Medication administration records and narcotic tracking logs did not match for 3 residents receiving opioid pain meds. A resident with chronic pain had multiple hydrocodone removals that were not documented on the MAR, and some MAR entries showed doses given before the narcotic log showed the med was removed. Two other residents also had discrepancies between opioid removal logs and MAR documentation, and staff acknowledged the mismatches.
A resident with impaired judgment had medication cups left unattended on an overbed table in the room, with tablets exposed and not fully contained. The resident had not been evaluated for self-administration, and the DON stated meds should not be left on residents’ tables or in their rooms if not given immediately.
Failure to Protect Residents from Resident-to-Resident Abuse: A resident with vascular dementia, severe cognitive impairment, poor impulse control, and a history of aggression was involved in three physical altercations with three other residents within a 24-hour period. The resident knocked snacks from one resident’s hands and hit and kicked them, kicked another resident near the nurses’ station, and struck a third resident in the leg/ankle while agitated. One resident said the aggressor scared them and another said they did not feel safe around the aggressor; staff later stated the incidents constituted abuse.
A resident with dementia and MS was admitted for respite care and was dependent on staff for eating and drinking. The care plan directed staff to encourage fluids, but intake records showed repeated low fluid intake over several days, and there was no documentation that the MD or resident representative was notified. The DON acknowledged the resident’s poor intake and progressive decline, and that no change of condition was sent per usual procedure.
A resident with obesity, a T-11 to T-12 SCI, multiple rib fractures, and a dislocated elbow was discharged to another SNF, but the facility did not provide recent information about a non-injury fall and an abuse-related sexual behavior allegation. Staff acknowledged no verbal report was given before discharge, and the receiving facility reported the resident arrived without authorization, report, or orders.
Failure to Provide Bed Hold and Transfer/Discharge Notices: The facility did not document providing bed hold notices for four residents who were transferred or discharged to the hospital, including one resident who was unresponsive at transfer. The facility also did not document a written transfer/discharge notice for one resident. Staff interviews and record review confirmed the notices were not found in the EHR, despite facility policy requiring written notice of bed-hold rights and appeal rights when a resident is transferred or discharged.
Hand hygiene, glove use, and EBP were not followed for multiple staff caring for a resident on EBP for an indwelling urinary catheter and bilateral lower leg wounds. Staff performed peri-care, catheter care, bowel movement cleanup, and contact with the resident’s belongings and bedding without proper hand hygiene between glove changes, and some staff did not wear a gown as indicated by EBP signage. The DON stated staff were expected to follow the facility’s hand hygiene policy and the EBP signage.
Failure to Prevent Resident-to-Resident Physical Abuse: Two separate resident-to-resident altercations occurred in the dining room. In one incident, a resident slapped another resident during an argument, and in the other, a resident grabbed another resident’s arm, causing pain and superficial bruising. Staff interviews and incident investigations confirmed both events as physical abuse, and the DON stated the facility expected residents to be free from abuse.
Failure to Provide Written Discharge Notice and Discharge Planning: A resident admitted for rehab after sepsis, falls, gait impairment, and confusion had no documented discharge plan or discharge goals in the care plan. Although skilled coverage ended and the resident appealed the termination, staff stated they usually notified residents verbally and the EHR did not contain a completed written transfer/discharge notice with appeal rights. The resident’s rep said they were rushed to find an AFH and felt the resident was not ready to leave.
The facility failed to keep several residents’ care plans complete and resident-specific. A resident with dementia and high elopement risk was listed in the elopement binder, but the care plan did not include that risk. A resident receiving antipsychotic and antidepressant meds had no psychotropic documentation or side-effect monitoring in the care plan, and multiple residents with frequent pain lacked non-pharmacological pain interventions and complete pain details. Two residents with restorative programs had no corresponding care plan entries, and residents with pressure ulcers or heel offloading needs also lacked wound-related care plan interventions.
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