Delayed Response to Resident Call Lights: Staff did not respond promptly to call lights for multiple residents, with logs showing repeated waits over 20, 30, and even 50 minutes, and some residents reporting waits up to 2 hours. Several residents said they became incontinent while waiting for bathroom help, and one resident was observed unable to reach her call light because it was disconnected from the extender. Residents also reported call lights left out of reach and concerns that staff were not available on the floor.
Staff failed to respond promptly to resident call lights for multiple residents, with repeated waits over 15 minutes and several waits over 30 minutes or more than an hour. Residents reported being left on the toilet, becoming incontinent, and seeing staff turn off call lights without helping. Staff said there were not enough walkie-talkies, and multiple employees were unaware of any set response-time expectation. The report also found unclear condom catheter care for a resident whose night catheter supplies were stored improperly and whose care instructions were not clearly detailed in the care plan or TAR.
Delayed Call Light Response: A resident reported that call lights were not answered quickly enough when staffing was short, and she became incontinent of bowel while waiting. Her record showed intact cognition, left-sided hemiplegia/hemiparesis, left leg contracture, left foot drop, and need for substantial to maximum assist with transfers. Call light logs documented multiple response times over 20 minutes, including several over 30 minutes, while staff gave differing expectations for response times and the facility policy required prompt answering of call lights and assistance alarms.
A CNA applied Nair to a resident’s anal area and inner buttocks without a physician’s order and outside CNA scope, after the resident requested hair removal and had purchased the product himself. The resident later had superficial excoriation/pink irritated skin in the area. The facility also had repeated delays answering call lights for several residents, with reports and resident interviews showing waits of 15 minutes to nearly an hour, despite staff stating call lights should be answered promptly.
A resident with intact cognition, obesity, depression, anxiety, chronic pain, constipation, fibromyalgia, overactive bladder, and bowel/bladder incontinence was left on a commode after her call cord did not activate and staff did not return to check on her. The resident had to yell for help, was found upset after waiting longer than she wanted, and the facility’s orange magnet process for indicating a resident was on the toilet/commode was not followed. The incident was identified as neglect, and the facility also did not assess other residents’ call cords for proper function.
Two residents experienced failures in timely implementation of physician orders and provider notification. One resident with cognitive impairment, respiratory failure, pneumonia, and a urinary catheter had a UA/UC ordered after increased confusion, but catheter change and urine collection were delayed and inconsistent, and an antibiotic order faxed for a UTI was left on a reception fax machine and never started before a later order changed therapy based on culture results. Lab reports showing Enterobacter cloacae and susceptibility to a different antibiotic were not consistently documented as reviewed, and the resident continued to exhibit confusion and flank pain until transfer to the ER. Another resident with ESRD on dialysis, hypotension, hypertension, and heart failure had orders for Midodrine with BP parameters and daily Metoprolol, but Midodrine was not given on dialysis mornings and Metoprolol was rarely given on dialysis days, without notifying the physician. Very low BPs were recorded without documented provider notification or repeat checks, despite a TAR requiring monitoring for post-dialysis complications. Interviews and policy review showed expectations to follow orders and notify physicians of abnormal labs, omitted medications, and changes in condition, which were not met in these cases.
A resident with a suprapubic catheter, diabetes, CKD, dermatitis, and morbid obesity had ongoing pink, moist, reddened, and excoriated skin in the abdominal fold and around the catheter site, with drainage, bleeding, and pain reported by the resident. Staff repeatedly cleansed the area and applied barrier cream, but the resident said the site was sore and that she wanted a sponge used. Assessments documented MASD on the abdomen and perineum, yet the record showed limited treatment documentation, no measurements, and inconsistent recognition of the worsening skin condition.
Staff did not ensure that four residents received regular weekly bathing and hygiene care according to facility expectations and resident needs. One resident with CHF and hypothyroidism was found in a room with a strong urine odor, urine‑stained bedding, and signs of poor hygiene, and records showed more than three weeks between documented baths without any refusals. Three other residents reported or demonstrated missed baths, with documentation revealing gaps of 14 to 21 days between baths or showers and no recorded refusals. During a period when the full‑time bath aide was on vacation, the DON and administrator stated that weekly baths were expected and that coverage was planned, but the bath aide reported residents sometimes did not receive baths when she was reassigned, and staffing schedules showed multiple weekdays with no staff assigned to provide baths, despite a policy emphasizing bathing for hygiene, comfort, observation, and safety.
Delayed response to call lights affected two cognitively intact residents. One resident with urinary incontinence and reduced mobility reported that slow call light response sometimes led to urinary incontinence, and her call light logs showed repeated waits over 15 minutes. Another resident with fractured ribs reported waiting up to an hour for help to the bathroom or for PRN pain medication, felt upset when staff seemed to forget her, and had multiple call light delays over 15 minutes. Staff interviews showed inconsistent pager use and expectations that call lights be answered within 5 to 15 minutes.
Failure to follow a resident’s care plan for arm support was identified for a resident with hemiplegia and dementia. Staff observed the resident seated in a wheelchair without the required pillow under her left arm, despite a posted sign and care plan direction to support the arm with a pillow when up in the wheelchair. The CNA acknowledged forgetting to place the pillow, and leadership stated CNAs were expected to follow the care plan.
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