A facility failed to include discharge planning in the care plans of six residents whose diagnoses included CKD, CHF, DM2, dementia, PTSD, epilepsy, metabolic encephalopathy, secondary parkinsonism, AFib, and hyperlipidemia. The DSW stated discharge planning was discussed during assessments but was not added as a care plan focus, and the DON stated discharge planning should be part of each resident’s person-centered care plan.
Improper Release of Resident Information: A resident with severe cognitive impairment and diagnoses including metabolic encephalopathy, secondary parkinsonism, and dementia had personal contact information included in the admission record. The LNHA contacted an outside facility, shared the resident’s information, and asked that facility to reach out to the resident’s family without first obtaining permission from the family, and without documentation showing the family knew the outside facility was being contacted. The LNHA later stated he had not completely followed the facility’s Release of Information policy.
Unsafe and Unclean Resident Environment: A resident was observed in bed with an emptied, needleless saline syringe left on top of the blanket, and a soiled paper towel was found inside a drawer outside a room that contained PPE gowns. The LNHA stated that saline syringes should not be left in a resident’s bed. The facility policy requires a clean, sanitary, and orderly environment.
Improper Physical Restraint Used During Respiratory Treatment: An RN secured a resident’s left hand to the side rail with a pillowcase while attempting to administer a nebulizer treatment after the resident became combative and removed the mask. The resident had dementia, severe cognitive impairment, respiratory failure, and functional quadriplegia, and the restraint was later observed by the hospice nurse and confirmed in the facility’s event investigation.
A resident with hemiplegia, severe cognitive impairment, a feeding tube, and surgical wounds was ordered EBP for a PEG tube, but the care plan did not include the EBP need or related interventions. The DON confirmed the omission and stated that the care plan is meant to communicate interventions for resident safety, protection, and care.
Incomplete Care Planning for Double Incontinence Brief Use: Two residents were observed wearing two incontinence briefs, and staff confirmed the residents had requested this practice. One resident had diagnoses including amputation, DM2, and repeated falls; the other had rhabdomyolysis, DM2, sepsis, and UTI and was incontinent of bowel and bladder, chairfast, and severely limited in walking. Staff stated the nurse was not informed before the briefs were applied, and the residents’ care plans were updated after the surveyor’s observations.
A resident with hemiplegia, DM2, and convulsions was admitted with an order for IV Vancomycin for infection, but the medication was not properly reconciled at admission and was not given when ordered. The admitting LPN expected the next shift to complete reconciliation, the order was not entered into the computer, the pharmacy delivery was delayed, and the first documented dose was not administered until the following day.
A resident with an ileostomy, intact cognition, and orders for pouch changes, skin protection, and behavior monitoring had those care instructions missing from the MAR/TAR. Progress notes documented fidgeting with the ileostomy bag and other related behaviors, but the MAR did not show the behaviors, non-drug interventions, or outcomes, and the DON stated the treatment orders should have been transcribed and documented.
An uncertified agency CNA impersonated another worker and provided direct care to 16 residents on two nursing units, including bathing, toileting, feeding assistance, dressing, and mechanical lift transfers. The issue was discovered after the DON and Staffing Coordinator confirmed the person working under the agency name was not the actual CNA and had used a sibling’s identity to gain access and work in the facility.
A facility failed to keep complete and readily accessible records for a resident with CHF, UTI, and polyosteoarthritis. The resident had a right shin hematoma, but nursing notes did not document the injury or notification to the EC/representative, and the investigation record lacked the name, date, and time of notification. CNA task records for bladder, bowel, and toileting hygiene also contained multiple blank and unsigned entries.
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