Citations in California
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in California.
Statistics for California (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in California
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident with a full code status did not receive immediate or effective BLS/CPR when found unresponsive, as staff delayed initiating CPR while searching for code status, failed to use a backboard or Ambu-bag, and performed inconsistent chest compressions. Some staff lacked current BLS/CPR certification, and the emergency cart was not properly stocked, resulting in inadequate life-saving measures.
The facility did not ensure that POLST and advance directive documents were consistently filed and readily accessible in the current medical charts for multiple residents, including those with impaired cognition and serious health conditions. During a medical emergency, staff were unable to locate a resident's POLST, resulting in default initiation of CPR. Staff interviews and record reviews revealed that required documents were often missing, stored in old charts, or not obtained, contrary to facility policy.
The facility's fire protection system was nonfunctional for several days, during which a fire watch was implemented and all fire exit doors were closed. Despite documented procedures requiring notification, the facility did not inform CDPH or HCAI of the system outage, as confirmed by the Administrator and Maintenance Supervisor.
Staff failed to immediately initiate CPR and call a code blue when a resident was found unresponsive. Instead, staff delayed action by searching for the resident's code status and did not use the backboard or Ambu-bag during resuscitation. CPR was performed incorrectly, with inadequate compressions and no rescue breaths, and EMS had to move the resident to the floor to continue efforts. These failures resulted in the resident's death and placed all full code residents at risk.
A resident with severe respiratory conditions did not receive prescribed respiratory medications as ordered, with numerous missed and undocumented doses. Staff failed to monitor or assess the resident for respiratory distress after new symptoms and abnormal lab and x-ray results were identified. Critical results were not effectively communicated to the physician, and the care plan was not updated to address the resident's worsening condition. The resident was later found unresponsive and died despite resuscitation efforts.
Licensed nurses did not administer or document multiple scheduled doses of prescribed respiratory medications for a resident with COPD, emphysema, and respiratory failure. The resident, who was oxygen-dependent and required total staff assistance, missed numerous doses of Acetylcysteine, Budesonide, and Ipratropium-Albuterol over several months, despite physician orders and care plan interventions requiring these treatments. The DON and physician confirmed the medications were not given as ordered, in violation of facility policy.
A resident with multiple respiratory conditions and impaired cognition had abnormal lab and chest x-ray results indicating a possible infection. Nursing staff failed to verify that these results were received by the physician or nurse practitioner, and there was no documentation of provider notification or follow-up. As a result, the resident did not receive timely medical intervention for the abnormal findings, and required notification procedures were not followed.
A resident with severe respiratory illnesses, dependent on staff for all care, did not have timely documentation of medication administration by nursing staff. Instead, LPNs entered medication records days or weeks after administration, often only after being alerted by medical records audits. Staff could not recall specific details about medication administration, and documentation was not completed as required by facility policy.
Two residents were affected by medication errors when an RN entered an anti-seizure medication order for the wrong patient during admission. One resident with a seizure disorder did not receive his prescribed Valproic Acid, while another resident without a clinical indication received multiple unnecessary doses. The facility lacked a written policy for the admission medication order process, and staff did not verify orders against hospital discharge records.
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Provide Timely and Effective BLS/CPR to Full Code Resident
Penalty
Summary
Facility staff failed to provide proper and effective Basic Life Support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code when found unresponsive, pulseless, and not breathing. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately call a code blue or initiate CPR upon discovering the resident's condition. Instead, staff delayed action while attempting to verify the resident's code status, and there was confusion and lack of clarity among staff regarding the resident's code status and the location of this information in the medical record. Chest compressions were not started until approximately 12 minutes after the resident was found unresponsive. When CPR was eventually initiated, it was performed on the resident's bed without first placing the resident on a firm, flat surface or using a backboard, which was available in the facility. Staff did not consistently perform continuous and uninterrupted CPR, and there were inconsistencies in the rate and quality of chest compressions. Additionally, staff failed to use the Ambu-bag for rescue breathing, instead placing a non-rebreather mask on the resident, which is not appropriate during CPR. EMS personnel arriving at the scene observed these deficiencies and had to move the resident to the floor to continue CPR. Interviews and record reviews revealed that some staff members lacked current BLS/CPR certification, and there were discrepancies in staff knowledge regarding proper CPR procedures, including compression rates and the use of equipment. Documentation and staff statements indicated that the emergency cart was not properly checked or restocked, resulting in missing essential equipment such as the Ambu-bag. These failures resulted in the resident not receiving timely and effective life-saving measures as required by their full code status.
