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    Category: Survey

    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

    Recent Survey Issues May – December, 2018

    Recent Survey Issues May – December, 2018 Resident Council Meetings: Residents not aware of Resident Council Meeting is held. Weight Loss issues: IDT not ruling…

    Jody Giacopuzzi November 20, 2018
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    Forum Description

    Recent Survey Issues May - December, 2018

    Resident Council Meetings:

    • Residents not aware of Resident Council Meeting is held.

    Weight Loss issues:

    • IDT not ruling out psychosocial issues related to weight loss when no clear medical cause indicated
    • Reason for weight loss not assessed at 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:

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

    Resident Rights/Person Centered Care/Dignity:

    • Call lights not answered in a timely manner
    • CNA refused to care for resident.
    • CNA overheard telling resident to come to her in order to provide care.
    • CNA did not inform RN that resident was in pain.
    • 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:

    • Hospice CPs not integrated with facility IDT.
    • 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 Base Line Care Plan within 48 hours of admission. Frequently cited.
    • No Comprehensive Care Plan with 15 days of admission.
    • Care Plan did not address resident’s anxiety and depression.
    • No signatures on Baseline Care Plan Meeting or Comprehensive CP meeting
    • Inadequate resident Care Plans- not addressing all required areas
    • 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

    Grievance:

    • Grievance reports with no follow-up or resolution
    • Grievance reports not completed despite the grievance being addressed and resolved.

    Theft and Loss:

    • SS staff not informed of missing items.
    • Response to f/u re: lost dentures not quick enough
    • Two discharged resident’s belongings mixed in with each others

    Medically-related Social Service:

    • Res failed to receive requested podiatry services.
    • Lack of f/u or support visit following injury related to alleged abuse.

    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

    Inventories:

    • No Inventory in chart.
    • Glasses indicated on MDS not listed on Inventory
    • Inventory not closed out at discharge

    Discharge Planning:

    • Home Health not referred despite MD order in chart.
    • 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”

    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.

    • No LCSW license on file.
    • Environment not home-like: no personal items and broken and torn screens in windows.
    • 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