State Findings:
Based on record review and interview, the facility failed to provide supervision for Resident #423 related to hazards secondary to the resident putting non-edibles in her/his mouth and for Resident #71 related to falls (2 of 4 residents reviewed for accidents and hazards).
On 07/16/19 at 11:16 AM, review of the nursing progress notes revealed on 11/25/18 at 2100 (09:00 PM) the nurse documented that the Certified Nursing Assistant (CNA) notified the nurse that the resident was unresponsive. The nurse did a sternal rub with no response. Vital signs were absent with no breath sounds and pupils fixed. Hospice notified of the change in the resident’s status. The notes further indicated that at approximately 2130 (09:30 PM) the hospice nurse arrived and went with the facility nurse to the resident’s room. The facility nurse decided that staff needed to check the resident’s mouth for any food that might have been left in their (sic) due to resident just eating dinner and while staff checked the resident’s mouth staff found something sticking out of her throat and staff pulled it out of the resident’s throat and it was a vinyl glove. The hospice nurse then started to make the necessary calls to the MD (Medical Doctor) and to the family. Review of the facility’s Five-Day Follow-Up Report dated 11/30/18 indicated at the time of the report the facility was awaiting an official cause of death from the county coroner. The report further indicated that on 11/29/18, the facility was notified by the police that the preliminary cause of death was noted as Dementia and that it remained unclear whether the glove played any role in the death.
At 10:52 AM, review of the care plan dated 08/30/18 revealed impaired decision making ability and memory deficits was identified as a problem area. There was no care plan related to behaviors.
During an interview on 07/16/19 at approximately 2:35 PM, the DON stated that the resident was known to eat napkins. During an interview on 07/17/19 at 11:30 AM, the DON confirmed that s/he reported on 07/16/19 that Resident #423 had a history of [REDACTED].
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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Personal Note from NHA-Advocates
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