Citations in Minnesota
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Minnesota.
Statistics for Minnesota (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Minnesota
A resident with severe cognitive impairment and dependence on staff for personal hygiene did not have their shaving preferences assessed or documented. Staff only provided shaving on bath days or upon request, and the care plan did not address the resident's grooming preferences, despite family input that daily shaving was preferred. Facility policy required grooming services based on assessment, but this was not reflected in the resident's records.
A resident with multiple diagnoses, including anemia and long-term anticoagulant use, had an abnormally high ferritin level identified in lab results. Facility staff did not document the lab draw or results in the medical record, nor was there evidence that the provider was notified of the abnormal finding, despite facility policy requiring timely reporting of such results.
Staff did not perform required hand hygiene after providing perineal care and handling bodily fluids for two residents who needed substantial assistance with ADLs. In both cases, staff failed to wash hands or use sanitizer after glove removal and before moving to another resident, despite facility policy and staff awareness of proper procedures.
Staff failed to consistently use required PPE when providing care to two residents on enhanced barrier precautions and one resident on enhanced respiratory precautions, with soiled linens and clothing left on the floor instead of being bagged. A clinical provider did not consistently wear a mask during a respiratory outbreak, and CPAP supplies for a resident were dried in a shared bathroom rather than in the resident's room, all contrary to facility policy and infection control standards.
A resident with hemiparesis, hemiplegia, severe kyphosis, and other conditions was unable to eat comfortably at the dining room table due to its height, which was at chin level while she was in her wheelchair. Despite requesting adjustments, the table could not be lowered further, leading the resident to eat from her lap. Staff were unaware of the extent of the issue, and facility policy requiring table adjustments for wheelchair users was not met.
The facility did not make the most recent recertification survey results available for review, as required by policy. An administrator confirmed the omission after a review of the survey binder, which contained all other required surveys except the latest recertification results.
A resident with significant mobility and cognitive impairments was transferred for a weight check without required footwear or a gait belt, and was left unsupported by staff. The resident lost balance while stepping off the scale, fell, and sustained a head injury resulting in a brain bleed. Staff and family interviews confirmed that the care plan was not followed during the transfer, leading to the incident.
A resident with Alzheimer's disease and a history of exit-seeking behavior eloped from the facility during severe winter weather after staff failed to recognize and communicate recent exit-seeking behaviors, did not update the care plan or elopement risk assessment, and discontinued the use of a wander guard. The resident was found outside in a wheelchair, inadequately dressed, after being last seen in a common area. Documentation and communication lapses among staff contributed to the lack of supervision and failure to prevent the incident.
A nursing assistant transferred a resident using an EZ stand lift without the required second staff member, despite the care plan and care cards specifying two-person assistance due to the resident's cognitive impairment, hemiplegia, and history of letting go of the lift handles. During the transfer, the resident let go, slipped from the harness, and fell, resulting in a closed fracture of the right humerus and severe pain requiring emergency care.
The facility did not have a registered nurse designated as the full-time DON after the previous DON's departure. For two weeks, an LPN acted in the role, and staff interviews showed uncertainty about who was responsible for DON duties, with the facility relying on a team approach and awaiting corporate hiring decisions.
Failure to Assess and Provide Shaving Preferences for Dependent Resident
Penalty
Summary
The facility failed to assess and provide for the shaving preferences of a resident with severe cognitive impairment and multiple diagnoses, including dementia and a traumatic brain injury. The resident required substantial to maximal assistance for personal hygiene, yet his medical record did not contain documentation of his shaving preferences. The care plan, while addressing the need for assistance with ADLs due to physical and cognitive limitations, did not specify shaving preferences. Observations revealed that the resident had significant beard growth and was not offered shaving assistance during care routines. Interviews with staff indicated that shaving was typically performed only on bath days or upon resident request, and if a resident was unable to request, shaving was not routinely provided outside of scheduled bath days. A family member reported that the resident had previously shaved daily and expressed difficulty in getting staff to maintain this routine. The facility's policy required necessary services to maintain grooming based on comprehensive assessment, but there was no evidence in the medical record to support that the resident's shaving preferences were assessed or addressed.
