Unattended Unit Leaves 41 Residents Without RN Coverage and Missed 6 AM Med Pass
Summary
The deficiency involves a nurse leaving her assigned unit and 41 residents without licensed nursing coverage, medication administration, or emergency care capability for over two hours during the night shift. According to the facility incident report and interviews, the RN assigned to the 4th floor (Nurse MI) clocked out and left the facility at 4:19 AM while responsible for 41 residents, with only two CNAs remaining on the floor. She did not wait for relief from another licensed nurse, did not provide a proper handoff, and did not notify the CNAs that she was leaving. Prior to leaving, she turned the medication cart and narcotic keys over to the front receptionist, a non-licensed staff member, instead of directly to another licensed nurse as required by facility policy. The report states that the receptionist, believing the keys should be held by licensed staff, took them to the 3rd floor nurse. The 3rd floor nurse, who already had 48 residents, refused to accept responsibility for the additional 41 residents and did not take the keys, stating it would be unsafe to be responsible for a total of 89 residents. No licensed nurse was present on the 4th floor from approximately 4:19 AM until about 6:30 AM, when the 4th floor unit manager arrived after being informed there had been no nurse on the unit for over two hours. During this period, only the two CNAs provided care, and they reported they were busy with resident care and did not realize the nurse had left until the morning nurse arrived. As a result of the absence of a licensed nurse, all 6:00 AM medications, assessments, and treatments for the 41 residents on the 4th floor were not administered or performed. Record review showed that one resident (R6) missed scheduled albuterol nebulizer treatments at midnight and 6:00 AM, and another resident (R5) did not receive scheduled suctioning by mouth at 6:00 AM, as well as scheduled PEG tube medications for cancer pain at 2:00 AM and 6:00 AM. A nurse who came on at 7:00 AM confirmed that 6:00 AM medications, vital signs due for medications, and nebulizer treatments were not given, and that she began the 8:00 AM medication pass upon starting her shift. Narcotic reconciliation records for the 4th floor medication carts showed missing or incomplete shift inventory documentation, including lack of a 7:00 AM shift entry for one cart and only a single nurse signature on multiple dates for the other cart, despite policy requiring two nurse signatures each shift. The facility’s resident rights policy and employee handbook, as cited in the report, specify residents’ rights to be free from neglect and require staff not to leave assigned workstations or leave work early without proper approval and handoff.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility did not maintain resident dignity in grooming and dining. A cognitively intact female resident with psychiatric diagnoses and a need for assistance with personal care was repeatedly observed in common areas with long white hairs on her chin, with documentation showing recent bed baths but no shaving, and she reported staff did not shave or offer to shave her chin. A CNA confirmed the presence of the chin hair and that the resident would allow shaving. In a separate instance, a visually impaired resident with dementia who was dependent for eating was assisted by a CNA who stood beside the resident for the entire meal rather than sitting, despite the CNA stating she normally sits to assist with feeding. These practices conflicted with the facility’s dignity policy requiring grooming as residents wish and a dignified dining experience.
A resident with dementia, anxiety disorder, and chronic respiratory failure, but with mild or no cognitive impairment, reported that staff often yelled at her and that some were “very nasty.” Video evidence and staff interviews confirmed that staff, including a CNA and an LPN, addressed the resident by her last name rather than her preferred first name. The resident’s daughter had emailed administrative staff and the state health department alleging that staff called the resident by her last name only, yelled at her, and spoke to her as if she were a child. Leadership denied prior knowledge of these concerns, and there were no related entries in the resident concern log, while the resident stated that being called by her last name was rude and disrespectful.
Two residents with cognitive impairment and significant ADL and nutritional support needs were not treated with dignity during feeding assistance. In both cases, staff members, including a CNA and a Medical Records Coordinator, stood over the residents while assisting with meals instead of sitting with them, despite care plans calling for supervised or assisted eating and a facility policy requiring residents be treated with respect and dignity. An LPN noted that one resident had recently declined and required staff to initiate feeding to stimulate eating.
