Citations in North Carolina
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in North Carolina.
Statistics for North Carolina (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in North Carolina
A resident with chronic pain syndrome had a significant quantity of Oxycodone 5 mg tablets and the associated controlled drug count sheet go missing from the medication cart. Despite correct narcotic counts at shift change and staff interviews, the missing medication could not be located, and the nurse with access during the relevant period was unavailable for interview. The incident was substantiated as misappropriation of property, and the resident continued to receive pain management without interruption.
The facility did not report a suspected misappropriation of a resident's narcotic medication to the State Agency within the required timeframe and failed to notify APS, as required by policy. The missing medication was confirmed after an internal investigation, and a nurse was identified and terminated. Law enforcement and the nursing board were notified, but the mandated notifications to the State Agency and APS were delayed or not completed.
Two residents had their MDS assessments inaccurately coded to reflect physician-prescribed weight loss regimens, despite no such orders being present. In both cases, staff responsible for completing the MDS did not verify the intent of weight changes or medication use with the RD or MDS Nurse, resulting in incorrect documentation of weight loss interventions.
The facility did not submit required Level II PASRR evaluations for three residents after new serious mental health diagnoses were identified, despite prior Level I determinations and clear indications for further screening. In each case, new psychiatric conditions such as delusional disorder and bipolar disorder were diagnosed, but no Level II PASRR requests were made due to lapses in communication and lack of a notification process between staff.
Surveyors found that open containers of food in the kitchen's walk-in cooler and freezer were not labeled or dated, expired food items were not discarded, and open food was not properly secured. Additionally, a freezer compressor was dripping condensation onto open boxes of food. Staff interviews confirmed lapses in daily checks and labeling procedures.
Surveyors observed that three residents receiving oxygen therapy did not have cautionary or safety signage posted outside their rooms to indicate oxygen was in use. Despite physician orders and active administration of oxygen, staff and leadership confirmed that the facility's policy was not to post such signs at resident rooms, relying instead on no smoking signs at facility entrances and exits.
A resident assessed as unable to self-administer medications was found with multiple pills and a liquid medication left at the bedside without nursing supervision. Nursing staff left the medications at the resident's request, unaware of the assessment status, resulting in a failure to follow professional standards for safe medication administration.
A medication error rate above 5% was identified when a nurse administered carvedilol to a resident without checking required blood pressure and heart rate parameters and failed to give ordered folic acid. The nurse overlooked the medication orders, and the electronic system did not enforce the necessary checks, resulting in two errors out of 26 opportunities.
Controlled substances, including lorazepam and morphine, were found stored in an unlocked box inside an unlocked refrigerator in the main medication room. The DON confirmed the box should always be locked, and a nurse admitted to forgetting to lock it after a medication count. The Administrator expected all controlled substances to be locked at all times.
A Wound Nurse failed to change gloves and perform hand hygiene between treating two separate wounds on a resident, contrary to facility policy. The nurse acknowledged the lapse, and facility leadership confirmed awareness of the incident and their expectations for proper infection control practices.
Misappropriation of Controlled Medication for a Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of controlled medications. A cognitively intact resident with chronic pain syndrome had an active order for Oxycodone 5 mg, both scheduled and as needed. On a morning medication pass, a medication aide discovered that the resident's narcotic medication card and controlled drug count sheet were missing from the medication cart, despite the narcotic count being correct at the previous shift change. The missing items were reported immediately, and an internal investigation was initiated. Interviews with staff who worked the relevant shifts revealed that none recalled removing the medication card or count sheet. The investigation determined that 53 tablets of Oxycodone 5 mg were missing and could not be located anywhere in the facility. The nurse who had access to the medication cart during the relevant period did not return to work and could not be reached for interview. The pharmacy confirmed that the facility reported the missing narcotics and that the resident continued to receive pain medication as ordered, with no interruption in pain management. The incident was substantiated as misappropriation of resident property, specifically controlled medication. The facility reported the event to appropriate authorities, including the Department of Health and Human Services, law enforcement, and the state nursing board. The resident involved reported no concerns with pain management and was assessed with no adverse consequences noted at the time of the incident.
