cms_SD: 41
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 41 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 610 | F | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and policy review, the provider failed to complete and fully investigate residents' incidents for 13 of 13 sampled residents' (3, 5, 6, 17, 33, 36, 37, 41, 42, 47, 53, 57, and 109) reviewed with incident reports and investigations. Findings include: 1. Review of resident 3's fall incident investigation reports revealed: *A fall report dated 7/11/17 completed by registered nurse (RN) G stated the resident had:-Fallen onto her bottom in the bath house. -The following areas on the incident investigation report had not been completed: --Mental status. --Physiological factors. --Predisposing situation factors. -There had been only one fall progress note regarding the 7/11/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 7/18/17 completed by licensed practical nurse (LPN) N stated the resident had: -Fallen when She missed the toilet and fell straight on her butt. Denies hitting head. -The following areas on the incident investigation report had not been completed: --Injuries Observed at Time of Incident. --Level of pain. --Mental status. --Predisposing environmental factors. -There had been only one fall progress note regarding the 7/18/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 7/20/17 completed by RN T stated the resident had: -Been found by staff sitting on the middle of the floor in her room. She denied hitting her head. She stated I was getting up to ask someone about lunch. -The following areas of the incident investigation report had not been completed: --Injury type No Injuries observed at. --Mental status. --Predisposing environmental factors. --Predisposing situation factor. -There had been no fall progress notes regarding the 7/20/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 7/29/17 completed by RN T stated, Resident was being transported back from being hospitalized at CRH (Custer Regional Hospital). She was in w.c. (wheel chair) and being assisted into van via lift operated by staff. She brushed her left arm on the lift control that caused it to start and she bumped her head on the doorway of the van. she was taken back into the ER and Dr (name) assessed and placed a gauze/Coban dressing over it. New orders were received from Dr (name) for wound care. -The following areas of the incident report had not been completed: --Mental status. --Predisposing environmental factors. --Predisposing physiological factors. --Predisposing situation factors. -There had been no fall progress notes regarding the 7/29/17 incident in her medical record. -There had been no documentation of an investigation having been completed. 2. Review of resident 33's fall incident investigation reports revealed: *A fall report dated 10/30/17 completed by RN T stated, Resident was using her walker and was preparing to sit in one of the chairs in the area by hall 3 exit door and as she was backing up to sit down in chair she slid down the front of chair and was found sitting on the floor. Denies pain and able to move all extremities. Denies hitting her head. Resident's POA (power of attorney) arrived for a visit just after the fall. Able to ambulate without difficulty following the fall. -The following areas of the investigation report had not been completed: --Level of pain. --Mental status. --Predisposing environmental factors. --Predisposing physiological factors. --Predisposing situation factors. -There had been no fall progress notes regarding the 10/30/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 11/15/17 completed by LPN M stated, Resident was in assisted in dining room when she had her walker against another resident's wheelchair. When the resident in the w/c started moving her walker rolled and she fell to her knees. -The following areas of the incident report had not been completed: --Level of pain. --Mental status. -There had been only one fall progress note regarding the 11/15/17 incident in her medical record. -There had been no documentation of an investigation having been completed. 3. Review of resident 47's fall incident investigation reports revealed: *A fall report dated 2/8/18 stated. Resident found to be sitting on the floor with her legs bent and feet not on the floor. Resident had no shoes or slippers on, just TED hose. Resident had previously been noted to be sleeping in her recliner by writer and CN[NAME] Resident stated she woke up and did not know where she was, and turned over. Resident states she then fell out of the chair and had been crawling on floor trying to get up. States knees hurt from crawling on floor. Denies any other pains or complaints. -The following areas of the incident report had not been completed: --Mental status. --Predisposing environmental factors. -There had been only the initial fall note on 2/818 identified in the resident medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 2/9/18 completed by RN U stated, Sitting in recliner and slid to the floor while trying to get out of recliner to plug in her cell phone. denies hitting head. Resident was talking on phone with family while incident happened. Family called this nurse to let us know that her mother needed her cell phone plugged in and that she had slipped onto the floor. -The following areas of the incident report had not been completed: --Level of pain. --Mental status. --Predisposing environmental factors. --Predisposing situation factors. --Notes. -There had been only the initial fall note on 2/9/18 identified in the resident's medical record. -There had been no documentation of an investigation having been completed. 