A resident with intact cognition, legal blindness, and dependence for ADLs had a physician’s order and care plan for weekly shaving and assistance with facial hair during scheduled twice-weekly showers. Although shower records showed that bathing occurred as scheduled, there was no documentation of facial hair care, and surveyors observed the resident with long, full facial hair on multiple occasions. The resident reported that staff had not attended to her facial hair in some time, and CNAs and an RN Supervisor acknowledged that facial hair care had not been provided as expected, including during a recent shower. This failed to follow the facility’s policy to promote hygiene by assisting with facial hair removal as needed and did not maintain the resident’s dignity.
A resident with dementia and multiple medical conditions, including urinary retention requiring an indwelling catheter, was observed seated in a wheelchair in a common TV lounge wearing a hospital gown with the urinary drainage bag hanging uncovered from the wheelchair, leaving urine visible to others passing by. A Regional Corporate Nurse confirmed the bag was uncovered and in view. Facility policy required that urinary drainage bags be kept in a privacy bag or decorative drainage bag that does not expose urine contents, but this was not followed, resulting in a failure to maintain the resident’s dignity.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
Failure to Maintain Resident Dignity in Grooming and Dining Assistance
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and personal grooming, and to provide a dignified dining experience. One cognitively intact female resident with paranoid schizophrenia, depression, anxiety, and a need for assistance with personal care was documented as requiring partial/moderate assistance for bathing/showering and setup or clean-up assistance for personal hygiene. Shower documentation for two dates showed she received bed baths with no shaving documented. Over multiple observations on consecutive days, surveyors noted long white hairs on the resident’s chin while she was in common areas, including sitting by the nurse’s station. The resident stated she sometimes shaved her chin herself, that staff did not shave it for her, and that staff did not offer to shave the hairs. A CNA reported that female residents were shaved on shower days and confirmed this resident would allow staff to shave her chin and that she had long white hairs present. The facility also failed to ensure a dignified dining experience for a resident with Alzheimer’s disease with early onset, dementia with agitation, severely impaired vision, and dependence on staff for eating. Physician orders and the MDS indicated the resident required assistance with feeding. During a meal observation, a CNA stood beside the resident for the entire meal while assisting with eating, rather than sitting. In a subsequent interview, the CNA acknowledged that she normally sits down to assist residents with meals, verified that she stood beside this resident during the observed meal, and explained that because the resident was blind, staff could hand finger foods but had to physically assist with the rest of the meal. These actions and inactions were inconsistent with the facility’s dignity policy, which states residents are to be groomed as they wish and provided with a dignified dining experience.
Failure to Address Resident by Preferred Name and Maintain Dignified Communication
Penalty
Summary
The facility failed to honor a resident’s right to dignity and self-determination by not ensuring staff addressed her using her preferred name. The resident, who had dementia, anxiety disorder, and chronic respiratory failure, was assessed as having mild or no cognitive impairment. A video dated 01/22/26 showed an unseen staff member addressing the resident by her last name during care. Emails from the resident’s daughter to administrative staff and the state health department reported that a CNA called the resident by her last name only, which the daughter considered disrespectful, and that an unidentified aide continued this practice. The emails also alleged that staff yelled at the resident and spoke to her as if she were a child. In interviews, the resident reported that workers yelled at her often and that some were “very nasty.” The Administrator, DON, ADON, and Regional Nurse denied knowledge of concerns about the resident being yelled at or not being called by her preferred name, and the facility’s resident concern log for the past year contained no documented concerns regarding this resident. An LPN and a CNA each acknowledged that they sometimes or routinely addressed the resident by her last name and stated they were unaware this was not her preference, and the CNA denied mistreating or yelling at the resident. The Regional Nurse confirmed that the video showed a staff member addressing the resident by her last name. In a later interview, the resident stated she preferred to be called by her first name and that staff sometimes called her by her last name, which she felt was rude and disrespectful.