Citations in District Of Columbia
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in District Of Columbia.
Statistics for District Of Columbia (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in District Of Columbia
A resident with severe cognitive impairment and multiple diagnoses was found with a right hip fracture of unknown origin. Staff became aware of the injury and ordered an X-ray, which confirmed the fracture, and the resident was transferred to the hospital. However, the required report to the State Agency was not submitted within 24 hours, as acknowledged by the DON, resulting in a deficiency.
A physician did not sign and date a progress note at the time of a psychiatric consultation for a resident with multiple diagnoses, including depression and anxiety. The note was signed 52 days after the visit, despite documentation of the visit and new medication orders in the medical record. The physician acknowledged the delay during a staff interview.
Surveyors identified widespread housekeeping deficiencies, including dust buildup, dirty and sticky floors, soiled toilets, stained privacy curtains, dirty trash cans, and a strong urine odor in several areas. These issues were acknowledged by facility staff and affected multiple resident rooms and common areas.
Staff did not maintain an effective pest control program, as flies were observed in three resident rooms. In one case, a soiled trash can with a dark substance attracted flies, while in another, flies were found near human waste under a portable toilet. Additional flies were seen on a privacy curtain and pillow in a third room. These deficiencies were confirmed by staff interviews and direct observation.
Facility staff did not post the most recent survey results in an accessible location and failed to provide survey reports from the past three years, including certification surveys and complaint investigations, upon request. When a resident's representative asked for the latest survey results, only an outdated report was provided, and staff were unable to promptly locate the required documentation.
A resident with complex medical needs, including chronic respiratory failure and mobility limitations, was discharged without proper coordination of home care and oxygen therapy services. The social worker did not document arrangements for post-discharge care or confirm acceptance by a home care agency, and family members reported that promised services were not provided, leading to the resident using outdated equipment and experiencing falls at home.
Facility staff did not ensure that a comprehensive care plan review and care plan meeting were conducted at least quarterly for a resident with severe cognitive impairment and multiple diagnoses. Documentation showed that the last care plan meeting was held over 90 days prior, and there was no evidence of timely interdisciplinary team review or revision of the care plan as required.
Two residents with COVID-19 and complex medical histories did not receive the full course of prescribed Paxlovid antiviral therapy as ordered by their physicians. Despite clear orders and care plans, both residents received fewer doses than required, and facility staff, including the DON and Infection Preventionist, were unaware of the missed doses until the issue was brought to their attention during the survey.
A resident receiving IV Vancomycin therapy for bacteremia was found with an unlabeled infusion tubing, contrary to facility policy requiring date, time, and initials on all IV tubing. The LPN present could not identify who hung the IV bag or when, and the issue was confirmed through observation and staff interviews.
A resident with severe cognitive impairment, anemia, and a swallowing disorder was administered crushed Ferrous Sulfate and Potassium Chloride ER tablets by an LPN, despite both medications being labeled 'Do not crush' and without a physician's order. The facility's policy required medications to be given as ordered and per manufacturer instructions, which was not followed.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
Facility staff failed to report an incident of injury of unknown origin to the State Agency within the required 24-hour timeframe for one resident. The resident, who had a history of repeated falls, difficulty walking, and seizures, was found to have severe cognitive impairment and required substantial assistance with activities of daily living. On the morning of the incident, the resident complained of right hip pain and was unable to get out of bed. Assessment revealed swelling and warmth in the right hip, and pain medication was administered without relief. An X-ray was ordered, which later confirmed an acute comminuted displaced intertrochanteric fracture of the right femur with associated soft tissue swelling. The resident was subsequently transferred to the hospital for further evaluation and admission. Despite being aware of the injury on the day it was discovered, facility staff did not submit the required Facility Reported Incident (FRI) to the State Agency until three days later. The Director of Nursing acknowledged the delay, attributing it to IT issues that prevented timely submission of the report. The failure to report the injury of unknown origin within 24 hours constituted a deficiency as identified by the surveyors.