Failure to Timely Report Misappropriation of Resident Property and Notify APS
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding timely reporting of suspected misappropriation of a resident's property. Specifically, the facility did not report an allegation of missing narcotics belonging to a resident to the State Agency within the required timeframe, and also failed to notify Adult Protective Services (APS) as required by policy. The facility became aware of the missing medication, which consisted of 53 tablets of Oxycodone 5 mg, but delayed reporting the incident to the State Agency until three days after initial awareness. The report to APS was not made at all, despite the policy requiring notification for such allegations. The investigation confirmed that the narcotics were missing and could not be located within the facility. The incident involved a nurse who was subsequently named in the investigation and terminated. The facility did notify law enforcement and the nursing board, but the required notifications to the State Agency and APS were either delayed or omitted. The administrator stated that the delay in reporting was due to uncertainty about whether the narcotics were actually missing, and the lack of APS notification was attributed to the belief that the resident was not directly affected.
Inaccurate MDS Coding for Weight Loss Regimens
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments regarding weight loss for two residents. For one resident with a diagnosis of malnutrition and a care plan addressing nutritional concerns, the quarterly MDS assessment was incorrectly coded to indicate the resident was on a physician-prescribed weight loss regimen. However, there were no physician orders for weight loss, and both the Registered Dietitian (RD) and MDS Nurse confirmed that the resident was not intended to lose weight nor prescribed any weight loss medication. The Dietary Technician, who completed Section K of the MDS, did not communicate this coding with the RD or MDS Nurse, leading to the inaccurate documentation. Another resident, with diagnoses including dementia, chronic kidney disease, and diabetes, experienced significant weight loss while receiving a diuretic medication as prescribed by a physician. The resident's MDS assessment was also coded as being on a physician-prescribed weight loss regimen, despite the absence of any such order. The RD and MDS Nurse clarified that diuretic use for fluid management should not be coded as a weight loss regimen unless specifically prescribed for that purpose. The Dietary Technician appeared to have misunderstood the intent of the medication and did not verify the coding with the RD or MDS Nurse. Interviews with facility staff, including the RD, MDS Nurse, and Administrator, revealed a lack of communication and verification regarding the coding of weight loss regimens on the MDS assessments. The Administrator stated that accurate coding is expected and that the Dietary Technician should have consulted with the RD and MDS Nurse when coding weight loss as physician-prescribed. The absence of such communication contributed to the inaccurate MDS documentation for both residents.
Failure to Submit Level II PASRR Evaluations After New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit requests for Level II Preadmission Screening and Resident Review (PASRR) evaluations for three residents after new serious mental disorder diagnoses were identified, despite previous Level I PASRR determinations. For one resident, the medical record showed a Level I PASRR determination with instructions that further screening was only required if a significant change occurred. The resident was later diagnosed with generalized anxiety disorder, delusional disorder, and hallucinations, but no Level II PASRR request was submitted. The social worker acknowledged awareness of the requirement but could not provide a reason for the omission. Another resident had a Level I PASRR determination and was admitted with unspecified psychosis and anxiety disorder. The resident later exhibited increased agitation and aggression, leading to the addition of a delusional disorder diagnosis and the initiation of antipsychotic medication. Despite these changes, there was no documentation of a Level II PASRR request following the new diagnosis. The social worker confirmed responsibility for submitting such requests and noted the absence of a process to notify her of new mental health diagnoses, resulting in delays. A third resident had a Level I PASRR completed prior to admission, with recommendations to resubmit for Level II if a new mental health diagnosis was suspected. The resident was later diagnosed with bipolar disorder, but no Level II PASRR request was documented. Interviews revealed that while the MDS nurse was supposed to notify the social worker of new diagnoses, there was no consistent system in place to ensure this communication, contributing to the failure to submit timely PASRR requests.
Failure to Properly Label, Date, and Store Food Items in Kitchen and Freezer
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and handling practices during a kitchen tour. In the walk-in cooler, an open container of liquid eggs was found without a date indicating when it was opened, and an open container of potato salad was present with an open date of 12/25/25, which was expired and had not been discarded. Additionally, an open bag of white chocolate chips was found in an open plastic bag inside a box, with neither the bag nor the box labeled with an open date. The Dietary Manager confirmed that these items should have been labeled and expired items discarded, but this had not occurred. Staff interviews revealed that the cook had opened the liquid eggs that morning and forgot to label them, and there was uncertainty about when the white chocolate chips had been opened. In the walk-in freezer, frozen hashbrowns were found in an open box without a date, and the bag containing the hashbrowns was open to air. An open box of bagged frozen bread was stored under the freezer compressor, which was dripping condensation directly onto the box, and the bread inside was also open to air. The Dietary Manager was unaware of the compressor dripping and acknowledged that the food should have been properly secured. The Dietary Manager reported that daily checks for expired foods were typically performed but had not been completed prior to the survey due to returning from vacation. The Administrator stated that monthly inspections had not previously identified these issues and was not aware of the compressor problem.
