Delayed Response to Resident Call Lights: Staff did not respond promptly to call lights for multiple residents, with logs showing repeated waits over 20, 30, and even 50 minutes, and some residents reporting waits up to 2 hours. Several residents said they became incontinent while waiting for bathroom help, and one resident was observed unable to reach her call light because it was disconnected from the extender. Residents also reported call lights left out of reach and concerns that staff were not available on the floor.
Expired hand sanitizer was found in many resident rooms, a linen cupboard lacked a covering to protect linens from airborne infectants, and a resident’s wheelchair had torn, dirty padding. Staff also failed to consistently follow EBP and hand hygiene during personal hygiene and wound care for residents with pressure ulcers, including not cleansing a wound before dressing it and bringing wound care supplies into multiple rooms without sanitizing equipment between residents.
Inaccurate MDS coding was found for two residents whose diabetes meds were non-insulin injectables. One resident with ESRD and diabetes had Ozempic ordered, and another resident with CKD and diabetes had Mounjaro ordered, but both MDS assessments incorrectly coded insulin use and hypoglycemic drug class use. The MDS coordinator acknowledged the coding error but did not update the assessments after learning of the inaccuracy.
Improper Storage and Dating of Oxygen and CPAP Equipment: Two residents had oxygen equipment and CPAP items observed out of proper storage, including nasal cannula tubing on the floor, undated or empty humidifiers, and a CPAP mask on the floor. One resident had OSA with an order for oxygen at bedtime and as needed, and the other had COPD with orders for nightly CPAP and continuous oxygen. Staff stated the tubing, humidifier, and CPAP mask should be stored and dated per facility practice, and the facility policy required weekly changes and dating of oxygen equipment.
Improper Hand Hygiene During Food Prep: A cook wore gloves while handling cucumbers, touched a garbage can lid, and then continued handling food without removing the gloves or washing her hands. She later changed gloves and resumed cutting cucumbers, then removed the gloves and washed her hands. The DM and the cook both stated hand hygiene was expected before gloving and after glove removal.
Nonfunctioning Resident Call Lights: A resident reported waiting a long time for staff to answer her call light and said it had been disconnected from the wall extender, while another resident said her call light had been unplugged and she had to get help by having a friend use his call light. Staff and residents also reported repeated call light problems for another resident, and the DON stated call lights were expected to always be in working order; the facility did not have a call light policy.
A resident received 2.5 mL of Morphine Sulfate PO instead of the ordered 0.25 mL dose after a CNA/MA medication error. The resident then developed decreased O2 levels, lethargy, respiratory distress, and apnea, and required Narcan. The EMR lacked documentation of post-error assessments, call times to hospice or Ecare, an incident report, and a documented physician order for the Narcan given by hospice.
Failure to timely report suspected abuse, neglect, and possible drug diversion. A resident alleged verbal abuse and neglect after two travel CNAs delayed call light response and refused to clean her after a transfer; the neglect allegation was validated, but the DON did not submit the required FRI to SD DOH. A second resident on hospice had morphine that appeared lighter in color, raising concern for tampering/diversion, and the DON acknowledged the state report was submitted late.
Staff failed to respond promptly to resident call lights for multiple residents, with repeated waits over 15 minutes and several waits over 30 minutes or more than an hour. Residents reported being left on the toilet, becoming incontinent, and seeing staff turn off call lights without helping. Staff said there were not enough walkie-talkies, and multiple employees were unaware of any set response-time expectation. The report also found unclear condom catheter care for a resident whose night catheter supplies were stored improperly and whose care instructions were not clearly detailed in the care plan or TAR.
A resident’s Dilaudid was received from the pharmacy and signed for by an LPN, but it was left unsecured in the med room instead of being double locked in the med cart. The next day, a CMA could not find the medication, and a facility-wide search confirmed it was missing. The DON stated the medication should have been secured in the cart, and the facility policy required Schedule II-V meds to be kept in separately locked, permanently affixed compartments.
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