4. Review of resident 57's fall incident investigation reports revealed: *A fall report dated 5/11/17 completed by RN T stated Resident fell against wall in DR (dining room) as he was standing up and getting ready to leave. -The following areas of the incident report had not been completed: --Level of pain. --Mental status. --Predisposing environment factors. --Predisposing situation factors. --There had been only the initial fall note on 2/9/18 identified in the resident's medical record. *A fall report dated 12/30/17 completed by RN T stated, CNA reports resident was as being transferred from toilet to w.c. He was holding onto handle bar as the CNA was bringing the w.c. into the bathroom for the resident to be seated on. Resident lowered self down to floor before CNA was able to lock the brakes. He was able to to continue holding on to the handle bar attached to wall while lowering self and siting on floor with feet on floor. -The following areas of the incident report had not been completed: --Level of pain. --Mental status. --Predisposing environmental factors. --Predisposing situation factors. -There had been no fall progress notes regarding the 12/30/17 incident in the resident's medical record. -There had been no documentation of an investigation having been completed. 5. Interview on 3/28/18 at 8:30 a.m. with the director of nursing revealed she: *Agreed the incident investigations for residents 3, 33, 47, and 57 were incomplete. *Expected the incident reports and fall progress notes to be completed. *Expected the nurses to begin a fall investigation. 6. Review of resident 17's medical record, incident reports, and investigations during the survey on 3/12/18 through 3/15/18 related to his verbal, physical, and sexually abusive behaviors involving other residents and staff members revealed he: *Had [DIAGNOSES REDACTED]. *Had a Brief Interview for Mental Status score of twelve meaning he had moderate cognitive impairment. *Was: -Independent with all activities of daily living (ADL). -Able to walk independently with the use of a single-point cane. *He had multiple incidents of inappropriate behaviors with other residents and staff. *No documentation to support: -Event reports or investigations had been completed on all of the resident-to-resident and resident-to-staff altercations above to rule out abuse/neglect. -The physician and family had been notified after each above event. -What interventions had been put in place to ensure that type of behavior exhibited by the resident would not have occurred again. -The inappropriate verbal, physical, and sexual behaviors exhibited above by the resident had been reviewed in full to ensure the mental health, personal privacy, residents' rights, and dignity was maintained for all who had been involved in those altercations. Refer to S550, findings 1, 2, and 3. Refer to S600, findings 1, 2, 3, and 4. 7. Review of resident 6's medical record revealed: *An admission date of [DATE]. *She had short and long term memory problems and was not interviewable. *Her [DIAGNOSES REDACTED]. *She was able to walk independently without the use of an assistive device. *She had: -Required staff supervision d/t poor decision making capabilities. -Been able to wander throughout the facility. -A history of attempting to elope from the facility. *No documentation to support her elopement from the building on 1/13/18 had been investigated and reported to the SD DOH. Review of resident 6's incident reports that included the investigations from 9/18/17 through 3/9/18 revealed: *She had made several attempts to leave the facility. *On 9/18/17 at 6:03 p.m. she had opened the exit door on hallway two. An unidentified CNA followed her outside and was able to redirect her back into the facility through another exit door. *On 10/20/17 at 10:28 p.m. she had an unwitnessed fall in her room. The staff found her sitting on the floor by her roommates bed. Her pants and incontinent brief were down, and there was bowel movement on the floor. No injury identified. *On 12/27/17 at 2:55 a.m. she had opened the exit door on hallway two and went outside. By the time the charge nurse arrived at that exit door the resident was walking down the sidewalk. She was half way to the parking lot by the time the charge nurse was able to reach her. She only had on pajamas, socks, and shoes. The charge