Failure to supervise a resident with severe dementia, impaired safety awareness, and a high fall risk led to an unwitnessed fall in a dayroom away from the nurses’ station. An RA placed the resident there after a shower and left the resident unattended while caring for another resident; the resident was later found on the floor with the arm twisted backward and was sent to the ED with a closed distal humerus fracture.
Failure to Protect a Resident from Inappropriate Touching A resident with severe cognitive impairment was inappropriately touched by another resident in the dining room. Staff interviews and record review showed a nurse witnessed the other resident rubbing the resident’s vaginal area over clothing, while another staff member reported the resident had touched her inappropriately and apologized after saying he thought she was a visitor. The incident was not immediately reported to the Administrator, and the resident representative later said the resident appeared withdrawn after being notified.
Failure to Timely Report Allegation of Abuse: A nurse witnessed one resident touch another resident inappropriately, but the incident was not reported within the required timeframe. The LPN separated the residents and addressed boundaries with the resident involved, but did not report the event because she believed the RN would notify the DON. The DON and Administrator later stated the incident had not been reported immediately as required.
Failure to report an allegation of abuse: A resident alleged that a nurse grabbed her arm and hurt her, but the DON did not create a reportable because there were no bruises. The DON and Acting Administrator stated allegations were investigated within two hours and were not reported if they were not substantiated.
A facility failed to document VS every shift for two residents despite physician orders. One resident had dementia, diabetes, UTI, and acute kidney failure; the other had hemiplegia, TIA, HTN, CKD, heart failure, and cystitis. Records showed multiple missing entries for O2 sat, pulse, respirations, temperature, and BP, and staff interviews confirmed that prior-shift VS were sometimes carried forward in the EHR instead of being obtained and documented each shift.
Failure to Follow Contact Precautions: A CNA entered a resident’s room without gloves, a gown, or hand hygiene despite contact precautions for ESBL and VRE. The CNA spoke with the resident, touched the resident’s bed sheet, and left without sanitizing her hands. The resident had osteomyelitis, ESBL resistance, VRE, and moderate cognitive impairment, and her care plan and orders required strict single-room isolation with contact precautions.
Failure to Protect Residents from Physical Abuse: A cognitively intact resident physically assaulted three other residents during separate altercations after verbal confrontations. The facility did not place the resident on 1:1 supervision after each incident, and the DON stated the other residents were simply moved away instead. The affected residents included one with severe cognitive impairment, one with moderate cognitive impairment, and one cognitively intact resident.
Delayed Notification for Missed IV Antibiotic Doses: A resident admitted with sepsis and other serious diagnoses had an order for IV Piperacillin-Tazobactam, but the medication was not available for the scheduled doses and was not administered until later the next day. The MAR showed the doses were delayed, and there was no documentation that the provider or NP was notified when the antibiotic was unavailable, despite the facility policy requiring physician notification when medications are not received timely from pharmacy.
A resident with dental caries, hemiplegia, visual loss, cognitive communication deficit, and a history of TBI was found with chlorhexidine mouthwash at bedside, even though the facility had no documented IDT assessment or care plan focus for self-administration. The MAR showed repeated mouthwash orders that allowed bedside storage, but the MDS Nurse found no meeting notes showing the request was discussed, and the DON confirmed no IDT discussion occurred regarding self-administration.
Resident health information was left visible during medication administration when an unattended medication cart was found unlocked with the narcotics book open and the computer displaying a resident's information. RN1 confirmed she forgot to lock the cart and close the narcotics book and computer while going back and forth to a resident's room, and the UM and DON verified the cart should have been locked and the information concealed.
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