Removal Plan
- Quality Assurance Nurse (QA) and the RN on duty review the current residents' care profile in the facility's electronic health record (EHR) system, Code Status.
- QA and the RN verify the residents' Code Status via POLST forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status.
- A copy of the list of Full Code residents is made readily available to staff at the nurse's station for reference and is updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed.
- DON/Designee provides in-service education to nursing staff regarding the availability of the list of residents who are Full Code.
- DON checks the Emergency Cart (EC) and ensures that CPR backboard is available.
- RN and/or Designated Licensed Nurse conduct inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This is validated by the DON and/or Designee.
- RN and/or Designated Licensed Nurse conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard.
- DON initiates in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly.
- DON initiates in-service to RNs, LVNs, and CNAs regarding providing rescue breathing, not placement of a non-rebreather mask.
- DON provides continued in-services for all of the facility's RNs, LVNs, and CNAs.
- DON initiates in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly.
- Director of Staff Development (DSD) reviews employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date.
- Identified CNA attends the CPR certification training and is put on temporary suspension until CPR certification is received as part of Direct Care Staff competency.
- Identified LVN that does not have a current CPR/BLS certification is placed on suspension and is not permitted to return to work without an active certification for CPR/BLS.
- Clinical Nurse Consultant provides 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards.
- DON/Designee provides in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- DON/Designee provides in-service to LVN 2 upon returning to work. LVN 2 is not on the schedule until education/reeducation is provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation.
- DON/Designee provides in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- A Certified CPR instructor provides mandatory re-education and training for all Licensed Nurses and CNAs which is also attended by the DON and DSD with return demonstration conducted.
- A series of ongoing CPR Certification Training sessions is provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training.
- A Code Blue drill is initiated and continues weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR.
- An RN is designated as the team leader for Code Blue emergencies.
- Additional CPR training is provided by a Certified CPR Instructor to provide mandatory re-education and training for all Licensed Nurses and CNAs with return demonstration.
- Any Licensed Nurses or CNAs are not permitted to work directly with patients if they do not complete the Certified CPR refresher course.
- Director of Staff Development (DSD)/Designee maintains a log for all Direct Care Staff of their active Certification for BLS/CPR.
- DSD/Designee notifies staff with BLS/CPR certification expiring within a month.
- DSD/Designee presents to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification.
- No Direct Care Staff are permitted to work directly with patients without an active BLS/CPR certification.
- QAA Committee reviews audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions.
Failure to Maintain Readily Accessible POLST and Advance Directives in Resident Charts
Penalty
Summary
The facility failed to ensure that Provider Orders for Life-Sustaining Treatment (POLST) and advance directives (AD) were consistently and readily retrievable in the current medical charts for 11 out of 100 sampled residents. This deficiency was identified through observation, interviews, and record reviews, which revealed that staff were unable to locate these critical documents during medical emergencies. In one instance, when a resident was found unresponsive and pulseless, nursing staff could not find the resident's POLST or code status in the current chart and, as a result, initiated CPR by default, treating the resident as full code. The Director of Nursing later found the resident's POLST in an old chart, confirming that the document was still valid at the time of the emergency but had not been placed in the current chart as required by facility policy. Further review of additional residents' records showed similar issues, with several POLST and AD documents missing from current medical charts. Interviews with staff, including nurses and the social worker, confirmed that these documents were either not obtained, not printed, or were kept in locations such as email inboxes or old charts rather than being filed in the residents' current medical records. The facility's policy and procedures, as well as the social worker's job description, require that POLST and AD documents be obtained within 48 to 72 hours of admission and be accessible in the medical record to all facility staff. However, staff interviews revealed a lack of consistent adherence to these procedures, with some staff unaware of whether residents had POLST forms or failing to ensure the documents were properly filed. The deficiency affected residents with a range of medical conditions, including chronic obstructive pulmonary disease, chronic kidney disease, dementia, quadriplegia, and other serious health issues. Many of these residents had impaired or severely impaired cognition and lacked the capacity to make decisions, making the presence and accessibility of POLST and AD documents especially critical. The failure to maintain these documents in the current medical charts was acknowledged by both the Director of Nursing and the social worker, who confirmed that the documents should be readily available in the chart and not stored elsewhere.
