A resident was transported from dialysis in a wheelchair that was not secured in the van. When the CNA lowered the lift gate and turned away, the resident rolled backward out of the van, struck his head on the ramp, and sustained head and arm injuries requiring ED evaluation. The resident had CKD stage 4 and hemiplegia, and the ED record documented head and arm contusions, a skin tear, and a small posterior head laceration.
Failure to provide required written transfer notice: A resident with respiratory failure and hypoxia was sent to a hospital with return anticipated, but the resident representative did not receive written notice with the reason for transfer, effective date, and destination. The BOM said she believed the resident was being discharged rather than transferred, and the Administrator confirmed the notice was not provided.
Failure to develop and implement comprehensive care plans: one resident with an active UTI had no care plan interventions for the new diagnosis despite a physician order for antibiotics, and another resident’s oxygen therapy care plan and physician order called for 3 L via NC, but staff observed and confirmed the resident was receiving only 2 L. RN and DON interviews confirmed care plans were expected to guide staff care and include interventions for new diagnoses.
A resident with CHF and COPD had a physician order for oxygen at 3 L/min via NC, but staff observed the resident receiving oxygen at 2 L/min on multiple occasions. An LPN confirmed the mismatch and stated there was no order authorizing the lower flow rate, while the MAR documented oxygen as being given at 3 L/min on those same dates.
Missing Separate Charge Nurse on Evening Shift: The facility failed to designate a separate charge nurse for the 3:00 PM to 11:00 PM shift, instead having the medication/treatment nurse also serve as charge nurse. The Staff Reporting Form showed no designated charge nurse for three reviewed shifts, and the DON and Administrator both confirmed this practice during interview, despite the state standard requiring a charge nurse to supervise total nursing activities on that shift.
A resident with dementia and severe cognitive impairment was found in bed with a flat sheet tied across her torso from side rail to side rail, restricting movement without a physician order. An RN removed the sheet and found no injury or distress. The CNA later stated she used the sheet to keep the resident from getting out of bed while staff were rounding, and the DON confirmed the resident’s care plan addressed supervision and fall prevention without restraints.
A resident admitted after hip surgery was not entered into the EMR, did not receive an admission assessment, ordered meds, pain management, toileting help, or other nursing care for hours after arrival, and later left the facility. In a separate incident, a cognitively intact resident with hemiplegia reported that a CNA used profanity and verbally abused him while helping him dress, and staff were suspended pending investigation.
Insufficient nursing staffing delayed incontinent care for two residents. One resident with morbid obesity, urinary incontinence, and limited mobility was found saturated in a brief with a strong urine odor and had reportedly been wet for hours, while another resident with a BKA and ESRD waited over an hour in a bowel movement-soiled brief after using the call light. Staff reported CNA coverage gaps, frequent call-offs, double shifts, and ongoing staffing shortages, and leadership acknowledged the facility did not have enough nursing staff to consistently meet resident needs.
Medication error rate exceeded the allowable threshold. During a med pass, an LPN found that three ordered meds were unavailable and did not administer them, but documented them on the MAR as held due to ordered parameters even though no physician orders or parameters existed. The resident’s record showed active orders for the meds, and the resident stated she was not told the prior day that the meds were unavailable.
Controlled substances were left unsecured in the DON’s office instead of being kept in locked storage. Two LPNs found the drawer seal broken and the drawer unlocked while trying to recover narcotics placed there per the former DON’s instruction. A maintenance employee, who was not authorized to handle medications, admitted removing the drugs, pouring cleaning solution over them, and discarding them in the dumpster. The facility could not verify that all of the medications were recovered.
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