facility’s policy required proper dating, FIFO rotation, and separate storage of bent or damaged cans.
Wet-Nested Steam Table Pans Stored in Dietary Area: Dietary staff failed to prevent wet-nesting of stored steam table pans, despite facility policies requiring dishware and serviceware to be air dried before storage. During observation, multiple stacks of steam table pans were found with moisture inside, and an LDM confirmed the pans were stored wet. A dietary staff member was then observed wiping a wet pan dry with a towel, while the DM confirmed towels were not to be used and all dishes should be air dried.
Hair Cut Without Consent: An LPN cut a nonverbal resident’s hair after believing there were bugs in it, but did not obtain family permission or notify the family beforehand. The resident was on a ventilator with a tracheostomy, and the care plan documented the family’s request that her hair not be cut due to cultural and religious preferences.
A nurse failed to sanitize hands between multiple glove changes during a resident's midline/PICC dressing change. The resident had IV access, IV meds, and a history of bacteremia, and the RN later confirmed hand hygiene should have been performed between glove changes. The NP/IP and DON both stated hand hygiene was required before gloves, after glove removal, and between glove changes during central line care.
An LPN was observed leaving an A-Hall med cart unsecured and unattended in a resident care area. The LPN confirmed the cart was unlocked and stated it should be locked immediately before walking away. The facility policy states meds and biologicals are to be stored safely and securely.
A resident with atrial fibrillation was ordered Eliquis and the MDS showed anticoagulant use, but the care plan did not address anticoagulant therapy. Staff interviews confirmed the plan should have included monitoring and care guidance related to bleeding risk, bruising, and related interventions.
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