Failure to Notify Authorities and Maintain Fire Protection System
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and visitors when the fire protection system became nonfunctional for a period of several days. During this time, all fire exit doors were closed as a precaution, and a fire watch was initiated by the Maintenance Supervisor and other staff, with hourly inspections documented. However, the facility did not notify the California Department of Public Health (CDPH) or the California Department of Healthcare Access and Information (HCAI) about the fire protection system malfunction, as required by regulations. The Administrator confirmed that the facility remained under a fire watch and acknowledged unawareness of the notification requirement. Review of facility documents and policies indicated that the fire alarm system is expected to be operable at all times and that maintenance personnel are responsible for keeping the fire alarm system in good working order. The facility's fire watch log and maintenance policies further outlined the procedures to be followed in the event of a system outage, including the implementation of a fire watch. Despite these documented procedures, the required notifications to regulatory agencies were not made during the period when the fire protection system was out of service.
Failure to Provide Qualified Emergency Response and CPR
Penalty
Summary
Facility staff failed to provide care by qualified persons according to a resident's written plan of care, specifically in the response to a full code resident who was found unresponsive. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately initiate a code blue or begin CPR when the resident was discovered unresponsive. Instead, staff delayed action by first attempting to verify the resident's code status and searching for the POLST form, rather than starting life-saving measures as required by facility policy and professional standards. Interviews and record reviews confirmed that staff were unclear about the correct sequence of actions and did not follow established protocols for emergency response. When CPR was eventually initiated, staff did not place the resident on a firm, flat surface or use the available backboard, as required to ensure effective chest compressions. Instead, CPR was performed on the bed, and the backboard was not utilized. Additionally, staff failed to provide rescue breaths using the Ambu-bag, despite its availability, and instead left the resident on a non-rebreather mask, which is not appropriate during CPR. EMS personnel arriving at the scene observed that CPR was being performed incorrectly, with inconsistent and inadequate chest compressions, and had to move the resident to the floor to continue resuscitation efforts. Documentation and interviews revealed further deficiencies in staff knowledge and execution of CPR, including incorrect compression rates, lack of rescue breaths, and failure to use proper equipment. The facility's own policies, as well as American Heart Association guidelines, were not followed. As a result, the resident was pronounced deceased after prolonged and inadequate resuscitation efforts. The failure to provide qualified and timely emergency care placed all full code residents at risk of not receiving proper life-saving measures during a code blue event.
Failure to Provide and Document Respiratory Care and Timely Physician Notification
Penalty
Summary
The facility failed to provide necessary respiratory care and interventions for a resident with multiple respiratory diagnoses, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and had significantly impaired cognition. Despite physician orders for scheduled respiratory medications—Acetylcysteine, Budenoside, and Ipratropium-Albuterol—there were numerous missed and undocumented administrations over several months, as evidenced by gaps in the Medication Administration Record (MAR). These medications were specifically ordered to manage the resident's COPD, chest congestion, and shortness of breath, but the resident did not consistently receive them as prescribed. In addition to missed medications, the facility did not adequately monitor or assess the resident for respiratory distress or changes in condition, even after new symptoms and abnormal findings were identified. When a nurse practitioner noted cough, congestion, abnormal lung sounds, and respiratory distress with low oxygen saturation, and when abnormal laboratory and chest x-ray results were received indicating possible infection, there was no documented assessment or monitoring of the resident's respiratory status. The care plan was not revised to address the new or worsening symptoms, and there was no evidence of nursing interventions being initiated in response to these changes. Furthermore, the facility failed to ensure timely and effective communication of critical lab and diagnostic results to the resident's physician. Although results were faxed and texted, there was no confirmation that the physician or nurse practitioner received or reviewed the information. Nurses did not follow up with phone calls or verify receipt, and there was no documentation of provider notification or discussion of the abnormal findings. This lack of communication delayed necessary medical evaluation and treatment. Ultimately, the resident was found unresponsive and pulseless, and despite CPR, was pronounced dead. The facility's policies required prompt assessment, monitoring, and provider notification for changes in condition, but these procedures were not followed.
