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 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