Physician Failed to Timely Sign and Date Progress Note
Penalty
Summary
A deficiency was identified when a physician failed to sign and date a resident's progress note at the time of the visit. The resident, who had multiple diagnoses including depression, anxiety disorder, sepsis, hyperlipidemia, and intrahepatic bile duct carcinoma, was admitted to the facility and underwent an initial psychiatric consultation. The consultation note included clinical observations and recommendations, such as continuing and potentially adjusting antidepressant medication. However, the physician did not sign and date the progress note until 52 days after the visit. This lapse was discovered through a review of the resident's medical record and confirmed during a staff interview. The nurse's note documented that the resident was seen by the behavioral MD and that a new medication order was entered, but the corresponding physician's note was not signed and dated contemporaneously. The physician acknowledged the delay, attributing it to a habit of reviewing notes later and sometimes forgetting to sign them.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Facility staff failed to provide adequate housekeeping services necessary to maintain a safe, clean, and comfortable environment for residents. During an environmental walkthrough, surveyors observed dust buildup under handwashing sinks, under beds, in wall corners, and around furniture in all resident rooms on two floors. Additional findings included soiled window tracks and frames with cobwebs in a dayroom, dirty and sticky floors in multiple resident rooms and common areas, and a strong urine odor in one resident care unit and a resident room. Toilets in two resident rooms were found soiled with dark stains, and trash cans in three rooms were dirty, with one having a broken step pedal. Further observations revealed stained privacy curtains in three resident rooms and dusty window blinds in five rooms. These environmental deficiencies were acknowledged by a facility employee during a face-to-face interview. The report does not mention any specific medical history or conditions of the residents affected, nor does it detail any immediate harm, but it documents the failure to maintain a clean and homelike environment as required.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program, as evidenced by the presence of flies in three out of thirteen resident rooms on the third floor. In one room, numerous flies were observed, and further investigation revealed a trash can with a dark substance at the bottom that appeared to attract the flies. In another room, flies were found, and a dark, lumpy substance identified as human waste was discovered on the floor under a portable toilet near the foot of a bed. In a third room, flies were seen on the privacy curtain and on a pillow on one of the beds. These findings were confirmed through direct observation and staff interviews.
Failure to Make Survey Results and Reports Readily Accessible
Penalty
Summary
Facility staff failed to post the results of its most recent survey in a location that was readily accessible to residents, family members, and resident representatives. Observations revealed that only a sign indicating the survey book was available upon request was posted at the front security desk, rather than the actual survey results. When a resident's representative requested the most recent survey results, she was provided with an outdated report from 2022. Additionally, during a surveyor's visit, the front desk staff were unable to immediately locate the survey book and had to refer the surveyor to the Administrator. The Administrator confirmed that only the 2024 survey report was available at the front desk at that time. Further investigation showed that the facility did not have reports from the three preceding years, including certification surveys, complaint investigations, and any plan of correction in effect, available upon request for review by any individual. The Administrator acknowledged the absence of these reports during the surveyor's inquiry. The deficiency was identified through direct observation, staff interviews, and review of the available documentation, which confirmed that the facility did not meet the requirements for making survey results and related reports accessible to residents and the public.
Failure to Ensure Safe Discharge Planning and Coordination of Post-Discharge Services
Penalty
Summary
The facility failed to implement its discharge planning process to ensure a safe discharge for a resident with multiple complex medical needs, including chronic respiratory failure, morbid obesity, and sleep apnea. The resident required substantial to total assistance with mobility and activities of daily living, was incontinent, and was receiving physical therapy, occupational therapy, and oxygen therapy. Documentation indicated that the resident was to continue receiving therapy and home health services, as well as oxygen therapy, after discharge. However, the discharge was not properly coordinated, as the social worker did not have documented evidence of arranging home care services or confirming acceptance by a home care agency. Additionally, the social worker did not coordinate ongoing oxygen therapy services, stating she was unaware of the resident's need for oxygen, despite documentation to the contrary. Family members reported that they were unable to reach the social worker after discharge and that promised wrap-around services were not provided. They also stated that they had to use an old oxygen concentrator from two years prior, and that the resident experienced falls at home post-discharge. The home care agency representative confirmed that services were verbally denied to the social worker, but there was no documentation of this communication. The lack of documented coordination and follow-through resulted in the resident being discharged without the necessary support and services to ensure a safe transition home.
