Failure to Address Abuse and Resident Boundaries: The DON and Administrator did not identify or act on repeated abuse concerns involving multiple residents. Staff reported one resident’s inappropriate sexual touching and boundary violations with other residents, including a cognitively intact resident who had set limits and a protected resident who could not consent under state law, yet the facility assessed and care planned the protected resident as able to consent. Two other residents were also involved in physical abuse, and the Former DON stated concerns were raised repeatedly with leadership and the owner.
The facility failed to protect residents from abuse by other residents. A cognitively intact resident verbally abused another resident by making a sexually explicit statement, while a severely cognitively impaired resident was care planned for sexual expression without a capacity-to-consent assessment. The facility also allowed a resident assessed as unable to consent to have repeated kissing and touching with another resident, including contact to the chest and inner thighs, with staff giving inconsistent accounts of whether the residents could be alone together or needed visual supervision. The report also describes physical altercations between other residents, including one resident striking another in the face and another incident involving residents hitting each other during a room altercation.
Abuse Policy and Capacity-to-Consent Failures: The facility failed to follow its abuse policy and did not ensure its sexual abuse definition and consent procedures met regulatory requirements. One severely cognitively impaired resident had a care plan for sexual expression but no available capacity-to-consent assessment, while another resident with dementia and court-appointed guardianship was assessed as unable to consent after the SSD completed the assessment and then created a sexual expression care plan. Staff observed kissing and intimate touching between residents, and the MD and FNP gave conflicting views about the resident’s ability to consent.
A resident with DM and MS had repeated blood glucose readings in the 30s and 40s across multiple shifts, including a reading of 32 mg/dL, but staff did not immediately notify the physician. The chart showed no BG parameters or notify orders, and an RN and LPN confirmed they did not contact the physician despite the resident’s ongoing low BG and poor intake; the physician was contacted only after the resident’s condition declined and the resident was sent to the ER.
Failure to provide NOMNC notification and notify responsible parties affected two residents with significant cognitive impairment. One resident had Alzheimer’s disease and severe cognitive impairment, and another had cerebral infarction with moderately impaired decision-making and memory problems. Both signed SNF ABN forms, but there was no documented evidence that the family/representative was properly informed, and the Bookkeeper stated conversations were not documented and no hard copies were mailed.
An LPN failed to promptly assess a resident who showed signs of aspiration, including vomiting, low O2 saturation, and abnormal vital signs, and the resident was later hospitalized with aspiration pneumonia. The RN stated the LPN should have listened to breath sounds to help confirm possible aspiration. The facility also continued a wander guard on a resident with no documented wandering or exit-seeking behavior, despite assessments and care plan conference notes stating the device should be removed, and staff were unclear who was responsible for discontinuing it.
Missing Physician Order for Dialysis Care: A resident with ESRD and severe cognitive impairment was documented as receiving hemodialysis, but the EMR contained no current physician order for dialysis treatment. Staff interviews confirmed dialysis residents should have an order directing access-site care, monitoring of the thrill and bruit, and documentation on the MAR, and the facility's hemodialysis policy required physician orders to include dialysis center visits and access-site care.
The facility failed to document alternative measures, risk-benefit discussion, and informed consent before side rail use for two residents. One resident with ESRD and severe cognitive impairment and another resident with dementia and intellectual disabilities were observed with side rails raised in bed, but records showed no current order for side rails and no documented evidence that alternatives were explored or that risks and benefits were reviewed with the resident or RP.
The SSD failed to properly assess residents’ capacity to consent to sexual contact and failed to provide psychosocial follow-up after a companionship ended. Two residents with severe cognitive impairment were involved in sexual relationship care planning, including one resident with a guardian and another whose decision maker was not informed or supportive. A cognitively intact resident reported that a relationship ended after an unwanted sexual comment, leaving the resident upset and crying for days, but the SSD did not ask about the resident’s distress or the reason the relationship ended.
A resident with type 2 DM and MS had ordered glimepiride and BG checks, but staff administered the medication despite BG readings in the 40s and poor oral intake. An LPN gave glimepiride after a low BG was reported, another LPN later gave the same medication again, and hospital records showed the resident was admitted to the ED for hypoglycemia and treated with IV dextrose.
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