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    Category: Recent Survey Issues

    Recent Survey Issues January to August 2019

    Downloadable Version Resident Council Meetings: Complaints in Resident Council not addressed Weight Loss Issues: Reason for weight loss not assessed as related to missing dentures…

    Jody Giacopuzzi August 6, 2019

    Recent Survey Issues November to May 2019

    Downloadable Version Resident Council Meetings: Residents not aware of Resident Council Meeting is held. Complaints in Resident Council not addressed Weight Loss issues: Reason for…

    Jody Giacopuzzi May 27, 2019

    Recent Survey Issues September 2018 – April 2019

    Downloadable Version Resident Council Meetings: Residents not aware of Resident Council Meeting is held. Weight Loss issues: Reason for weight loss not assessed as related…

    Jody Giacopuzzi April 8, 2019
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    Forum Description

    Downloadable Version

    Resident Council Meetings:

    • Residents not aware of Resident Council Meeting is held.

    Weight Loss issues:

    • Reason for weight loss not assessed as related to missing dentures

    Request/Refuse/Treatment/Advanced Directives:

    • Advanced Directives Acknowledgement form signed by resident/representative.
    • Resident missing an Advanced Directive

    Environmental/Home-Like Environment:

    • No personalized items in long -term resident’s room (photos, artwork, etc)

    Resident Rights/Person Centered Care/Dignity:

    • Photo of resident posted on social media
    • CNA calling adult brief – “resident’s diaper” in a negative manner
    • Eye drops being administered in dining room- dignity issue
    • Resident food preferences not followed
    • Resident served food that resident previously indicated she did not want
    • Resident found with maggots in foot wound

    Hospice:

    • No CP re: end of life care
    • Hospice staff name and phone number not on resident’s chart for easy access
    • Lack of IDT communication with hospice agency

    Care Planning:

    • No BaseLine Care Plan within 48 hours of admission. Frequently cited.
    • No Comprehensive Care Plan with 15 days of admission.
    • Care Plans not updated as resident condition changed
    • Comprehensive Care Plan did not adequately address resident’s foot wound and maggots
    • No Comprehensive Care Plan until day 41 of admission
    • Care Plans not individualized- computer generated without individualizing
    • Problems & interventions realistic?

    Grievance:

    • Grievance reports with no follow-up or resolution
    • Grievance reports not completed despite the grievance being addressed and resolved
    • SSD not informed of resident grievance

    Theft and Loss:

    • Two discharged resident’s belongings mixed in with each others
    • Lack of documentation that resident/representative was satisfied with resolution
    • Lack of documenting that resident was informed, in writing, the risk of keeping cash at bedside

    Medically-related Social Service:

    • Res failed to receive requested podiatry services.
    • Lack of f/u or support visit following injury related to alleged abuse.
    • SSD asked by Surveyors if she had a “script of questions” when investigating abuse complaints

    Behavior Management/Psychotropic Medications:

    • PRN Seroquel used beyond the 14 days allowed in new regulations. Cited several times.
    • No consent for psychotropic medication.
    • Behavior monitored does not match orders.
    • No GDR documented
    • No documentation of potential triggers prior to medication being prescribed
    • Behaviors related to psychiatric diagnosis or symptoms of dementia?
    • Justifications for GDRs and no GDRs

    Inventories:

    • No Inventory in chart- frequently cited
    • Glasses indicated on MDS not listed on Inventory
    • Inventory not closed out at discharge
    • Items in resident’s room not on Inventory.
    • Inventory lacking 2 signatures

    Discharge Planning:

    • Notice of transfer/discharge not faxed when resident was admitted to hospital- cited frequently
    • Lack of SS discharge planning notes- need to demonstrate “sufficient preparation for d/c”
    • Ombudsman not informed of resident discharge

    POLST:

    • POLST indicates No DNR, no order chart.
    • MD orders say “follow the POLST”- POLST was not signed by MD.
    • No MD signature on POLST
    • MD section incomplete

    MISC.

    • Comprehensive Care Plan not reviewed with resident/representative
    • No P & P for vision services, including monitoring appointments
    • Residents not aware of where Survey Results are posted
    • Resident’s personal food in refrigerator not dated
    • Quality Assurance program did not address repeated issues regarding inadequate wound care