Print Inspection: NFW4

Based on record review and interview it was confirmed that the facility failed to investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Findings include but not limited to:

A review of facility incident report dated 6/11/2022 revealed that  Resident #2 (R2) had an unwitnessed fall in their apartment and was found on the floor with urine-soaked pants. There is no further investigation noted or available. No further notation on this incident report was completed until 6/21/2022 when it is noted that R2 was hospitalized "due to CHF exacerbation and UTI". There are no interviews or witness statements.

A review of R2's service plan dated 5/25/2022 indicated that "Community team members to assist with daytime wellness checks" and "team members to report to the nurse if the resident is missing any meals". A review of PCC charting revealed that resident was only checked on once during day shift at 9:18am. A review of facility's meal check-off sheet dated 06/11/2022 was marked with "?" for breakfast and lunch and "no response" noted in margin.

During interview, Staff #4 stated that R2 did not come down for breakfast and lunch that day and that culinary did not send a meal to R2's room for either meal. They also stated that culinary staff attempted to contact care team to follow up about R1's meals but that there was no response.

These findings were reviewed with and acknowledged by Staff #1-#2 and Staff #5 on 8/25/2022 who were in agreement.

Facility POC: Facility nurse to document when resident was last seen by staff, location of resident, interviews with staff, resident, family and witnesses and plan for resident safety, before closing risk management/incident report.

A review of facility incident report dated 6/11/2022 revealed that Resident #2 (R2) had an unwitnessed fall in their apartment and was found on the floor with urine-soaked through their pants.

A review of R2's service plan dated 5/25/2022 indicated that "Community team members to assist with daytime wellness checks" and "team members to report to the nurse if the resident is missing any meals". A review of PCC charting revealed that resident was only checked on once during day shift at 9:18am. A review of facility's meal check-off sheet dated 06/11/2022 was marked with "?" for breakfast and lunch and "no response" noted in the margin.

A review of facility call-light logs for July 2022 revealed many incidences of response times greater than 20 minutes. This occurred six times on 6/11/2022 and 13 times on 6/12/2022.

During interview, Staff #4, Staff #6 and Staff #7 stated:

*R1 did not come down for breakfast and lunch on 6/11/2022 and that culinary did not send a meal to R1's room for either meal.

*Culinary staff attempted to contact care team to follow up about R1's meals but that there was no response from the care team.

*Staffing can be a problem.

*Sometimes they are short-staffed, especially on the weekends.

*Sometimes they cannot meet resident's needs because there are so many call pendants going off.

These findings were reviewed with and acknowledged by Staff #1-#2 and Staff #5 on 8/25/2022.

Facility Plan of Correction: Facility is now using an ABST.