Failure to Notify Provider of Abnormal Lab Result
Penalty
Summary
The facility failed to promptly notify the primary care provider of an abnormal laboratory result for one resident who was cognitively intact and required significant assistance with daily activities. The resident had diagnoses including atrial fibrillation, anemia, depression, long-term use of anticoagulants, and dysphagia. Orders were in place for annual blood tests, including a comprehensive blood count, basic metabolic panel, thyroid stimulating hormone, prothrombin time, and ferritin level. The medical record did not contain documentation of the lab work being drawn or the results, despite the resident receiving iron supplementation for anemia. Laboratory results from November showed an abnormally high ferritin level, but there was no documentation in the resident's progress notes or provider visit notes indicating that the results were reviewed or that the provider was notified. Interviews with nursing staff and the DON revealed that it was not the facility's practice to document labs drawn or lab results in the resident charts, and that nurse managers were responsible for reviewing and scanning lab results into the medical record. However, it was acknowledged that it would be difficult to determine if results had been reviewed or if the provider had been notified of abnormal findings. The facility's policy required timely reporting of lab findings to the ordering provider, but this was not followed in the case of the resident's elevated ferritin level, as there was no evidence of provider notification or review.
Failure to Perform Hand Hygiene After Personal Care
Penalty
Summary
Staff failed to perform appropriate hand hygiene during and after providing personal care to two residents requiring substantial or maximal assistance with activities of daily living (ADLs). One resident with severe cognitive impairment, dementia, and a traumatic brain injury required assistance with personal hygiene and toileting, including the use of a mechanical lift and catheter care. During observed care, staff donned gowns, gloves, and masks but did not use hand sanitizer before gloving. After performing perineal care and handling bodily fluids, staff continued to wear the same gloves, did not perform hand hygiene after glove removal, and exited the resident's room without washing hands or using hand sanitizer. In a separate instance, staff entered another resident's room—who had left-sided hemiplegia and required assistance with toileting—without performing hand hygiene. The staff member applied gloves, assisted with perineal care, and then removed gloves without washing hands or using hand sanitizer before leaving the room. Interviews with staff confirmed awareness of the hand hygiene requirements, and facility policy mandated hand hygiene at specific moments, including after glove removal and before entering another resident's room. These actions and inactions directly led to the identified deficiency in infection prevention and control.
Infection Control Deficiencies: PPE Noncompliance, Improper Linen Handling, Mask Use, and Unsanitary CPAP Drying
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed in several instances involving the use of personal protective equipment (PPE), handling of soiled linens and clothing, mask use during a respiratory outbreak, and the sanitary drying of CPAP supplies. Staff did not consistently don required PPE, such as gowns and gloves, when providing care to residents on enhanced barrier precautions (EBP) and enhanced respiratory precautions (ERP). Specifically, a trained medication aide (TMA) was observed providing direct care to two residents requiring EBP without wearing a gown or gloves, despite signage on the door indicating the need for such precautions. The TMA stated she was unaware of the need for PPE as she did not see the signs. Additionally, the TMA did not use a face shield when required for a resident on ERP, incorrectly believing that eyeglasses were sufficient. The facility also failed to follow proper infection control practices regarding the handling of soiled linens and resident personal clothing. Used linens, towels, and clothing were observed left on the floor in the rooms of two residents on EBP, rather than being bagged as required. Staff interviews confirmed that placing soiled items on the floor was not appropriate and that items should be bagged to prevent contamination, especially in shared rooms. During a period when the facility was under outbreak status and masking interventions were in place, a clinical provider was observed multiple times in patient areas and common spaces without wearing a face mask. The provider acknowledged awareness of the mask policy but did not consistently comply, only donning a mask when observed by surveyors. Facility leadership confirmed that mask use was expected for all staff and providers during outbreak precautions. Additionally, a resident's CPAP supplies were repeatedly observed drying on a towel bar inside a shared bathroom, contrary to facility policy and staff expectations that such equipment should be dried in the resident's room to prevent contamination.
