A resident who was dependent on two staff and required a mechanical sling lift for all transfers was manually moved from bed to wheelchair by two CNAs without the lift while an LPN briefly left the room. During the transfer, the resident's leg became trapped under the wheelchair, but the event was not promptly reported to nursing or medical providers. The resident later developed ongoing pain and swelling, was found to have multiple fractures after an X-ray and ER evaluation, declined, was transferred to hospice, and died from complications of the injuries.
A resident with multiple chronic conditions and frequent incontinence had a urine culture ordered for altered mental status. The facility received an abnormal culture showing ESBL Klebsiella but did not report it to the NP for several days, and treatment was delayed until the resident was later found slow to respond with bradycardia and unresponsiveness and was sent to the hospital, where UTI, AKI on CKD, and IV antibiotics were documented.
Uncomfortable Resident Room Temperatures: The facility failed to keep resident room temperatures at a comfortable level for 25 residents. During survey observations, two AC units were out, room temperatures ranged from 68 to 80.4 degrees, and several residents said their rooms were too hot or too warm. Staff confirmed the AC problem had been ongoing for weeks, while temperature logs showed hallway readings but no room temperatures were recorded by Maintenance.
Unsafe and Uncomfortable Room Temperatures: Surveyors observed multiple common areas and resident rooms above the facility’s allowed temperature range, with some areas reaching 90 degrees or higher. Residents were seen using washcloths for relief, and a resident reported the room felt hot. The Maintenance Director verified the readings, and the issue affected nearly all residents in the facility.
Infection Control and Medication Handling Failures: An LPN entered a room on contact precautions without a gown or gloves, handled wound care supplies and dressing changes without proper hand hygiene between glove changes, and a roommate without isolation needs was cohorted with a resident on CRAB precautions despite available rooms. In separate observations, an RN and an LPN handled medications with bare hands, including a tablet dropped on the med cart, instead of following infection control procedures.
Failure to perform hand hygiene was observed during resident care and when moving between residents. Two CNAs assisted a resident with toileting, removed gloves, and left the room without hand hygiene, then entered two other residents’ rooms without cleaning their hands. One CNA sat on a resident’s bed and talked with the resident, and another assisted with a bedside table, both without hand hygiene on entry or exit. Interviews confirmed the missed hand hygiene, and facility policy required hand hygiene before and after glove removal, after contact with potentially contaminated surfaces, and before caring for another resident.
A resident with dementia, severe cognitive impairment, and extensive assistance needs was observed being assisted from her room in a shower chair while wearing a nightgown that exposed her lower body in the hallway in front of other residents. The CNA confirmed the exposure and said she was going to cover the resident with a sheet. The facility’s dignity policy requires residents to be cared for in a manner that protects bodily privacy during personal care.
Infection control measures were not followed during wound care for a resident with a right ankle wound, osteomyelitis, and other significant diagnoses. An LPN performed the wound treatment without a gown and did not perform hand hygiene between glove changes, despite EBP orders and facility policies requiring gowns, gloves, and hand hygiene during wound care.
Admission seizure medication orders were not timely processed for a resident with tracheostomy status, epilepsy, and convulsions. The hospital discharge paperwork listed lacosamide, Keppra, and Depakene, but the facility initially had only the AVS and did not enter orders for Keppra or Depakene; lacosamide was entered later. The MAR showed no evidence the resident received Keppra or Depakene, and staff interviews confirmed the missing orders were not fully communicated or processed at admission.
Inaccurate MDS assessments were completed for two residents. One resident with respiratory failure, pneumonia, COPD, and diabetes was incorrectly coded as receiving insulin injections and not taking an antibiotic, even though the record showed Levaquin and no insulin orders. Another resident on hospice with chronic respiratory failure, quadriplegia, and depression was incorrectly coded on the MDS prognosis item as not having a life expectancy of less than 6 months, which an LPN confirmed was wrong.
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