A resident with severe dementia and a known wandering/elopement risk eloped from the facility after staff lost track of the resident during the evening. Staff searched the building and grounds, notified law enforcement, and the resident was later found walking along a roadway in the rain. Surveyors also found multiple exit doors, only one audible alarm, delayed door closure on several exits, and nonfunctional cameras near most exits, while staff reported the resident frequently wandered, entered other residents’ rooms, and tested exit doors.
Failure to protect a resident from sexual abuse by another resident. A resident with severe cognitive impairment and depression was involved in two separate incidents with another resident who had documented hypersexual behavior, impaired cognition, and conflict with female residents. Staff witnessed one incident in which he attempted to get her to open her mouth so he could insert his penis, and another in which he exposed his penis to her; both allegations were substantiated.
Medication administration errors were observed for 3 of 32 opportunities, resulting in a 9.37% error rate. An LPN gave a multivitamin, aspirin chewable, and memantine 5 mg that did not match the physician orders on the MAR for two residents. The LPN confirmed the discrepancies, and the DON stated medications should match the orders and that the MAR had linked the wrong memantine strength to the pharmacy supply.
Failure to report an allegation of sexual abuse involving a second resident. Staff and resident interviews, along with record review, showed that an FRI addressed an incident involving one resident, but the DON’s email and resident statements identified another resident as also being involved in sexual activity with a male visitor. The facility did not include that resident in the FRI, despite a policy requiring all abuse allegations to be reported immediately to the Administrator and appropriate agencies.
Unsanitary areas, unsecured oxygen tanks, dirty IV stands, and leaking HVAC units were observed throughout the facility. The laundry room had debris on the floor, missing tiles, water damage, and a sink with stagnant water; the shower room had stained grout; empty O2 tanks were left unsecured outside the storage cage; two residents receiving enteral feedings had metal IV stands and bases with dried brown residue; and leaking AC/heating units in two rooms had basins placed underneath them. The DON and Maintenance Director confirmed several of these conditions.
Failure to protect resident privacy and confidentiality occurred when tracheostomy care was provided to two cognitively intact residents with the room door open and the privacy curtain not drawn, allowing the treatments to be visible. The facility also mistakenly mailed a room change notice containing another resident's name to an unauthorized family member, and the DON/Administrator confirmed the error.
Failure to timely report a resident-to-resident abuse allegation. A resident with moderate cognitive impairment reported that another resident with dementia made an inappropriate sexual comment in the lobby area, and the resident said no physical sexual act occurred. The resident told staff the same evening, but police were not contacted until the next day after the resident reported it herself, and the SA report was submitted later that day. The facility policy required immediate reporting, but not later than 2 hours, for abuse allegations.
A facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents. One resident with depression, altered mental status, and moderate cognitive impairment reported that another resident made inappropriate sexual comments, but the investigation did not include key staff interviews, a detailed interview of the alleged victim, witness interviews, or review of whether other female residents had similar concerns. The Administrator stated the investigation was vague and lacked needed details and documentation.
Inaccurate MDS Coding for Resident Fall: A resident with dementia and behavioral disturbances had a quarterly MDS that did not include a documented unwitnessed fall with bruising and a laceration, even though the event occurred during the assessment period. The MDSC confirmed the fall should have been included, and the DON stated the MDS was to be accurate.
Failure to Provide Timely ADL Care, Bathing, and Personal Hygiene: The facility failed to provide timely incontinence care for one resident who was dependent for toileting, failed to ensure bathing/showering occurred as documented for three residents who were dependent for bathing, and failed to provide shaving and nail care for a totally dependent resident. Observations, resident interviews, record review, and staff statements showed delayed incontinence care, sparse or missing bath/shower documentation, and a resident left unshaven with overgrown fingernails.
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