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity during feeding assistance. For one resident with cerebral ischemia, vascular dementia, and significant cognitive impairment, the MDS showed a need for substantial or maximal assistance with eating, and the care plan included assistance with meals as needed. During a lunch observation, a CNA initially sat at the dining table while assisting this resident, then left to help another resident. When the CNA returned, she remained standing next to the resident while assisting him with the remainder of his meal, rather than being seated. The CNA confirmed in interview that she was standing while assisting and acknowledged she should have been seated with the resident. A second resident, admitted with vascular dementia, Type II diabetes, altered mental status, adjustment disorder with depressed mood, muscle weakness, cognitive communication deficit, and dysphagia, was documented on the MDS as cognitively impaired and requiring supervision while eating. The care plan identified an ADL self-care performance deficit related to cognitive and functional issues, with interventions including eating supervision or touching assist, and helper cues or steadying. Observation showed the Medical Records Coordinator standing next to this resident while feeding him his meal, rather than being seated. In interview, the staff member verified she stood over the resident while assisting with eating. An LPN reported that this resident had a recent decline characterized by sitting and staring instead of eating, and that staff had been feeding him at the start of meals to gain his interest. Facility policy on Resident Rights stated that residents would be treated with respect and dignity.
Failure to Maintain Resident Dignity Through Ordered Facial Hair Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s dignity by not providing facial hair care as ordered and care planned. The resident was admitted with diagnoses including hypertension, atrial fibrillation, and legal blindness, and had intact cognition but required extensive assistance with all ADLs. A physician’s order dated 07/17/25 specified that the resident was dependent for shaving and required weekly shaving, and the care plan directed staff to assist with or shave facial hair and to perform nail and hair care weekly with showers. The shower schedule showed the resident was to receive showers every Monday and Thursday, and shower records from 03/12/26 to 04/13/26 confirmed twice-weekly showers or bed baths as scheduled, but there was no documentation regarding facial hair care. On 04/13/26 at 1:00 P.M., surveyors observed the resident lying in bed with long, full facial hair. In an interview on 04/15/26 at 1:45 P.M., the resident stated she wanted staff to take care of her facial hair but reported they had not done so in a while; observation during this interview confirmed she still had a face full of facial hair. In a subsequent interview at 2:00 P.M., a CNA and an RN Supervisor reported that the resident received showers on Monday and Thursday afternoons and that they addressed facial hair at that time, but they acknowledged the resident’s facial hair had not been cared for in a while, as evidenced by its length. Another CNA interviewed on 04/16/26 at 2:45 P.M. stated the resident was supposed to be shaved every Monday with her bath or shower and confirmed she did not shave the resident during the shower on 04/13/26. The facility’s shaving policy, updated 05/01/25, stated that staff were to promote resident hygiene by assisting with removal of facial hair as needed, which was not followed in this case.
Uncovered Urinary Catheter Bag Exposed in Common Area
Penalty
Summary
The facility failed to treat a resident with respect and dignity related to management of an indwelling urinary catheter. The resident, admitted on 04/03/26 with diagnoses including orthopedic aftercare, fall with fracture at home, pain, dementia, osteoarthritis, and hypertension, had a physician’s order dated 04/06/26 for an indwelling urinary catheter for urinary retention/possible bladder outlet obstruction, with catheter care to be provided every shift. On 04/06/2026 at 9:59 A.M., the resident was observed in the TV lounge area in a wheelchair wearing a hospital gown, with the urinary catheter drainage bag hanging from the wheelchair uncovered and the urine visible, while other residents and staff passed through the area. At 10:01 A.M., a Regional Corporate Nurse confirmed that the catheter bag was uncovered and in view. Review of the facility’s undated “Catheter Care, Urinary” policy showed staff were required to ensure the urinary drainage bag was kept in a privacy bag or a decorative drainage bag that did not expose the urine contents, which was not followed in this instance. This deficiency demonstrates noncompliance investigated under Complaint Number 2596634.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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