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.
Incomplete post-fall investigations and missing fall assessments were identified for two residents. One resident with dementia and a prior femur fracture was found on the floor, complained of hip pain, and was later hospitalized with a hip fracture, but the post-fall investigation packet could not be found. Another resident with multiple diagnoses and repeated falls had no admission fall risk assessment, no fall risk assessment after a prior fall, and no event report for a later unwitnessed fall. The DON confirmed the missing documentation, and the facility policy required admission fall risk assessments, incident reports, and post-fall assessments/debriefings.
Three residents had incomplete physician documentation in their records. One resident admitted for rehab after sepsis secondary to a UTI had unsigned admission orders, a missing initial H&P in the EMR at review, and a delayed discharge summary signature; two other residents had admission orders signed by nursing but not by the MD, and each had a physician visit note that was signed late. The facility policy required physician orders and progress notes to be maintained per State and Federal regulations.
Failure to Respond to Family Grievance: The facility did not respond to a family member’s email grievance about a resident’s PT/OT, toileting, CNA mobility assistance limits, physician visits, and an inaccurate PMH entry. The ADM initially reported no grievances, later found the email in spam, and acknowledged there was no documented investigation, resolution, or timely follow-up communication despite OT notes showing repeated complaints from the family member.
Failure to fully cover urinary drainage and leg bags: A resident using a urinary drainage bag and later a urinary leg bag was observed with the bag only partially covered or not covered by a privacy/dignity bag while out of the room and in the dining area. The resident stated concern that the bag should always be covered and that the exposed leg bag made the resident uncomfortable because it was visible to others. RN and DON both confirmed that urinary bags should always be fully covered with privacy or dignity bags.
A resident with a catheter was observed with the catheter bag and tubing exposed outside the privacy bag and resting directly on the floor, and the resident moved the wheelchair over the bag. An RN later confirmed that catheter bag and tubing should not be in direct contact with the floor.
A pill cutter in the station 1C med cart was observed with large amounts of white and brown sediments inside it during survey. An RN administering meds from the cart confirmed the contamination and stated it was from not cleaning the cutter, adding that it should be cleaned after each use.
Failure to Provide Ordered AROM Program: A resident with weakness, pain, and a history of falls did not receive the ordered AROM restorative program 6 times a week as care planned. Record review showed some weeks with fewer than the required interventions, with treatments sometimes refused and sometimes not offered. The MDSC confirmed the frequency was not met and that refusals were not being addressed in the RNA program.
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