Citations in Alabama
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Alabama.
Statistics for Alabama (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Alabama
The facility did not provide two residents and their representatives with written transfer notices containing all required information during emergent hospital transfers. Instead of specifying the actual medical reasons for transfer, the notices used a generic statement, and there was no documentation in the EMR that written notices were given, only that representatives were notified by phone.
A resident with severe mental illness and behavioral disturbances physically struck two other residents on separate occasions in the dining room. Despite a history of unpredictable and aggressive behaviors, the care plans lacked specific supervision interventions, and no assessment was conducted to determine the necessary level of supervision after the first incident. Multiple staff were present but did not witness the abuse until after it occurred, and the facility did not adequately analyze or address the causes to prevent recurrence.
A resident with severe mental illness and dementia, known for unpredictable and aggressive behaviors, was not adequately supervised or provided with individualized behavioral interventions. This lack of supervision led to two incidents where the resident physically struck other residents, with staff and witness interviews confirming the actions were linked to delusional thinking. Facility records and care plans did not reflect ongoing supervision or updated interventions despite the resident's history and repeated incidents.
Staff did not follow the care plan and facility policy requiring a mechanical lift with two-person assistance for a resident with severe mobility and cognitive impairments. Instead, a staff member performed a lift alone in the morning, and later, two staff members completed a manual transfer without the lift. These actions resulted in the resident sustaining a large bruise and experiencing significant pain, necessitating pain medication.
A resident with severe cognitive impairment was subjected to physical and mental abuse when an LPN placed a hand over the resident's mouth and pinched the nose to force medication administration, despite the resident's right to refuse treatment. The incident was witnessed by a CNA, and subsequent staff interviews confirmed that such actions were improper and could be considered abuse. Facility policies clearly state residents' rights to refuse care, but the LPN admitted to the coercive act, and the facility failed to provide adequate oversight upon the LPN's return to work.
A resident with severe cognitive impairment was physically and mentally abused by an LPN during medication administration, when the LPN covered the resident's mouth and pinched their nose to force medication intake. A CNA witnessed the incident but failed to intervene or report it immediately, and the LPN continued working without supervision. Facility administration did not initially identify the event as abuse, allowing the LPN to return to work and administer medications to other vulnerable residents without monitoring.
A resident with severe cognitive impairment was subjected to physical and mental abuse by an LPN, who attempted to force medication administration by pinching the resident's nose and covering their mouth. A CNA witnessed the incident but did not immediately intervene or report it, leaving the resident alone with the LPN. The facility failed to suspend the LPN as required by policy, allowing the LPN to continue working and placing other residents at risk. The facility's investigation did not initially substantiate the abuse, and staff interviews confirmed that abuse prevention and reporting protocols were not followed.
A CNA failed to immediately report an observed incident where an LPN used physical force to administer medication to a resident with severe cognitive impairment, resulting in a delay in notifying facility administration and the State Agency. The LPN continued working without oversight, and staff interviews confirmed a lack of understanding regarding immediate abuse reporting requirements.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
Staff served pureed menu items using a #16 scoop (1/4 cup) instead of the required #8 scoop (1/2 cup), resulting in at least three residents on a pureed diet receiving inadequate portions at dinner. The error was discovered during trayline observation, and interviews confirmed that the incorrect scoop size was used before being corrected.