Failure to Provide Appropriate Table Height for Resident with Physical Limitations
Penalty
Summary
A deficiency occurred when the facility failed to provide an appropriate table height in the dining room for a resident with significant physical limitations. The resident, who was cognitively intact and required assistance with activities of daily living due to hemiparesis, hemiplegia, severe kyphosis, and other conditions, was observed eating with the tabletop at chin height while seated in a wheelchair. As a result, the resident placed her plate on her lap to eat, as the table was too high for comfortable or safe dining. Staff were observed placing the plate on the table, but the resident consistently moved it to her lap, indicating ongoing difficulty. Interviews with staff revealed that they had not noticed the resident's adaptation of placing the plate on her lap, and the resident reported having asked for the table to be lowered but was told it could not be adjusted further. The facility's policy required that tables be adjusted to accommodate wheelchairs and ensure appropriate positioning at mealtime, but this was not achieved for the resident. The director of nursing acknowledged that more should have been done to improve the resident's dining experience, but the table's adjustability was limited.
Failure to Provide Access to Most Recent Survey Results
Penalty
Summary
The facility failed to ensure that the most recent recertification survey results were available for review by residents, family members, visitors, and staff. During a review of the survey binder, it was found that while all required recertification and complaint investigation surveys were present, the most recent recertification survey was missing. The administrator confirmed that the latest survey results were not included in the binder, despite facility policy requiring all survey results and plans of correction to be accessible in an easily viewable location for all interested parties. The responsibility for maintaining the availability of these documents was identified as belonging to the administrator.
Failure to Follow Care Plan During Transfer Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a transfer, resulting in a fall and significant injury. The resident, who had diagnoses including hypertension, atrial fibrillation, generalized weakness, and mobility impairments, required substantial or maximal assistance for transfers and mobility, as well as the use of a gait belt and appropriate footwear. On the day of the incident, a nursing assistant transferred the resident from bed to the bathroom for a weight check without providing footwear or using a gait belt, and left the resident standing unsupported on the scale. While stepping off the scale, the resident lost balance and fell, hitting her head against the wall. The fall was witnessed, and it was documented that the staff did not assist the resident during the transfer as required by the care plan. The resident was on blood thinners, which increased the risk of complications from head injuries. Following the fall, the resident exhibited increased confusion and drowsiness, and was later found to have a brain bleed confirmed by CT and MRI scans. Interviews with staff and family confirmed that the care plan was not followed during the transfer, and that the resident was left unsupported and without necessary safety measures. The incident was reported to the provider and family, and neuro checks were initiated. The failure to adhere to the care plan and established safety protocols directly led to the resident's fall and subsequent injury.
Failure to Prevent Elopement of Cognitively Impaired Resident During Hazardous Weather
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, dementia, and paranoid personality disorder was not provided adequate supervision and was able to elope from the facility during hazardous winter weather. The resident had a documented history of exit-seeking behavior, impaired cognition, and poor safety awareness, and had previously required a wander guard device. However, the wander guard was discontinued after staff determined there were no recent exit-seeking behaviors, and the elopement risk was removed from the care plan. Despite this, the resident continued to display confusion, impulsivity, and had triggers related to the holiday season that were not adequately considered in risk assessments or care planning. On the day of the incident, the resident was last seen by staff in the facility's common area and was later found outside in a wheelchair, inadequately dressed for the severe weather conditions. The resident had expressed a desire to leave and was looking for his truck the evening prior, but this information was not effectively communicated between shifts. Staff interviews revealed that the resident required supervision due to his cognitive deficits and that staff were expected to check on him every two to three hours, but closer monitoring was not implemented despite recent exit-seeking behaviors. Documentation and communication failures contributed to the deficiency. The resident's care plan and elopement risk assessments did not reflect his ongoing risk factors, including his history of elopement, cognitive impairment, and seasonal behavioral triggers. Staff were unaware of the resident's increased risk and did not implement appropriate interventions or monitoring. The lack of timely reassessment and failure to update the care plan after the resident expressed exit-seeking behavior directly led to the resident's unsupervised exit during dangerous weather conditions.
