A resident with severe BUE contractures, paralysis of the left side from a stroke, and total dependence for ADLs did not have specific modified handling and dressing instructions in the care plan to protect the contracted UEs during care. A PT later observed the left shoulder out of alignment, and imaging confirmed a left anterior shoulder dislocation and anterior humeral head dislocation, requiring transfer for closed reduction.
Opened Resident Mail Delivered: A resident reported receiving several pieces of mail, including bank statements and personal letters with checks, already opened before delivery. Staff stated the business office receives resident mail and that mail is not opened except for residents for whom the facility is the rep payee; the resident was not listed as one of those residents. The DON and Administrator confirmed resident mail is supposed to be delivered unopened.
The facility did not show proof of written discharge notification for a resident transferred to the hospital. The record showed the resident's representative was notified by phone, and the SSD said the form was mailed but could not provide verification. The facility policy required transfer/discharge notice to the resident or responsible party in accordance with federal regulations.
Failure to develop care plans for two residents’ skin conditions. One resident had left shin cellulitis with orders for saline cleansing, Mupirocin, and a dressing after a fall-related injury, but no care plan was in place. Another resident with PVD, malnutrition, and polycythemia vera had reddened, shiny feet with small open wounds; although staff were cleansing the feet with saline, applying Aquaphor, and covering them with gauze in bed, no care plan was found. An RN, an LPN, and the DON confirmed the missing care plans.
A resident receiving Citalopram, Trazodone, and Risperidone for dementia-related conditions had a partially completed Medication Informed Consent form. Blank sections included ineffective non-drug approaches, the reason for the medication, expected benefits, and the proposed course of treatment, and the DON confirmed the form should have been completed before telephone consent was obtained from the resident’s representative.
A resident with a left shin wound and cellulitis was not placed on EBP despite facility policy indicating EBP for residents with wounds and requiring a gown for wound care. During observed wound care, no EBP signage was posted at the room entrance and the RN did not wear a gown while applying ordered mupirocin and changing the dressing. The DON confirmed the resident should have been on EBP.
An LPN used shared blood pressure equipment on one resident, placed it back near the med cart without wiping it, and then used the same equipment on two other residents without disinfecting it between uses. The IP stated shared medical equipment must be cleaned with disinfecting wipes between uses, and the facility policy required shared equipment to be cleaned and disinfected before and after use on another resident.
Failure to assess, document, and report resident pain: Staff reported that a resident grimaced, became loud, and appeared to have hip pain during turning and care, but the RN did not document an assessment or notify the MD. Family also reported facial grimacing and pain concerns during a video call, yet no EHR note reflected the concerns or follow-up. The MAR showed pain recorded as 0 on the affected shifts, with no PRN pain medication documented.
The facility failed to provide written transfer/discharge notices, bed-hold notices, and documentation of Ombudsman notification for multiple residents sent to the ED or hospital. Records for several residents showed transfers for conditions such as low BP, hypoxia, pain, and difficulty breathing, but the EHRs lacked proof that the resident or RRP received the required notices, and the DON confirmed the written notices were not being provided.
Failure to document a new admission’s nausea, vomiting, and mild pain led to a deficiency. A resident admitted for rehab after a brain bleed complained of swallowing difficulty, could not eat dinner, received antiemetic medication, and was reported to have vomited clear secretions and food particles; MAR/TAR also showed Ondansetron doses and mild pain, but no health note was entered for the day and there was no explanation for why Tylenol was not given. The DON, RN, and EC confirmed the missing documentation and stated that significant findings, treatment response, and changes in condition should have been charted.
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