Failure to Provide Required Written Transfer Notices with Specific Reasons
Penalty
Summary
The facility failed to provide residents and their representatives with written notices of transfer that included all required information during emergent transfers to the hospital. Specifically, for two residents who experienced acute medical events requiring hospital transfer, there was no documentation that written transfer notices were given to either the residents or their representatives at the time of transfer. In both cases, the facility's documentation only indicated that the representatives were notified by phone, and there was no evidence in the electronic medical record (EMR) that written notices were provided as required by facility policy. Additionally, the transfer notices that were completed did not specify the actual medical reasons for the transfers. Instead, the notices used a generic statement of "inability to meet resident's needs" rather than detailing the specific clinical circumstances, such as allergic skin reaction with difficulty breathing or symptoms like pallor, diaphoresis, lethargy, low blood pressure, and urinary issues. Interviews with facility staff, including the DON, confirmed the lack of documentation and the omission of specific reasons for transfer in the written notices.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to protect residents from physical abuse perpetrated by another resident with a known history of severe mental illness and behavioral disturbances. One resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, Dementia with Behavioral Disturbance, and severely impaired cognition, was involved in two separate incidents where they physically struck other residents in the dining room. The first incident involved this resident approaching and hitting another resident on the right upper arm without provocation, and the second incident involved the same resident getting up from their chair and hitting a different resident on the left shoulder during a meal. Despite the resident's documented history of unpredictable and aggressive behaviors, including resistance to care, verbal aggression, and poor impulse control, the care plans did not include specific interventions or guidance for staff regarding the level of supervision required to prevent further abuse. Staff interviews confirmed that the resident's behaviors were unpredictable and that constant supervision would be necessary to prevent such incidents. However, after initial one-to-one supervision was discontinued following the first incident, no assessment was conducted to determine the ongoing level of supervision needed, and the resident was able to commit a second act of physical abuse. The facility's investigative files and staff interviews revealed that during both incidents, multiple staff members were present in the dining room, but most were unaware of the abusive acts until after they occurred. Only one staff member witnessed each event directly. The facility did not analyze or review the incidents in a manner that would determine the underlying causes or implement effective corrective actions to prevent recurrence, resulting in repeated abuse affecting multiple residents.
Failure to Supervise Resident with Psychosis Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide adequate supervision and appropriate behavioral health interventions for a resident with a known history of chronic delusions, psychosis, restlessness, agitation, and aggressive behaviors. This resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, and Dementia with Behavioral Disturbance, exhibited impaired cognition and was documented as resistant to care, wandering, and receiving antipsychotic medication. Despite these known risk factors and a history of unpredictable and aggressive behaviors, the facility did not consistently implement or document supervision or individualized interventions to prevent harm to other residents. Two separate incidents occurred in which the resident physically struck other residents on the shoulder. In both cases, the actions were linked to the resident's delusional thinking and psychosis, as evidenced by statements made during investigations and interviews with staff and witnesses. Staff interviews confirmed that the resident's behaviors were unpredictable and that effective prevention would require close or one-to-one supervision when the resident was in common areas with others. However, the facility's records and care plans did not reflect ongoing or routine supervision or specific interventions to address the risk of harm to others, despite the resident's established behavioral history and previous incidents. Facility policies on abuse prevention and behavior management required individualized assessment and intervention for residents with behaviors that could harm themselves or others. However, after the initial incident, there was no documented assessment to determine the appropriate level of supervision needed for the resident, and the care plan was not updated to reflect the physical aggression. The lack of consistent supervision and failure to update care plans or implement effective interventions resulted in repeated incidents of resident-to-resident abuse, as observed and reported by staff and documented in investigative files.
Failure to Follow Safe Transfer Procedures Results in Resident Injury
Penalty
Summary
Staff failed to follow established safe transfer procedures for a resident with significant mobility and cognitive impairments. The resident, who had diagnoses including heart failure, chronic pain, and cognitive communication deficit, was care planned for transfers using a full body mechanical lift with two-person assistance due to an inability to stand or assist with transfers. On the morning of the incident, a staff member transferred the resident from bed to chair using the mechanical lift but did so alone, without the required second staff member present. Later that same day, two staff members transferred the resident from a Broda chair back to bed without using the mechanical lift at all, instead performing a manual two-person lift. Both staff members admitted in interviews that they did not follow the care plan or facility policy, which required the use of a mechanical lift with two-person assistance for this resident. The staff could not provide a valid reason for not using the lift, with one stating she was following the other's lead and another citing being in a rush. As a result of these actions, the resident sustained a 10-centimeter bruise to the left lower leg, experienced pain rated up to seven out of ten, and required both Tylenol and Hydrocodone-Acetaminophen for pain management. The injury was discovered during routine rounds, and subsequent investigation by the facility determined that the bruise was most likely caused by the improper manual transfer. The failure to adhere to the resident's care plan and facility policy directly led to the resident's injury.