Failure to Administer Prescribed Respiratory Medications
Penalty
Summary
Licensed nurses failed to administer prescribed respiratory medications to a resident with chronic obstructive pulmonary disease (COPD), emphysema, respiratory failure with hypoxia, recurrent pneumonia, and vascular dementia. The resident was oxygen-dependent and required staff assistance for all activities of daily living. The care plan specifically included interventions to administer medications as ordered for impaired gas exchange and ineffective airway clearance. A review of the Medication Administration Records (MAR) for three months revealed that multiple scheduled doses of three critical respiratory medications—Acetylcysteine Inhalation Solution, Budesonide Inhalation Suspension, and Ipratropium-Albuterol Inhalation Solution—were not documented as administered. Specifically, there were 25 undocumented doses of Acetylcysteine, 31 undocumented doses of Budesonide, and 60 undocumented doses of Ipratropium-Albuterol. Physician progress notes during this period consistently indicated the need to continue regular breathing treatments as scheduled, and nursing notes documented episodes of shortness of breath and diminished lung sounds. During interviews, the Director of Nursing confirmed the absence of documentation for the administration of these medications and acknowledged that the resident did not receive them as ordered. The attending physician also confirmed that missing several doses of these medications, especially consecutively, could trigger a COPD exacerbation. Facility policy required medications to be administered in accordance with prescriber orders, but this was not followed in this case.
Failure to Notify Physician of Abnormal Lab and Diagnostic Results
Penalty
Summary
The facility failed to verify receipt or follow up with the attending physician or nurse practitioner regarding abnormal laboratory and diagnostic results for a resident who exhibited signs of infection. The resident, who had a history of chronic obstructive pulmonary disease, emphysema, respiratory failure with hypoxia, recurrent pneumonia, and aneurysm, was admitted with significant cognitive impairment and was dependent on staff for all care. Orders were placed for a chest x-ray and laboratory tests due to respiratory symptoms, and results showed an elevated white blood cell count and abnormal chest x-ray findings suggestive of an infectious process. Despite these abnormal findings, there was no documented evidence that the physician or nurse practitioner was notified of the results. The results were faxed and texted by the RN to the nurse practitioner and physician, but there was no confirmation of receipt or response. Interviews revealed that the nurse did not verify whether the results were received and did not follow up with the physician. The physician and nurse practitioner both stated they never received the results, and the facility did not have the correct contact information for text communication. The facility's policy required direct communication and documentation of physician notification, especially in cases of significant change in condition, but this was not followed. The lack of communication and verification resulted in the resident not receiving necessary medical intervention for the abnormal findings. The resident subsequently experienced a significant decline, was found unresponsive, and was pronounced deceased. There was no documentation of a change in condition report or assessment related to the abnormal laboratory or diagnostic results, and the required notification procedures were not followed as outlined in the facility's policies.
Failure to Timely Document Medication Administration for Resident with Respiratory Conditions
Penalty
Summary
A deficiency occurred when licensed nursing staff failed to document medication administration for a resident with significant respiratory conditions, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and required multiple inhaled medications as part of their treatment plan. The Medication Administration Record (MAR) and audit reports revealed that documentation of medication administration was not completed at the time medications were given, but instead was entered days or even weeks later, often only after audits identified missing entries. The audit of the resident's MAR for December showed numerous instances where scheduled medications were administered at times different from those ordered, and documentation was delayed until prompted by the facility's Medical Records Assistant (MRA). Interviews with the involved LVNs confirmed that they could not recall specific details about medication administration for the resident, including which medications were given or the exact times of administration. The LVNs admitted to documenting medication administration retroactively after being notified of missing documentation during audits, rather than at the time of administration as required by facility policy. The facility's policy stated that staff must document medication administration immediately after giving each medication and before administering the next one. The DON confirmed that timely documentation is necessary for accurate monitoring of medication effectiveness and adverse reactions. However, the practice observed was that documentation was completed only after audits identified missing entries, and there was no contemporaneous record of medication administration or reasons for late documentation in the resident's progress notes.
Medication Order Entry Errors Result in Missed and Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that residents received medications as clinically indicated and were free from unnecessary medications for two out of four sampled residents. One resident, admitted with a history of seizures and acute kidney failure, did not receive his prescribed anti-seizure medication, Valproic Acid, because the order was not entered into his medication list upon admission. Instead, the medication order was mistakenly entered for another resident who did not have a clinical indication for Valproic Acid. The second resident, admitted with diagnoses of rhabdomyolysis and muscle weakness, received Valproic Acid in error. This resident was administered a total of nine doses of the medication over several days, despite having no clinical indication for its use. The error was confirmed through review of the medication administration records and interviews with facility staff, including the DON and the admitting RN, who acknowledged the mistake in entering the medication order for the wrong resident. The facility did not have a written policy and procedure for the admission process, including medication orders. The admitting RN stated she did not double-check the medication order against the hospital discharge records or confirm with the physician prior to entering the order. The pharmacist confirmed that pharmacy review of new admission medication orders does not typically include review of hospital discharge records, which is considered the facility's responsibility. As a result, one resident did not receive necessary medication for his condition, while another received unnecessary medication.