Failure to Post Oxygen in Use Signage Outside Resident Rooms
Penalty
Summary
Surveyors found that the facility failed to post cautionary and safety signage outside the rooms of three residents who were receiving oxygen therapy. Each of these residents had physician orders for oxygen administration due to chronic or acute respiratory failure with hypoxia, and observations confirmed that oxygen was actively being administered via nasal cannula during multiple surveyor visits. Despite this, there were no signs posted at the entrances to these residents' rooms to indicate that oxygen was in use. Interviews with facility staff, including a nursing assistant, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, revealed that the facility did not have a practice of posting oxygen in use signage at individual resident rooms. The DON and Administrator stated that because the facility was non-smoking and had no smoking signs posted at entrances and exits, they believed it was not necessary to post oxygen in use signs at resident rooms. This practice was confirmed by staff and observed by surveyors during their visits.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
A resident admitted with respiratory failure and generalized muscle weakness was assessed as unable to self-administer medications, as documented in the self-medication assessment. Despite this assessment, an observation revealed that the resident had multiple pills and a cup of liquid medication left at the bedside within reach, without nursing supervision. The resident stated familiarity with the medications and indicated that the nurse would leave the medications for self-administration, returning later to collect the empty cups. The resident also expressed a preference to take medications independently and did not require observation. Nurse interviews confirmed that medications were left at the bedside at the resident's request, and the nurse was unaware of the resident's assessment status regarding self-administration. The nurse acknowledged that medications should not have been left unattended. The Director of Nursing confirmed that the resident had been assessed as unable to self-administer medications and that the nurse should not have left the medications at the bedside. The administrator also confirmed that the resident should not have had medications left for self-administration, as per the assessment.
Medication Error Rate Exceeds Acceptable Threshold Due to Nurse Oversight
Penalty
Summary
A medication error rate of 7.69% was identified during a medication pass observation, exceeding the acceptable threshold of less than 5%. Specifically, two medication errors occurred out of 26 opportunities for one resident with hypertension. The first error involved a nurse administering carvedilol, a medication with specific parameters requiring blood pressure and heart rate assessment prior to administration, without performing these assessments. The nurse did not notice the parameters attached to the order and administered the medication without obtaining the necessary vital signs. The second error occurred when the same nurse failed to administer folic acid as ordered for the resident. The nurse stated she overlooked the folic acid order. Interviews with the nurse, the nurse practitioner, and the DON confirmed awareness of these errors. The DON noted that the electronic system did not enforce the required parameters for carvedilol, which contributed to the error, but also stated that the nurse should have checked each medication order more carefully.
Controlled Substances Not Secured Under Double Lock in Medication Room
Penalty
Summary
Surveyors observed that controlled substances, specifically four bottles of liquid lorazepam and two bottles of liquid morphine, were stored in an unlocked box inside an unlocked refrigerator in the main medication room. The Director of Nursing (DON) confirmed that the box containing these controlled substances should always be locked, and Nurse #2, who had the key, acknowledged that she had forgotten to lock the box after counting the medications with the third shift nurse earlier that morning. The Administrator stated that her expectation was for all controlled substances to be locked at all times, whether stored in the medication cart or refrigerator. This failure to secure controlled substances under a double lock in the medication room was directly observed and confirmed through staff interviews, constituting a deficiency in the facility's medication storage practices.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency was identified when the Wound Nurse failed to follow the facility's Hand Hygiene policy during wound care for a resident. During an observation, the Wound Nurse donned a clean gown and gloves, removed the old dressing from the resident's left hip, sanitized her hands, and donned new gloves before cleaning the wound. However, after treating the left hip wound, the Wound Nurse did not remove her gloves or perform hand hygiene before proceeding to treat a second wound on the resident's right ankle. She applied skin prep to the right ankle while still wearing the same gloves used for the previous wound. The facility's policy requires hand hygiene and glove changes before moving from a soiled body site to a clean body site on the same resident. The Wound Nurse acknowledged during an interview that she did not sanitize her hands or change gloves between the two wound sites, attributing the lapse to being distracted by activity in the room. The Director of Nursing and Infection Preventionist confirmed awareness of the incident and stated their expectation for staff to follow infection control best practices. The Administrator also indicated that the Hand Hygiene policy should have been followed during wound care.
