Facility leadership failed to oversee resident care and staff performance effectively. Staff reported a week-long shortage of insulin syringes, during which nurses borrowed insulin pens and vials from other residents and gave them to different residents, while one resident missed insulin and another had delayed blood sugar checks and insulin coverage. Interviews also described an LPN threatening a resident, delayed incontinence care, intimidation of staff who reported concerns, and other allegations of misconduct, while the DON and RN/ADON did not fully investigate several of the reported issues.
Staff failed to timely report multiple allegations of abuse, neglect, misappropriation, and resident rights violations, including claims that a former CNA had sexual contact with residents for money, staff sold drugs to residents, and property was taken from a deceased resident. A resident also reported that an LPN did not complete ordered blood sugar checks and insulin coverage on time, and another resident was told to leave a unit or police would be called while he was calm and speaking with an RN. These events were known to staff and residents but were not reported to management or investigated before survey review.
Missed physician-ordered daily weights were found for three residents with conditions including CHF, CKD/ESRD, dementia, and diabetes. Records showed repeated gaps in weight documentation across multiple days, despite orders for daily monitoring, and the DON verified the missed weights and stated they should have been identified.
Improper Release of PHI: A staff member released a resident’s requested medical records to the resident’s son, but the packet also included skilled progress notes and other PHI for 12 unrelated residents. The error occurred when the staff member printed records from the EMR using only the first few letters of the resident’s name and did not recognize that multiple residents’ documents had been selected before sending the scanned records by secure email.
Urine Culture and Sensitivity Not Obtained as Ordered: A resident with a suprapubic catheter, quadriplegia, and a history of UTI had cloudy, odorous urine and diaphoresis. Urology ordered the catheter changed and urine collected for C&S, but although the specimen was placed in the specimen refrigerator, no C&S results were received and the DON later verified the lab had no record of the specimen being picked up.
A resident with CKD, HTN, and dialysis dependence was told by an LPN to leave another unit or police would be called, even though he was calm and was only speaking with an RN he knew well. The resident said he was trying to ask about delayed pain medication and later returned to the unit at shift change to talk with the RN. The RN confirmed he was calm and had not done anything, while the LPN acknowledged telling him to go back to his side and threatening police if he did not leave; the event was not documented or investigated by management.
A facility failed to timely investigate allegations that nurses were taking insulin from one resident and giving it to another when insulin syringes were reportedly unavailable. Residents and LPNs described sharing insulin pens and vials between residents, and one resident reported missing insulin on at least one occasion. The DON was notified of the concern but initially only checked supply availability rather than interviewing residents or staff about whether insulin had been borrowed or misused.
A nursing facility failed to provide insulin using accepted standards when staff reported being out of insulin syringes for about a week. Nurses stated they borrowed insulin pens or vials from one resident and gave them to another, and several LPNs confirmed they did this because residents did not have their ordered insulin. A resident with diabetes and intact cognition reported hearing staff discuss sharing insulin pens, another resident said he missed insulin one day, and facility policy stated insulin pens are for single-resident use only.
Two residents dependent on staff for ADLs did not receive showers as scheduled or per preference. One resident with diabetes, HF, depression, and HTN reported going weeks without a shower and said staff only gave bed baths; another resident with legal blindness, schizoaffective disorder, HTN, and chronic pain syndrome reported not getting the twice-weekly showers ordered in his care plan. CNA interviews cited staffing shortages and inability to complete all assigned showers, and the DON confirmed bathing was documented in the EHR.
Ostomy care was not provided or documented as ordered for two residents. One resident with an ileostomy and abdominal surgical incision had no documented wound care, stoma assessment, or output monitoring despite hospital and NP orders, and was later sent to the ER with a prolapsed stoma. Another resident with a colostomy reported the appliance was only changed when it failed and had worn the same bag for about a month; the DON confirmed there were no orders for stoma monitoring, emptying, or changing the appliance.
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