Citations in Illinois
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Illinois.
Statistics for Illinois (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Illinois
Multiple residents experienced significant delays in call light response, with some waiting up to two hours for assistance. Grievance logs and resident council minutes documented ongoing concerns about slow staff response, and interviews confirmed that both cognitively impaired and intact residents were affected. Facility policy required call lights to be answered within 10-15 minutes, but this was not consistently achieved.
Three dependent residents did not consistently receive the required number of showers or bed baths, with some reporting long periods without bathing and issues with hot water availability. Staff confirmed that not all residents received two showers weekly and could not provide accurate documentation of bathing schedules, resulting in a deficiency related to inadequate ADL support and personal hygiene.
The facility failed to maintain complete and accurate medical records for several residents, including one who was not assessed by a nurse during a five-hour stay and others who did not receive adequate showers or bed baths. Documentation related to care was found to be inaccurate and altered, with inconsistencies in signatures and use of correction tape, in violation of facility policy.
A deficiency was identified when multiple residents and staff reported ongoing shortages of clean towels and linens, leading to the use of makeshift items such as sheets, pillowcases, and diapers for personal care. Staff described receiving far fewer towels than needed, with some resorting to cutting up old towels or purchasing their own wipes. Residents with significant care needs were unable to maintain personal hygiene due to the lack of supplies, and stained or damaged linens were observed in use because laundry staff could not replace them with new items.
Two residents were involved in a physical altercation, resulting in one sustaining a facial abrasion. The incident occurred as one resident was leaving the dining room and was struck by another, who was a new admission with no prior behavioral issues. Staff provided first aid, notified appropriate parties, and documented the event, but the facility failed to prevent the assault.
Two residents were involved in a physical altercation resulting in injury, which was reported internally and to law enforcement, but the required notification to the State Agency was not completed due to miscommunication between the Administrator and DON. Facility records and State Agency confirmation showed no evidence of the mandated report being submitted, despite facility policy requiring prompt reporting of abuse incidents.
A resident alleged verbal and mental abuse by two staff members, but the facility did not follow its policy to immediately suspend the accused staff during the investigation. The Administrator allowed the staff to continue working, citing staffing needs and the resident's absence, despite the policy requiring suspension to protect residents. The DON confirmed the policy was not followed.
Two residents did not receive prescribed medications as ordered, including missed doses of eye drops for glaucoma and intravenous antibiotics for cellulitis. MAR reviews and staff interviews confirmed the omissions, with staff unable to explain the missed administrations. Facility policy requires medications to be given and documented as ordered.
A resident with impaired cognition and total dependence for mobility was found to have sustained fractures of unknown origin, which were only discovered after a hospital transfer. The facility did not report the injury within the required timeframe as outlined in its abuse prevention policy, submitting the report to authorities later than the 24-hour window allowed.
A resident with impaired cognition and multiple medical conditions was admitted with bilateral heel deep tissue injuries, but the facility failed to accurately assess and document these injuries or update the care plan to include necessary interventions such as heel protectors. Weekly skin assessments did not reflect the resident's true condition, and discrepancies existed between assessment tools and the care plan regarding the resident's mobility and needs.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents, as evidenced by grievance logs and resident council minutes documenting extended wait times for assistance. Grievance logs from October, November, and December 2025 recorded multiple instances where residents waited prolonged periods for help with various activities. Resident council minutes from December 2025 noted that staff needed to respond to call lights more quickly, with 13 residents present at the meeting. Interviews with residents and family members confirmed delays, including one resident who did not have a standard call light but instead used a bell that went unanswered several times. Medical records and interviews provided further details about the affected residents. One resident, admitted with multiple diagnoses including weakness, hemiparesis, cognitive decline, and multiple sclerosis, lacked an admission assessment or note from a licensed nurse during their stay. Another resident with cognitive impairment reported call light response times ranging from 30 minutes to two hours. A third resident, cognitively intact, also reported waiting up to two hours for assistance. Facility policy and statements from the corporate nurse and DON indicated that call lights should be answered within 10-15 minutes, but this standard was not met.
Failure to Provide Required Bathing Assistance and Maintain Hygiene
Penalty
Summary
The facility failed to provide adequate bathing assistance to three dependent residents who required help with activities of daily living (ADLs). One resident, admitted with acute osteomyelitis, weakness, chronic atrial fibrillation, and chronic kidney disease, reported not receiving a shower or bed bath for approximately two weeks prior to a recent bed bath, which was given with lukewarm water obtained from another area due to a lack of hot water in the resident's hall. The resident stated that the hot water issue had persisted for a couple of months and affected the entire hall. Another resident with chronic obstructive pulmonary disease, respiratory failure, and diabetes reported not consistently receiving the required two showers per week, though the showers received were warm. A third resident, admitted with a left fibula fracture and repeated falls, communicated that the lack of hot water on her hall had lasted over a month and that she was taken to another part of the facility for showers, but did not feel she received enough showers overall. Interview with the corporate nurse confirmed that not all residents were receiving the required two showers weekly and that accurate documentation of shower dates could not be provided. The facility's ADL policy requires that residents unable to perform ADLs independently receive necessary services to maintain personal hygiene, including regular bathing. The failure to provide consistent bathing services and maintain proper documentation led to the deficiency identified during the survey.
Incomplete and Inaccurate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for four residents reviewed. One resident was admitted from a hospital with multiple diagnoses, including weakness, hemiparesis, cognitive decline, and multiple chronic conditions. There was no admission assessment or nursing note documenting the time of arrival or any assessment by a licensed nurse during the five hours the resident was in the facility before being transferred to another facility. Both the family member and facility staff confirmed that the resident was not assessed by a nurse during this period, and the medical record lacked any documentation of an assessment or admission note. Additionally, three other residents reported not receiving adequate showers or bed baths, with one stating they had not received a shower or bed bath for approximately two weeks. Review of the facility's shower documentation revealed inaccuracies and alterations, including the use of correction tape and inconsistent signatures compared to staff assignment sheets. The facility's own policy requires that each resident's medical record accurately reflect the care and services provided, with documentation completed at the time of service or by the end of the shift, which was not followed in these cases.
