Citations in Alaska
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Alaska.
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Latest Citations in Alaska
Two residents were discharged without adequate planning, resulting in unsafe and inappropriate transitions. One was sent home to an inaccessible and unsafe environment without necessary support or services, leading to distress, a fall, and reliance on unplanned third-party assistance. Another was discharged despite unresolved behavioral and cognitive issues, without required mental health referrals or involvement of their representative, causing distress and confusion. The facility lacked documented discharge planning standards and failed to coordinate essential post-discharge care.
A resident with dementia, depression, anxiety, and other complex conditions was admitted without the PASRR Level II report being available or reviewed. The facility did not initiate specialized mental health services as required, delayed updating the care plan, and discharged the resident without addressing PASRR-identified needs or following recommended discharge options. This resulted in untreated behavioral symptoms and increased psychotropic medication use.
A resident with complex medical needs developed multiple pressure ulcers and infections due to the facility's failure to provide timely and consistent wound care interventions, delayed care planning, poor documentation of noncompliance, and lack of coordination for higher-level wound care referrals. Discrepancies between wound care provider recommendations and actual treatment orders, as well as improper antibiotic administration in relation to dialysis, contributed to persistent wound infection and ultimately led to hospitalization with sepsis and death.
Systemic failures in the QAPI program led to ongoing deficiencies in staffing, grievance procedures, activities, medication management, and therapy services. Residents experienced long wait times for assistance, were not properly informed about grievance processes, and were not consistently offered activities as documented in their care plans. Incomplete narcotic count documentation and lapses in therapy services further contributed to suboptimal care.
Two residents did not receive care according to physician orders and care plans. One resident with hypertension and heart failure had daily vital signs ordered but only had them documented twice over several months. Another resident with skin breakdown risk had orders for offloading boots and wound care that were not implemented, as observed during the survey. Facility policies required adherence to these orders and care plans.
A resident with dementia and a documented POA was discharged without the facility providing the Notice of Medicare Non-Coverage (NOMNC) to the POA or obtaining the POA's signature. Instead, the NOMNC was signed by the resident, and there was no documentation that the POA was informed of appeal rights prior to discharge.
Two residents did not receive comprehensive, person-centered care plans addressing their specific needs. One resident with dementia and behavioral symptoms lacked dementia-related interventions in the care plan, despite documented diagnoses and medication use. Another resident, identified as high risk for falls after spinal surgery, did not have fall-risk interventions documented in the care plan and subsequently experienced a fall. Facility assessments and policies required these care plans, but they were not implemented.
A resident with cognitive impairment and a history of exit-seeking behaviors, who was on wander guard precautions, was able to leave the facility undetected after staff failed to respond to an activated wander guard alarm. The resident exited through the front door, took a cab to a local store, and was missing for over two hours before being returned by members of the public. Facility policies lacked clear instructions for staff response to wander guard alarms, contributing to the delayed intervention.
A resident with significant mobility impairments and recent spinal surgery did not receive ordered physical therapy for an extended period when the facility's PT went on leave. Despite ongoing physician orders for skilled PT, services were interrupted for several days, with no documented updates to care plans or formal notification to the resident or their representative. Facility staff confirmed the lapse and lack of documentation regarding communication or order changes during the interruption.
Two residents experienced harm due to the facility's failure to provide timely wound care and respond appropriately to changes in condition. One resident did not receive scheduled wound treatments or adequate assessment of increased pain, leading to wound infection and adverse effects from antibiotics. Another resident with a recent pacemaker procedure had a change in the surgical site that was not promptly escalated to the wound care team, resulting in infection, hospitalization, and surgical intervention.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure that residents were discharged in a manner that protected their health, safety, and psychosocial well-being. Specifically, the facility did not develop or implement an effective discharge planning process for two residents, resulting in unsafe and inappropriate discharges. The facility lacked documented standards for discharge planning, relying instead on verbal expectations within the social services department. Discharge planning was limited to care conferences at admission and two weeks prior to discharge, with no ongoing reassessment or structured involvement of resident representatives. The facility also did not conduct home visits prior to discharge, and referrals for post-discharge services and equipment were inconsistently arranged or delayed. One resident was discharged to a home environment that was known to be unsafe and inaccessible, without adequate caregiver support or required services in place. The resident, who had a history of joint replacement surgery, infection, and a recent femur fracture, required wound care, mobility assistance, and ongoing medical follow-up. Despite the resident's home being multi-level, in disrepair, and infested with rodents, the facility proceeded with discharge planning that did not ensure safe access or adequate support. The resident was left reliant on unplanned third parties, such as the fire department and community members, for essential care and experienced distress, emotional harm, and physical compromise, including a fall after discharge. Another resident with cognitive impairment, acute behavioral changes, and a documented need for nursing facility level care and specialized mental health services was discharged without required referrals or representative involvement. The facility did not review or incorporate the resident's PASRR Level II findings into the discharge plan, nor did it address a documented change in condition on the day of discharge. As a result, the resident experienced distress, confusion, and loss of security, with the POA having to assume unplanned caregiving responsibilities to prevent harm. The failures in discharge planning led to actual physical and psychosocial harm for both residents.