nurse was able to redirect her back into the facility. *On 1/13/18 at 5:52 p.m. she had opened hallway one's exit door. The alarm sounded, but by the time an unidentified CNA got to the door she was out of her sight. The CNA did not open the door and do a complete check to ensure no one was outside of the building. When the CNA looked straight out the door she had not seen anyone. The resident was able to walk down the sidewalk and into the visitor parking lot. A visitor had been coming back into the building and brought her with them. The temperature was documented in the mid-thirties. *On 2/28/18 at 2:16 p.m. she went outside through hallway two's exit door. Staff were able to redirect her back into the building. *On 3/1/18 at 9:49 a.m. the maintenance staff had been testing the door alarms. She attempted to go outside hallway two's exit door. The door alarm sounded, and the staff had been able to redirect her back into the building. *On 3/9/18 at 5:55 p.m. she attempted to sit down on the floor when the staff were walking her out of the dining room. The staff lowered her to the floor with no injury. *For all of the above incidents and investigations there was no evidence to support a thorough investigation had occurred. -There were multiple areas of missing documentation in the incident reports. *The documentation had not supported: -That a root cause analysis of the reports had been determined. -The facility response and action plan to ensure she had been safe without the inability to elope from the building. *The incident reports failed to consistently identify: -Mental status at the time of the events. -Predisposing environmental factors. -Predisposing physiological factors. -She was an active exit seeker under predisposing situation factors. Interview on 3/28/18 at 3:10 p.m. with the administrator regarding resident 6 confirmed they had identified her as a safety risk. He had been reviewing an alarming/locking system for the exit doors. He had recently received permission from the manager of Regional Health Systems to install a Wander Guard system. -That system would start with the new budget starting 7/1/18. Review of the provider's 6/27/16 Elopement/Elopement Attempts policy revealed: *(Facility name) strives for resident safety. Nursing personnel must report and investigate all reports of missing residents. *Upon return of the resident to the facility, the staff nurse should: -Examine the resident for injuries, notify the physician, and representative. -Update resident's care plan to reflect interventions implemented. -Complete initial report to South Dakota Department of Health online. 8. Review of resident 5's medical record revealed:*She had been admitted on [DATE]. *She had short and long term memory problems. *Her decision making ability was moderately impaired. *Her [DIAGNOSES REDACTED]. Review of resident 5's incident reports including the investigations from (MONTH) (YEAR) through 3/12/18 revealed:*On 10/5/17 she had physical behaviors of hitting her roommate. *On 10/18/17 she had an unwitnessed fall. *On 11/3/17 she had gone outside and was found in the parking lot after the door alarm rang. *On 11/19/17 she had an unwitnessed fall and hit her head. *On 11/28/17 she had an unwitnessed fall. *On 12/18/17 she had a witnessed fall in the lobby during activities where she tripped over another resident's walker. *On 1/16/18 she had a witnessed fall in the lobby when she tried to pick something up off the floor. *On 2/21/18 she had an unwitnessed incident where she was found to be chewing on a box of tissues and had a tissue in her mouth in the lobby. *On 2/28/18 she had an unwitnessed fall in the lobby and had redness on her cheek and left arm from it. -There was no mention of the physician having been notified. *On 3/3/18 she had an unwitnessed fall in the lobby during a movie activity. *For all of the above incidents and investigations there was no evidence to support a thorough investigation had occurred. -There were areas of missing documentation in the incident reports. *The documentation had not supported that: -Staff had been interviewed to give details related to the incidents. -A root cause of the incident had been or could have been determined. -Potential abuse had been ruled out. 9. Review of resident 37's medical record revealed:*She had been admitted on [DATE]. *Her 8/24/17, 11/7/17, and 2/7/18 Brief Interview for Mental Status examination scores indicated she had moderate to severe cognitive impairment. *Her [DIAGNOSES REDACTED]. Review of resident 37's interdisciplinary behavior progress notes from her 8/18/17 admission through 3/28/18 revealed:*On 8/23/17 she .became upset and pushed CNA out of the room . *On 10/5/17, CNA overheard this resident tell her roommate 'stop hitting me.' CNA was outside of room and did not witness this resident being hit. Resident states she did not get hurt, assessed and no injury noted. CNA redirected the roommate of this resident out of the area. *On 11/1/17, At pm meal this resident attempted