Failure to Provide Adequate Clean Towels and Linens for Resident Care
Penalty
Summary
The facility failed to provide an adequate supply of clean towels and linens in good condition for resident care, as evidenced by multiple observations, interviews, and record reviews. Residents reported having to purchase their own towels due to shortages, and staff confirmed that there were not enough towels and linens available to meet the needs of all residents. On several occasions, staff resorted to using sheets, pillowcases, or even diapers to clean residents when towels and washcloths were unavailable. The laundry staff acknowledged delivering significantly fewer towels than required, and described cutting up bath towels to create makeshift washcloths, which were observed to be tattered, frayed, and stained. Clean linens and blankets were also observed to have persistent stains, including feces, pus, and blood, which could not be removed despite laundering. Residents affected by this deficiency included individuals with significant care needs, such as those who were always incontinent of urine and bowel, required maximal assistance for hygiene, and had multiple comorbidities including morbid obesity, diabetes, contractures, and mobility limitations. These residents were dependent on staff for all aspects of personal care, including bathing, toileting, and hygiene. The lack of adequate linens and towels directly impacted their ability to maintain personal cleanliness and dignity, as they were sometimes unable to wash their faces or be properly cleaned after incontinence episodes. Staff interviews revealed that the shortage of towels and linens was a recurrent and well-known problem, with CNAs frequently having to search other units or purchase their own wipes to provide care. Laundry staff reported being unable to discard stained or damaged linens due to insufficient supply, and did not have access to new linens stored in a locked supply closet. Nursing and administrative staff were aware of the issue, with some indicating that they had provided instructions for reporting shortages, but the problem persisted due to lack of communication and inadequate replenishment of supplies.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault involving two residents, resulting in one resident sustaining a skin abrasion. One cognitively intact resident reported being struck on the left side of her face by another resident as she was leaving the dining room. She experienced bleeding from a small abrasion and sought assistance from staff, who provided first aid. The resident declined hospital treatment, reporting only a minor scratch and no ongoing pain. Staff observed a small scar on her face with no signs of infection during the survey. Interviews with staff revealed that the incident was reported promptly, and the involved resident was described as calm and non-provocative. The resident who committed the assault was a new admission with no prior signs of agitation or aggression. Staff and police were notified, and the resident responsible for the assault was sent for psychiatric evaluation. Documentation confirmed the physical altercation and the resulting injury, and the facility's abuse policy was referenced, which states that residents have the right to be free from abuse.
Failure to Timely Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the State Agency as required. On the day of the incident, one resident was struck in the face by another resident while entering the dining room, resulting in a bleeding abrasion on the left side of the face. The injured resident, who was cognitively intact, reported the incident to staff, and the LPN on duty observed the injury and notified the Assistant Director of Nursing, the police, both residents' physicians, and family members. The resident who committed the act was sent to the hospital for psychiatric evaluation. Despite internal notifications and documentation of the incident, there was confusion among facility leadership regarding who was responsible for submitting the required report to the State Agency. The Administrator believed the DON was responsible, while the DON stated she was not able to submit the report due to being offsite and without computer access, and that the Administrator had agreed to handle it. Both parties referenced their usual practices for reporting but could not provide evidence that the report was submitted for this specific incident. Review of facility records and confirmation from the State Agency indicated that no report was received for the incident. The facility's own policy requires that all allegations of abuse involving injury be reported to the State Agency within two hours, with a final report submitted within five business days. For this incident, the initial and final reports provided by the facility were undated, untimed, and lacked any evidence of submission. The absence of confirmation documentation and the statements from both the Administrator and DON confirmed that the required reporting did not occur for this event.
Failure to Follow Abuse Investigation and Suspension Policy
Penalty
Summary
The facility failed to follow its policy regarding the investigation and prevention of further abuse following allegations made by a resident. Specifically, a resident reported that a CNA was verbally abusive and that a Restorative Aide engaged in mental abuse. The resident could not recall the exact date or time of the incidents, and there were no witnesses. Upon being informed of the allegations, the Administrator acknowledged that there were no prior reports against the staff members in question but stated she would follow up. The facility's policy requires immediate suspension of any staff accused of abuse pending investigation to protect residents from potential harm. However, the Administrator did not suspend the accused staff, citing the need to maintain staffing levels during the holidays and the resident's absence from the facility. The Administrator conducted interviews with the accused staff and completed the investigation quickly, allowing the staff to continue working without suspension. The Director of Nursing confirmed that the facility's policy is to immediately suspend any staff accused of abuse, whether they are on duty or scheduled to work, until the investigation is complete. Documentation reviewed included the facility's abuse policy, investigation and reporting documents, and in-service attendance records. The failure to suspend the accused staff during the investigation was not in accordance with the facility's established policy and procedures.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medications as prescribed by physicians for two residents. One resident, with diagnoses including glaucoma, anxiety disorder, and major depressive disorder, did not receive all required doses of her prescribed eye drops (brimonidine tartrate) on two occasions, as confirmed by both her statements and a review of the Medication Administration Record (MAR). The MAR was not signed for these doses, and the nurse responsible could not provide an explanation for the missed documentation or administration. Another resident, with complex medical conditions including cellulitis, MRSA infection, and an open wound, did not receive his prescribed intravenous antibiotic (daptomycin) on three separate occasions. The MAR confirmed these missed doses, and the Assistant Director of Nursing acknowledged that the antibiotic should not have been missed to ensure proper treatment of the infection. The nurse practitioner indicated that insurance issues delayed approval for the medication, leading to a change in antibiotic therapy after several missed doses. Facility policy and job descriptions require medications to be administered as ordered and documented accordingly.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse prevention policy regarding the timely reporting of an injury of unknown origin for one resident. The resident, who had significant cognitive impairment and was dependent on staff for all mobility and transfers, was transferred to the hospital after being found weak, pale, and difficult to arouse. Hospital records revealed that the resident had sustained a fracture of the right acetabulum and a compression fracture of the first lumbar vertebra. There was no documentation or evidence of a fall or trauma at the time of the hospital transfer, and the facility only became aware of the fractures upon the resident's return from the hospital. According to the facility's abuse prevention policy, injuries of unknown origin must be reported immediately, but no later than two hours after the allegation is made if abuse or serious injury is involved, or within 24 hours if not. The facility submitted the initial report to the State Agency one day after learning of the fractures, rather than within the required 24-hour timeframe. The final investigation report did not determine how the injuries occurred. This failure to report the injury of unknown origin in a timely manner was not in accordance with the facility's policy.