Removal Plan
- A complete head to toe health assessment was completed for R1 upon return to facility
- R1's provider was updated
- An elopement assessment with past and recent risk for elopement was included
- A wander guard was placed on R1's wheelchair
- Reviewed and revised R1's care plan to ensure it included details related to holiday challenges, staff communication, behavioral tracking, and interventions for exit seeking
- Elopement assessment practices were reviewed and revised to best determine resident elopement risk, including consideration of history, mental health, seasonal challenges, and medication changes
- Nursing staff completing elopement assessments were retrained on recognizing and responding to exit seeking behavior
- All staff were trained on R1's care plan changes and facility policy changes
- Facility education document 'Critical Safety Alert: Elopement Prevention & Emergency Protocol' with mandatory interventions and communication requirements was issued
Failure to Follow Care Plan for Resident Transfer Results in Fall and Fracture
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) independently transferred a resident who required the assistance of two staff members, as specified in the resident's care plan and functional abilities assessment. The resident, who had mild cognitive impairment, hemiplegia, vascular dementia, chronic pain, osteoporosis, and was non-ambulatory, was being transferred using an EZ stand mechanical lift. The care plan and facility documentation clearly indicated that two staff were required for all transfers due to the resident's history of letting go of the lift handles and periods of unresponsiveness, especially when fatigued. During the transfer, the NA attached the harness and straps to the EZ stand and attempted to help the resident hold onto the handlebars. However, the resident let go of the handles and began slipping out of the harness. The NA, who had only been employed for a few weeks, attempted to retrieve the wheelchair but was unable to prevent the resident from falling. The resident fell to the floor, initially reported shoulder pain, and was later diagnosed with a closed fracture of the proximal end of the right humerus after being sent to the emergency department. The resident's pain was severe, and she required narcotic pain medication and a sling for her right arm. Interviews with staff revealed that the expectation for two-person assistance during transfers was well established in the care plan, care cards, and among experienced staff. The NA involved in the incident was aware of the care plan instructions but stated that other NAs had told her transfers could be done with one person, leading her to believe it was acceptable. Other staff confirmed that the resident's care plan had been updated to require two-person assistance due to her declining strength and tendency to let go of the lift handles. The failure to follow the care plan directly resulted in the resident's fall and injury.
Failure to Designate a Full-Time Registered Nurse as DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full-time basis after the previous DON was terminated. For approximately two weeks, an LPN was the only administrative staff on duty and had been acting as the DON, despite not being a registered nurse. Interviews with facility staff, including the Director of Human Resources and the Administrator, revealed uncertainty about who was currently fulfilling the DON role, with the corporate office handling the hiring process for a new DON. The facility was relying on a team approach involving the assistant director of nursing, nursing staff, and the President of Clinical Services to cover the responsibilities of the DON, but no one was officially designated or able to assume the role full-time. No facility policy regarding required nursing services was provided upon request.
Some of the Latest Corrective Actions taken by Facilities in Minnesota
- Re-educated staff on Abuse/Neglect/Accident Reporting, safe and appropriate care, and resident protection with verification through interviews and training records (J - F0600 - MN)
- Conducted staff re-education on mechanical-lift policies and procedures with competency testing (J - F0689 - MN)
- Developed an ongoing safe-transfer education plan within the QAPI program (J - F0689 - MN)
Unsupervised Medication Administration by Unlicensed Nursing Student
Penalty
Summary
The facility failed to ensure that an unlicensed nursing student (NS) was properly supervised during the administration of medications, including high-risk medications such as insulin, liquid morphine, and other controlled substances. The NS, who did not possess a nursing license, competencies, or the required certification for medication administration, was observed administering medications independently to multiple residents without direct supervision by a licensed nurse. Observations included the NS administering insulin via pen and performing blood glucose checks without oversight, while the assigned RN was not present in the immediate area. Documentation and interviews revealed that the NS administered controlled substances and other medications to residents with complex medical histories, including diagnoses such as respiratory disease, dementia, chronic pain, diabetes, and hypertension. The NS was not a trained medication aide and was unclear about the scope of tasks she was permitted to perform, lacking immediate access to competency documentation. The NS stated she typically checked with a nurse before administering insulin but did not do so during observed instances. The RN on duty confirmed she had not seen the NS's completed competencies and was not acting as the NS's preceptor at the time. Further interviews with facility staff and the nursing program director indicated confusion and lack of clarity regarding the supervision and competency requirements for the NS. The apprenticeship program guidelines required direct supervision for medication administration, but this was not followed. The NS was allowed to work on the floor and administer medications without the necessary oversight or verification of competencies, affecting several residents who received medications from the NS during this period.