to make her tablemate put his nasal cannula back on, telling him that he had to and she knew so because she once worked her. When this nurse intervened to separate this resident and her tablemate this resident became very angry striking out at this nurse then grabbing my arm and trying to yank me around. This nurse to resident 'that's enough, take your hands off me and don't touch me like that, it's not acceptable' Resident began to yell again that she can do what she wants because she once worked here. Tablemate removed and placed at a different table secondary to this resident would not calm down and quit yelling. This resident struck out at and grabbed this nurse 2 more times. Staff will continue to monitor. *On 11/7/17, At app. 1015 this am this resident was sitting in a chair, and approached by another resident. This resident started yelling at the other resident, telling her to sit down. The other resident did not sit down, so this resident then took her by the hand and physically sat her down in the chair. She then yelled 'I used to work here, and you stay there!' This resident was then educated on not touching others. She kept repeating but 'I used to work here, I was a CNA!' I explained to her that she no longer works here, and cannot touch other residents. She then promised that she wouldn't do that again. *On 11/20/17, CNA informed this nurse that the resident has been having behaviors of: Wandering into other resident's rooms, attempting to help residents out of bed (even residents that require extensive/dependent assist), taking items and clothing that do not belong to her. Refusing to change clothes even after wearing the same clothes for days . *On 12/17/17, This nurse heard resident yelling at her roommate. Upon entering her room this resident had privacy curtain pulled around her roommates side of the room and had resident cornered yelling at her. This nurse told this resident that she needed to go back to her side of the room. Resident swung her arm at me and yelled that she was a CNA here and that she could do as she wished. I again told resident to go to her side of the room and keep her hands to herself. Resident continued to yell and tried x4 to grab this nurse. Resident eventually did go and sit on her bed but continue to yell out until staff left room . *On 12/31/17 two notes: -Resident yelling at roommate, stating roommate was in her room . -Second episode of behaviors this shift. Resident again yelling at roommate as roommate was playing with the cables at the midway point of the room. Resident could be heard by writer near nurse's station . *On 3/23/18, CNA reports resident has items of clothing that belong to her roommate. When the CNA asked her about it, this resident started yelling at the CNA and hit her on CNA's rt (right) hand . On 3/28/18 at 9:25 a.m. copies of incident reports and investigations for resident 37 were requested from the director of nursing support person B. Interview on 3/28/18 at 12:50 p.m. with the DON regarding resident 37 revealed: *No incident reports or investigations were completed for the resident from her 8/18/17 admission through 3/28/18. *She confirmed events that included resident-to-resident altercations should have had incident report and investigations. *For the above behaviors and events there was no evidence to support a thorough investigation had occurred. *The documentation had not supported that: -Staff had been interviewed to give details related to each event. -A root cause of the incident had been or could have been determined. -Potential abuse had been ruled out. 10. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had short and long term memory problems. *Her decision making ability was severely impaired. *Her [DIAGNOSES REDACTED]. Review of resident 41's incident reports including the investigations from her admission on 8/1/17 through 3/12/18 revealed: *On 8/3/17 she had an unwitnessed fall between the office and the dining room and had hit her head causing a cut to her left eyebrow. *On 8/15/17 she had an unwitnessed fall in the hallway near the vending machines. -There was no mention of notification to her family. -There were notes several days later on 8/21/17, 8/28/17, and 9/6/17 from fall meetings. --Those notes did not include investigation specific related to each fall that occurred. *On 9/7/17 she was seen going out an exit door. *On 9/12/17 she had an unwitnessed fall in her room. -There was no mention of notification to her family. *On 9/25/17 she had an unwitnessed fall in her room, hit her head causing a laceration to her right forehead, and was sent to the emergency room for evaluation by ambulance. -There were notes on 9/27/17, 10/2/17, and 10/4/17 that included: -- .CNA says that resident appears to become more agitated and impulsive towards the evenings. Note left for Dr. (name). Nurse encouraged to use her PRN [MEDICATION NAME] if other interventions are not successful. -Review of the final Required Healthcare Facility Event Reporting form for the 9/25/17 