Some of the Latest Corrective Actions taken by Facilities in California
- Made an up-to-date list of Full-Code residents available at the nurses’ station, updated on every admission/readmission (J - F0678 - CA)
- Required licensed staff to complete an Emergency Cart checklist every shift to verify availability of all items, including the CPR backboard (J - F0678 - CA)
- Delivered facility-wide CPR/BLS re-education with return demonstrations covering code activation, backboard placement, rescue breathing, and high-quality compressions, led by a certified instructor (J - F0678 - CA)
- Scheduled Code Blue drills weekly (once per shift for three months) and monthly thereafter to validate staff BLS skills (J - F0678 - CA)
- Maintained a log of active BLS/CPR certifications, provided 30-day expiration notices, and submitted the log to the QA Committee monthly for oversight (J - F0678 - CA)
- Barred direct-care staff from working without an active BLS/CPR certification (J - F0678 - CA)
- Designated an RN as Code Blue team leader to ensure organized emergency response (J - F0678 - CA)
- Updated the Dialysis Care policy and flow sheet to include RN and Charge Nurse signatures and the Nursing Facility Pre/Post Dialysis Assessment form (J - F0698 - CA)
- Implemented a requirement that returning dialysis residents receive prompt post-treatment assessment of access site, vitals, bleeding, and condition, with findings documented on revised forms (J - F0698 - CA)
- Trained nursing staff on the revised dialysis policy, focusing on comprehensive post-dialysis assessment, monitoring, and documentation (J - F0698 - CA)
Failure to Provide Timely and Effective BLS/CPR to Full Code Resident
Penalty
Summary
Facility staff failed to provide proper and effective Basic Life Support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code when found unresponsive, pulseless, and not breathing. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately call a code blue or initiate CPR upon discovering the resident's condition. Instead, staff delayed action while attempting to verify the resident's code status, and there was confusion and lack of clarity among staff regarding the resident's code status and the location of this information in the medical record. Chest compressions were not started until approximately 12 minutes after the resident was found unresponsive. When CPR was eventually initiated, it was performed on the resident's bed without first placing the resident on a firm, flat surface or using a backboard, which was available in the facility. Staff did not consistently perform continuous and uninterrupted CPR, and there were inconsistencies in the rate and quality of chest compressions. Additionally, staff failed to use the Ambu-bag for rescue breathing, instead placing a non-rebreather mask on the resident, which is not appropriate during CPR. EMS personnel arriving at the scene observed these deficiencies and had to move the resident to the floor to continue CPR. Interviews and record reviews revealed that some staff members lacked current BLS/CPR certification, and there were discrepancies in staff knowledge regarding proper CPR procedures, including compression rates and the use of equipment. Documentation and staff statements indicated that the emergency cart was not properly checked or restocked, resulting in missing essential equipment such as the Ambu-bag. These failures resulted in the resident not receiving timely and effective life-saving measures as required by their full code status.
Removal Plan
- Quality Assurance Nurse (QA) and the RN on duty review the current residents' care profile in the facility's electronic health record (EHR) system, Code Status.
- QA and the RN verify the residents' Code Status via POLST forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status.
- A copy of the list of Full Code residents is made readily available to staff at the nurse's station for reference and is updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed.
- DON/Designee provides in-service education to nursing staff regarding the availability of the list of residents who are Full Code.
- DON checks the Emergency Cart (EC) and ensures that CPR backboard is available.
- RN and/or Designated Licensed Nurse conduct inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This is validated by the DON and/or Designee.
- RN and/or Designated Licensed Nurse conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard.
- DON initiates in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly.
- DON initiates in-service to RNs, LVNs, and CNAs regarding providing rescue breathing, not placement of a non-rebreather mask.
- DON provides continued in-services for all of the facility's RNs, LVNs, and CNAs.
- DON initiates in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly.
- Director of Staff Development (DSD) reviews employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date.
- Identified CNA attends the CPR certification training and is put on temporary suspension until CPR certification is received as part of Direct Care Staff competency.
- Identified LVN that does not have a current CPR/BLS certification is placed on suspension and is not permitted to return to work without an active certification for CPR/BLS.
- Clinical Nurse Consultant provides 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards.
- DON/Designee provides in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- DON/Designee provides in-service to LVN 2 upon returning to work. LVN 2 is not on the schedule until education/reeducation is provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation.
