Staff failed to respond promptly to resident call lights, and multiple residents reported long waits for help, including one resident whose call light was left on for over an hour and another who sometimes urinated before assistance arrived. Call light reports showed repeated delays for several residents, with many responses over 20 minutes and some over 60 minutes or longer. Interviews with residents and staff showed inconsistent response expectations, limited radio use, and situations where staff in one room were unaware that other residents needed assistance.
Missed physician orders, delayed wound care, and delayed incontinence care: A resident with a recent fall and anticoagulation therapy had ordered labs and a head CT not entered into the EMR, and was later transferred to the ED after worsening symptoms and hospitalization for AKI and metabolic acidosis. In a separate event, a resident with diabetes and a complex foot wound missed a timely OPWC visit after transport problems, and another resident with severe cognitive impairment did not receive expected q2h brief checks, resulting in wet clothing and urine odor.
Failure to Provide Timely Incontinence Care, Repositioning, and Meal-Time Supervision: Multiple residents were found heavily incontinent at the start of the day shift after night staff did not complete expected q2-3 hour rounds, repositioning, or brief changes. One resident with severe cognitive impairment and a high Braden score was observed lying in soiled linens with urine odor, another resident was found sideways in bed with urine-stained sheets, and a resident with moderate cognitive impairment and total ADL dependence was left alone in the dining room for over three hours after a meal by a contracted CNA.
A facility failed to complete required neuro checks after unwitnessed falls and possible head injuries for multiple residents. One resident with severe dementia and continuous O2 orders was found on the floor with his concentrator off and had several missed neuro assessments while sleeping or drowsy. Another resident with severe cognitive impairment and repeated unwitnessed falls had incomplete neuro flow sheets that lacked required components, and a third resident with dementia had a fall with chin impact and pain, but the full neuro assessment was not documented before transfer to the ED.
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.
A resident with quadriplegia, neurogenic bowel, and multiple pressure wounds had NPWT ordered for a left buttock wound, but staff placed the tubing incorrectly and a reddened area developed above the wound. The resident and his wife reported prolonged time in stool during bowel prep, a wound vac alarm that was shut off without troubleshooting, delayed call light response, and that the NPWT machine was not sent with him to the hospital. RN/MDS staff noted the LTC nurses were less comfortable with wound vacs than rehab nurses.
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.
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