Removal Plan
- Review the nurse apprenticeship program.
- Provide re-education to nurse apprentice on program expectations prior to returning to work.
- Educate all staff responsible for administering medications and/or supervising a nurse apprentice on the apprentice program and review the orientation education agenda.
- Review all resident records for medication errors.
Failure to Prevent Elopement of Cognitively Impaired Resident During Hazardous Weather
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, dementia, and paranoid personality disorder was not provided adequate supervision and was able to elope from the facility during hazardous winter weather. The resident had a documented history of exit-seeking behavior, impaired cognition, and poor safety awareness, and had previously required a wander guard device. However, the wander guard was discontinued after staff determined there were no recent exit-seeking behaviors, and the elopement risk was removed from the care plan. Despite this, the resident continued to display confusion, impulsivity, and had triggers related to the holiday season that were not adequately considered in risk assessments or care planning. On the day of the incident, the resident was last seen by staff in the facility's common area and was later found outside in a wheelchair, inadequately dressed for the severe weather conditions. The resident had expressed a desire to leave and was looking for his truck the evening prior, but this information was not effectively communicated between shifts. Staff interviews revealed that the resident required supervision due to his cognitive deficits and that staff were expected to check on him every two to three hours, but closer monitoring was not implemented despite recent exit-seeking behaviors. Documentation and communication failures contributed to the deficiency. The resident's care plan and elopement risk assessments did not reflect his ongoing risk factors, including his history of elopement, cognitive impairment, and seasonal behavioral triggers. Staff were unaware of the resident's increased risk and did not implement appropriate interventions or monitoring. The lack of timely reassessment and failure to update the care plan after the resident expressed exit-seeking behavior directly led to the resident's unsupervised exit during dangerous weather conditions.
Removal Plan
- A complete head to toe health assessment was completed for R1 upon return to facility
- R1's provider was updated
- An elopement assessment with past and recent risk for elopement was included
- A wander guard was placed on R1's wheelchair
- Reviewed and revised R1's care plan to ensure it included details related to holiday challenges, staff communication, behavioral tracking, and interventions for exit seeking
- Elopement assessment practices were reviewed and revised to best determine resident elopement risk, including consideration of history, mental health, seasonal challenges, and medication changes
- Nursing staff completing elopement assessments were retrained on recognizing and responding to exit seeking behavior
- All staff were trained on R1's care plan changes and facility policy changes
- Facility education document 'Critical Safety Alert: Elopement Prevention & Emergency Protocol' with mandatory interventions and communication requirements was issued
Failure to Protect Resident from Neglect and Delay in Reporting Fall
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, severe cognitive impairment, and a history of falls was not protected from neglect. The resident required assistance from two staff members for all transfers, as documented in her care plan and physical therapy evaluations. Despite these directives, a nurse aide (NA) transferred the resident alone using an EZ stand, left her unattended on the edge of the bed, and the resident subsequently fell, sustaining a laceration to her forehead, bruising, a concussion, and a fracture of the sternum. Following the fall, the NA did not immediately report the incident or seek medical attention for the resident. Instead, the NA cleaned the resident, changed her clothing, attempted to stop the bleeding, and placed her back in bed without notifying a nurse or following facility policy, which required immediate reporting and assessment by a licensed nurse before moving a resident after a fall. The incident was not reported until approximately two hours later, resulting in a delay in necessary medical care. The NA also attempted to conceal the incident by disposing of bloody clothing and providing false information to staff and investigators. Interviews and documentation revealed that staff were aware of the resident's need for two-person assistance and her inability to safely sit on the edge of the bed unattended. The NA's actions were contrary to the care plan and facility policies, and the delay in reporting and seeking care contributed to the severity of the resident's injuries. The incident was later investigated by facility leadership and law enforcement, confirming that the NA acted alone, failed to follow the care plan, and intentionally delayed reporting the fall.
