A resident with muscular dystrophy, paraplegia, and severe mobility dependence was transferred with a Hoyer lift using a blue sling sized for much heavier residents than her documented weight. During a shower transfer with 2 CNAs, she slipped through the sling, fell to the floor, and sustained a hematoma to the back of her head; EMS was called and a CT later showed a small scalp hematoma.
Unlabeled Food Stored in Kitchen: Food items in the kitchen were observed without required date labels, including turkey, hardboiled eggs, pork ribs, lima beans, and hamburger rolls. The DM confirmed that refrigerated and frozen foods should be dated when opened and stated there was no schedule for checking food for date labels or expired items.
A resident who needed ADL assistance had fingernails that were repeatedly observed as over one fourth inch long and dirty with brown/red or dark substance underneath them. The resident said staff would not cut his fingernails even when he asked, and both a CNA and an LPN confirmed the nails were not clean or trimmed as required by facility policy and the resident's care plan.
Failure to provide ordered hand devices for a resident with bilateral hand contractures. The resident had severe cognitive impairment and upper extremity impairment, and the care plan and order summary directed cushion carrots/palm guards to both hands every shift. During observations, one or both hands were without the device, and an LPN and the DON confirmed the resident should have a device placed in both contracted hands.
A facility failed to follow physician orders for oxygen administration and did not have oxygen storage bags present for two residents receiving oxygen. One resident with COPD and other respiratory diagnoses was observed receiving less oxygen than ordered, and an LPN confirmed the ordered flow rate was not being followed and that no storage bag was present. Another resident with acute respiratory failure with hypoxia and severe cognitive impairment was also observed receiving less oxygen than ordered, with an LPN confirming the discrepancy and the absence of a storage bag. The DON confirmed that oxygen orders should be followed and that storage bags should be present.
A resident with ESBL and severe cognitive impairment was placed on contact isolation, but the chart contained no physician's order for transmission-based precautions. Staff observed that the room had only a personal trash can, with no separate receptacle for isolation PPE, and the DON confirmed PPE had been disposed of in the resident's personal trash can.
A resident's omeprazole dose was left in an unmarked cup on top of an unattended med cart while the RN assisted another resident. The RN later returned the opened medication to the cart and administered it later, despite the UM, IP, and DON stating opened medication should not be put back in the cart and should be discarded.
Failure to use required PPE for droplet precautions: A resident with pneumonia due to mycoplasma pneumoniae, COPD, and oxygen dependence was on droplet isolation, but an RN and a CNA entered the room wearing only a mask and gloves. The door had an enhanced barrier precaution sign and supplies, but no goggles or face shield were available at the room, and staff stated they believed only a mask and gloves were required.
A resident with severe cognitive impairment, confusion, and repeated exit-seeking behavior successfully eloped from the facility and was found outside on the sidewalk near an active highway before staff realized he was missing. Records showed he had diagnoses including cerebral infarction and traumatic subdural hemorrhage, with a BIMS score of 0 and documented disorganized thinking, while staff notes described him as combative, difficult to redirect, and insisting on going home. Interviews confirmed staff did not know he had left until another resident alerted them.
A resident with a G-tube, dysphagia, and severe cognitive impairment did not receive appropriate tube-site care. The record showed no orders or care plan guidance for G-tube management, and staff were unsure how often the dressing should be changed or how the site should be cared for. Surveyors observed an old dressing stuck to the skin with crusted drainage around the stoma, and the resident had recently been treated for a G-tube site infection and cellulitis.
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