Failure to Use Gait Belt During Assisted Ambulation: A CNA assisted a resident with a walker to the bathroom without using a gait belt, and the resident lost balance and fell, sustaining an elbow abrasion and a fractured femur requiring surgery. The resident had COPD, dementia, repeated falls, and a history of TBI, and her care plan called for one staff member to assist with toileting and transfers using a gait belt, wheelchair, or sit-to-stand lift as needed. Interviews showed staff relied on the care plan or Kardex for assistance needs, while the facility policy stated gait belts should be used with assisted ambulation unless medically contraindicated.
A CNA/QMA accepted a resident’s offer to cash scratch tickets in exchange for part of the winnings and also took a discharged resident’s Mounjaro injection for personal use. The resident with intact cognition confirmed the money arrangement, and an RN administered the unlabeled injection after the CNA/QMA asked her to do so. The facility’s policies prohibited staff from accepting resident money or gifts and defined diversion of a resident’s medication for personal use as financial abuse.
Staff failed to respond promptly to resident call lights, and multiple residents reported long waits for help, including one resident whose call light was left on for over an hour and another who sometimes urinated before assistance arrived. Call light reports showed repeated delays for several residents, with many responses over 20 minutes and some over 60 minutes or longer. Interviews with residents and staff showed inconsistent response expectations, limited radio use, and situations where staff in one room were unaware that other residents needed assistance.
Medications were left unsecured on medication carts and one cart was observed unlocked and unattended. An RN left an opened antibiotic for a resident on top of a cart, another RN left Polyethylene Glycol and Fluticasone nasal spray on top of a cart while administering meds, and a CMA was observed with an unlocked cart whose drawers were easily opened. The DON stated medications should be locked in the cart and refrigerated meds returned to the refrigerator after use.
An RN failed to maintain a resident's dignity and respect when she told him to "stop talking" after he asked about the timing and contents of his meds. The resident had moderately impaired cognition and multiple mental health diagnoses, and his care plan directed staff to use supportive communication, allow time to respond, and explain all procedures, treatments, and medications. Interviews with the CNA, RN, DON, and administrator confirmed that telling a resident to stop talking was not considered dignified care.
An LPN assisted four residents with supper without performing hand hygiene between resident contacts, touching residents and their items while feeding and handing out utensils. In the kitchen, a cook with a beard was observed preparing raw chicken and other food without a hairnet covering his beard, despite staff stating that beard coverings were expected anytime food was being prepared.
A CMA and a CNA provided high-contact care to a resident on EBP while wearing gloves but no gowns, and they did not perform hand hygiene each time they removed gloves. The resident had intact cognition, quadriplegia, kidney stones, and a nephrostomy tube, and her care plan required gowns and gloves for high-contact care such as repositioning, hygiene, changing linens, and device care.
A resident with dementia and a care plan for two-person full body mechanical lift transfers was pivot-transferred from his wheelchair to bed without a gait belt after staff found no sling under him. An LPN directed the transfer despite knowing the care plan, and the resident’s leg was caught on a bed frame with a missing cover plug, causing a large skin tear and puncture that required ER repair with staples and stitches.
RN/MDS coordinator review showed multiple MDS assessments were not signed by an RN within the required 14-day timeframe after the ARD for numerous residents, including quarterly, annual, PPS, significant change, and entry tracking assessments. The facility also failed to complete a discharge MDS for a resident who was transferred to the hospital and did not return; the RN/MDS coordinator confirmed the omission.
An LPN was observed administering insulin to a resident using a NovoLog pen that had a blank yellow expiration label. Review of insulin pens stored in the med cart found three open insulin pens for two residents, and none had expiration dates recorded on the labels. The DON stated the nurse who first opened each pen was expected to document the date opened and the shortened expiration date, and facility guidelines identified both NovoLog FlexPen and Lantus SoloStar as expiring 28 days after opening.
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