Removal Plan
- Implemented immediate resident protection.
- Revised R1's Care Plan to include stand pivot transfer with assist of two if alert.
- Implemented Hoyer lift, assist of two with medium sling.
- Re-educated staff on Abuse/Neglect/Accident Reporting, providing safe and appropriate care, and resident protection.
- Verified education through interview and training records.
Failure to Timely Investigate and Protect Residents After Abuse Allegations
Penalty
Summary
The facility failed to immediately respond, investigate in a timely manner, and implement resident protections following allegations of verbal, mental, and physical abuse, as well as neglect of care, for two residents. In the first case, a resident with dementia and impaired mobility required staff assistance for repositioning. The resident and a family member reported that a nursing assistant used inappropriate language and physically handled the resident in a rough manner, including throwing the resident's legs against the wall. The incident was reported to the social worker, and both the administrator and DON were notified. However, the investigation lacked interviews with other staff or residents, and there was no documentation of protective measures taken during the investigation. Progress notes did not mention the incident, and the staff member involved was not immediately suspended. In the second case, a resident with moderate cognitive impairment and limited mobility required assistance with activities of daily living and was at risk for pressure injuries. The resident's family member reported overhearing a nursing assistant refuse to provide timely incontinence care, make threatening statements about using the call light, and remove the resident from her room while she was wet and in her nightgown, placing her in a public area without her phone. The investigation documentation lacked interviews with other staff or residents, and the staff member was only removed from caring for the resident but continued to work with other vulnerable residents. The incident was not reported to the State Agency as required, and the investigation was not thorough. Interviews with facility staff, including the social worker, LPN, RN, and administrator, revealed inconsistencies and gaps in the investigation process. Staff acknowledged that best practices, such as suspending the alleged perpetrator and interviewing all relevant parties, were not followed. Facility policy required prompt reporting, suspension of the alleged perpetrator, and comprehensive investigation, but these steps were not consistently implemented. The administrator and DON did not ensure timely communication with families or complete documentation, and there was a lack of clarity regarding which incidents were reportable and how investigations should be conducted.
Removal Plan
- Reviewed and revised policies and procedures related to abuse reporting, protections, and investigating allegations of abuse.
- Educated all staff and leadership on the above policies and procedures with competency. Training included conducting thorough investigations.
- Assessed all residents for abuse who had contact with implicated staff.
- Care plans for R2 and other affected residents were updated to include specific protections and interventions.
- Staff involved in the allegations were removed from the schedule to eliminate access to resident pending completion of the investigations.
- Thorough investigations were completed for the incidents and were reported to the State Agency.
Failure to Provide Prescribed Diet Results in Fatal Choking Incident
Penalty
Summary
A resident with a history of schizophrenia, diabetes, major depression, obsessive-compulsive personality disorder, and lung disease was assessed as having mild cognitive impairment and required moderate assistance with eating. The resident was on a prescribed Level 1 Dysphagia pureed diet, which required smooth, pudding-like food textures to prevent choking. There were no prior issues with choking while the resident was maintained on this diet. On the day of the incident, a registered nurse assisted the resident in purchasing a sticky bun from a vending machine, despite the resident's dietary restrictions. The nurse did not consider the resident's ordered diet at the time of the purchase. After receiving the sticky bun, the resident began eating it in the dining room, subsequently started to choke, became unresponsive, and fell from his chair. Staff initiated CPR and emergency services were called. Food was found lodged in the resident's throat and was removed during resuscitation efforts. The resident was transported to the hospital, where he was found to have suffered a witnessed aspiration event, cardiac arrest, cervical and rib fractures, anoxic brain injury, and seizure activity. He was later placed on comfort care and pronounced brain dead. The failure to adhere to the prescribed pureed diet and the provision of an inappropriate food item directly led to the choking incident and subsequent fatal outcome.
Removal Plan
- Vending machines were locked in the conference room.
