Failure to Address PTSD Triggers and Supportive Interventions: The facility did not identify, assess, or include trauma history, triggers, or non-pharmacological interventions in the care plans for three residents with PTSD. One resident had documented trauma, abuse history, nightmares, irritability, and anxiety; another reported recurring bad dreams and triggering resident behaviors; and a third had PTSD with psychotropic medications and observed mood changes and distractibility. Staff interviews confirmed PTSD care plans should include triggers and interventions, but the plans did not reflect those needs.
Failure to issue emergency discharge notice: A resident was sent to the hospital for uncontrolled pain and then told the facility would not accept the resident back because the acuity of care was higher than anticipated. The record contained no documentation of an emergency discharge notice, and the DON and Administrator stated the resident’s needs could not be met and no written discharge was issued.
Failure to provide timely CPR and EMS activation for a resident with conflicting code status documentation. A resident admitted for respite care with Hospice services was documented as Full Code in the chart, while other records referenced DNR status. When the resident was found unresponsive, staff were confused about the code status, CPR was delayed, and there was disagreement among the DON and LPNs about whether a signed DNR was present before life-saving measures were started.
A resident’s right to choose an attending physician was not honored when the facility changed the resident’s PCP from Physician A to Physician B after discontinuing services with Physician A. The resident was cognitively intact and stated he/she wanted to stay with Physician A but did not have a choice. Social services documented the PCP change and later asked if the resident wanted to return to Physician A when that physician resumed practice at the facility.
Infection prevention and control was deficient when staff failed to follow EBP and hand hygiene practices during resident care. An LPN provided wound care to one resident with a pressure ulcer and catheter without a gown, missed hand hygiene opportunities, placed wound care supplies directly on the bed without a protective barrier, and did not change gloves or clean hands between wound care tasks. Another resident with a feeding tube and catheter received tube feeding assistance without a gown, and the LPN said he/she did not know the resident was on EBP.
Facility staff limited residents to two condiment packets per meal and allowed staple foods such as cold cereal, brown sugar, and cottage cheese to run out, despite policy requiring resident preferences to be honored and staple inventory to be maintained. Three residents with cognitive and psychiatric diagnoses reported being denied requested condiments or food items, including butter, ketchup, parmesan cheese, and cereal, and one resident was observed receiving fewer condiments than requested.
A facility failed to ensure two residents were treated with dignity and respect when a CNA spoke to them in a loud, rude, and short-tempered manner. One resident, who was not cognitively intact and had multiple psychiatric and developmental diagnoses, was denied a snack request after being spoken to disrespectfully and became visibly upset. Another resident with impaired cognition, autism, epilepsy, severe intellectual disabilities, intermittent explosive disorder, and cerebral palsy was told to stop moving in a disrespectful tone and began hollering. The CNA admitted being frustrated and short tempered with the residents.
A resident with significant cognitive loss and a history of behavioral problems, including self-harm gestures, aggression toward others, and destructive acts, was hospitalized after escalating violent behaviors. The facility then initiated an emergency discharge and refused to allow the resident to return, but the transfer/discharge form in the record was incomplete and the administrator stated there was no transfer and discharge policy.
Delayed reporting of an abuse allegation occurred when a resident with cognitive impairment and ADL dependence reported that a CNA put a finger into the resident’s rectum during care. The report was first shared with a housekeeper, then delayed while staff tried to identify the resident, and it was not escalated to the Administrator or DHSS within the required timeframe.
Failure to assess skin on readmission and obtain wound care orders. A resident returned from the hospital, but staff did not document the required skin assessment. During observation, an unlabeled bandage was found on the back of the resident’s left leg, and when removed, a large open area was seen. An LPN said the wound was not known to staff and no wound care order could be found; the DON and administrator said a skin assessment should have been completed on readmission and the nurse would obtain physician orders if a skin concern was identified.
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