A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Submit Final Abuse Investigation Reports: The facility did not submit required final investigative reports to the SA after alleged abuse incidents involving two residents. One resident with epilepsy, dementia, schizophrenia, and reduced mobility was involved in a witnessed altercation with a roommate after a dispute over the TV, and the incident was investigated and verified, but the final report was not filed. Another resident with schizoaffective disorder, bipolar type, schizophrenia, and dementia also had a completed abuse investigation, but no final report was submitted within the required timeframe.
Failure to Readmit Resident After Hospital Transfer: A resident with quadriplegia, chronic pain, constipation, and anxiety reported chest tightness, chills/diaphoresis, headache, and abdominal discomfort. The RN assessed the resident, offered transfer to the local ER, and after the resident declined that option, the DON arranged transport by facility van to another ER with the RN accompanying the resident. The resident was medically stable for transfer, but while the resident was out, housekeeping was asked to clean the room and the resident declined multiple times; afterward, an administrative decision was made not to readmit the resident.
Failure to document thorough investigations for alleged abuse and neglect incidents involving multiple residents. An LPN overheard one resident accuse another of kicking, a CNA reported a skin tear during a brief change involving a combative resident, and another incident involved one resident touching another in the dining room followed by a slap to the hand. The CNO could not produce the investigation records for these FRIs, and the DON stated investigations should include staff interviews, camera review, additional interviews as needed, and written documentation of findings.
A resident with quadriplegia, chronic pain, constipation, and anxiety was sent to an ER after reporting chest tightness and other symptoms, choosing transport to a different ER after declining the local ER. While the resident was out, housekeeping was asked to clean the room, but the resident declined multiple times, and the facility then decided not to readmit the resident. The record did not document the specific needs the facility could not meet or the attempts made to meet the resident’s needs before the readmission denial.
A resident with quadriplegia, chronic pain, constipation, and anxiety was transferred from the facility to an ER after reporting chest tightness, chills/diaphoresis, headache, and abdominal discomfort. The RN accompanied the resident after the resident declined the local ER and chose another ER, but the facility did not provide written bed-hold notice to the resident or the resident’s family/legal rep at the time of transfer. The SSD could not verify documentation of the bed-hold notice, and the resident’s discharge notice had later been rescinded after the Ombudsman said there was insufficient justification for discharge.
A resident with vascular dementia and exit-seeking behavior eloped through an alarmed door after staff failed to check all exit doors when the alarm sounded. Staff checked only some doors, assumed the alarm had been addressed when it shut off, and did not verify the resident’s location. The resident was later found outside on the ground with pain and injuries, and imaging showed a possible proximal femur fracture.
Care Plan Not Updated After Resident Fall During Elopement: A resident with Parkinson’s dementia, impaired cognition, and a history of falls had a fall care plan for unsteady gait, but after eloping from the facility and being found on the ground in a nearby parking lot with reported pain, the record showed the care plan was not reviewed or updated. The RN said the plan was not revised because the fall occurred outside the facility, while the DON confirmed it should have been revised and was not.
A resident with Parkinson's dementia and a history of falls eloped through the front entrance while the front desk was unmanned during a receptionist break and was later found on the ground in a nearby shopping complex parking lot after falling. EMS notified the facility, the RN said staff did not realize the resident was missing until EMS arrived, and the DON confirmed the resident had left without supervision. The record also showed the ordered 1:1 supervision ended without documented provider re-evaluation.
Failure to Provide and Document Enteral Nutrition: A resident with dysphagia, G-tube status, and aphasia was admitted without a documented physician order for enteral formula, and the record showed only one 240 ml water flush with no documented enteral nutrition, alternate formula, or IV fluids. Staff reported the resident needed a specific vegan tube feeding formula that was not available, and the DON acknowledged the lack of documentation for nutrition provided during the resident’s stay.
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