A resident with chronic pain, dementia, and other diagnoses repeatedly requested PRN oxycodone-acetaminophen after being assisted to bed, while multiple CNAs alerted an RN that the resident was also making threatening comments. The RN addressed the behavior but did not complete a documented pain assessment, contact the provider, or give the opioid until hours later, after the resident reported being in agony and said the medication had been withheld because of her statements.
Resident choice was not honored when three residents who were documented as able to smoke or vape safely were still placed on supervised smoking with fixed times. One resident with intact cognition and safe smoking behaviors, another resident with stroke-related weakness but observed safe smoking, and a third resident with intact cognition and an incomplete smoking evaluation were all restricted by a facility-wide supervised smoking policy despite staff acknowledging they could smoke safely on their own. In addition, a resident with psychiatric diagnoses asked to stop olanzapine because of weight gain and pain, but the medication change was not completed as ordered at the time.
Incomplete and inaccurate resident records were found for three residents. One resident’s psychotropic medication notes were entered late and did not match the timing of the physician visit and medication changes, another resident’s wander guard checks were inconsistently documented on the MAR despite the device being observed in place, and a third resident’s Lyrica documentation included late entries and conflicting information about the medication order and administration.
The facility failed to maintain documentation for 4 staff members regarding COVID-19 vaccination. Record review showed no evidence that the staff were educated on the vaccine’s benefits and risks, offered the vaccine or information on how to obtain it, or had their vaccination status documented for CDC NHSN reporting. The DON stated the COVID-19 immunization was offered to all staff during flu season, but it was not documented.
Failure to document informed consent for Olanzapine. A resident with multiple psychiatric diagnoses had an order for OLANZapine 10 mg at bedtime, but the medical record contained no consent form. The DON stated there was no documentation that the resident was informed in advance of the risks and benefits of the medication or of treatment alternatives.
A resident with MDD with psychotic symptoms, unspecified psychosis, delusional disorders, anxiety, and PTSD asked to be taken off Olanzapine because of weight gain and increased pain, but the medication was only reduced and then continued for weeks. The record showed an unsigned 7.5 mg order, a psychotropic note describing a taper schedule that was not an actual order, and staff interviews confirmed the resident’s request to stop the medication had not been carried out as documented until the medication was later discontinued.
A resident with diagnoses including osteomyelitis, bacteremia, MRSA infection, type 1 DM, and psychoactive substance abuse was assessed as needing assisted smoking and supervision while smoking. His care plan stated he would not smoke without supervision and that tobacco supplies were stored in the smoking box, yet surveyors observed a nicotine vape in his possession during an interview. An LPN said vaping was not allowed in the building and should be stored with smoking supplies, and the DON was unaware the resident had the vape.
Failure to document required provider visits. A resident with multiple serious diagnoses, including metabolic encephalopathy, vertebral osteomyelitis, pressure ulcers, MI, and chronic respiratory failure, had provider visits documented only on two dates after readmission, with no April visit note found in the record. The DON stated she was unsure of the required visit schedule, said the MD tracked visits, and could not provide the missing note even though she said the MD had it.
A resident with Alzheimer's disease and severe dementia with psychotic disturbance consented to receive the pneumococcal vaccine, but the medical record contained no documentation that it was administered. The DON confirmed the resident did not receive his immunizations.
Failure to Supervise Residents at Risk for Elopement: Two residents who were at risk for wandering or elopement left the facility without proper supervision. One resident with moderate cognitive impairment left in an Uber and later called his daughter because he did not know how to get back, and another resident who required supervised LOA left unaccompanied and was reported missing until he returned on his own. Records showed missing or unclear elopement assessments and no care plan for one resident, and no care plan or progress notes for the other.
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