- DON/Designee provides in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- A Certified CPR instructor provides mandatory re-education and training for all Licensed Nurses and CNAs which is also attended by the DON and DSD with return demonstration conducted.
- A series of ongoing CPR Certification Training sessions is provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training.
- A Code Blue drill is initiated and continues weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR.
- An RN is designated as the team leader for Code Blue emergencies.
- Additional CPR training is provided by a Certified CPR Instructor to provide mandatory re-education and training for all Licensed Nurses and CNAs with return demonstration.
- Any Licensed Nurses or CNAs are not permitted to work directly with patients if they do not complete the Certified CPR refresher course.
- Director of Staff Development (DSD)/Designee maintains a log for all Direct Care Staff of their active Certification for BLS/CPR.
- DSD/Designee notifies staff with BLS/CPR certification expiring within a month.
- DSD/Designee presents to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification.
- No Direct Care Staff are permitted to work directly with patients without an active BLS/CPR certification.
- QAA Committee reviews audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions.
Failure to Assess and Monitor Dialysis Resident Post-Treatment Resulting in Fatal Hemorrhage
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, anemia, atrial fibrillation, and a history of removing her own dialysis access site dressing was not properly assessed or monitored upon return from an outpatient hemodialysis treatment. The resident was prescribed Eliquis, increasing her risk for bleeding, and had documented prior incidents of prematurely removing her AV fistula dressing, resulting in bleeding. Despite these known risks and care plan interventions requiring monitoring of the access site and leaving the dressing in place for at least four hours post-dialysis, staff failed to conduct a post-dialysis assessment or monitor the resident for complications upon her return. On the day of the incident, the resident returned to the facility at approximately 7:10 p.m. after hemodialysis. The assigned RN assisted the resident to her room but did not visually inspect the AV fistula site, check vital signs, or document the resident's return. The RN assumed the site was not bleeding because the resident's clothing was not wet and did not notify other staff of the resident's return. Both the LVN and CNA assigned to the resident were on their lunch breaks and were not informed of the resident's return. No staff member was designated to receive or assess the resident upon her arrival, and there was no documentation of a post-dialysis assessment in the medical record. Approximately 40 minutes later, the CNA discovered the resident unresponsive, with the AV fistula dressing removed and active bleeding from the site. Blood was found on the bed, floor, and the resident's clothing. Emergency measures were initiated, but the resident was pronounced deceased by paramedics. Interviews and record reviews confirmed that facility staff did not follow established policies and procedures for post-dialysis assessment, monitoring, and documentation, nor did they implement the resident's care plan interventions for AV fistula care and monitoring.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with RN 1 and LVN 1, review of facility's P&P on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis treatment, identifying failures related to post-dialysis assessment, monitoring, communication, and documentation.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN, including direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents receiving hemodialysis treatment, finding no other residents with deficiencies similar to those found for Resident 1.
- The Administrator and the DON reviewed and updated the P&P on Dialysis Care. The Dialysis Flow Sheet-Return Assessment form was updated to include signature columns for the Charge Nurse and RN Supervisor, as well as the inclusion of the Nursing Facility Pre and Post Dialysis Assessment form. The updated policy became effective and will be presented to the Quality Assurance Committee at the next monthly meeting.
- The Administrator notified the Medical Director regarding the details of the IJ issued by the SSA and the updated policy on Dialysis Care.
- The DON provided one-on-one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care, focusing on conducting pre and post dialysis assessments, assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications, and documentation requirements.
- The facility will ensure that residents who require hemodialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
- The DON and DSD provided in-service education to nursing staff regarding the updated policy on Dialysis Care, with emphasis on comprehensive assessment and monitoring of residents by LVNs or RNs post dialysis treatment, completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment, and nursing progress notes documenting the date and time residents return to the facility.
- The DON performed a competency check of RN 1 regarding dialysis care, including monitoring, documentation, and communication.
- The DON performed competency checks of licensed nurses regarding post dialysis observation, reporting, monitoring, interventions, and proper documentation.
- The DSD performed competency checks of CNAs regarding observation and reporting on resident's return post-dialysis and post procedure, monitoring, safety, and communication of observations.
- The DON conducted an audit on residents who returned from hemodialysis, showing all requirements were completed and in place for each of the reviewed residents, and that a process is in place to ensure appropriate assessment, monitoring, documentation, and clinical oversight for residents returning to the facility following outpatient hemodialysis.
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