A resident with personal care needs, AFib, anxiety, and cognitive communication deficit was subjected to verbal abuse when a CNA responded in an elevated tone during a care interaction and re-entered the room after being told to leave. The resident reported the CNA yelled, acted in an intimidating manner, and said, “I hope you don’t make me leave,” while another CNA described the tone as inappropriate.
Incomplete Care Plans for Medications, Foley Catheter Care, and Pain The facility failed to develop resident-specific care plans for high-risk meds, Foley catheter care, and pain management for three residents. One resident had orders for spironolactone, methadone, and PRN hydromorphone, but no care plan addressed monitoring for side effects. Another resident had a Foley catheter and an order for routine site cleansing, yet the care plan lacked catheter care interventions and goals. A third resident had chronic pain treated with oxycodone, but the pain care plan contained blank SPECIFY fields and was not individualized.
A resident admitted with bilateral primary osteoarthritis of the knee received Hydrocodone-Acetaminophen for pain management after a physician order was entered and the medication was administered on multiple days. The President of Clinical Services could not locate a signed consent, and the DON confirmed informed consent had not been obtained before administration of the opioid and that it should have been obtained so the resident was aware of the risks and benefits.
A resident with polyneuropathy, ankylosing spondylitis, osteoarthritis, and spinal stenosis had a physician order for daily chair time and required a 2-person Hoyer Lift for transfers. Staff did not consistently honor the resident’s request to get out of bed, citing short staffing, and the resident was often only assisted out of bed for showers or a few times per week instead of daily.
A resident with chronic respiratory failure, COPD, pulmonary hypertension, and oxygen dependence repeatedly asked to have an ID wrist band removed, but it remained on the resident’s wrist during multiple observations. The resident said the LPN insisted the band be worn at all times, while the LPN confirmed the resident had requested removal for months. Staff stated the wrist bands were used as a double check for med admin, and the DON and Administrator were unaware the resident’s request had not been communicated to staff.
Failure to protect a resident from peer physical abuse: a resident punched another resident in the face in the activity room, causing a superficial abrasion and minimal bleeding. The aggressor had a documented hx of prior aggressive behaviors toward staff and others, but the care plan did not address those behaviors before the incident. The injured resident later avoided the activity room and stated the other resident was dangerous.
Care plan not implemented for aggression and wound care: A resident with a history of physical and verbal aggression had a care plan that called for staff to analyze triggers and document de-escalation methods, but the DON stated the record and treatment plan did not include methods staff would use to de-escalate the behaviors, and a later aggressive episode was not accurately captured on the behavior task. Separately, a resident with a right heel wound had ordered wound care documented as completed on the TAR, but the floor nurse and wound care LPN confirmed the dressing was not in place and the wound care had not actually been performed by the assigned nurse.
Unattended Medications and Improper Pain Medication Handling: Staff left medications at a resident’s bedside for self-administration without an order or care plan allowing it, and another resident was found with a cup of pills left in the room by an RN. A third resident with chronic pain and neurologic impairment was reported to have oxycodone and morphine left in the room, which the resident hoarded; the record lacked evidence of self-administration ability. The DON and other staff confirmed medications were to be administered and observed until swallowed, but that did not occur in these cases.
Wound care was documented as completed for a resident with a right heel wound, but the dressing was not in place and the care had not actually been performed. The resident had an open wound with bleeding from the heel, and the floor LPN and Wound Care LPN each indicated the other was responsible for the treatment, while the DON stated the treatment should not have been charted complete unless it was done.
A resident with hemiplegia, major depressive disorder, and a history of intentional self-harm was found to have hoarded oxycodone and morphine pills that an RN had reportedly left with the resident. The resident said the pills were kept so they could self-administer them if pain occurred and staff could not be reached. A Unit Manager LPN found unsecured pain pills in the room, estimated about 15 pills, and confirmed the meds were accessible to residents and staff; the DON stated nurses were expected to verify swallowing before leaving the room.
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