Nursing Home News — Page 594

The contaminated cup was then placed on the nursing station desk, further spreading potential infectious agents throughout the care environment.

The previous DON had departed several months earlier, leaving other staff members to assume portions of the critical leadership role's responsibilities.

The agreement waives the resident's right to pursue legal action through the court system.

The remaining 105 residents received nutrition through feeding tubes.

The inspection resulted in documented violations of federal nursing home regulations.

## Critical Communication Failures Investigation revealed concerning gaps in staff knowledge regarding the resident's care preferences.

One resident lost 14.29% of their body weight over six months and 7.9% in approximately three months, meeting the criteria for significant weight loss.

According to the facility's physician, this oxygen level should have triggered an immediate transfer to the emergency room.

The facility's own care plan, initiated on September 17, 2024, identified the resident's "behavior wandering into other resident's room" as a focus area.

The failure occurred when both the ignition control module and gas valve malfunctioned, requiring replacement parts that were not immediately available.

The incident occurred despite a hand washing sink being available at the nursing station.

The aide later confirmed she understood the resident required Enhanced Barrier Precautions but failed to follow the protocol.