A resident with CKD stage 5 and ESRD had an MDS that did not indicate dialysis in Section O, even though the resident had active orders for dialysis, a care plan for dialysis-related needs, and staff confirmed he was receiving dialysis at an outside clinic on a regular schedule. The MDS nurse stated dialysis should have been triggered on the assessment and described the omission as an oversight/data entry error.
Insulin Pen Not Primed Before Administration: An LVN administered Lantus to a resident with diabetes without priming the insulin pen first. The resident had orders for Lantus 30 units BID, and the LVN stated he was not familiar with priming the pen. The DON stated the pen should be primed before use to ensure the resident receives the appropriate dose.
A resident with dysphagia and a hx of stroke was ordered a slow-flow adaptive drinking cup with fluids, and the care plan and meal ticket also identified the need for the device. During a meal observation, a CNA served cranberry juice in a regular cup instead, and the resident drank from it and immediately coughed. The CNA, an LVN, the SLP, and the DON all acknowledged the resident should have received the ordered adaptive cup.
Missing Hospice Election and Certification Documents: The facility failed to coordinate hospice care planning and ensure a resident’s hospice binder contained the election/cancellation/update form and the physician’s certificate of terminal illness. A resident with schizophrenia, metastatic breast cancer, and severe cognitive impairment was receiving hospice services, and the DON stated the hospice company was responsible for the binder after the missing forms were identified and faxed.
An LVN failed to follow hand hygiene and insulin pen preparation practices during a medication pass for a resident with diabetes. After washing his hands, he turned off the faucet with his bare hand, then administered insulin without cleaning the insulin pen’s rubber seal with alcohol first. The DON stated both actions were a break in infection control, and the facility policy required proper hand hygiene and noted that gloves do not replace hand hygiene.
Food service safety standards were not followed in the kitchen. Two 5-lb containers of cottage cheese and two 5-lb containers of sour cream were found in the refrigerator without labels showing when they were received, opened, or when they should be discarded. In addition, personal items were on food prep counters during meal prep, including 2 cell phones, a charger and wires, a personal vape, and a drink tumbler. The FSM stated opened foods should be labeled and used within 7 days, and that the items on the counters could contribute to an unsanitary food prep area.
Cell Phone Use During Resident Care: CNAs were observed by 11 confidential residents using personal cell phones while providing showers, peri-care, and other hands-on care, as well as while walking in halls, at the nurses’ station, and in the dining area. Residents said the phone use made them feel ignored, embarrassed, and that their privacy was violated. The DON and ADM stated staff should give residents full attention and not use cell phones in patient care areas, and the facility policy required residents be treated with kindness, respect, dignity, and confidentiality.
Kitchen Sanitation and Food Labeling Failures: Surveyors observed a fryer, toaster oven, wall behind the dishwashing station, and hot holding trays/cookie sheets with heavy grease and grime buildup. Multiple canned goods, pantry snacks, prepared gravy, and prepared pureed chicken were also found without required use-by or expiration dates. Dietary staff and ADM stated staff were responsible for cleaning, labeling, and dating food items, but several items were left undated and the dietary mgr was unavailable.
Care Plan Not Revised for New Fluid Restriction: A resident with CHF and intact cognition was placed on a new 1500 cc/24 hr fluid restriction, but the care plan only addressed diet and liquids and did not include the restriction or related non-compliance. An LVN said staff were aware of the order, while the ADON stated the new restriction should have been added to the care plan and revised after changes in care.
A resident with a right foot fracture was observed wearing an orthopedic boot, but the chart lacked a physician order and the care plan had no focuses, goals, or interventions for the boot. The charge nurse and ADON both acknowledged the missing order and care plan, even though the resident had been admitted post-hospitalization with a camboot and the boot was being used daily to immobilize the fracture.
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