A resident with chronic fatigue syndrome, a prior R humerus fracture, OA, repeated falls, and substantial transfer assistance needs fell while ambulating with a walker. Staff found the resident on the floor in the tub room with severe pain, and the facility determined that a CNA had transferred the resident without using the required gait belt during the assisted transfer.
Failure to protect residents from inappropriate sexual contact occurred when a resident with dementia and a history of inappropriate touching placed a hand down another resident's shirt. The other resident also had dementia and severely impaired cognition. Staff reported the incident, separated the residents, and noted the first resident frequently touched staff and residents and required redirection.
Infection control standards were not followed during care for two residents on EBP with indwelling catheters. During one resident’s bed bath, a CNA used the same washcloth for peri-area, catheter tubing, legs, buttocks, and back care, did not cleanse the genital area last, and did not sanitize the bedside table after removing the basin. During another resident’s lift transfer, staff did not use the required gown and glove PPE.
A facility failed to provide enough nursing staff to meet resident needs and to answer call lights promptly. One resident waited 34 minutes for bathroom assistance after a call light was turned off, two roommates waited for help and one became incontinent before a CNA arrived, another resident reported call lights being turned off without help and waits as long as four hours, and a fourth resident said staffing delays kept her from getting up for lunch and that waits could be as long as 45 minutes.
The facility failed to review and revise care plans for two residents to match their current status and orders. One resident with a left hip fracture was observed being transferred with a full body mechanical lift even though the care plan called for a sit-to-stand lift, and another resident's care plan did not reflect physician orders for heel boots to be on at all times and heels to be offloaded for pressure ulcers.
Failure to reposition and use pressure relief devices appropriately led to pressure ulcer care deficiencies for two residents. One resident with buttock skin breakdown and incontinence was observed seated in a reclining wheelchair for hours without repositioning or a brief change, and another resident with spinal cord injury and diabetes was observed in bed with blankets draped directly over the feet instead of over the ordered foot cradle, while a new deep tissue injury was documented and the record lacked repositioning documentation.
A resident dependent on staff for toileting was found in a bathroom with a urine odor and urine-colored water in the toilet after staff had assisted with a bed pan. The resident’s spouse reported staff did not always flush the toilet after emptying the bed pan and sometimes found bowel movement in the toilet and an odor in the bathroom. An admin staff member stated staff are expected to flush the toilet after bedpan emptying and resident toileting.
Resident-to-resident abuse occurred when a resident with dementia and a BIMS score of 9 slapped another resident during a verbal exchange over eyeglasses placed on a therapy cat. The other resident had dementia, anxiety, and impaired cognition with confusion and nonsensical responses during interview. Camera footage confirmed the open-hand contact, and both residents later could not recall the incident.
Inaccurate MDS coding affected 3 residents when staff failed to correctly record a pressure-reducing mattress for one resident and coded bed rails as restraints for two residents. Observations and record review showed the mattress and assist/grab bars were present, while facility evaluations determined the bars were not restraints; an admin nurse confirmed the MDS coding errors.
The facility failed to update care plans for two residents to reflect current needs and assessments. One resident had DVT, was receiving an anticoagulant, and had a recent upper GI bleed, but the care plan was not revised for anticoagulant-related issues. Another resident had depression, anxiety, and a trauma assessment related to her son's death, but the care plan lacked trauma-related problems, goals, and interventions.
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