Failure to Timely Assess and Update Care Plan for Pressure Injuries
Penalty
Summary
The facility failed to timely and accurately assess a resident for pressure injuries and did not update the care plan after the identification of bilateral heel deep tissue injuries. The resident, who had impaired cognition and was non-ambulatory, was admitted with significant medical diagnoses including metabolic encephalopathy and fractures. Upon admission from the hospital, the resident had right and left heel deep tissue injuries, which were treated with skin prep and foam dressing. However, the use of heel protectors was not included as a physician order or as an intervention in the care plan. The Braden assessment inaccurately documented the resident's mobility status, conflicting with the Minimum Data Set (MDS) and care plan, which indicated the resident was dependent and non-ambulatory. Weekly skin assessments conducted by the facility repeatedly documented no loss of skin integrity, even after the hospital and facility records confirmed the presence of bilateral heel pressure injuries. One assessment was recorded while the resident was not present in the facility, and subsequent assessments failed to note the existing injuries. The facility's policy required that actual pressure injuries be addressed in the care plan and that assessments be timely and accurate, but these steps were not followed for this resident.
Some of the Latest Corrective Actions taken by Facilities in Illinois
Staff Education & Policy Enhancements
- Provided in-service training to the Administrator and DON on the Resident Possession & Use Policy and Illicit Drug Use Program (J - F0689 - IL)
- Delivered facility-wide education on positioning beds away from heating units (J - F0689 - IL)
- Educated all staff on elopement policy, door-alarm monitoring, and prohibition against silencing alarms (J - F0689 - IL)
- Revised outdoor-access policy with CNA feedback and educated all staff and agency personnel on new safety checks and documentation requirements (J - F0689 - IL)
Continuous Monitoring, Audits & Safety Controls
- Assigned Administrator and DON to oversee enhanced monitoring of residents with substance-abuse histories (J - F0689 - IL)
- Established ongoing maintenance rounds and audits to verify bed placement away from heating units and proper radiator function, with findings reviewed through QAPI (J - F0689 - IL)
- Implemented weekly audits of all door alarms to ensure functionality and audibility (J - F0689 - IL)
- Secured all facility exit door keys in a controlled location (J - F0689 - IL)
- Created and implemented a resident outdoor-safety assessment tool for all current and new admissions, with audits by DON (J - F0689 - IL)
- Installed a timer and log system to ensure timed safety checks and hydration offers for residents outside (J - F0689 - IL)
- Directed DON or designee to conduct ongoing audits of compliance with the outdoor-safety policy (J - F0689 - IL)
Failure to Monitor and Investigate Resident Illicit Drug Use
Penalty
Summary
The facility failed to implement an effective system to monitor and investigate how a resident with a known history of substance abuse was able to obtain and use illicit drugs while residing in the facility. Despite the resident being cognitively intact and having no independent outside pass privileges, there were multiple documented incidents where the resident was found in possession of illicit substances and drug paraphernalia, and subsequently tested positive for cocaine, fentanyl, and opiates. Staff discovered a white powdered substance and a crack pipe in the resident's room on more than one occasion, and hospital records confirmed the resident's admission of drug use within the facility. There was a lack of consistent documentation and follow-through regarding the monitoring and supervision of the resident after each incident. Although the resident's care plan and behavior contract addressed substance abuse, there were no additional interventions documented after repeated hospitalizations for drug use. The facility's own policies required immediate assessment, drug screening, and restriction of passes, but there was no evidence of a thorough investigation into how the drugs were obtained or brought into the facility. Staff interviews revealed uncertainty about the process for handling contraband, inconsistent communication, and a lack of clarity regarding the involvement of law enforcement or addiction specialists. Furthermore, there was insufficient documentation of frequent monitoring and supervision of the resident following each incident, as required by facility policy. Staff did not consistently document monitoring on various shifts, and there was no evidence of a substance abuse assessment, psychiatric evaluation, or referral for addiction treatment after the resident's repeated positive drug screens and hospitalizations. The facility's failure to investigate the source of the drugs and to implement effective interventions contributed to the ongoing risk and ultimately resulted in the resident requiring multiple hospital transfers due to drug use while in the facility.
Removal Plan
- Regional Director of Operations in-serviced the Administrator regarding the facility's Resident Possession & Use Policy and the Illicit Drug Use Program.
- Administrator will be responsible for overseeing the Social Service Director in ensuring all residents identified with a history of substance abuse and drug seeking behaviors are closely monitored with appropriate and effective interventions.
- Regional Nurse Consultant in-serviced the Director of Nursing regarding the facility's Resident Possession & Use Policy and also the Illicit Drug Use Program.
- Director of Nursing will be responsible for overseeing nursing staff in ensuring all residents identified with a history of substance abuse and drug seeking behaviors are closely monitored with appropriate and effective interventions.
Failure to Prevent Severe Burns Due to Bed Placement Near Radiator
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia, heart failure, and cerebrovascular disease suffered severe burns after falling out of bed and coming into contact with a radiator heater. The resident's bed had been positioned against the wall, adjacent to the radiator, which was a standard room setup for two residents in the facility. The resident had a history of falls, confusion, and required assistance with bed mobility and transfers, as documented in care plans and assessments. On the night of the incident, the resident was last seen by staff at approximately 2:30 AM and was found around 3:00 AM lying on top of the radiator after a loud noise was heard from the room. Upon assessment, the resident was found to have burns on the right cheek, right arm, and right leg, with subsequent medical evaluation confirming first, second, and third-degree burns. The burns were severe enough to require hospitalization in an intensive care unit specializing in burn care for five days. Staff interviews revealed that the bed was placed against the wall due to room size constraints and that this was a common practice. The radiator cover had become dislodged during the fall, exposing the resident to the hot surface and resulting in the burns. Maintenance staff were not routinely checking the radiators unless issues were reported, and there was no prior awareness of burn incidents related to the radiators. Documentation and interviews indicated that the resident was at high risk for falls due to cognitive impairment, impaired mobility, and a recent history of falls. The care plan included interventions such as floor mats and one-person assistance for bed mobility, but did not address the hazard posed by the proximity of the bed to the radiator. The facility's failure to identify and mitigate the environmental hazard of the radiator heater, combined with inadequate supervision and monitoring of bed placement, directly led to the resident's injuries.
