Failure to maintain dignity through grooming assistance: A resident with dementia, diabetes, and muscle weakness had moderate cognitive impairment and needed partial/moderate help with personal hygiene. Staff confirmed shaving was to be offered on shower days and as needed, but the resident was observed in bed with a large amount of facial hair and had not been shaved, despite expressing interest in having it removed.
Failure to Honor Bathing Preferences: Two residents did not receive the showers they preferred and were scheduled for, and instead were given bed baths without documentation of shower refusal. One resident with fx of the L femur, DM, and muscle weakness stated he had not received a shower since admission, while another resident with dementia, anxiety, muscle weakness, and depression had only received bed baths despite a stated preference for showers. Staff and the DON confirmed showers were to be offered first and refusals documented, but no refusal documentation was found.
An LPN left Medication Cart 1 unlocked and unattended while preparing medications, then confirmed the cart had been left unsecured. Facility policy required drugs and biologicals to be stored in locked compartments with access limited to authorized personnel, and the DON confirmed medication carts should be locked when unattended.
Misappropriation of resident property and medication: A cognitively intact resident with dementia-related diagnoses returned from a hospital stay and found a wallet and ring missing from a room lockbox; a CNA later confessed to taking the wallet and cash. In a separate incident, an LPN found a suspicious narcotic count and missing oxycodone for a resident with severe cognitive impairment and chronic pain; the count sheet had been altered, and the agency nurse involved was later found to have surrendered their license for medication diversion.
A resident with intact cognition and multiple medical diagnoses alleged physical abuse by an LPN, including improper handling during a transfer and use of a lock on the wheelchair. The facility was aware of the allegation the same day, but the LPN continued working while the investigation remained open. Resident interviews and skin assessments were not completed until about a month later, and the DON and Administrator stated the investigation tasks should have been completed within the required 5-day timeframe.
Failure to Submit Timely PASRR After New Mental Health Diagnoses: The facility failed to submit new Level I PASRRs for two residents after new mental health diagnoses were identified. One resident had a new psychotic disorder diagnosis, and another had PTSD documented in the record; both had prior PASRRs, but no updated PASRR was submitted after the new diagnoses were identified. The DON confirmed that a new Level I PASRR should be submitted with any new major mental health diagnosis.
A resident with obstructive sleep apnea and shortness of breath had a C-PAP machine present in the room and reported using it for over 15 years, but the medical record did not include a physician order for C-PAP use. An LPN and the ADON both confirmed the missing order.
Failure to Perform Hand Hygiene During Meal Service and Keep C-PAP Equipment Clean: An AD delivered and set up meal trays for four residents but did not offer hand hygiene to the residents or sanitize her hands between trays, despite facility policy requiring hand hygiene before serving food and between residents. In a separate finding, a resident’s C-PAP mask and tubing were observed resting on the bed with a brown substance caked inside the mask; the resident did not know when it was last cleaned, and an LPN and ADON confirmed the mask was dirty and needed cleaning.
Failure to Document and Process Missing-Item Grievance: A resident with hemiplegia and hemiparesis and intact cognition was documented as missing a light blue shirt, but no grievance or concern was recorded in the facility log. Interviews showed the SSD, BOM, and Administrator described a grievance/reimbursement process for missing items, yet no grievance, reimbursement, or documentation of discussion was found for the resident's missing property.
A resident with an indwelling suprapubic catheter, severe cognitive impairment, and diagnoses including neurogenic bladder and CKD received improper catheter care when a CNA cleaned the catheter site without stabilizing the tubing and tugged on it during wiping. Facility policy and the catheter care skills checklist required the catheter to be secured and stabilized during care, and the DON stated staff were expected to follow the checklist.
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