Failure to Incorporate PASRR Level II Findings into Care and Discharge Planning
Penalty
Summary
The facility failed to comply with PASRR (Pre-admission Screening and Resident Review) requirements by not incorporating the PASRR Level II determination into the assessment, care planning, and discharge planning for a resident with multiple mental health diagnoses. The PASRR Level II evaluation, which identified the need for continued nursing facility services and specialized mental health services, was not available at the time of admission and was not reviewed during the resident's stay or at discharge. The Level II report was only retrieved after the resident had already been discharged, and its recommendations were not integrated into the resident's care plan or discharge process. The resident in question had a complex medical history, including dementia, depression, anxiety, delirium, encephalopathy, and a recent femur fracture with surgical site infection. The PASRR Level II assessment specifically noted the need for specialized services to address mental health needs and provided recommendations for care and discharge options. Despite these findings, the facility did not order or initiate any specialized mental health services during the resident's stay. The care plan was delayed and, when eventually updated, did not include the specialized services recommended by the PASRR Level II evaluation. Throughout the resident's admission, there were documented episodes of aggression, combativeness, and non-compliance, which led to the initiation and escalation of psychotropic medications. The discharge summary and post-care instructions did not address the need for specialized mental health services or follow the recommended discharge options outlined in the PASRR Level II report. Facility staff acknowledged that the lack of access to and review of the PASRR Level II report negatively impacted the adequacy of care planning and discharge for the resident.
Failure to Provide Appropriate Pressure Ulcer Care and Timely Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a facility-acquired pressure ulcer. The resident, who had significant comorbidities including end-stage renal disease and diabetes, developed multiple wounds during their stay, including a left iliac crest pressure injury and sacral wounds. There were significant delays and inconsistencies in wound assessment and treatment orders, with documented discrepancies between wound care provider recommendations and the actual orders transcribed and implemented by nursing staff. For example, wound care interventions recommended by the wound care team were not consistently reflected in the Treatment Administration Record (TAR), and antibiotics were not always administered as prescribed, particularly in relation to the resident's dialysis schedule, resulting in subtherapeutic dosing. Documentation revealed that wound care interventions were not promptly added to the resident's care plan, with a delay of 21 days after wounds were first identified. There was also a lack of documentation regarding the resident's reported noncompliance with repositioning and wound care, as noted by the wound care provider, with no corresponding nursing or CNA notes, risk/benefit documentation, or care plan updates to address these issues. Additionally, there was a failure to initiate and document referrals for higher-level wound care as recommended by external providers, and the facility did not coordinate or document efforts to ensure the resident attended outpatient wound care or follow-up appointments, despite family requests and external provider recommendations. Throughout the resident's stay, wound healing was minimal, and infections persisted despite multiple rounds of antibiotics, which were at times administered incorrectly or not as ordered. The lack of timely and appropriate wound care interventions, poor communication and documentation among staff, and failure to coordinate necessary higher-level care contributed to the resident's hospitalization with sepsis and subsequent death. The facility's actions and inactions directly resulted in a deficiency related to the provision of pressure ulcer care and prevention of new ulcers.