- No staff would assist a resident to get food out of the vending machine.
- If a resident requested an item against his prescribed diet orders, staff would notify the charge nurse, offer a safe snack, and always verify the diet before offering food or drink.
- All snacks for residents must be approved by the dietician and come from dietary services.
- Facility policy updated to require staff to check resident's code status prior to performing CPR, initiate CPR if full code, call 911, and remove visible obstruction during every pulse check.
- Staff are re-educated on choking procedures annually.
- Nursing and dietary staff receive additional training regarding the different types of mechanical soft diets, where to find a resident's diet type, and feeding assistance/aspiration prevention techniques.
- DON completed random diet order checks for ten residents twice a week.
Significant Medication Error Due to Transcription and Administration Failures
Penalty
Summary
A significant medication error occurred when a resident was administered 40 mg of methadone, which was 16 times the prescribed dose of 2.5 mg. The error originated from a handwritten order by a hospice RN, which incorrectly indicated the volume to be administered and did not comply with Board of Pharmacy requirements for prescription clarity. The order was then transcribed into the electronic health record as 4 mL instead of the correct 0.25 mL, due to misinterpretation of the handwriting and lack of a leading zero. The medication bottle from the pharmacy had a different instruction, indicating a dose of 0.5 mL (5 mg), further adding to the confusion. The resident, who had no cognitive impairment but was dependent on staff for activities of daily living and had diagnoses including a femur fracture and COPD, received the incorrect dose via g-tube. The nurse administering the medication noticed the discrepancy between the MAR and the medication bottle but proceeded to give the dose listed in the MAR, believing it to be the most current order. The nurse did not seek clarification despite the mismatch. The double-check process for new orders was not completed, as the order sheet was left next to the computer without verification by another nurse, contrary to facility protocol. Following administration, the resident exhibited symptoms of opioid overdose, including lethargy, low respiratory rate, low oxygen saturation, and unresponsiveness. Narcan was administered at the facility, and the resident was transferred to the hospital, where they required intensive care and a continuous Narcan infusion due to persistent symptoms of methadone overdose. Interviews with staff confirmed that the medication should not have been administered when discrepancies were noted, and that the double-check process was not followed due to a busy shift.
Removal Plan
- Suspend the nurse who administered the incorrect dose and educate all nurses.
- Educate the nurse manager on clarification of any orders that are scribbled, dose increase that is too high or the handwriting is not legible.
- Educate the nurse who administered the incorrect dose that whenever a discrepancy on the MAR and the medication bottle or bubble pack, the order must be clarified, and the medication should not be administered.
- Educate hospice agency nurse related to transcription error and conflicting orders from the hospice doctor and the nurse.
- Revise hospice agency procedure for ordering medications.
- Audit all hospice residents' provider orders and correct any errors. Audit all new orders.
- Educate all licensed nursing staff/contracted agency nurses on the rights of medication administration, transcription of medications, processing of medications, narcotic administration and side effects, and what to do when a med error occurs. Ensure all staff receive education before their next shift.
- Develop a system to ensure appropriate transcription and order double check. Nurses confirm knowledge of the new transcription procedure into the electronic health record system. Add triple check of all new orders to the night shift nurse duty list.
- Review policies and procedures related to medication administration, transcription, and transcription errors.
- Review hospice contracts for medication management.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Visitor
Penalty
Summary
A resident with severe cognitive impairment, Parkinson's disease with dyskinesia, and total dependence on staff for mobility and personal care was subjected to repeated inappropriate touching by a visiting assisted living resident over approximately 38 minutes. The resident was unable to consent or protect herself due to her medical condition, which included dementia and physical limitations. The incident occurred in a common area, where the perpetrator lifted the resident's skirt and made skin-to-skin contact with her thighs and vaginal area multiple times, as captured on facility surveillance footage. Staff present in the area observed unusual behavior, such as the perpetrator watching staff closely and remaining near the resident, as well as the resident's skirt being repeatedly bunched up. Despite these observations and suspicions of inappropriate contact, staff did not intervene to remove the perpetrator or the resident from the situation. One staff member pulled the resident's skirt down several times but did not take further action, citing uncertainty about how to handle the situation and fear of the perpetrator's reaction. The incident was not immediately reported to facility leadership, and the administrator and DON were only notified the following day. Interviews with staff revealed a lack of clarity regarding their responsibilities in suspected abuse situations, with some staff expressing uncertainty about the resident's ability to make decisions and discomfort with the situation. The failure to intervene and report promptly allowed the inappropriate contact to continue for an extended period, leaving the resident unprotected despite her vulnerability and care plan identifying her as at risk for abuse or neglect.
