November 5, 2019 IDR Committee Notes

November 5, 2019 SNF IDR Meeting

F 685 D One resident was observed, during survey, without his hearing aids four times. Per committee discussion the resident’s aids were locked in the med-cart and he needed help to get them in properly. Sustained at “D”

F 725 F Per committee discussion residents reported to the surveyors that call light wait times were lengthy. One resident reported waiting over two hours to be assisted out of bed. Staff interviewed during the survey reported being short staffed regularly. Sustained at an “F”

F 923 D Bathrooms are required to have either mechanical ventilation or an outside window. Per committee discussion 37 of 75 bathrooms did not have working fans or an outside window. Sustained at “D”

F 658 D Facility failed to ensure assessment of two residents following unwitnessed falls. LPN reported a fall to the RN, the RN did not feel she needed to assess because the resident did not sustain an injury. Sustained at “D”

F 658 D Nursing staff failed to sign out narcotics at the time of administration, per surveyor observation. Sustained at “D”

F 677 E Residents who need assistance with ADLs and grooming should receive that support. Per documentation one resident, who had a stroke, failed to receive 9 of 9 scheduled baths. A second dependent resident failed to receive 5 of 9 scheduled showers.  Sustained at “E”

F689 G One resident was not assessed for fall risk at the time of admission, had a fall two days after admission. Resident’s care plan, that was developed four days after admission, did not address fall interventions. Resident fell and fractured hip and finger four days after admission, prior to fall interventions being implemented. Sustained at “G”

F 725 E Per resident complaints, during survey, the facility did not have enough staff to provide timely showers per the shower schedule, had excessive wait times for call lights to be answered and one call light was observed to go unanswered for 1 ½ hours. Sustained at “E”

F 550 D One resident reported to surveyor that he was approached, by unit manager and social worker, with a behavior contract that they asked him to sign or be given a 30 day notice. Resident claimed he had never been told that his behaviors were an issue. Resident said he was “humiliated and belittled” during the meeting. Sustained at “D”

F 679 D Two residents reported to the surveyors that they were bored and were not offered activities of interest to them. Upon review of the resident care plans surveyor reported that the plans were not individualized and did not address areas of interest for the two residents. Sustained at “D”

F 744 D Per surveyor report residents in secure dementia care unit did not have individualized care plans that addressed individual interests or suggested interventions if residents were displaying agitation or unrest. Sustained at “D”

F 573 D A resident that discharged from the facility requested a copy of her medical records. Although discharging facility faxed the records to the resident’s current facility the resident did not receive a copy timely.  Sustained at “D”

F 557 G Per surveyor observation one resident with dementia was taken to her room during the lunch hour. The resident had a bowel movement and yet was not given incontinent care and was served her meal while sitting in a soiled brief. One resident was left in w.c. for over an hour while requesting help to reposition due to pain. Several staff in the dining room were overheard using the terms “feeders, honey and sweetie” when speaking with residents. Sustained at “G”

F 677 D Facility failed to provide showers to residents that needed help. Surveyor observed resident in the dining room who needed help cutting up a pancake, her care plan supported the need for assistance with meals. There was a CNA at the table with the resident that needed help as well as an LPN that walked by and observed the resident struggling to cut her pancake. Sustained at “D”

F689 G Resident stated she was too weak to transfer to the commode and requested bed pan. CNA assisted resident to the bathroom, resident attempted to transfer and fell. Resident fractured her ankle and wrist. Sustained at “G”

F550 D Resident was embarrassed by staff when he lit a cigarette, with his oxygen on, and was severely reprimanded in front of others. The resident had been residing in facility for 3 weeks and stated he was never told that he could not smoke with his oxygen on. Sustained at “D”

F 677 D Surveyor observed dark matter under a resident’s finger nails twice during survey. Upon review of shower records there was a lack of documentation to support facility claim that resident received regular showers. Sustained at “D”

F 679 D Surveyor observed resident in his room watching TV daily during survey. Resident stated there were many things he had asked about doing but none were provided so he just watched TV. Sustained at “D”

F 684 D Resident with an order for compression socks was observed throughout survey without compression socks. Sustained at “D”

F 686 G Resident with in-house acquired stage 3 wound to coccyx failed to be repositioned regularly per physician orders. Sustained at “G”

F 687 E Facility had identified quality issue with in house acquired pressure ulcers and developed a performance improvement plan (PIP). However, with plan in place facility found two facility acquired ulcers and survey team identified two more residents with pressure ulcers that the facility was unaware of. Sustained “E”

F 564 E Facility sent a letter to residents and families stating that facility was starting quiet hours between 10 pm and 6 am. If visitors wanted to stay the night it would require administrator approval and a $100 fee. Per committee discussion residents in the facility were not included in the decision to institute quiet hours and staff were told to ask visitors to leave at 10:00 pm. Sustained at “E”