Removal Plan
- Resident R2's bed was moved away from the wall and heating unit.
- The Maintenance director/Designee completed rounds to ensure that all heating units are working adequately, and all beds are moved away from the heating unit/Wall.
- All staff were provided with education by the Maintenance director/Designee, training including but not limited to ensuring the positioning of beds are away from the heating unit/Wall.
- The Medical Director, Administrator, DON and Maintenance director reviewed the facility's policies which include but are not limited to: Guidelines on preventative maintenance measures.
- New hires will be in-serviced by the Maintenance, or Designee.
- All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work.
- The facility does not utilize agency staff however the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift.
- The Maintenance director/designee will conduct audits to identify any potential concerns related to this plan of removal.
- During the weekends and holidays, the Maintenance director/Designee will conduct the audits, ensuring beds are away from the heating units. Any identified concern will be addressed immediately.
- To ensure compliance, the results of the audit will be reviewed during the meeting which is attended by the leadership which includes but is not limited to the: DON, ADON, Maintenance director and the Administrator/Designee.
- The Maintenance/Designee will conduct random staff interviews for at least 5 employees to gauge knowledge for retention and determine if additional training is required.
- Any identified concern will be addressed immediately and will also be discussed during the Adhoc QAPI.
- All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance.
- The Administrator, Maintenance director and Designee will monitor completion of this plan of removal.
Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Door Alarms
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to elopement risks. Multiple observations revealed that door alarms were either not functioning, turned off, or not responded to in a timely manner. On several occasions, doors leading to the outside were found cracked open or could be opened without triggering an alarm, and staff were observed not checking on residents who were at risk of elopement. These lapses allowed a severely cognitively impaired resident, who was identified as an elopement risk, to repeatedly leave the facility unsupervised, including incidents where the resident was found outside in unsafe conditions such as in the middle of the road or inside a visitor's van. The resident in question had a history of alcohol-induced dementia, Wernicke's encephalopathy, and chronic kidney disease, and was documented as being ambulatory and prone to wandering. Despite being placed on frequent checks and having a wander guard, the resident was able to exit the facility multiple times. Staff interviews confirmed that the resident was able to find ways to leave the building, sometimes with the assistance of visitors or by exploiting malfunctioning or inaudible alarms. Documentation also indicated that staff were aware of the resident's repeated elopements, but there was a lack of consistent monitoring and timely response to alarms, and the resident's legal guardian was not notified of these incidents. Another resident, also identified as an elopement risk with cognitive impairment and mobility limitations, was able to exit the facility on multiple occasions. This resident was found outside in inclement weather, inadequately dressed, and required staff intervention to be brought back inside. Staff interviews and progress notes indicated that alarms did not always sound when doors were opened, and there was uncertainty about how long the resident had been outside. The facility's own logs did not consistently document these incidents, and staff acknowledged that some doors were routinely left unalarmed for convenience, further contributing to the risk.
Removal Plan
- Facility Elopement Policy was reviewed by Regional Director of Operations and was found to be in compliance with state and federal regulations.
- Facility Administrator or designee initiated in-servicing for all staff on the elopement policy and procedures. In-servicing will be completed by the start of each staff members next shift.
- Facility Administrator or designee initiated in-servicing for all staff on ensuring all staff are monitoring door alarms and responding immediately. In-servicing will be completed by the start of each staff members next shift.
- Maintenance Director or designee will conduct an audit of all facility door alarms and to be completed weekly to ensure they are adequately functioning and audible to staff areas.
- Administrator or designee to conduct Elopement Drill weekly x4 weeks to ensure monitoring and compliance.
- The Administrator or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand elopement policies and procedures.
- IDT team (Admin, DON, SSD, MDS, DM) has assessed R4 and care plan updated to reflect new interventions for R4 being placed on the locked unit.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents for the potential to elope and care plans updated to reflect interventions to protect residents from elopement.
- R4 was placed on the locked unit.
- All facility exit door keys were removed and placed in secured location.
- Facility Administrator or designee initiated in-servicing for all staff to not turn off door alarms. In-servicing will be completed by the start of each staff members next shift.
- Maintenance Director replaced the door lock to 300 Hall door to courtyard and is functioning properly.
Failure to Prevent and Manage Pressure Ulcers Due to Missed Assessments and Treatments
Penalty
Summary
The facility failed to implement and document new care plan interventions to prevent new or worsening pressure ulcers for a resident with multiple risk factors, including diabetes, peripheral vascular disease, and immobility. The staff did not consistently complete skin assessments, ensure the availability of wound care supplies, or perform wound treatments as ordered. As a result, the resident developed a stage II pressure ulcer on the right buttock, a stage III pressure ulcer on the left buttock, and experienced worsening of an existing right heel wound, which required antibiotic treatment. These wounds were discovered by a nurse practitioner during rounds, not by facility staff, indicating a lack of timely identification and intervention. Observations and record reviews revealed that the resident was left in a wheelchair for extended periods without adequate repositioning, and incontinent care was delayed, as evidenced by a full brief with bowel movement upon being returned to bed. Documentation showed repeated lapses in wound care, with multiple entries indicating that treatments were not completed due to unavailable supplies or lack of documentation. There were also missed or delayed skin assessments, including after hospital readmission, and no evidence that new wounds were promptly identified or addressed by staff. Behavioral tracking did not indicate that the resident refused care or treatments during the relevant period. Interviews with facility leadership and clinical staff confirmed expectations that nurses should follow up on treatment changes, document assessments, and notify supervisors if supplies are lacking. However, the nurse practitioner and administrator acknowledged that these processes were not followed, and new wounds were only discovered during external wound care rounds. The facility's own policy required regular skin inspections, timely repositioning, and the use of appropriate pressure-relieving equipment, but these measures were not consistently implemented for the resident in question.
