A hospice resident with COPD, opioid dependence, chronic pain, and anxiety received Narcan nasal spray from staff without a physician order or standing order after being found unresponsive. After the dose, the resident developed flailing and jerking movements, respiratory distress, and signs consistent with opioid withdrawal, and was transported to the hospital where she received lorazepam and morphine and was admitted.
Failure to obtain proper informed consent for meds, vaccines, and side rails: staff used resident signatures or verbal consent when guardians/POAs were in place, and several consent forms were incomplete or missing key details such as dates, witness info, and goals/behaviors for psychotropic meds. Records showed mismatches between legal decision-makers and the people documented on consents, including a resident with guardianship, a resident with a DPOA, and incomplete documentation for bedrails, vaccines, opioids, and psychotropics.
Late Reporting of Facility-Reported Incidents and Investigations: The facility did not report two incident allegations to the State Survey Agency within the required timeframe and did not submit investigation results within five working days for multiple incidents involving residents. The late reports included allegations of neglect, verbal abuse, staff-to-resident abuse, resident-to-resident verbal abuse, unauthorized Narcan administration, and CPR initiated when a POLST was not readily available. Staff member A stated she was responsible for the reports and acknowledged several findings were submitted late.
Delayed Toileting and ADL Assistance for Multiple Residents A resident was left on the toilet for an extended period after staff failed to return to assist him off the toilet, and he was later described as sore for several days. Two other residents who required staff help with toileting and personal care did not receive the needed assistance during the day shift, with statements indicating the CNA said she would return but did not. Records showed one resident was dependent for toileting hygiene and another had moderate cognitive impairment with significant assistance needs, and both were later found saturated with urine.
Failure to Timely Report Abuse and Neglect Allegations: The facility failed to maintain an effective system for timely reporting allegations of abuse and neglect after a prior F609 citation for the same issue. Surveyors found nine late reports involving multiple residents, and staff and the administrator acknowledged ongoing difficulty tracking when reports were due, with most late reports occurring during the monitoring period after the earlier deficiency.
Failure to provide written transfer and bed-hold notice: A resident with dementia and a BIMS score indicating mild to moderate impairment was found on the floor, sent to the hospital, and admitted. The resident received verbal notice of transfer, but the POA/rep was not sent the required written Notice of Transfer/Discharge with the reason for transfer and bed-hold information; staff said the form probably was not mailed because the responsible staff member was off work.
A resident reported that an NF2 hit her on the arm and used abusive language toward her, and the allegation was later substantiated by the facility. The resident later did not recall ongoing concerns, and the arm bruise could not be definitively tied to the incident because she also received routine insulin injections. Staff stated the NF2 had no concerning background issues, and the employee file showed a passed background check, negative drug screen, current abuse training, and no licensure issues.
A resident with a documented DNR POLST experienced cardiac arrest, and staff initiated CPR because they could not locate the POLST or verify code status in the EHR. The signed POLST had been sent to medical records for scanning instead of being immediately available on the unit, and staff reported the resident’s code status was later confirmed by the son and EMS.
Incomplete Investigation of Verbal Abuse Allegation: The facility did not thoroughly investigate an allegation of verbal abuse involving a resident with intact cognition. The file lacked documentation of interviews with accused staff, witnesses, and others with knowledge of the allegation, and it did not include records supporting the facility’s findings. The only available documentation showed a follow-up resident interview and referenced psychosocial monitoring, but the EHR did not contain that monitoring record.
A resident with CVA with hemiparesis, epilepsy, and TBI fell forward from a shower chair after bathing when he was left alone while the aide stepped out of the room. Records showed the resident had a history of falls and required max assist for transfers, but the care plan did not include standby assistance at all times before the fall. The facility’s investigation found the bathing supervision and transfer assistance did not match the resident’s assessed needs or care plan.
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