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
  • Advanced dementia not indicated as related to weight loss

Request/Refuse/Treatment/Advanced Directives/POLST

  • MD not talking to resident when completing POLST
  • No SS documentation of speaking to resident/representative about completing an AD
  • POLST missing MD signature and date
  • POLST indicates No DNR, no order chart.
  • MD orders say “follow the POLST”- POLST was not signed by MD.
  • MD section incomplete

Environmental/Home-Like Environment:

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

Resident Rights/Person Centered Care/Dignity:

  • Resident served food that resident previously indicated she did not want
  • No communication board on wheelchair
  • No communication board in room


  • 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:

  • 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?
  • Missing care plan for non-English speaking residents
  • No Care Plan to address resident’s diagnosis of dementia


  • Grievance reports not completed despite the grievance being addressed and resolved
  • SSD not informed of resident grievance

Theft and Loss:

  • 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:

  • 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
  • GDR, no individualized reason for no dose reduction
  • GDR not done on a regular basis


  • 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
  • Inventories not reflecting resident items in room

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
  • Resident discharge to independent living center when resident required medication management
  • Resident discharged to unlicensed assisted living


  • 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
  • Review of closed charts from 2016 and 2017
  • Requested copy of Room Change P & P
  • Request for recent SS Consultant Report
  • Request copy of Consultant SW License
  • Surveyors came in on a complaint, then asked to see charts of two discharged residents
  • Face Sheets needs to list alternate MD by name
  • Review for Bed Hold Notices in closed charts
  • Pain and SS documentation and care plan not addressing psychosocial aspects of residents pain

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