Removal Plan
- Facility pressure ulcer prevention policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
- R1 was seen by Wound Care Provider and received new treatment orders, LAL (low air loss) mattress ordered, and wheelchair cushion replaced.
- Director of Nursing or designee initiated in-servicing for all facility and Agency nursing staff to include RNs, LPNs and CNA's, on the pressure ulcer prevention policy and procedures.
- In-servicing will be completed by the start of each staff member's next shift.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on pressure ulcer prevention.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all newly acquired pressure wounds are identified timely and addressed immediately by reviewing shower sheets daily and ensuring all skin assessments are completed timely and thoroughly.
- Director of Nursing or designee will in-service all facility and Agency nursing staff to include RNs, LPNs and CNA's on identifying all newly acquired pressure areas timely by completing assessments timely and accurately.
- All nursing staff will be educated by the beginning of their next shift.
- Director of Nursing or designee will conduct audits of skin assessments weekly to ensure all new skin conditions are identified timely and addressed accurately as part of the QA process.
- The Director of Nursing or designee will interview 3 staff members weekly x4 weeks to ensure that staff are completing assessments and addressing any new pressure areas.
- Director of Nursing and or designees will conduct skin assessments on all to ensure that any pressure areas are being identified and addressed.
- The staff members responsible for not completing assessments or wound treatments as ordered have been disciplined.
- The DON or designee will review all new admissions to ensure that all assessments are completed.
- The DON or designee educated all facility and agency nurses of how and when to complete skin assessments.
- All facility and agency nurses will be educated by the beginning of their next shift.
- R1 has had a full skin assessment performed by the ADON to ensure all areas of concern have been identified and addressed appropriately.
- All facility and Agency nursing staff to include RNs, LPNs and CNA's, educated by DON or designee that all residents need to be turned and repositioned at least every two hours and as needed.
- All in-servicing will be completed by the beginning of the staff member's next scheduled shift.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents to determine if they are at risk for potential for impaired skin integrity.
- IDT team ensured all skin assessments have been done timely, all new skin areas have been identified and addressed accordingly including care plan review.
Failure to Implement Wound Care Orders and Maintain Pressure Relief Equipment
Penalty
Summary
The facility failed to follow and implement wound care orders from the Wound Nurse Practitioner (NP) in a timely manner for a resident with multiple complex wounds, including stage 3 pressure ulcers and chronic skin conditions. Orders for wound dressings, specialty equipment such as a low air loss mattress, and heel float boots were not promptly initiated or maintained as directed. Documentation shows that wound care treatments were delayed, incorrect treatments were applied, and there were multiple instances where dressing changes and skin assessments were either not performed or not documented as completed according to the NP's orders. The resident's low air loss mattress, which was ordered to provide pressure relief and prevent further skin breakdown, was not maintained in proper working order. Staff, family members, and the resident reported that the mattress frequently lost air, leaving the resident lying on a hard surface, which caused significant pain and discomfort. The mattress was described as being held together with duct tape, with hoses repeatedly disconnecting and the air pump malfunctioning. Despite repeated notifications to facility leadership and maintenance, the issues with the mattress persisted for an extended period before a replacement was provided. As a result of these failures, the resident experienced worsening of wounds, which became infected with multiple organisms including MRSA, Pseudomonas, Enterococcus faecalis, and ESBL E. coli. The infections led to several hospitalizations, surgical debridement, and the need for intravenous antibiotics. The facility's lack of timely and appropriate wound care, failure to maintain essential equipment, and inadequate documentation directly contributed to the deterioration of the resident's condition and the escalation of her wounds.
Removal Plan
- Facility wound care policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
- Director of Nursing or designee initiated in-servicing for all nursing staff on the wound care policy and procedures.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on wound care policy and procedures.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all wound orders are carried out and all interventions are in place.
- Director of Nursing or designee will conduct audits of all wound care orders and interventions weekly.
- The Director of Nursing or designee will interview 3 staff members, 3 times weekly to ensure that staff understand wound care policies and procedures.
- Maintenance Director checked all Low Air Loss (LAL) mattresses to ensure proper functioning.
- Maintenance will perform checks of LAL mattresses weekly to ensure proper functioning.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents with wounds to ensure all orders have been processed and treatments are being done correctly.
- R2's mattress was replaced with a new mattress.
Failure to Communicate Critical Lab Result Leads to Resident Death
Penalty
Summary
A facility failed to ensure that laboratory results, specifically a critical potassium level, were communicated to the ordering provider in accordance with its policy and procedures. One resident, an elderly female with multiple cardiac and vascular comorbidities, had a laboratory result indicating a critically elevated potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The result was reviewed by an LPN, who documented that the lab was relayed to the nurse practitioner via phone and that a response was awaited. However, there was no further documentation of actions taken, confirmation that the provider was made aware, or evidence of nursing assessment or clinical intervention in response to the critical value. Interviews with facility staff revealed that the LPN may have attempted to notify the provider by text or voicemail but did not receive a response and subsequently cleared the lab notification in the electronic medical record. This action prevented other staff from seeing the critical result. The LPN did not escalate the issue to the medical director or telehealth, as required by facility policy, nor did she initiate emergent care or further monitoring. Other nurses and leadership confirmed that the expectation was for critical labs to be communicated immediately and for escalation if the provider could not be reached, especially for life-threatening values such as a potassium of 8.4 mEq/L. The resident was found unresponsive in the facility four days after the critical lab result was obtained and subsequently expired. The death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required that critical lab results be communicated to a licensed practitioner within one hour, with repeated attempts and escalation to the medical director if necessary. The failure to follow these procedures resulted in the deficiency and was cited as Immediate Jeopardy.
Removal Plan
- DON had 1:1 in-service with (V4) and all LPN's and RN's regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call; in-services are ongoing. V4 termed.
