Failure to complete required skin assessments and maintain ordered wound care: A resident with lymphedema, CVI, diabetes, and chronic pain had ordered compression wraps removed and not replaced, leaving both lower legs open to air with redness, a blister, and open areas on the shins. An LPN reported the change in skin integrity and the lack of a current skin assessment over several days, while the unit manager and DON confirmed the last skin assessment was not done within the required weekly timeframe and should have been completed after the change was reported.
A resident was injured when staff failed to properly use a Hoyer lift during a chair-to-bed transfer. An LNA asked a Support Aide to help, even though the aide’s role did not include lift transfers and she had no training on how to assist with them. The resident fell to the floor during the transfer and sustained a head strike, RUE pain, and bilateral hip pain; the roommate with BIMS 15 reported that the resident was dropped by the staff using the lift.
Lack of Mechanical Lift Competency for Direct Care Staff: A resident sustained a witnessed fall from a Hoyer lift during a transfer by two staff members and was later noted to have pain in the RUE and bilateral hips, with a head strike also documented. Review of staff files showed one LNA had no documented mechanical lift training or competency, and a Support Aide who sometimes helped with Hoyer transfers reported she had not received facility training on transfers or lift use.
Failure to communicate a dialysis dietary recommendation for a resident with DM2, CKD stage 5, and elevated phosphorus. Dialysis labs showed a phosphorus level of 7.8 and noted to encourage avoiding ice cream, but the resident continued receiving dairy items such as ice cream, yogurt, and milk. The UM described a process for sharing new diet orders via a communication slip, yet the Dietary Mgr could not find one and the Dietary Tech said the recommendation was never communicated or entered into the system.
Failure to prevent resident elopement: A resident with intact cognition, a walker, and documented fall risk left the facility without authorization and walked about 0.7 miles to a spouse’s apartment after learning the spouse was hospitalized. Police located the resident and returned them to the facility. Staff later confirmed the resident exited through the front door while a visitor entered, and the resident had balance issues, poor safety awareness, and shortness of breath with ambulation.
The facility failed to notify the LTC Ombudsman of the transfer or discharge of three residents. Record review showed no documentation of Ombudsman notification for the residents, and the Administrator confirmed the facility does not notify the Ombudsman’s office for planned transfers or discharges to other SNFs.
Failure to Report Resident-to-Resident Altercation as Abuse: A resident with significant cognitive impairment willfully hit another resident in the chest with a closed hand after becoming angry over a shirt. Staff reported the incident to the shift supervisor, who determined it did not signify abuse, and the DON was not notified immediately as required.
Food storage and kitchen sanitation were deficient when surveyors found undated leftovers and chicken cutlets, spill puddles in the refrigerator, a dirty standing mixer, sticky kitchen floors, dented cans used as a door stop, and wet pots stacked for storage. The Kitchen Manager confirmed the observations, and repeat visits showed the same dirty conditions remained, with the facility policy requiring food to be dated and labeled and equipment to be cleaned, sanitized, and dried after use.
The facility failed to implement its Legionella water management program and did not consistently use PPE as required. Leadership could not show that monitoring or control measures in the water management plan were being followed, and laundry staff handled dirty linen with gloves only while clean mop heads and wet Hoyer sling pads were drying in the dirty linen area. In addition, a nurse entered a resident’s room without hand hygiene and moved a catheter bag without the required gown and gloves for Enhanced Barrier Precautions.
Failure to Treat a Resident with Dignity: An LNA made dismissive comments about a resident’s cognition and incorrectly stated the resident had had a stroke while the resident was upset during a Hoyer lift transfer. The resident, who had a TBI, was also denied more coffee at breakfast by an LPN despite not being on fluid restrictions, even after the resident requested it again.
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