Resident Rights Violated During Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) administered medication to a resident with severe cognitive impairment and a history of acute respiratory failure, dementia, and cerebrovascular disease. During the medication administration, the LPN placed his hand over the resident's mouth and pinched the resident's nose to prevent the resident from spitting out the medication. This act was witnessed by a Certified Nursing Assistant (CNA), who observed the resident's face turning red and the resident struggling and moving their head from side to side in response to the force used by the LPN. The CNA considered the LPN's actions to be abusive and left the room to report the incident. Interviews with other staff members, including additional LPNs, the Unit Manager, the Social Worker, and the Director of Nursing (DON), confirmed that the resident had the right to refuse medication and that placing a hand over a resident's mouth to force medication was improper, could be considered abuse, and posed a risk of aspiration. The facility's own policies on medication administration and the Resident Bill of Rights explicitly state that residents have the right to refuse treatment and must not be subjected to coercion or force. Despite this, the LPN admitted to placing his hand over the resident's mouth to prevent the medication from being spit out, acknowledging that this was not appropriate and that the resident should have been allowed to refuse the medication. Following the incident, it was revealed that the LPN was suspended but returned to work without direct monitoring or oversight. There was no evidence that the facility took steps to ensure that the LPN did not repeat this behavior with other residents during medication administration. The lack of immediate and ongoing supervision after the incident, combined with the failure to protect the resident's right to refuse care, led to the citation of Immediate Jeopardy under F578 for violation of resident rights.
Abuse During Medication Administration and Failure to Protect Residents
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of acute respiratory failure, dementia, and cerebrovascular disease was subjected to physical and mental abuse by an LPN during medication administration. The LPN placed his hand and a paper towel over the resident's mouth and pinched the resident's nose to force the resident to swallow medication, while telling the resident to take the medication. This act was witnessed by a CNA, who observed the resident's face turning red and the resident struggling and moving their head from side to side. The CNA left the room, leaving the resident alone with the LPN, and did not immediately report the incident. The LPN continued to work his scheduled shift after the incident, as the facility administration did not immediately identify the event as abuse or take appropriate corrective action to protect residents. The LPN was only suspended after administration was made aware of the incident later in the day. Despite the seriousness of the event, the LPN was allowed to return to work after a brief suspension and was not monitored or supervised while administering medications to other vulnerable residents, including those with dementia, who could be at risk of similar abuse. Interviews with staff familiar with the resident confirmed that the LPN's actions were physically, emotionally, and psychologically abusive, and could have resulted in aspiration. The responsible party for the resident stated that having a hand placed over the resident's mouth would have caused significant fear. The facility's failure to recognize, report, and respond appropriately to the abuse, as well as the lack of monitoring of the LPN after the incident, resulted in a finding of immediate jeopardy due to the likelihood of serious injury, harm, impairment, or death to residents.
Failure to Implement Abuse Prevention Policy and Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policy and did not take appropriate actions to protect a resident from abuse by an LPN. On the morning of the incident, the LPN was observed by a CNA placing a paper towel over the resident's nose and pinching it, while also covering the resident's mouth, in an attempt to force the resident to swallow medications. The resident, who had a history of severe cognitive impairment and multiple medical diagnoses including acute respiratory failure, dementia, and cerebrovascular disease, was left alone with the LPN after the CNA witnessed the event. The CNA did not immediately intervene or report the abuse, instead leaving the room and only reporting the incident to the DON several hours later. Despite the facility's policy requiring immediate suspension of any employee accused of abuse and immediate reporting, the LPN continued to work and administer medications to residents during the survey period, placing other residents at risk. The facility's investigation did not initially substantiate the abuse, and the LPN was allowed to return to work after a brief suspension. The facility's failure to recognize and act upon the abuse allegation resulted in the LPN maintaining access to residents for over a month after the incident. Interviews with staff revealed a lack of timely reporting and intervention in response to the witnessed abuse. The CNA who observed the incident did not follow the facility's abuse policy for protecting residents, and other staff members did not take immediate action when informed of the situation. The facility's leadership, including the DON and Administrator, acknowledged that the abuse policy was not followed and that the resident was not adequately protected from potential harm.