Removal Plan
- Education for all staff covering definitions and types of abuse, staff responsibilities for prevention and reporting, mandatory reporting timelines and procedures, internal facility reporting process, resident rights and protections, zero-tolerance policy and disciplinary actions
- AP banned from facility
- Assessment of R1 for injury and mental anguish as able
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer of a resident using an EZ Way smart lift, resulting in the resident falling from the sling and sustaining a scalp contusion and a closed wedge compression fracture of the T4 vertebra. The resident, who had diagnoses of intellectual disabilities and osteoporosis and was fully dependent on staff for transfers, required two staff members and the use of a mechanical lift for all transfers according to her care plan. On the day of the incident, two nursing assistants, both under the age of eighteen, attempted to transfer the resident without following facility policy or the manufacturer's instructions. During the transfer, one nursing assistant attached only the upper right sling strap and was distracted by another resident's needs, leaving the area. The other assistant, also underage, began operating the lift without verifying that all straps were secured and without the required adult supervision. As a result, the resident leaned forward and fell out of the lift onto the floor. Interviews confirmed that both staff members were aware that at least one adult should have been present and that all straps needed to be checked before operating the lift, but these procedures were not followed. The EZ Way representative confirmed that the lift and sling were functioning properly and that the incident was due to improper use. The facility's policies and the manufacturer's instructions both required two staff to be present, with one being at least eighteen years old, and for all four sling straps to be checked before lifting. The medical director confirmed that the injuries were acute and directly resulted from the fall during the transfer.
Removal Plan
- Reviewed policies on use of mechanical lifts.
- Re-assessed R1 and all residents who utilize a mechanical lift.
- Re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing.
- Completed audits observing staff transferring residents with mechanical lifts; results would be brought to Quality Assurance and Performance Improvement (QAPI) committee.
- Developed an ongoing plan for safe transfer education in QAPI meeting.
Medication Transcription Errors Lead to Resident Harm and Hospitalization
Penalty
Summary
A medication transcription error occurred when a resident with chronic kidney disease, renal insufficiency, and other comorbidities was prescribed Bumex 2 mg by mouth daily for three days. The order was incorrectly transcribed as Bumex 2 mg by mouth three times daily with no stop date, resulting in the resident receiving 36 doses over 12 days instead of the intended 3 doses. This error led to an 18.8-pound weight loss, critical laboratory abnormalities, vomiting, and ultimately hospitalization for acute kidney injury and infection. The error was not identified by staff until after the resident exhibited significant symptoms and laboratory results indicated dehydration and kidney dysfunction. The facility's process for transcribing and verifying medication orders was inadequate. The health unit coordinator (HUC) responsible for transcribing the order was new to the position and lacked a medical background, including knowledge of common medical abbreviations such as QD and TID. The nurse manager, who was supposed to perform a second check of the transcription, failed to do so, allowing the error to persist. Additionally, staff did not recognize the inappropriateness of administering a diuretic in the evening or the resident's significant weight loss, and a scheduled weekly weight was missed during the period of the error. Further review revealed two additional medication transcription errors involving another resident, where antipsychotic and bladder medications were administered at incorrect dosages due to similar transcription mistakes. In these cases, the errors were identified by the facility pharmacy and corrected, but no audits of other recently transcribed orders were conducted at that time. The cumulative failures in order transcription, verification, and monitoring led to significant harm for the affected resident and demonstrated systemic issues in medication management within the facility.
Removal Plan
- Determine the root cause for transcription/medication errors and put in place additional safeguards.
- Review and revise policy and procedures as needed.
- Educate staff on new procedures.
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