Failure to Conduct Timely Quarterly Care Plan Review
Penalty
Summary
Facility staff failed to ensure that a comprehensive care plan review and care plan meeting were conducted at least quarterly for one resident with multiple diagnoses, including schizophrenia, hypertension, and major depressive disorder. The resident, who has a legal guardian and is coded as DNR, was admitted to the facility and had a documented severe cognitive impairment based on a BIMS score of 00. The last documented care plan meeting for this resident occurred over 90 days prior to the review, and there was no evidence that the interdisciplinary team (IDT) reviewed or revised the care plan within seven days of the most recent quarterly MDS assessment. Record review and staff interviews confirmed the absence of required quarterly care plan meetings and timely IDT review for the resident. The Social Services Director acknowledged that the last care plan meeting was held more than 90 days ago and could not provide a reason for the delay. Documentation did not show that the care plan was reviewed or updated as required by regulation, resulting in a deficiency related to care plan management for this resident.
Failure to Administer Prescribed Antiviral Medication as Ordered
Penalty
Summary
Facility staff failed to ensure that two residents received their prescribed Paxlovid antiviral medication for the full duration as ordered by their physicians. Both residents had multiple significant diagnoses, including epilepsy, cerebral infarction, and malignant neoplasm of the liver, and were diagnosed with COVID-19 during their stay. Physician orders and care plans clearly directed that each resident was to receive Paxlovid twice daily for five days, totaling ten doses per resident. Medical record reviews and Medication Administration Records (MAR) revealed that the residents did not receive the full course of medication as ordered. One resident received only six out of ten doses over three days, while the other received seven out of ten doses over three and a half days. Documentation showed repeated notes indicating that the pharmacy was called regarding the medication, but there was no evidence that the orders were adjusted or that the full course was administered as prescribed. Staff interviews confirmed that facility leadership, including the DON and Infection Preventionist, were unaware that the residents had not received the complete course of Paxlovid. The deficiency was further substantiated by a complaint received by the State Agency, which reported that patients had not received medication for several days and described medication errors and staffing issues. The failure to administer medications as ordered was not identified or addressed by facility staff prior to the survey.
Failure to Label IV Tubing During Antibiotic Administration
Penalty
Summary
Facility staff failed to minimize risks for a resident receiving intravenous (IV) therapy by not labeling and dating the IV infusion tubing as required by facility policy. The policy specified that all IV tubing must be labeled with the date, time, and initials. During an observation, a resident with a midline IV site in the left upper arm was found connected to infusion tubing and an empty IV Vancomycin medication bag, but the tubing was not labeled with the required information. At the time of observation, the LPN present was unable to identify who had hung the IV bag or when it was done. The resident involved had multiple diagnoses, including epilepsy, cerebral infarction, and a benign neoplasm of the cerebral meninges, and was receiving Vancomycin IV therapy for bacteremia as ordered by a physician. Documentation showed that the midline was placed and the resident tolerated the procedure well, with no adverse reactions noted. However, the failure to label the IV tubing was directly observed and confirmed by staff interviews, indicating non-compliance with established protocols for safe IV administration.
Failure to Follow Medication Administration Protocols for Resident with Swallowing Disorder
Penalty
Summary
Facility staff failed to demonstrate competent nursing skills in the administration of medications for one resident with multiple diagnoses, including schizophrenia, hypertension, major depressive disorder, and anemia. The resident had severe cognitive impairment, a swallowing disorder, and was on a mechanically altered diet. Physician orders specified oral administration of Ferrous Sulfate and Potassium Chloride ER tablets, both of which were labeled 'Do not crush.' During a medication pass, an LPN was observed crushing these medications and mixing them with applesauce for administration, despite the clear labeling and absence of a physician's order to do so. The LPN explained that all medications were being crushed for the resident due to her swallowing issues and thickened liquid diet. However, the medical record did not contain any current physician order authorizing the crushing of these medications. The facility's policy required medications to be administered as ordered and in accordance with manufacturer specifications, which was not followed in this instance. The deficiency was confirmed through observation, record review, and staff interviews.
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