Meals were not served according to residents’ meal tickets and dietary needs. A resident who was supposed to receive chocolate pudding did not get it, a resident with a milk allergy and dislike of fresh vegetables was served raw vegetables and a milk-containing supplement, another resident did not receive the ordered water with lunch, and a resident did not receive the listed sandwich toppings. The Dietary Mgr and Regional Dietary Mgr acknowledged the meal ticket mismatches.
Dietician-approved pureed menu not followed for two residents with pureed diet orders. Staff served pureed eggs, pureed pork breakfast sausage patties, and grits instead of the approved pureed pancakes and hash browns with thickened gravy, and the Dietary Manager stated the menu changes had not been approved by the dietician.
Aspiration precautions were not followed when an LPN fed a resident with dysphagia, dementia, and significant cognitive impairment. The resident’s care plan and ST recommendations called for small bites, alternating bites and sips, no straws, and slow feeding, but the LPN used overfilled spoonfuls, did not offer fluids between bites, and gave cola through a straw while the resident coughed during the meal.
Failure to Protect Resident from Physical Abuse: A resident with a hx of TBI, schizophrenia, and intermittent explosive disorder physically assaulted another resident in the dining room after an exchange of words. The assaulted resident had Alzheimer’s disease and dementia, was severely cognitively impaired, and sustained a hip fx and multiple rib fx requiring emergent surgery. Staff and the NP confirmed the abuse, and the aggressor stated he would do it again.
Failure to timely report alleged abuse and neglect: A resident’s fall with injury was later found to involve a femur fracture, but the incident was not reported within the required 24-hour window. In a separate event, a resident reported verbal abuse by an agency CNA, and the DON acknowledged the allegation was not reported to the state agency within the required 2 hours.
A resident with Alzheimer's disease, HTN, and anxiety disorder did not receive the final dose of an ordered Lasix regimen, and a chest x-ray ordered for edema was not sent to imaging in a timely manner. The record later showed a large L-sided pleural effusion with overlying atelectasis vs consolidation, and the resident was sent to the ER for evaluation of pleural effusion and SOB. The Unit Manager and DON acknowledged the missed Lasix dose and delayed x-ray.
Missing Psychotropic Consent for Zoloft: A resident with vascular dementia, pseudobulbar affect, and depression had an order for Zoloft 25 mg daily, but the medical record did not contain a psychotropic consent for the medication. During interview, the Unit Manager acknowledged the consent was missing.
A resident with TBI, schizophrenia, and behavioral outbursts was emergently transferred after an altercation and then involuntarily discharged. The discharge notice listed an effective date tied to the transfer, was sent to the resident and others after discharge, and did not include the required mailing address, email address, and phone number for the protection and advocacy agency for individuals with mental illness.
Controlled medication records were not maintained and reconciled for one narcotic on Medication Cart B. A resident's Phenobarbital 64.8 mg count was inconsistent between the medication card and the narcotics log, and an LPN acknowledged she did not sign out the dose when it was administered. The facility policy stated narcotics must be accurately accounted for and inventoried at every shift change.
Hand hygiene and glove use were not followed during pericare for a resident with bowel and bladder incontinence, moderately impaired cognition, and EBP orders for gown and gloves during high-contact care. A CNA entered the room without sanitizing, donned gloves without hand hygiene, handled fecally soiled gloves and supplies, changed gloves without sanitizing, touched clean items while still wearing soiled gloves, and handled trash without hand hygiene afterward.
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