Failure to Supervise Resident at Risk for Elopement: A resident with severe cognitive impairment and known exit-seeking behavior was not accurately assessed or care planned for elopement risk. Staff observed the resident in another resident’s room, then an exit alarm sounded; an LPN closed the door and reset the alarm without checking outside, and staff later could not locate the resident. The resident was found outside the secured unit in cold weather with injuries and confusion, while video showed the resident leaving the building and staff not stepping outside to verify whether anyone had eloped.
Failure to Follow Transfer Plan During Shower Care Resulted in Resident Hip Fracture A resident with dementia, impaired mobility, and a history of falls required a 1-person assist with a 2WW for transfers. During shower care, a CNA transferred the resident without a gait belt or walker, and the resident was lowered to the floor. When staff later tried to stand the resident, the resident had severe R hip pain, a shortened and externally rotated leg, and was sent to the hospital with an intertrochanteric femur fracture.
Food was not maintained in a safe and sanitary manner. A scoop was left in a flour bin, bacon and pie crusts were uncovered and unlabeled in the walk-in refrigerator, a staff member with facial hair was not wearing a beard restraint, and food brought in by a family member was found unlabeled and undated in a hallway refrigerator. The DM acknowledged the issues and stated the items should have been covered, labeled, dated, and properly restrained.
Missing QAPI Training for CNAs: Mandatory yearly QAPI in-service training was not documented for 5 sampled CNAs. The facility assessment listed several yearly staff training topics and competencies, but QAPI was not included in the training plan. The NHA confirmed CNAs are required to complete yearly in-service hours and stated CNA training should include QAPI, though the facility does not provide training directly titled QAPI.
Five of five sampled CNAs did not have documented yearly compliance and ethics in-service training. The facility assessment states staff are to receive training upon hire and on a yearly basis, and the NHA confirmed that CNA annual in-service education should include compliance and ethics after reviewing the nurse aide in-service records.
Five of five sampled CNAs did not have documented annual in-service education totaling 12 hours, and their records did not include dementia management or abuse prevention training. The facility assessment listed abuse and caring for persons with dementia among required training topics, and the NHA agreed the CNA in-service records did not meet the yearly hour requirement and should include dementia and abuse education.
The facility failed to keep call lights within reach for multiple residents and failed to provide needed grooming assistance for a resident who required help with ADLs. Residents were observed in bed or in a wheelchair without accessible call lights, and one resident with dementia and neurocognitive disorder with lewy bodies had long facial hair despite needing staff assistance for shaving. Staff interviews confirmed the call lights were not properly accessible and that the resident needed help with personal hygiene.
Medications Left at Bedside Without Self-Administration Assessment: A resident with a BIMS of 15 and diagnoses including polyneuropathy and vitreous degeneration had medications left in a cup at the bedside on two observations. The resident's assessment stated she did not desire to self-administer medications, and there was no physician order or care plan documentation for self-administration. An MT said she left the medications for the resident to take, while an RN said the resident was supposed to be watched but preferred to take meds on her own.
A resident with multiple orthopedic and neurologic diagnoses and a BIMS of 13 voiced frustration that therapy was not scheduled at specific times and said it caused him to wait around all day and risk missing appointments. Staff acknowledged that residents commonly complained about therapy timing, but the concern was not documented as a grievance, investigated, tracked, or followed up through the facility's grievance process, despite the policy requiring verbal complaints to be recorded and resolved.
A resident admitted with major depressive disorder had a PASARR Level I screen indicating suspected serious mental illness, but the medical record did not include a PASARR Level II screen. The SW confirmed she was responsible for obtaining PASARR screenings and stated the resident should have had a Level II screen completed but did not.
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