A resident with a PEG tube, dysphagia, dementia, epilepsy, and other neurologic conditions had scheduled meds ordered through the tube, but the eMAR showed no meds documented for an entire evening med pass. The RN/UM said she worked a double shift because of a nursing call-out and forgot to document the meds as given, and the DON acknowledged the missed documentation.
Failure to Report Injury of Unknown Origin: A resident with dementia, Parkinson's disease, and a prior traumatic subdural hemorrhage sustained an unwitnessed head injury after being seen trying to climb back into bed. Staff documented blood on the floor and the resident's head, and the resident was sent to the hospital. Although the injury was investigated and staff negligence was found unsubstantiated, the DON stated the event was not reported to the State Agency because it was not considered abuse or an injury of unknown origin, despite facility policy requiring immediate reporting of injuries from an unknown source.
A resident with dementia and severely impaired decision-making developed a facility-acquired skin impairment that progressed from MASD to an unstageable pressure ulcer/injury, but the resident's representative was not documented as being notified when the condition first appeared or when it worsened. Facility records showed the update to the representative occurred later, and staff interviews confirmed there was no note of earlier notification despite policy requiring notification of the resident/representative for changes in condition and new pressure ulcers.
A resident with dementia, metabolic encephalopathy, and severely impaired decision making was dependent for transfers and had therapy documentation indicating the need for a mechanical lift with two staff members. The care plan and EMR profile did not include the mechanical lift requirement, and a CNA transferred the resident from bed to a shower chair alone by lifting under the arms. The resident was later found to have a swollen, deformed left arm, and hospital imaging confirmed an acute displaced distal humerus fracture.
Failure to provide adequate supervision for a cognitively impaired resident with a high fall risk. The resident had severe cognitive impairment, hydrocephalus, restlessness, agitation, and difficulty walking, and required assistance with toileting and other ADLs. The resident had multiple unwitnessed falls and floor incidents, including being found on the floor in the room, in bathrooms, and in a hallway, with one event causing a head laceration and eyebrow hematoma. Staff notes and fall investigations showed the resident was impulsive, moved quickly, and at times was left unattended during toileting or was found away from the assigned room.
Dirty D Wing hallway floors were observed with dark brown areas throughout the corridor, including near the nurse’s station and around wet floor signs. A porter said the marks were deep and ground in, not removable by mopping, and that the area needed stripping and waxing. Leadership acknowledged D wing needed floor care, and the facility’s schedule showed incomplete documentation for D wing hallway stripping and waxing.
A facility failed to timely provide incontinence care to two residents who needed staff assistance with ADLs. One resident with Alzheimer’s disease and dementia was found with a urine-soaked brief, draw sheet, and bed pad, and an LPN UM and CNA confirmed the resident had not been checked at the start of the shift. Another resident with cerebral vascular disease and dementia was observed with a very saturated brief, wet bed pad, and strong urine odor after saying they had been changed an hour earlier; the LPN UM, RN, and CNA confirmed the resident was soaked through to the bedding.
An LPN prepared a resident's Lactulose solution from a medication cart even though the bottle's resident label had come off and was unreadable. In a separate finding, an expired Omeprazole solution remained in a medication refrigerator's active inventory past its Use By date. The DON, UM/LPN, and consultant pharmacist all acknowledged that medications should be labeled and expired medications removed from active inventory.
Failure to Document and Implement Verbal Nystatin Order: A resident with encephalopathy, cachexia, and severely impaired cognition had a fungal rash to the sacrum and anus, and an NP gave a verbal order for Nystatin cream and a wound consult. The order was not transcribed to the MAR/TAR, the Order Summary did not show it, and there was no nursing documentation of the NP evaluation or implementation of the verbal order.
A resident’s admission record was sent with another resident to a third-party appointment, resulting in confidential medical and personal information being mixed between two residents. The resident whose information was sent had diagnoses including metabolic encephalopathy, type II DM, and atrial fibrillation, while the other resident’s paperwork included diagnoses such as acute osteomyelitis, type II DM, and memory deficit following cerebral infarction. The LNHA said a new Unit Clerk being trained by Medical Records staff mixed up the documents.
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