- DON/designee completed an in-service to all nurses including agency nurses regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- All newly employed nurses will have orientation including change in condition policy review and the expected appropriate documentation; in-service is ongoing.
- DON had 1:1 in-service with ADON to ensure accurate monitoring of critical labs and potassium.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding potassium order per MD order.
- The Medical Director was made aware and in agreement with the abatement and an in-service was conducted with her Nurse practitioner regarding critical labs.
Failure to Promptly Intervene and Escalate Care for Severe Hypoglycemia
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including type II diabetes mellitus, experienced a severe hypoglycemic episode that was not managed according to professional standards of practice and facility policy. The resident was first found to have a critically low blood glucose level of 42 mg/dl in the early morning by a night shift LPN, who administered glucagon but did not promptly notify the nurse practitioner or physician as required. Despite repeated low blood glucose readings and additional doses of glucagon and oral carbohydrates, the resident's condition did not improve, and there was a prolonged period—over two hours—where the resident remained hypoglycemic and increasingly unresponsive. The nursing staff failed to escalate care in a timely manner. The night shift LPN endorsed the situation to the incoming day shift LPN without notifying the medical provider, and both nurses continued to monitor and treat the resident without achieving a safe blood glucose level or seeking immediate higher-level intervention. Documentation and interviews confirm that the nurse practitioner was not notified until the resident developed respiratory distress and further decline in condition. Only at this point was 911 called and the resident transferred to the hospital. Throughout this episode, facility policy and standard hypoglycemia protocols were not followed, specifically regarding prompt provider notification and emergency escalation for persistent severe hypoglycemia. The lack of timely intervention and failure to follow established protocols resulted in the resident experiencing prolonged hypoglycemia, decreased responsiveness, and ultimately requiring emergent hospital transfer, where the resident expired the same day.
Removal Plan
- Juice was provided to the resident to improve the blood glucose level.
- Glucagon was administered.
- Blood glucose monitoring was performed.
- Nurse Practitioner was notified and resident transferred to ER via 911.
- R1 no longer resides in the facility.
- 1:1 education was provided to the day shift nurse and night shift supervisor regarding hypoglycemia protocol, change of condition policy, following physician orders, and emergency response associated with severe hypoglycemia.
- The night shift nurse is no longer employed by the facility.
- DON/designee conducted a whole-house audit of residents who require blood glucose monitoring to ensure blood glucose results are within the ordered parameters, and if physician / NP is notified if the results are outside the parameters.
- Residents who are at risk for hypoglycemia (residents with diagnosis of diabetes, receiving insulin) were reviewed to ensure the plan of care includes a physician order for parameters of blood glucose level to monitor signs and symptoms of hypoglycemia, administer interventions for treatment of hypoglycemia, and physician notification.
- Staff education was conducted by the DON, Regional Nurse Consultant and shift supervisor. Education included: Notification of a change in condition, Medical emergency procedure associated with hypoglycemia, Following the physician's orders, Hypoglycemia Protocol.
- All licensed nurses received education prior to working their next scheduled shift. Staff not on site for education were contacted by telephone and received verbal education. They will sign in-service education forms at the time of their next shift. This includes PRN staff.
- Understanding of the in-service content was evaluated at the time of in-service through questions and answers.
- Director of Nursing or designee will audit resident records to ensure prompt notification to physician/ NP of an episode of hypoglycemia (change in condition) and following the physician's orders for notification of blood sugars outside of established parameters.
- Director of Nursing or designee will review the clinical record to monitor staff response to residents with signs and symptoms of hypoglycemia, monitor residents experiencing hypoglycemia, including severe hypoglycemia, administer interventions for treatment of hypoglycemia, and when emergency transport (911) and the medical provider are notified.
- Audits will be conducted 5 times a week for all residents with blood glucose monitoring orders.
- Audits will be conducted weekly for a sample of 10% of residents with blood glucose monitoring.
- Results of the audits will be presented to the QAPI committee for recommendations of further auditing and actions as appropriate.
- Root cause analysis is completed, and the action plan is discussed and approved by the Ad-Hoc committee.
Failure to Implement and Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to provide effective fall prevention and adequate supervision for a resident with a documented history of frequent falls and severe cognitive impairment. This resident experienced 50 falls over an eight-month period, many resulting in injuries such as hematomas, lacerations, and head injuries, some of which required emergency room visits. Despite being identified as a high fall risk and having multiple interventions listed in the care plan, staff did not consistently implement or update these interventions after each fall, and several falls were not addressed in the care plan at all. Additionally, fall risk assessments were not completed after every incident as required by facility policy. Observations and interviews revealed that staff often failed to keep the resident's call light within reach, did not maintain the resident in visible areas for supervision, and did not follow specific care plan interventions such as increased toileting rounds or ensuring environmental safety (e.g., removing nightstands, keeping doors open for visual checks). On multiple occasions, the resident was found lying on the floor or in bed with saturated linens, indicating a lack of timely assistance with activities of daily living and incontinence care. Staff were observed opening the resident's door to check if he was breathing but did not provide further care or ensure his safety, and transfers were performed without the use of gait belts or proper technique, increasing the risk of falls and injury. Interviews with facility leadership and clinical staff confirmed that there was an expectation for staff to follow all care plan interventions and maintain resident safety, but these expectations were not met. The facility's own policies required prompt response to resident needs, regular fall risk assessments, and implementation of individualized interventions, none of which were consistently followed. The failure to implement and monitor effective fall prevention strategies and provide adequate supervision directly resulted in repeated injuries and placed the resident in Immediate Jeopardy.
Removal Plan
- A fall risk assessment was completed for R2 and placed on 1:1 supervision.
- 1:1 sitters were in-serviced on 1:1 expectation related to coordination of care for R2.
- IDT team reviewed R2 falls to ensure that appropriate current interventions are in place.
- Facility Administrator, DON, ADON, MDS Coordinator were in-serviced on Fall Prevention Policy.
- In-service front-line staff on Fall Prevention Policy and where to verify Care Plan Interventions.