Failure to Immediately Report and Intervene in Observed Resident Abuse
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to immediately report an observed incident of abuse involving a resident with severe cognitive impairment. The incident involved a Licensed Practical Nurse (LPN) who placed his hands over the resident's mouth and nose, using a paper towel to pinch the nose, in an attempt to force the resident to swallow medication. The resident, who had diagnoses including acute respiratory failure with hypoxia, dementia, cerebrovascular disease, and pain, was observed struggling, turning red in the face, and pushing their head from side to side during the incident. The CNA, after witnessing this, initially attempted to inform another LPN, who declined to get involved, and then delayed reporting the incident to facility administration. The facility's policy required that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, but no later than two hours after the allegation is made, to the administrator or other officials. In this case, the CNA did not report the incident to the Director of Nursing (DON) until several hours after the event, and the abuse was not reported to the State Agency until later that day. During this time, the LPN involved continued to work his shift without direct monitoring or oversight. Interviews with staff confirmed that the CNA did not understand the importance of immediate reporting and that other staff members did not intervene or ensure the report was made promptly. The delay in reporting and failure to protect the resident from further potential harm constituted a violation of the facility's abuse prevention policy. The deficiency was substantiated through interviews, record reviews, and examination of the facility's own investigative documentation. The incident affected one resident who was sampled for abuse, and the failure to report and intervene as required placed the resident at risk.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Incorrect Portion Sizes Served for Pureed Diets
Penalty
Summary
The facility failed to ensure that correct portion sizes of pureed food were served to residents on a pureed diet during dinner service. According to facility policy and menu documentation, pureed menu items such as Cheeseburger Soup, Carrots (substituted for Creamy Tomato & Onion Salad), and Fortified Mashed Potatoes were to be served using a #8 scoop (1/2 cup) for each portion. However, during observation, staff were found using blue-handled #16 scoops (1/4 cup) for these items. This resulted in residents receiving smaller portions than required by the menu and facility policy. Interviews with the Nutrition Department Director and Nutrition Manager confirmed that the incorrect scoop size was used for at least three of eleven residents on a pureed diet before the error was identified and corrected. The Nutrition Manager and Director both acknowledged that using a smaller scoop led to inadequate servings, which could affect the nutritional intake of residents. The staff involved were not aware of who placed the incorrect scoops in the food pans, and the error was only discovered after several trays had already been served.
Some of the Latest Corrective Actions taken by Facilities in Alabama
- Implemented monthly printing of the Medication Administration Record (MAR) to ensure availability during internet outages, with responsibility assigned to the Director of Nursing, Assistant Director of Nursing, or Unit Manager (L - F0760 - AL) (L - F0580 - AL) .
- Conducted in-service training for all LPNs and RNs to ensure they know the location of the paper MAR and update it promptly with any new admissions or physician order changes (L - F0760 - AL) (L - F0580 - AL) .
- Educated all nursing and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR, including the importance of documenting medication administration at the time of administration (L - F0760 - AL) (L - F0580 - AL) .
- Established a monthly MAR printout schedule to ensure clarity and preparedness for potential internet downtimes (L - F0760 - AL) (L - F0580 - AL) .
- Conducted mock drills for nursing personnel to practice procedures during internet outages (L - F0760 - AL) (L - F0580 - AL) .
- Replaced the facility's router to improve internet reliability and reduce the likelihood of future outages (L - F0760 - AL) (L - F0580 - AL) .
- Held an ad-hoc Quality Assurance meeting to discuss the deficient practice and plan of correction, ensuring continuous improvement and oversight (L - F0760 - AL) (L - F0580 - AL) .
Medication Administration Failure During Internet Outage
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors during a forecasted snowstorm when the internet connection was lost, preventing access to the Electronic Health Record (EHR) and Electronic Medication Administration Record (eMAR). This resulted in the failure to administer critical medications, including insulin and other significant medications, to residents from the evening of one day until the following evening. The deficiency was identified as Immediate Jeopardy, indicating that the non-compliance was likely to cause serious harm or death. Resident Identifier #12, who had Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hyperglycemia, did not receive their prescribed insulin doses and blood glucose monitoring during this period. Similarly, Resident Identifier #15, with diagnoses including Type 2 Diabetes Mellitus and Hypertension, missed doses of insulin, blood pressure, and seizure medications. Resident Identifier #30, with conditions such as Type 2 Diabetes Mellitus and Chronic Heart Failure, also missed critical medications, including insulin and anticoagulants, and did not have their blood glucose monitored. Resident Identifier #308, who had epilepsy, did not receive their anticonvulsant medications, increasing the risk of seizure recurrence. Interviews with nursing staff revealed that the lack of access to the eMAR due to the internet outage was a significant barrier to medication administration. Some staff were unable to administer medications or monitor blood glucose levels because they did not have access to the necessary records. The facility's policy required medications to be administered in a timely manner and in accordance with prescriber orders, but the outage led to a failure in adhering to these protocols, affecting the care of the residents involved.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing educated all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR.
