A resident with moderate cognitive impairment and diagnoses including a femoral neck fracture and pain had Norco delivered to the facility, but the narcotic was not properly signed into the cart or reconciled. When the resident later requested PRN pain medication, none was available, and the facility’s investigation found that an RN failed to complete the narcotic sign-in process and the medication was never located.
A resident with cellulitis and MS, who was Full Code and not on hospice, developed confusion and jerking movements and was found to have a change in condition. The physician ordered labs and other tests, but the labs were not obtained promptly and there was little documented ongoing monitoring for hours. Staff gave conflicting accounts about assessments and the timing of escalation, and EMS was not called until the resident had deteriorated to cardiac arrest; he was transported to the hospital and later pronounced dead.
Failure to Employ a Qualified Full-Time Social Worker: The facility, certified for 226 beds, went for about three months without a qualified SW while the former SSD had left and the new SSD was still in training. Other staff without the required SW qualifications helped with social services tasks, and during this period a resident received a defective discharge notice that lacked sufficient support for the stated discharge reason and did not include accurate appeal information.
A resident with intact cognition and diagnoses including muscle wasting/atrophy and chronic hepatitis C was discharged after the facility issued a notice stating his health had improved and he no longer needed facility services. However, the resident said he was told he had no payor source and did not qualify for the level of care, and records showed the Medicaid LOC denial occurred because the facility failed to submit requested information, not because he no longer needed care. Interviews with the CL, DON, and Administrator confirmed the discharge was based on that denial.
A resident with intact cognition was given a discharge notice stating he no longer needed the facility’s services, but the notice did not include accurate required appeal information. The form lacked correct contact details for the state appeal entity and ombudsman, and the resident later appealed with ombudsman help; the appeal was upheld because the notice was incorrectly completed.
A resident with multiple diagnoses was affected when the facility failed to provide requested Medicaid LOC information needed to determine continuing eligibility and payor source status. KLOCS sent a lack-of-information notice, but no additional information was submitted, the request was denied, and the resident later received a discharge notice based on the denial. Interviews showed the CL handled KLOCS without formal training, the SSD had no knowledge of why the information was not forwarded, and the Administrator was unaware the denial resulted from the facility’s failure to respond.
Infection Control Breach During Wound Care: An RN and the SDC failed to follow aseptic technique during wound care for two residents. One RN placed supplies on an unclean bedside table, did not perform hand hygiene before donning PPE, left soiled dressings on the bed, reused contaminated gloves while touching the bed and resident, and reapplied a stained wrap. The SDC changed gloves during wound care but did not perform hand hygiene between glove changes while handling a soiled dressing. Facility policy, nursing standards, and staff interviews confirmed that hand hygiene, glove changes, and clean-field practices were expected during dressing changes.
A resident with schizoaffective disorder, dementia, and cognitive impairment became agitated, grabbed a unit manager, and broke a window with a wheelchair leg rest before being sent to the hospital. The ER physician and psych intake nurse found no medical or psychiatric reason for admission and documented that he should return to the facility, but the facility refused to readmit him, stating he was unsafe and that there was no room because the broken window had not yet been fixed.
A resident was discharged before the LPN completed the discharge review, and a KMA handed over medications from the cart without a double-check. The resident left with her own meds plus Keppra that belonged to another resident with epilepsy, and she later took one of the wrong pills because she thought it was hers. The resident had no order for Keppra and no order for discharge meds to be sent home, and the facility’s policy required medication reconciliation and review before discharge.
A resident with severe cognitive impairment and diagnoses including intracerebral hemorrhage, disorientation, and atrial fibrillation had an unwitnessed fall, but the primary contact/POA was not notified until the next morning. The facility policy required timely notification of the resident representative/provider, yet staff delayed the call after assessing the resident, returning her to bed, and determining she had no apparent injury. Interviews showed staff expectations varied, but leadership stated the notification was not timely and the resident's family should have been contacted sooner.
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