- In-serviced Nursing staff on how to find care plan/fall interventions in EHR. Staff will not work next shift until Fall Prevention In-service is completed.
- An initial audit will be completed of all falls to ensure current interventions are initiated and effective. Care plans will reflect interventions that are effective.
- Initial audit completed of fall risk assessments to ensure that appropriate prevention interventions are in place and care plans are reflecting those interventions.
- A quality assurance tool was implemented: An audit will be completed during clinical meeting to ensure that any fall has a root cause analysis, progressive intervention, and care plan is updated.
- A root cause analysis for Fall Prevention and interventions being placed on care plan and physically in place will be reviewed weekly during Facility Risk Meeting.
- Review of the Fall Prevention Policy.
Failure to Prevent Neglect and Address Fall Risks
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including schizophrenia, malnutrition, and a history of frequent falls, was not adequately monitored or provided with appropriate interventions to prevent neglect and injury. Despite being identified as a high fall risk and having a care plan that documented numerous falls, staff repeatedly failed to implement or update fall prevention interventions after each incident. The resident experienced multiple falls, some resulting in injuries that required emergency room visits, yet new or effective interventions were often not put in place, and fall risk assessments were missing after several incidents. In addition to the failure to address fall risks, staff did not consistently follow existing care plan interventions such as frequent toileting, ensuring the call light was within reach, and performing regular checks. The resident was observed on several occasions lying in bed for extended periods, saturated in urine and feces, with the call light out of reach and the door closed, making the resident not visible to staff. Staff members were seen opening the door, looking in, and leaving without providing care or cleaning the resident, even after being aware of the resident's condition. The resident remained soiled for at least five hours, and staff failed to respond to his needs despite clear evidence of incontinence and discomfort. Interviews with staff and medical professionals confirmed that the standard of care was not met, as the resident was left unattended and in an unhygienic state, and interventions to prevent falls and address incontinence were not followed. The facility's own policies defined such actions as neglect, including inadequate provision of care, poor hygiene, and leaving someone unattended who needs supervision. The repeated lack of appropriate response and disregard for the resident's care, comfort, and safety led to the identification of neglect and the declaration of Immediate Jeopardy.
Removal Plan
- R2 was provided with 1:1 sitter.
- DON/ADON completed skin assessment on R2 with no negative outcomes noted.
- Administrator, DON & ADON were in-serviced by the RNC on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Administrator in-serviced all department heads on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Department managers in-serviced department staff members on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Staff will not work until in-serviced on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- DON/ADON/Department Manager will in-service any future agency employees on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- The DON/ADON/Licensed staff completed skin assessment on residents requiring incontinent care.
- A quality assurance tool was implemented: DON/ADON/CNA Supervisor will conduct audits on residents requiring incontinent care and completed in timely manner.
- A quality assurance tool was implemented for SSD (Social Service Director) or designee to conduct resident interviews to ensure there are no concerns related to Abuse/Neglect.
- The DON/ADON will complete audit review during daily morning clinical meeting to ensure compliance.
- Audit tool will also include review of new/re-admit fall risk assessments for resident high risk to ensure prevention measure are in place.
- Root cause analysis completed for neglect related to coordination of care provided to residents.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another cognitively impaired resident. Both individuals resided in the memory care unit and lacked the capacity to consent to sexual activity, as confirmed by medical documentation and staff interviews. The incident occurred when a CNA entered the resident's room and found both residents naked, with one resident standing over the other and engaging in thrusting motions. The CNA intervened and separated the residents, but the event was not immediately reported to the state, and there was confusion and inconsistency in the accounts provided by facility staff and administration regarding the nature of the incident. The administrator conducted an internal investigation but did not report the incident to the state, reasoning that no intercourse had occurred. Documentation of the incident, including risk assessments and family notifications, was incomplete or missing from the resident's chart. Staff interviews revealed that the normal protocol for documenting and assessing such incidents was not followed, and there was a lack of clarity and consistency in communication with the resident's family. Multiple staff members, including the CNA and LPN involved, expressed concerns about the residents' inability to consent and described the event as sexual abuse, yet the facility's response was delayed and inadequately documented. Further interviews with the resident, her family, and other staff indicated that the resident reported being raped and expressed distress about the incident. The medical director and psychiatric nurse practitioner confirmed the resident's inability to consent due to her cognitive status. The facility's staffing levels were also called into question, as only one CNA was present on the unit during certain shifts, limiting the ability to monitor residents effectively. The failure to protect the resident from abuse, promptly report the incident, and properly document and investigate the event constituted a deficiency and resulted in an Immediate Jeopardy finding.
Removal Plan
- R1 and R2 were immediately assessed for injury, changes in condition and psychosocial impact.
- R1 and R2 POAs, Police and MD were notified of the incident.
- R1 was sent to the ER for evaluation.
- R1 and R2 care plans were updated to reflect enhanced safety interventions.
- R1 and R2 had the Abuse, Neglect and Trauma assessment and Trauma Informed Care Assessment / PTSD was completed.
- The Social Services Director interviewed/assessed all residents with BIMS scores of 8 and above for potential abuse.
- All residents with a BIMs score of 7 or less were assessed using the Abuse Screening Adapted for Cognitive Impairment form.
- A hall monitor was added to the memory care unit to ensure no resident enters another resident's room.
- The Hall Monitor is a dedicated staff member and will have no other duties.
- R2 was immediately placed on a 1:1 until hall monitor was established.
- Abuse investigation procedure and documentation process were reviewed.
- DON, ADON, and Administrator re-educated all staff on facility abuse policies.
- DON, ADON, and Administrator educated all staff on the Intimate Resident Behavior, Privacy and Relationships policy updated to reflect residents within the memory care unit do not have the capacity to consent to sexual relationships.
- In the event of any future resident to resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete.
- Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management.
- DON, ADON, and Administrator educated staff on the Hall Monitor duties and responsibilities and that the Hall Monitor is a dedicated individual with no other responsibilities.
- Administrator was educated by Regional Nurse on abuse policy which includes thorough investigation immediately upon receiving report or allegation of abuse.
