Hazardous bedside storage and lack of smoking safety assessments: Surveyors observed aerosol products and a cigarette lighter stored at a resident’s bedside, with the same items still present later. Two residents who smoked had histories of stroke with left-sided hemiplegia and BIMS scores of 15, but the record lacked evidence of a completed safe smoking assessment for either resident. One resident had burn holes on a wheelchair cushion, cigarettes and a lighter kept in a nightstand drawer that was not used, and the other had cigarettes observed on a desk and nightstand with no smoking-related interventions in the care plan.
A resident’s urinary catheter was repeatedly observed hanging from the bedframe and visible from the doorway. The resident said it bothered him/her that the Foley could be seen, and an LPN noted the catheter was not covered. The charge nurse stated it was likely a hospital Foley that had remained in place since the resident returned and should have been changed out or at least covered.
A resident with L hemiplegia from stroke, nicotine dependence, and COPD had a care plan that addressed smoking but did not include interventions for smoking safety related to the resident’s abilities and deficits. The resident was cognitively intact, required substantial to maximum assistance with transfers, was dependent for ADLs, used a wheelchair, and confirmed that someone brought cigarettes into the facility. Leadership was informed that the care plan did not address smoking safety.
Unclean Resident Rooms and Cluttered Surfaces: Surveyors found a strong urine odor, debris, spilled powder, open food, soiled bedding, and piles of clothing in a resident room, with an LPN confirming the conditions. In another room, an extinguished cigarette butt was found on a keyboard, and a resident’s wheelchair armrest was worn and torn, exposing foam padding and creating an uncleanable surface.
Incomplete ADL Documentation for a Dependent Resident: A resident who was dependent on staff for toileting transfers, hygiene, and mobility had multiple missing CNA ADL entries across day, evening, and night shifts. Facility policy required CNA documentation each shift, and both a CNA and the DON stated ADL care should be documented before the end of the shift, but the record lacked evidence of toileting and hygiene assistance on numerous occasions.
Incomplete Investigation of Resident-to-Resident Altercations: The facility failed to fully investigate two resident-to-resident altercations and did not provide complete follow-up documentation to the survey team. One incident involved a resident slapping another resident and hitting the resident with a slipper, and the other involved a resident threatening another resident and being struck on the arm. The DON and unit manager acknowledged missing investigation pieces, including witness interviews and other follow-up details.
A resident's Foley catheter was observed hanging from the bedframe and visible from the doorway, with yellow liquid in the bag. The resident stated the visible catheter had been on and off for a long time and questioned whether it would be concerning. The DON observed the uncovered Foley and confirmed the bag should have been covered.
A resident admitted with AFib, HF, and morbid obesity had a care plan that was not developed within 48 hours to include required baseline information. The plan lacked goals and interventions for anticoagulant therapy (Eliquis) and ADL assistance needs, and the DON confirmed the omissions during interview.
A resident with a foley catheter was observed with the catheter hooked to the bedframe and visible from the door. The resident stated the foley had been in place for quite some time, but the care plan lacked goals and interventions for catheter use. During review with the DON, the concern was confirmed.
Failure to monitor psychotropic medication side effects. A resident with depression, bipolar disorder, and ADHD had orders for mirtazapine, aripiprazole, and trazodone, but the clinical record lacked evidence of daily monitoring for side effects or behaviors. Facility policy required daily target behavior and side effect documentation, and both an LPN and the DON confirmed that such monitoring should have been documented.
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Citations used to create this checklist
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