event indicated: --In the brief explanation: .It was noted that (name) was wearing shoes and had just minutes before had been seen walking to her room from the nurses station . --There was no mention if her care plan had been followed since she required staff assistance with walking. --The conclusionary statement stated she had a short hospital stay for observation and received stitches to her laceration. -Action taken was personnel education. --Which staff and what education was done was not specific related to the resident's incident. --There was only mention of a nurse who completed the wrong report for the department to get education. *On 9/29/17 she had a witnessed fall by the door of the dining room. -There was no mention of the physician being notified until a note on 10/4/17. *On 10/6/17 she had an unwitnessed fall in her room and pulled a shelf down in her room. -There was no mention of notification to her family. *On 10/10/17 she had a witnessed fall when attempting to walk without her walker. *On 10/13/17 she had a near fall in the commons areas for staff outside of the dining room. -There was no mention of how she got into that commons area. *On 10/24/17 she had an unwitnessed fall in the dining room and injured her right shoulder/arm. She was sent to the emergency room by ambulance. -A note several days later on 10/30/17 stated, Resident prior to fall was in the dining room per staff with a pink bucket (basin). This is not per interview with staff a Witnessed fall. Staff did administer PRN medications when resident became agitated and not redirectable in the most recent past. --That note was unclear as to when/how the information was obtained. -A note almost two months later on 1/17/18 stated Fall team met and discussed falls on 12/13/17, 12/17, 1/02/18, and 1/7/18. Resident is on Restorative program for ambulation and is working with therapy on improving toileting with verbal cues, hygiene and self feeding. Is on Q (every) 2 hour toileting, Q 2 hour resident checks. -There was no mention of the resident having a right shoulder dislocation as found during her emergency room evaluation. --The above fall with major injury and transfer to the hospital for evaluation had not been reported to the South Dakota Department of Health (SD DOH). *On 11/7/17 she had a witnessed fall in the hallway near the dining room where she hit her head and left elbow. -There was no mention of notification to her family. *On 12/13/17 she had a witnessed fall in the lobby and bumped her head. -A note over a month later on 1/17/18 was the same as the 10/24/17 fall. *On 12/28/17 she had an unwitnessed fall in her room with the following documented: - resident laying on ground, next to bed, with gown off and brief pulled down, bed wet. CNA had last been in room [ROOM NUMBER] minutes prior, doing safety check, and at that time resident was asleep. Resident bed in low position, floor mat next to bed (under resident). -There was no mention of when she had last been assisted to the bathroom. -A note several weeks later on 1/17/18 was the same as the 10/24/17 fall note. *On 1/3/18 a witnessed fall sliding from her low bed onto her fall mat. -The note several days later on 1/17/18 was the same as the 10/24/17 fall note. *On 1/7/18 she had an unwitnessed fall in her bathroom. -The description was Resident states 'I fell and hit my back here.' pointing to the bathtub. Resident was sitting on toilet, pull up wet. --There was no mention of when she had last been assisted to the bathroom. -Ten days later on 1/17/18 the note was the same as the 10/24/17 fall note. *On 1/7/18 she had a physical altercation with another resident in the lobby area that was witnessed by a third resident. -A note several days later on 1/23/18 stated, Resident placed on 30 minute status location monitoring. --There was no mention of how long those 30 minute checks would remain in effect. *On 1/22/18 the resident had a bruise-like area to the end of her left great toe. -There was no mention of how that bruise might have occurred or if any staff were interviewed about the injury. *On 1/31/18 she had an unwitnessed fall in hall outside her room with injuries with the following documented: - .resident laying on her left side with blood coming from her left eyebrow and mouth. ROM (range of motion) completed to all but resident's left arm secondary to resident yelling out in pain saying, 'don't touch it, it's broke.' Staff assist x 3 with gait belt to get resident to stand and place in a W/C . -She was sent to the emergency room by facility staff and van. -A note over a month later on 3/1/18 stated Pressure alarm placed with family consent to alert staff of attempt to transfer without assist . -Review of the final Required Healthcare Facility Event Reporting form for the 1/31/18 event indicated: --In the brief explanation: .CNA report that they had just checked on resident 5 minutes prior and she was in bed napping . --There was no mention if her care plan had been followed since she required staff assistance with