- Emergency QAPI meeting was held where the abuse policy and intimate relations policy were reviewed along with incident and root cause analysis.
- The Social Services Director or designee will continue to interview residents with BIMs score of 8 or higher on a monthly basis to ensure they have not experienced abuse.
- All residents with a BIMs score of 7 or less will be assessed using the Abuse Screening Adapted for Cognitive Impairment form.
- Any reports of abuse will be immediately reported and investigated.
- The finding to be presented to the Quarterly QAA Committee.
Failure to Initiate CPR Due to Lack of Code Status Documentation
Penalty
Summary
Facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive, despite the resident being a full code. The resident was discovered without a pulse or respirations by two CNAs, who then notified a Registered Nurse (RN). The RN did not know the resident's code status and did not initiate CPR, assuming the resident was a Do Not Resuscitate (DNR) because there was no documentation in the electronic medical record. However, the resident's progress notes and hospital discharge summary indicated that the resident was a full code. The care plan and physician order summary did not document the code status, and the POLST form was not completed during the resident's 12-day stay at the facility. Multiple staff members, including CNAs and nurses, were unaware of the resident's code status at the time of the incident. The CNAs relied on the RN for direction, and the RN failed to check or confirm the code status before pronouncing the resident deceased. The facility had a system in place to indicate code status with colored stars outside resident rooms and in the electronic medical record banner, but this information was either missing or not utilized. Staff interviews revealed confusion and lack of familiarity with the resident and the facility's protocol for determining and documenting code status. The failure to initiate CPR was contrary to facility policy, which states that in the absence of a documented code status, staff should treat the resident as a full code and begin CPR. The lack of documentation, incomplete admission paperwork, and failure to verify code status led to the resident not receiving life-sustaining measures when found unresponsive. The resident was pronounced dead at the facility without any attempt at resuscitation, and the incident was identified as Immediate Jeopardy due to the failure to provide basic life support as required.
Removal Plan
- V2 (Director of Nursing), V14 (LPN / MDS) and V20 (LPN) were educated by V10 (Regional Clinical Director) on code status policy, death of a resident and change of condition policy, and the CPR policy.
- V4 (Registered Nurse) was educated by V2 on Code status policy, death of a resident, change in condition policy, notifications, and CPR policy.
- V9 (Social Services Director) and V14 completed an audit of all residents to ensure an order for a code status was in place, POLST form was in place and care plan indicates the order appropriately.
- V3 completed an audit of all staff who are CPR certified and schedule a class for the staff who are not.
- V3 reviewed the facility policy on CPR.
- V2 initiated and completed the following in-servicing with all nursing staff on CPR initiation policy including immediate initiation of CPR for all full code residents when unresponsive, documentation of a death, code status when to initiate CPR and change in condition policy.
- V9 (Social Service Director) will be doing ongoing monthly audit to ensure all code status orders remain accurate and current.
- V2 (Director of Nursing) will monitor. Random audits of 3 resident records per week for accuracy of code status and 2 staff interviews to verify knowledge of protocol. Results will be reviewed by V1 (Administrator) and the Quality Assurance Committee monthly.
Resident Left Unattended Outside Resulting in Hospitalization for Heat-Related Illness
Penalty
Summary
A dependent resident with multiple medical conditions, including rheumatoid arthritis, major depressive disorder, encephalopathy, acute kidney failure, and peripheral vascular disease, was left outside in her reclining wheelchair for two hours without water or a means to call for help. The resident was entirely dependent on staff for all activities of daily living and mobility, as documented in her care plan. On the day of the incident, she was placed directly in the sun after lunch, and staff failed to provide the required supervision and monitoring. Staff interviews revealed that the usual practice was to set a timer for 10-20 minutes when the resident was taken outside, with checks at those intervals due to her inability to signal for assistance or return inside independently. However, on this occasion, there was confusion and lack of communication among staff regarding who was responsible for monitoring the resident and whether a timer had been set. Multiple CNAs stated that the resident did not have water with her and could not hold a drink, and there was no call light or device for her to request help. The resident was not in direct view of the door, and staff were unaware of her presence outside until she was found unresponsive by another CNA. Upon discovery, the resident was unresponsive, with her eyes rolled back and twitching, and was noted to be red, hot, and very thirsty. Immediate interventions included providing water, applying cold compresses, and administering oxygen. She was subsequently transferred to an acute care hospital, where she was treated for heat exhaustion, sunburn, hypoxia, altered mental status, and dehydration. Hospital records confirmed sunburn to her face, neck, and chest, hypoxia, and improvement after IV fluids. The facility's policy required 15-minute checks for residents outside, but this was not followed, resulting in the resident's prolonged exposure and subsequent hospitalization.
Removal Plan
- An assessment form was created and implemented to assess the residents' ability to safely be outside unattended. All residents have a completed assessment for going outside unattended. Newly admitted residents will have a completed assessment for going outside unattended. This assessment will be reviewed if there is any change in condition. Audits will be completed by DON or designee.
- Current policy reviewed. Input from Certified Nursing Assistants (CNAs) was collected via Survey Monkey. Policy updated with feedback from managers and CNAs. The policy includes identifying safety measures and resident assessment, timely checks on the resident and documentation on a log. A timer is placed at the door entry (Door 4) where residents go outside. The log book is stationed at Team B nurses' station, next to Door 4. The log includes documenting time going outside, checks, notes regarding resident, hydration offered, time coming in, and staff signature.
- All managers were educated on the new policy/procedure. Managers then educated their staff. This ensured that staff were educated on the policy and procedure prior to their next shift worked. Agency: New policy & Procedure has been sent to agency organizations who will in turn disseminate to their staff. Agency staff will be educated on arrival by DON or designee.
- Policy states that whoever takes the resident outside is the one responsible to ensure check is conducted. A timer is set to alert for checking on the resident outside. If the CNA is unable to check on resident, CNA must find another CNA to check on the resident. CNA must confirm with other CNA that the check is being conducted, either verbally or over the walkie/talkie. If the CNA is unable to find another individual to do the check, the resident is brought back in to the facility.
- Audits will be conducted by DON or designee.
Explore Popular Searches
