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.
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.
A CNA applied Nair, a chemical hair removal cream, to a cognitively impaired resident’s perineal area at the resident’s request, using a product kept in the room without a physician’s order or secure storage. The resident, who had MS, CVA with hemiplegia/hemiparesis, DVT, epilepsy, and required extensive assistance, was unable to remove the cream herself. The next day an LPN noted redness and soreness in the peri area during routine wound care and confirmed with the CNA that Nair, not shaving, had been used. Hospital records later described chemical burns to the resident’s thighs and labia and cellulitis from the burn. Staff interviews and facility policy indicated that over-the-counter products like Nair require a physician’s order, must be locked, and that chemical hygiene products should be applied by nursing staff, not CNAs, but these requirements were not followed in this case.
Two residents with significant symptoms did not receive timely completion of ordered diagnostic tests. For one resident with cirrhosis and acute kidney failure who reported painful urination, fever, and urinary urgency, a physician ordered a same‑day UA, but facility staff did not collect the sample as ordered; the resident was later evaluated at a clinic, found to have urinary retention, had a Foley catheter placed, and was treated for suspected UTI. For another resident with intracerebral hemorrhage who had dark black stools and strong‑smelling urine, the physician ordered CBC, CMP, and UA on the same day staff reported these symptoms, but the order was not acknowledged for several days, the CBC result was not available, the CMP had to be recollected, and the UA was delayed and ultimately not obtained after the physician later indicated it was unnecessary without additional symptoms. Staff and the DON acknowledged that physician orders were expected to be processed immediately and that these labs and UA should have been collected on the day the orders were received.
Non-compliance with F684 occurred when a resident was left without repositioning or continence care for about nine hours overnight due to an unupdated CNA assignment sheet and lack of hand-off communication during a split shift. Another resident, whose care plan required Cares in Pairs because of behavioral and safety concerns, was assisted with toileting by a single CNA, contrary to the documented intervention. In a separate event, a resident who activated a call light for incontinence care waited roughly one and a half to two hours before a CNA changed her brief, after the assigned CNA turned off the call light, returned to another room, and later dismissed reports of the resident hollering, leading another CNA to eventually provide the needed continence care.
A deficiency was identified when a CNA failed to provide care in pairs as required for a resident with cognitive and psychosocial needs, and another CNA did not use the required mechanical lift for a resident with severe cognitive impairment, resulting in a fall. Both incidents involved staff not following clearly documented care plans and care sheets.
A resident with multiple comorbidities and a history of pressure ulcers developed new wounds on the lower legs and foot. Staff failed to promptly assess, document, and communicate these wounds, leading to delays in treatment and a lack of timely interventions. Inaccurate information was sent to the physician, and several days passed without care for the wounds, resulting in the resident's condition worsening and requiring hospitalization. Facility policies for skin integrity monitoring and response were not followed, contributing to the deficiency.
A deficiency was identified when an LPN did not assess a resident or notify the physician after a family member reported concerns of a possible GI bleed, despite facility policy requiring immediate action for such symptoms. The resident, who had multiple co-morbidities and a significant drop in hemoglobin, did not receive timely evaluation or escalation of care, resulting in delayed medical intervention.
Two residents who required significant staff assistance experienced unmet care needs due to insufficient overnight staffing. One developed a Stage II pressure ulcer after admission, with incomplete care planning and inadequate repositioning, while another was left incontinent overnight after a CNA failed to provide timely toileting assistance. Staff interviews and records confirmed that only one CNA and one nurse were often responsible for up to 40 residents overnight, making it difficult to meet care needs, especially for those with high acuity.
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