walking and toileting. --The conclusionary statement stated Investigation is ongoing per DON. Resident returned from hospital on [DATE] @ 16:10 (4:10 p.m.) with dx (diagnosis) of fx (fracture) to L elbow .Staff per investigation, state she was sleeping in her bed only five minutes prior to her being found on floor .Resident had not been ambulating recently due to medical diagnosis .Facility and staff have tried every available option for decreasing her fall risk for example anti roll back on w/c, providing activity/diversion with any increased agitation that was not easily redirected. Primary provider and family discussion with nursing on 2/2 and decision to initiate pressure alarm to alert staff of resident attempts to self transfer to decrease her risk of falls . -Action taken was other: Discussion with family and Physician on safety concerns. *On 2/19/18 nursing found discoloration areas to the back of her head, both heels, and buttocks. -Immediate action taken was new mattress applied, foam boots and cream to buttocks applied.-Injury type was unable to determine for all four areas. -There was no mention of how those areas might have occurred. *On 2/26/18 nursing found .a softer absorbing blister like spot, tan/brown in color, soft at tip of toe. Wears only slipper socks and foam boots. Not going to classify as pressure area at this time. Treatment in to monitor daily. Area measures 1.3 x (times) 1.0 (centimeters). -There was no mention of how that blister like spot could have occurred. *For all of the above incidents and investigations there was no evidence to support thorough investigations had occurred. -There were areas of missing documentation in the incident reports. *The documentation had not supported that: -Staff had been interviewed to give details related to the incidents. -A root cause of the incident had been or could have been determined. -Potential abuse had been ruled out. Review of resident 41's interdisciplinary progress notes revealed: *She had an unwitnessed fall on 11/9/17 in the hallway. -She received a skin tear. *She had an unwitnessed fall on 11/30/17 in her bathroom. *Those falls had not been part of the incident or investigation forms. 11. Review of resident 53's medical record revealed: *He had been admitted on [DATE]. *He had short term memory problems and severely impaired decision making ability. *His [DIAGNOSES REDACTED]. Review of resident 53's interdisciplinary progress notes from his 2/14/18 admission through 3/15/18 revealed:*On 2/22/18 .Bruised area to left shin measuring 2.1 cm (centimeters) x 1.1 cm covered with ABD pad and cling to secure for protection. -There was no mention of how that bruise had occurred or if it was a new area. *On 2/26/18 .Has blood blister like area 1.7 x 1.0 left lower shin with tx (treatment) for protection started . -There was no mention: --If that was the same area identified on 2/22/18 or if it was a new area. --How the blood blister had occurred. -On 3/12/18 that area was opened. *On 3/12/18 .Has skin tear on right wrist . -There was no mention: --If that was a new skin tear. --How the skin tear had occurred. *The above injuries were of unknown origin and had no incident or investigation reports related to them. Review of resident 53's incident reports and investigations from his admission through 3/15/18 revealed:*On 3/4/18 he had an unwitnessed fall in his room where CNA's found resident on floor beside bed- resident c/o (complained of) rib and back pain. Resident stated 'I was trying to go home. -There was no mention of: --How he might have gotten out of his bed to the floor. --What happened after he was sent to the hospital. -That event had not been reported to the SD DOH. *On 3/8/18 resident has two small skin tears to left hand cause unknown. -There was no mention of: --Witnesses. --Notification to his physician or family. --What might have caused those skin tears. *On 3/10/18, Resident presents with open pressure ulcer to the right shoulder no drainage [MEDICATION NAME] applied.-There was no mention of: --Witnesses. --Notification to his family. --What might have contributed to that pressure ulcer. *For all of the above incidents and investigations there was no evidence to support thorough investigations had occurred. -There were areas of missing documentation in the incident reports. *The documentation had not supported that: -Staff had been interviewed to give details related to the incidents. -A root cause of the incident had been or could have been determined. -Potential abuse had been ruled out. 12. Interview on 2/14/18 at 1:21 p.m. with licensed practical nurse (LPN) A and registered nurse (RN) G regarding residents' incidents including falls, resident-to-resident altercations, and injuries of unknown origin revealed: *LPN A was a traveling nurse and had worked in the facility for about one month. *RN G had been working in the facility for about a year. *They stated when a fall or incident had occurred with a resident the nurse should have: -Assessed the r | 2020-09-01 |