A CNA failed to treat a severely cognitively impaired resident with dignity and respect while redirecting the resident near the nurses' station. Witnesses reported the CNA used demeaning language such as "you're nasty" and "you're gross," and placed a hand on the resident's chest while telling the resident to move away. The resident had Parkinson's disease, schizophrenia, and a BIMS score indicating severe cognitive impairment, and the DON confirmed the interaction was not respectful or professional.
Failure to immediately report abuse and resident altercation allegations: Staff did not promptly notify administration after an LPN witnessed possible verbal and physical abuse between a CNA and a resident, instead leaving a note that was not found until days later. Staff also delayed reporting a resident-to-resident physical altercation involving two residents, with the DON learning of it nearly five hours after it occurred, despite policy requiring immediate reporting.
Incomplete abuse investigation and inaccurate DPH reporting: The Facility failed to document a thorough investigation and timely final report after an allegation that one resident punched another resident in the nose. The HCFRS report listed the wrong time and witness information, while the investigation file showed the incident occurred earlier and included staff witness statements, but no documentation supported the alleged push by the other resident or an interview with the reported resident witness. The DON said she could not explain the discrepancies and reported the time based on when staff notified her.
A resident who was dependent on staff and required assist of one for ceiling-lift transfers was being moved from a wheelchair to bed when a CNA did not fully secure all sling loops to the overhead lift. As the resident was raised and the wheelchair was moved away, one upper loop detached, the resident slipped from the sling, and was lowered to the floor, hitting his/her head and sustaining a small eyebrow swelling and lip bleeding.
Incomplete wound care documentation for multiple residents: Nurses signed the TAR showing daily dressing changes were completed for residents with pressure wounds and other wounds, but the records did not include wound appearance, drainage type or amount, odor, or treatment effectiveness. The DON stated she expected documentation of wound location, drainage, pain, and signs of infection with each dressing change, and noted the TAR did not provide a place to record specific wound characteristics.
Failure to Protect Resident Information: A CNA took a screenshot of a resident’s facility face sheet and sent it to another person without the resident’s knowledge or consent. The image included the resident’s name, DOB, room number, allergies, BP, respiratory rhythm, and other PHI, and the resident was alert and oriented with a BIMS of 15 and diagnoses of DM2 and COPD.
A resident who required a mechanical lift for all transfers was moved using a repositioning pad instead of a designated lift sling. Staff noted the device lacked the usual leg straps and was not intended for use with the lift, but it was still used for transfers from bed to wheelchair and back. During the later transfer, the resident slid out of the lift, fell to the floor, hit the head, and was sent to the ED, where CT showed an IPH.
CNA Performed Manual Disimpaction Outside Scope of Practice: A resident with multiple cardiac and chronic conditions reported that a CNA inserted a finger into the rectum to remove stool after the resident felt constipated and said something was stuck. The resident said it was painful, and the DON later stated the CNA admitted doing it and said she thought she was helping, even though the facility’s policy said nurses and CNAs are not to perform manual digital disimpaction.
Failure to Notify Provider and HCP After Medication Error: An LPN gave one resident another resident’s morning meds in error after misidentifying the resident in the dining room. The nurse later realized the mistake but did not notify the resident’s MD or activated HCP, and another nurse who learned of the error also did not notify the MD. The DON stated the physician should have been notified right away.
Medication Given to Wrong Resident: A resident with multiple chronic conditions, including Parkinson's disease, DM, epilepsy, dementia, and AFib, received another resident's scheduled morning meds in error. The nurse prepared the wrong resident's meds, did not verify identity using a second identifier, and administered them after the resident incorrectly identified himself as the other resident. The error was later recognized when the other resident reported the mix-up to nursing staff.
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