Without proper compression, the drains essentially stop working.
Nursing Home News — Page 835
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The resident at Griffith Park Healthcare Center required all medications to be crushed because he could not swallow whole pills.
She told inspectors she acted at the resident's request but now realizes she should have refused.
The incident occurred at Folsom Care Center, where Resident 1 has lived since 2020 with diagnoses of traumatic brain injury and dementia.
Yet the Medical Records Director revealed the signature problem went deeper than simple oversight.
RN 1 spoke with the resident's family member at 4:47 a.m.
The resident arrived at her doctor's office on October 13 with wet dressings covering two open wounds on her left foot.
The breakdown in communication centered on Resident #1, whose scheduled bath days were Monday, Wednesday, and Friday.
She told inspectors the facility had no proof residents were receiving their scheduled baths.
The resident never returned from the hospital.
Federal inspectors found the practice violated requirements to provide activities that meet residents' individual needs and preferences.
During a November 26 interview at 2:29 p.m., she admitted she had not started any specialized training in infection prevention.