An LPN found a resident’s insulin vial missing the opened date during administration, and a second vial was also unlabeled. A check of the medication cart found multiple residents’ multi-dose insulin vials without opened dates, while MARs showed the vials had been used repeatedly after pharmacy delivery dates. Staff, including the pharmacist, DON, ADON, and MD, stated the opened date should be on the vial and that opened insulin is limited to 28 days unless the manufacturer states otherwise.
A resident with type-2 diabetes, malnutrition, depression, and unsteadiness on feet required extensive help with bathing, dressing, transfers, toileting, and meals, but the facility repeatedly failed to document ADL care such as bed mobility, dressing, toileting, bowel and bladder elimination, transfers, and snacks. Interviews with the CNA, ADON, and DON confirmed that charting was expected to reflect care provided, and facility in-services directed staff to document meals, bowel movements, grooming, skin changes, refusals, and other assigned tasks accurately and on time.
A resident with HTN, ESRD on dialysis, CKD, DM2, and depression returned from the hospital with an order for an antihypotensive medication to be given TID and held if SBP was greater than 120. Facility staff entered and administered the medication incorrectly, giving it multiple times when SBP was above the ordered parameter and missing doses when SBP was below it. The family questioned the order during a care plan meeting, and the DON acknowledged the issue was a med error; the MD stated staff were expected to follow the order.
Failure to Timely Report Suspected Sexual Abuse: A resident with severe cognitive impairment, dementia, and dependence for ADLs had a suspected rape allegation discovered by staff, but the report was not sent to the State Agency within the required timeframe. The DON stated the facility believed it had 24 hours to report abuse unless bodily injury was involved, while other leadership stated abuse should be reported immediately or within a few hours.
Failure to Report Injury of Unknown Origin Within Required Timeframe: A resident with vascular dementia, contractures, and total dependence on staff was found to have multiple recent rib fractures after being sent to the ER for vomiting. The incident was not reported to OLTC within the required two hours, even though the Administrator and DON stated that injuries of unknown origin must be reported immediately and within two hours, and the facility policy required the same.
A resident with severe cognitive impairment, wandering behavior, and a known elopement risk exited through an alarmed kitchen door after staff cleared the alarm without checking the outside area. Staff later found the resident outside near another entrance and returned the resident inside. The resident had diagnoses including dementia, was care planned for wandering, and had orders and assessments documenting high risk for elopement.
Failure to timely report allegations of abuse: a resident with severe cognitive impairment made two sexual assault allegations, and staff did not ensure the reports were promptly escalated to the Administrator and SSA as required. One LPN was unaware of the reporting requirements, and the facility’s records showed delays in notifying the State and internal leadership.
Failure to Monitor Resident Trust Fund Deposits: A resident with severe cognitive impairment, dementia, and disorientation had authorized the facility to manage personal funds and receive monthly income on the resident’s behalf. The facility failed to notice that two pension checks stopped being deposited into the resident’s trust account, while funds continued to be used for patient liability, insurance premiums, and personal needs. Staff stated the missing deposits were not identified until the account balance had significantly declined, and the BOM and Administrator acknowledged the account should have been reviewed and reconciled monthly.
A resident admitted with atrial fibrillation, a history of falls, gait impairment, and weakness was not accurately placed on the baseline care plan. The care plan did not identify the anticoagulant ordered and administered twice daily or include fall-risk interventions, even though the fall risk assessment showed a high-risk score and staff interviews confirmed they relied on the care plan for resident care. The resident later fell in the facility and was found on the floor with a head laceration, shallow respirations, and no verbal response.
Survey results were not readily available for resident and family review. The admission packet and Resident Council minutes did not reference the right to see survey results, the posted resident rights did not include that right, and cognitively intact residents said they did not know where the results were kept or had not seen them. A surveyor could not find the results in common areas, and the DON ultimately produced the only survey results book, which was stored in a drawer at the security officer's desk near the side entrance.
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