- In-service included the standard of practice to administer medication, monitor blood glucose, implement the prescribing physicians' orders, and the importance of documenting medication administration at the time of administration.
- In-service included calling the physician as well as notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how it led to neglect and the facility's Abuse Policy.
- A printed MAR will be ready and a copy will be kept at each nurses' station for use during downtime.
- RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both are responsible to print the paper MAR to be ready and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Neglect and Verbal Abuse During Internet Outage
Penalty
Summary
The facility failed to protect residents from neglect during a forecasted winter storm that caused an internet outage, preventing access to the Electronic Health Record (EHR) system. This outage occurred on January 21 and 22, 2025, and the facility did not have systems in place to ensure continuity of care. As a result, pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) were not available for the licensed nursing staff to use for resident care, treatment, and medication administration. Consequently, residents on the second and third floors did not receive their medications as ordered by the physician during this period. The nursing staff, including the nurse supervisor on duty, failed to ensure that residents received their medications and treatments as ordered. They also did not notify management staff or the residents' physicians of their inability to safely administer medications. This lack of communication and failure to implement a backup plan for medication administration during the internet outage led to a situation where residents did not receive necessary medications, including insulin and other significant medications, for more than 24 hours. Additionally, the facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The CNA, who was reportedly tired and frustrated from working a double shift, verbally abused the resident by using derogatory language. The resident reported feeling shocked and stunned by the CNA's behavior. The facility's investigation substantiated the allegation of verbal abuse, and the CNA was subsequently terminated.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff and provided the education with 1:1 in-service to specific staff.
- The in-services included the policy titled Policy on Computer or Internet Downtime and EHR, the standard of practice to administer medication, monitor blood glucose, the implementation of the prescribing physicians' orders, the importance of documenting medication administration at the time of administration.
- Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order.
- Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy.
- The in-service was completed for all nurses, PT staff, and administrative staff.
- The nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to specific staff.
- The in-service included that a printed MAR will be ready for each month.
- A copy of the paper MAR will be kept at each nurses' station for use during downtime.
- Education included that RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both of them are responsible to print the paper MAR to be ready for each month and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- A report was generated from the electronic medical records to see which residents could have been affected.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting which included the entire IDT team was conducted to discuss the deficient practice and plan of correction.
- The nurses that were responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
- The QA team discussed the needed in services/education for specific staff.
Failure to Notify Physician of Medication Administration Issues During Internet Outage
Penalty
Summary
The facility failed to ensure that the physician was notified when residents on the second and third floors did not receive their medications and treatments as ordered due to an internet outage. This outage occurred on January 21 and 22, 2025, and prevented access to the Electronic Health Record (EHR) system. As a result, nurses did not have access to pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) to administer medications during this period. The facility staff did not notify the Director of Nursing (DON), residents, or resident representatives about the residents not receiving their ordered medications and treatments. Interviews revealed that the Licensed Practical Nurse (LPN) who was a supervisor during the snowstorm was unsure if the residents received their medications and did not inform the DON or Administrator (ADM) about the system being down. The DON was not at the facility during the outage and was not informed about the issue until March 20, 2025. Similarly, the ADM was unaware that residents did not receive their medications until informed by the survey team. The Physician/Medical Director was also not informed about the facility's computer system being down and the residents not receiving their medications. The physician expressed that he would have liked to have been informed of this situation, as missing medications could lead to various health issues for the residents. The facility's non-compliance with the requirement to notify the physician and other relevant parties was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, leading to an Immediate Jeopardy citation.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing, Assistant Director of Nursing, or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current residents and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- In-services were conducted to educate all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR, standard practices for administering medication, monitoring blood glucose, implementing physician orders, and documenting medication administration.
- In-service included calling the physician and notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how the situation led to neglect and the facility's Abuse Policy.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that they are responsible for printing the paper MAR and placing it by each nurse's station.
- A monthly MAR printout schedule was created for clarity.
