A resident who required two-person assistance was transferred by one CNA and fell to the floor during the transfer. Another resident who required supervision and a fire-resistant smoking apron was observed smoking without the apron in place, and an LPN stated they did not normally supervise smoke breaks or know which residents needed an apron. The facility also left an electrical room door unlocked, with paint, power tools, insect spray, electrical cords, and enabler bars inside.
Unsanitary ice machine observed with a black slimy substance on the underside of the plastic rim inside the ice compartment. The dietary manager stated the substance appeared to be grime and should not have been in the ice machine, and noted the unit was due for weekly cleaning. The kitchen provided nourishment to 85 residents.
Failure to Provide Scheduled Bathing Assistance: Three residents who required help with ADLs did not receive bathing as scheduled. One resident had COPD, DM, and CHF and needed help with personal hygiene; another had a functional deficit and needed partial bathing assistance; all had bath schedules for 3 times weekly, but shower sheets showed missed or inconsistent baths. The DON stated showers should occur 3 times weekly and that refusals should be documented with a bed bath offered, while CNA and RN interviews indicated showers were sometimes missed and shower sheets were not always completed.
A facility failed to ensure residents were free from significant medication errors when one resident drank coffee containing another resident’s medications. The DON stated medications should always be observed during administration, but a CMA said they did not watch the resident take the meds and gave them in coffee without observing the resident drink it. The physician was notified and reviewed the medications involved.
Failure to Protect Resident from Physical Abuse: A resident reported that two CNAs were rough while moving them up in bed and bumped their head into the headboard, causing pain. Another resident heard the incident, and the DON and administrator later confirmed the abuse allegation and failure to report were substantiated after the facility investigation.
Failure to Report Alleged Physical Abuse: A resident alleged that two CNAs were rough while repositioning them in bed and that the resident’s head was bumped into the headboard, causing pain. One CNA confirmed the head bump occurred during care, and the administrator stated the abuse allegation and failure to report were substantiated because the staff did not report the incident immediately.
A resident's urinary catheter drainage bag was observed on the floor at the bedside on two occasions. The facility's policy stated catheter tubing and drainage bags should be kept off the floor, and CNAs, an LPN, and the DON all stated the bag should be hung on the bed frame or side of the bed and not touch the floor.
A resident at risk for weight changes did not have all ordered weekly weights documented. The care plan directed weights per MD orders, but the nurse failed to record one of the scheduled weekly weight checks, and the corporate nurse acknowledged that some ordered weights had been missed for some residents.
Failure to Timely Report Allegation of Abuse: The facility failed to report an allegation of abuse for a resident with chronic pain syndrome, rheumatoid arthritis, major depressive disorder, and moderate cognitive impairment within the required 2-hour timeframe. The DON stated the ADON completed the investigation but did not timely notify OSDH, and there was no documentation that APS or the Nurse Aide Registry was notified at the time of the initial report.
Failure to Thoroughly Investigate Abuse Allegations: The facility did not thoroughly investigate abuse allegations involving two residents. One resident with mood, anxiety, and impulse disorders was hit in the face by another resident, but there were no documented resident or staff interviews or investigative notes. Another resident with chronic pain, RA, major depressive disorder, and moderate cognitive impairment had an allegation of physical abuse, but the record lacked interviews with the reporter, alleged perpetrator, or others with knowledge of the event; the DON stated the investigation lacked documented interviews.
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