Systemic QAPI Failures Result in Multiple Deficiencies Across Facility Operations
Penalty
Summary
The facility failed to develop, implement, and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, analyzed, and corrected systemic quality deficiencies. Despite collecting data from various sources such as electronic health records, staffing reports, maintenance logs, and resident council feedback, the QAPI committee did not effectively use this information to identify trends, prioritize high-risk issues, or implement and sustain corrective actions. This resulted in ongoing patterns of deficient practice in areas including staffing, grievance process, clinical care, activities, medication management, therapy services, discharge planning, environmental conditions, and care planning. Internal reports, resident council concerns, medical record documentation, staffing data, and direct observation all indicated these issues, but they were not recognized or acted upon through the QAPI process. Staffing deficiencies were evident, particularly on weekends, where staffing levels consistently fell below the facility's own assessment standards. Payroll Based Journal (PBJ) data and review of staffing schedules showed that the number of nurses, CNAs, and restorative aides scheduled was frequently less than the minimum required. Residents reported long wait times for assistance, with one resident waiting over two hours to be helped out of bed, and another experiencing delays in having a urinal emptied. Resident council meeting minutes repeatedly documented concerns about inadequate staffing and slow response times, with little evidence of effective facility response or improvement. The administrator and QAPI committee were not aware of the low weekend staffing, relying instead on reports that did not reflect actual staffing shortages. Additional deficiencies included failures in the grievance process, where residents were not properly informed of the current grievance officer, and posted information was outdated. Residents and council members were unaware of the new grievance officer, and there was no documentation of her introduction or updated contact information. The activities program was also deficient, with multiple residents reporting that they were not offered or able to participate in activities as documented in their care plans and assessments. Activity flowsheets showed minimal or no activity participation or offers for extended periods. Medication management was compromised by incomplete narcotic count documentation, with missing required signatures in narcotic logbooks across multiple units and months. Physical therapy services were not provided as ordered for a resident due to staff absence, with no evidence of alternative arrangements or continuity of care.
Failure to Follow Physician Orders and Care Plans for Vital Signs and Pressure Reduction
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and person-centered care plans for two residents. For one resident with a history of hypertension, heart failure, and transient ischemic attack, there was a physician's order for daily vital signs and an order for antihypertensive medication. However, record review showed that vital signs were only documented twice over a period of 177 days, despite the daily order. The acting DON confirmed that daily monitoring should have occurred, and facility policy required vital signs to be monitored as ordered for residents on antihypertensive medications. For another resident with diagnoses including weakness, mild cognitive impairment, and osteoarthritis, there were orders for wound care to leave the left heel open to air and to use offloading boots for the left lower extremity. Observation revealed the resident was lying in bed with both heels on the mattress and covered by non-skid socks, with no offloading boots in place. The care plan did not include interventions for keeping the left heel open to air or for the use of offloading boots, and a licensed nurse confirmed the order for heel boots. Facility policy required care plans to reflect services necessary to maintain the resident's highest practicable well-being and to follow recognized standards of practice.
Failure to Provide NOMNC to Resident's POA
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) was provided to and signed by the legally authorized Power of Attorney (POA) for a resident who had documented dementia and a legal POA with authority over insurance and government benefit decisions. Instead, the NOMNC was signed by the resident, whose signature did not match their legal name, and there was no documentation that the POA was informed of the notice or the associated appeal rights prior to discharge. The facility's process, as described by the Director of Social Services (DSS) and Social Services Coordinator (SSC), was to review the NOMNC with the POA and obtain their signature if the resident had a POA, but this was not followed in this case. Record review confirmed that the POA was listed as the resident's agent in the medical record and that the POA was not provided the NOMNC paperwork or informed of appeal rights before discharge. The POA stated in an interview that they were unaware of the appeal rights and would have considered appealing the discharge decision. The DSS acknowledged that the NOMNC was signed by the resident and not the POA, and there was no documentation of the notice being reviewed with the POA.
Failure to Develop and Implement Comprehensive Care Plans for Dementia and Fall Risk
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with identified needs. For one resident with a diagnosis of unspecified dementia and behavioral disturbances, the care plan did not address dementia-related interventions. Despite multiple medical records and provider notes indicating a history of dementia and the use of antipsychotic medication for behavioral symptoms, the resident's MDS did not code for dementia, and the care area of cognitive loss/dementia was not triggered or addressed in the care plan. The facility's own dementia clinical protocol requires the interdisciplinary team to identify and document resident-centered care plans for individuals with confirmed dementia, but this was not followed in this case. For another resident with a history of spinal surgery, radiculopathy, and spinal stenosis, assessments upon admission identified the individual as a moderate to high risk for falls. The Morse Fall Assessment and nursing observations documented impaired gait, non-ambulatory status, and dependence on a wheelchair or geri-chair for mobility. The resident's MDS triggered the care area of falls, but the care plan did not include any interventions or documentation addressing fall risk. Subsequently, the resident experienced a fall while attempting to use the bathroom independently, resulting in pain and further medical evaluation. Interviews with facility staff confirmed that care plans should have included interventions for both dementia and fall risk based on assessments and diagnoses. Facility policies require comprehensive, person-centered care plans with measurable objectives and interventions derived from thorough assessments. However, these requirements were not met for the two residents, as evidenced by the lack of appropriate care planning and documentation for their specific needs.
