Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin: Staff did not immediately report two resident-to-resident sexual abuse incidents involving one resident touching two others, and staff also did not immediately report bruising of unknown origin on another resident. A CNA redirected the resident during the abuse incidents but did not notify the charge nurse, DON, or Administrator, and an RN and LPN did not escalate the bruising after assessing it and hearing it described as handprint-like. The delayed reporting prevented timely initiation of the abuse investigation process and resident assessment.
A CNA witnessed two incidents of resident-to-resident sexual abuse/inappropriate sexual contact involving a resident with dementia and severe cognitive impairment, including touching one resident’s breasts and reaching under another resident’s blanket, but did not immediately report either event to the charge nurse, DON, or Administrator. The incidents were later discovered in EMR alerts, and the DON stated the facility was unaware of them for about two days because the CNA failed to report them.
The facility failed to maintain an effective grievance process for residents and family members to file grievances verbally or anonymously. Although the Resident Rights and grievance policy allowed oral and anonymous complaints, only small grievance notices were posted, and no grievance forms or grievance box were available at the receptionist area. Residents said they did not know how to file anonymously, the receptionist was unsure how anonymous filing worked, and the DON stated the facility previously had grievance forms and a drop box but they were removed.
Failure to Perform Required Overnight Resident Checks: A resident with a history of falls, confusion, and gait/balance problems was not checked at least every two hours overnight as expected. Staff later found the resident on the floor in the room with the door closed, dried blood on the head, face, and hands, and the resident reported trying to get help after falling while going to the bathroom. The resident was hospitalized with a traumatic head hematoma and traumatic rhabdomyolysis, and the ER noted the blood appeared to have been present for a prolonged period of time.
Improper transfer of a non-weight-bearing resident: Staff transferred a resident who was ordered for Hoyer lift assistance using a two-person stand-pivot transfer instead of the required lift and without a gait belt. The resident reported pain during the transfer and later had bruising, swelling, and a left ankle fracture. Records showed the resident was dependent for transfers and the care plan directed mechanical lift assistance x 2.
A resident with dementia, weakness, hallucinations, and a history of falls was left unattended on the toilet and tried to transfer to a wheelchair without help, falling onto the right side and later found to have a right femoral neck fracture. The resident had a prior fall as well, but the care plan did not document the fall history, fall risk status, or fall interventions. Staff interviews confirmed residents should not be left alone in the bathroom, and the resident was resistive to care and dependent on staff for transfers and toileting.
Failure to notify a resident representative of a change in condition: A resident with severe cognitive impairment had an unwitnessed fall, complained of pain, refused ordered x-rays, and later was found to have a fractured R femoral neck before being sent to the hospital. The record did not document that the POA was notified of the x-ray refusal, the fracture results, or the transfer, despite facility policy requiring notification of the resident representative after accidents/incidents and significant changes in condition.
A resident admitted with a fractured leg, anxiety, depression, and ADHD did not receive ordered PRN pain medication for about 22 hours and went six days without medications for anxiety, headaches, and ADHD after a third-party provider placed the drugs on hold pending physician review. The resident reported throbbing pain, poor sleep, headaches, anxiety, depression symptoms, and difficulty focusing, while the attending physician was not aware the medications had been held and the record showed no timely physician review of the held orders.
A resident with malnutrition, chronic iron deficiency, and total dependence for transfers developed an unstageable, necrotic pressure injury to the coccyx/sacrum. Facility records showed the wound was first identified by nursing staff, but the resident’s DPOA/POA was not notified at the time of the significant change in condition; the POA later said they only learned of the wound during a separate call about a fall. The NP also reported no documentation that he/she was notified or addressed the wound.
The facility failed to ensure complete orders and documentation for cardiac device monitoring for two residents with pacemakers/cardiac monitoring devices. One resident had a pacemaker with orders that lacked monitoring parameters and no documented checks, while another resident had a Medtronic Loop Recorder with no monitoring parameters or recorded documentation. Facility leadership stated nurses were responsible for documenting monitoring and carrying out orders, and the resident’s representative reported the facility did not notify them when the device was disconnected.
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