Delay in Starting Antibiotics for Positive Wound Culture: A resident with an abdominal wound, ileostomy, and recent surgical aftercare had a wound culture that grew E. coli, but the positive result was not communicated promptly and antibiotics were not started until several days later. The wound nurse, LPN, DON, ADON, administrator, and NP all confirmed the delay, and the resident reported she believed she was already supposed to be receiving antibiotics.
Failure to Protect Resident From Neglect and Unsafe Conditions: A resident with dementia and total-care needs was found in a room with a soiled brief on the floor, caked dried fecal material on both feet, and a mattress with dried fecal smears and odor. A male resident with severe dementia was observed wandering the secure unit and entering her room without staff monitoring or redirection. Staff were unaware of the fecal soiling, the room-based activity record was absent, and the resident had no TV in her room.
A resident with dementia and severely impaired decision-making repeatedly paced the unit, pushed on exit doors, and triggered the emergency door alarm, but staff did not escalate supervision or respond appropriately when the alarm sounded. Video showed the resident leaving through an exit door and descending the stairs, while security later reset the alarm without checking the area. The resident was not accounted for for about two hours and was later found to have fallen outside, sustaining a head injury and facial abrasion that led to hospitalization.
A resident with cerebral palsy and dependence for transfers had a care plan requiring a Hoyer lift and two staff for all transfers, but a CNA attempted a manual stand-and-pivot transfer instead. During the transfer, the resident’s weight shifted, she was guided to the floor, and she later reported being dropped and injured. Hospital imaging confirmed fractures of the distal femur and patella, and staff interviews confirmed the resident’s transfer status required a lift with two-person assistance.
A resident with Type 1 DM and a recent DKA history developed worsening hyperglycemia, emesis, confusion, and altered mental status, but critical labs showing glucose 592 and CO2 <5 were not promptly communicated or acted on. Staff documented elevated blood sugars and symptoms, yet provider notification and 911 activation were delayed until the resident was critically ill with suspected DKA and severe metabolic acidosis, requiring EMS transfer to the ER.
A resident with chronic kidney disease, recent digestive surgery aftercare, and a nephrostomy tube, who required maximal assist for transfers and used a wheelchair, was being transported by a CNA-driver for follow-up care and subsequent ER evaluation. Instead of proceeding directly to the ER, the CNA-driver diverted to a personal dental appointment, parked the facility van in an unshaded area, turned the engine off, and left the resident strapped in the wheelchair in the back of the van without supervision. The van’s doors and windows were largely closed, it became very hot inside, and the resident, who remained cognitively intact, called 911 reporting she was locked in and getting warm. Police and Fire Department responders found the non-running van with only a slightly open door and one window down, noted the resident was visibly sweating, and removed her from the vehicle. The facility’s own policies prohibited leaving residents unattended in vehicles and required continuous supervision during transport, but these were not followed, resulting in a finding of neglect and Immediate Jeopardy.
Failure to Provide Diabetic Monitoring and Treatment: An IDT failed to recognize that a resident with type II DM, CKD, and recurrent UTIs needed a diabetic treatment plan after re-admission. Although an abnormal BG was documented, staff did not notify the MD, no diabetic orders were entered, and BG monitoring stopped for weeks. Staff later gave conflicting explanations about hospice status and family wishes, but there was no documentation that the resident or representative declined diabetic care. The resident was ultimately found with severe hypoxia and a BG reading too high for the device, then transferred by 911 with sepsis and HHS requiring ICU care.
The facility failed to enforce its Smoking/Vaping policy for multiple smokers, including oxygen‑dependent residents, allowing them to keep cigarettes and lighters on their person or in their rooms and to smoke inside, including while oxygen was in use. One oxygen‑dependent resident with COPD and intact cognition had a documented history of smoking in his room and bathroom despite prior staff observations and care plan interventions requiring supervised smoking. Staff, including CNAs, an RN, and the DON, were aware of repeated in‑room smoking and residents’ refusal to surrender smoking materials but generally did not confiscate supplies, relying instead on notifying management while rounding remained infrequent. This inaction culminated in an event where a resident’s nasal cannula ignited while he smoked in his room, causing second‑degree facial burns and respiratory distress, and surveyors later observed other smokers, including another oxygen‑dependent resident and a roommate of an oxygen‑dependent resident, leaving the designated smoking area and returning to oxygen‑posted rooms with cigarettes and lighters still in their possession.
Failure to Protect a Vulnerable Resident from Sexual Abuse: A cognitively impaired resident was found in bed with another resident who had a documented hx of sexually inappropriate behavior toward staff and residents. Staff observed thrusting movements and the other resident on top of her, while the resident was later sent to the hospital for rape kit and STD testing as a suspected sexual battery. Records showed the resident had severe cognitive impairment, and the other resident had a care plan for inappropriate sexual behaviors and required 1:1 supervision.
Two residents were involved in a sexual abuse incident when a CNA entered a darkened room and found one resident in a wheelchair at the bedside of another, who was lying in a fetal position with her brief pulled down, while the wheelchair-bound resident had a clenched fist against her genital area and his other hand on his exposed penis. The alleged victim had dementia, a BIMS score indicating significantly impaired cognition, and a documented lack of capacity for sexual consent, with a care plan calling for cueing, reorientation, and supervision. Staff and leadership reported that the alleged perpetrator frequently visited other residents’ rooms and masturbated in his shared room, and a prior inappropriate interaction between the same two residents in the dining room had been redirected but not reported. The resident’s representative also reported multiple prior occasions of finding the male resident in the female resident’s room with the door shut and notifying staff, who stated they would separate and monitor them more closely, indicating a failure to adequately identify, assess, and monitor behaviors that could lead to resident-to-resident sexual abuse.
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