- The DON and ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of an outage, and nurses were educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director, and no adverse effects were identified.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Failure to Monitor Vital Signs in Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a system was in place to assess the vital signs of newly admitted residents at a frequency expected by the physician or CRNP. Specifically, a resident admitted after hospitalization for Atrial Fibrillation with Rapid Ventricular Response had orders for vital signs to be checked only once a month, contrary to the physician's expectation of daily assessments for new admissions. This oversight led to a situation where the resident's heart rate was significantly elevated, reaching 142 bpm, without timely intervention. The deficiency was further compounded by the lack of established parameters for when the physician should be notified of abnormal vital sign values. On one occasion, the resident's heart rate was recorded at 120 bpm, but no action was taken until the resident experienced chest pain and shortness of breath, prompting a request for hospital transfer. Interviews with facility staff, including the DON and CRNP, revealed a discrepancy between the expected and actual practices for monitoring vital signs in newly admitted residents. The facility's non-compliance with the requirements of participation was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, resulting in an Immediate Jeopardy citation. The deficiency was identified during the investigation of a complaint, highlighting the need for a systematic approach to vital sign monitoring and physician notification for newly admitted residents.
Removal Plan
- The facility failed to ensure a system was in place to ensure newly admitted residents' vital signs were assessed at a frequency expected by the physician/CRNP.
- Resident specific vital sign parameters were established including when the physician should be notified of abnormal values.
- The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
- The Medical Director was contacted by the DON on his expectations on vital sign monitoring.
- An updated New Admit/Readmit Checklist was implemented to ensure vital sign frequency and parameters are established at the time of admission.
- The vital sign monitoring policy was updated by the RDHS to require at least daily vital signs for all newly admitted or readmitted residents for 2 weeks.
- The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
- The Medical Director was contacted by the DON on his expectations on vital sign frequency.
- Vital sign parameter thresholds and frequency were updated for all newly admitted or readmitted residents over the last 30 days, vital sign orders by the RDHS and DON.
- The Daily Clinical Meeting form was revised by RDHS to include review of vital signs outside physician ordered parameters with follow up documentation.
- The DON and Staff Development Coordinator provided education for licensed staff on the updated VS Monitoring Policy, monitoring residents' vital signs at least daily for 2 weeks following an admission or re-admission and vital signs thresholds that require physician notification, and process to document vitals, notification, and physician recommendations.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident identified as RI #497. On January 4, 2025, the resident experienced an elevated heart rate of 142 beats per minute at 1:24 PM, which was not communicated to the physician. Later that day, at 9:22 PM, the resident's heart rate remained elevated at 120 beats per minute, yet again, the physician was not informed. This lack of communication resulted in no additional treatment or interventions being implemented, leading to a delay in necessary medical care. The resident, who had a history of Chronic Obstructive Pulmonary Disease and Atrial Fibrillation, continued to experience elevated heart rates and eventually complained of chest pain and difficulty breathing. Despite these symptoms, the resident was not transferred to the hospital until the early hours of January 5, 2025. Upon arrival at the hospital, the resident was admitted to the Intensive Care Unit for treatment of Atrial Fibrillation with Rapid Ventricular Response. Interviews with facility staff revealed that there was a failure to follow the facility's policy on notifying physicians of changes in a resident's condition. The Registered Nurse and Licensed Practical Nurse involved did not notify the physician or follow up on instructions given by the Certified Nurse Practitioner. This oversight was identified as a deficiency under Resident Rights, specifically regarding the notification of changes in a resident's condition.
Removal Plan
- The Director of Nursing (DON) provided 1:1 in-service with the licensed nurse who failed to notify the physician on physician notification when resident experiences change in condition and notification parameters on vital signs.
- All residents in house most recent vital signs were reviewed by the DON, Regional Director of Health Services and Regional Assessment Coordinator for any change of condition as well as vital signs outside parameters that were set forth by the Medical Director.
- Any resident with a change of condition or vital signs outside the parameters, the provider was notified by DON, Unit Manager or Charge nurse for any additional orders or treatment.
- All licensed nurses, which are 31 in total, were educated on notification to the provider for change in condition, to include vital signs outside the parameters given by the DON and Staff Development Coordinator. Any licensed nurse who did not receive the in-service will not be allowed to work until the in-service has been provided. There is 1 LPN pending (on medical leave) and the DON is responsible to ensure they are educated before working.
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