Failure to Respond to Wander Guard Alarm Leads to Resident Elopement
Penalty
Summary
A deficiency occurred when a resident identified as high risk for elopement, with diagnoses including a displaced hip fracture, chronic kidney disease, schizophrenia, and anxiety, was not adequately supervised despite being on wander guard precautions. The resident had a documented history of exit-seeking behaviors and was assessed as cognitively impaired and unable to make independent decisions. The care plan included interventions such as the use of a wander guard, routine checks of the device, and monitoring for elopement risk, but did not specify staff response protocols for wander guard alarms. On the day of the incident, the resident left the facility by calling a cab and was able to exit through the front door. Although the wander guard alarm was triggered, staff did not respond to the alarm, and there was no one present at the front desk to intervene. The absence of immediate action allowed the resident to leave the premises undetected for approximately two and a half hours. Staff only became aware of the resident's absence when attempting to deliver medications and meals, at which point a search was initiated. The resident was eventually found stranded at a local store by members of the public and returned to the facility. Review of facility policies revealed that while the use of wander guards and care plan updates were required, there was a lack of clear guidance on staff roles and required actions when a wander guard alarm was activated. This contributed to the delayed response and failure to prevent the resident's elopement.
Failure to Provide Ordered Physical Therapy Services During Therapist Leave
Penalty
Summary
The facility failed to ensure continuity of ordered physical therapy (PT) services for a resident with significant mobility and functional limitations, including radiculopathy, spinal stenosis, and a recent lumbosacral spinal fusion. The resident was admitted with orders for skilled PT five times per week for four weeks, with specific goals and interventions outlined in the physician's plan of care. Documentation showed that after the facility's physical therapist went on leave, PT services were not provided for 12 calendar days (8 business days), despite no modifications, discontinuation, or suspension of the physician's orders during this period. Interviews with facility staff, including the Director of Rehabilitation and the Regional Director of Clinical Nursing Services, confirmed that PT services were interrupted due to the therapist's leave and that efforts to secure a replacement were ongoing during the lapse. There was no documentation that residents or their representatives were formally notified of the interruption, nor were care plans or physician orders updated to reflect the change in services. The facility's assessment indicated that they provide rehabilitative services to meet resident needs, but during this period, the ordered PT services were not delivered as required.
Failure to Provide Timely Wound Care and Change in Condition Response
Penalty
Summary
The facility failed to provide necessary care and services to two residents, resulting in harm. For one resident with a history of myasthenia gravis, lymphoma, immunodeficiency, asthma, and chronic respiratory failure, the facility did not administer scheduled wound treatments and dressing changes for abscesses on the right thigh and buttock on two specific dates. Although the electronic Treatment Administration Record (eTAR) was signed off as if the treatments were completed, interviews and documentation revealed that the dressings were not changed, and the wounds were not visually assessed during that period. The resident reported increased pain, which was only addressed with PRN pain medication, without further assessment or escalation to the wound care team or provider. When the wound care team finally assessed the wounds, they found significant infection and deterioration, requiring painful debridement and intravenous antibiotics, which caused additional adverse effects due to the resident's underlying conditions. Another resident, who had a pacemaker implanted and a recent generator replacement, experienced a change in the surgical site condition, including the development of scabs, erythema, and later, wound dehiscence with purulent drainage. Initial nursing assessments documented the changes and implemented standard wound care, but the wound care team was not immediately notified. The wound care nurse was only brought in several days after the initial change in condition, at which point a significant infection was identified. The resident was subsequently hospitalized for an extended period, required surgical intervention to relocate the pacemaker, and underwent extensive wound therapy. The cardiologist later confirmed that the infection was related to the resident's underlying gall bladder infection and emphasized that immediate notification should have occurred when the wound dehiscence was first noted. Facility policy required regular wound assessments, prompt documentation and intervention for pain, and immediate reporting of changes in condition, including signs of infection or wound deterioration. In both cases, the facility failed to follow these protocols, resulting in delayed interventions, progression of infections, and significant harm to the residents. Documentation showed that scheduled treatments were not completed as ordered, changes in condition were not promptly escalated, and communication with providers and specialized teams was not timely.
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