Some of the Latest Corrective Actions taken by Facilities in North Carolina
- Installed wander guard transmitters for all residents identified as able to wander (J - F0689 - NC)
- Assigned on-duty staff as wandering-resident monitors to observe residents and exit points (J - F0689 - NC)
- Delivered facility-wide training on supervision of wandering residents, observation techniques, escalation procedures, and environmental-risk identification (J - F0689 - NC)
- Required dementia and behavior-management training for all current and new employees as a condition of employment (J - F0689 - NC)
- Prohibited unsupervised courtyard access for at-risk residents and designated staff to continuously monitor the courtyard (J - F0689 - NC)
- Established routine environmental rounds to identify elevated surfaces and climbing risks (J - F0689 - NC)
- Integrated behavioral-escalation triggers into resident care plans (J - F0689 - NC)
- Adopted a protocol requiring prompt nurse-manager notification and intervention (assessment, wander guard, care-plan update) upon new agitation or exit-seeking behavior (J - F0689 - NC)
- Added review of new wandering or exit-seeking cases to regular clinical meetings (J - F0689 - NC)
- Assigned DON accountability for completion of wandering assessments, notifications, wander guard initiation, and care-plan revisions (J - F0689 - NC)
- Maintained an up-to-date list of exit-seeking/wandering residents reviewed by DON and Social Worker (J - F0689 - NC)
- Initiated ongoing DON/ADON audits of wandering assessments and documentation to verify interventions and wander-guard usage (J - F0689 - NC)
- Directed At-Risk IDT and QAPI Committees to review audit results for further action (J - F0689 - NC)
- Mandated wandering/exit-seeking assessments on admission, quarterly, and after significant condition changes (J - F0689 - NC) (J - F0689 - NC)
- Conducted comprehensive staff education on Elopement Prevention and the Missing Person Policy, incorporating it into new-hire orientation and barring work until completion (J - F0689 - NC)
- Instituted a visitor sign-in/out and badge system overseen by receptionists, with all other exits locked and controlled by staff (J - F0689 - NC)
- Established protocols for receptionists and nursing staff to verify identities at the main entrance, lock doors when unattended, and manage access when reception is unavailable (J - F0689 - NC)
Failure to Prevent Accident Hazard Due to Inadequate Supervision of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment, alcohol-induced dementia, and a court-appointed guardian was not provided with effective supervision, resulting in a serious incident. The resident, who had a history of confusion, agitation, and impaired judgment, was allowed unsupervised access to an enclosed courtyard where he was considered a safe smoker. On the day of the incident, the resident became upset after being told by staff that he would be moved to a secured unit. Subsequently, he stacked patio furniture, climbed onto an awning, and then accessed the facility's roof. Staff observed the resident running and sitting on the edge of the roof, prompting the fire department to be called for his safe removal. Prior to this event, the resident had not exhibited wandering or exit-seeking behaviors, but staff had noted increased agitation and unsafe behaviors, including attempts to take his non-smoking roommate outside to smoke. Despite these observations and discussions with the guardian about escalating behaviors and the potential need for a higher level of care, the resident remained in the unsecured unit. The resident's care plan had not been updated to reflect the increased risk, and he was not placed under enhanced supervision or restricted from unsupervised courtyard access until after the incident occurred. Additionally, the facility failed to complete a smoking assessment on admission and quarterly for another resident to determine if independent smoking was safe or if supervision was required. The lack of timely reassessment and supervision for residents with cognitive impairment and behavioral changes contributed to the occurrence of the incident and the identified deficiency.
Removal Plan
- Resident #120 was placed on enhanced supervision and restricted from unsupervised courtyard access after the incident.
- Resident #120 was reassessed and changed from a safe smoker to a supervised smoker.
- Resident #120 was relocated to a room closer to the nurses' station for increased observation.
- All residents with cognitive deficits and physical capabilities were assessed for wandering, change in behavior, increased agitation, and problematic behaviors.
- Wander guard transmitters were placed on all residents identified as having the ability to wander.
- The Interdisciplinary Team reviewed all residents to identify those with wandering or exit-seeking behavior.
- Staff members were assigned as wandering resident monitors on duty to monitor wandering residents and points of egress.
- All staff received in-service training on supervision of wandering residents, continuous observation, escalation of concerns, and environmental risk identification.
- Staff were instructed to relocate residents displaying exit-seeking or wandering behavior to the secure unit and notify the DON for evaluation.
- All employees were re-hired by new ownership and required to complete dementia and behavior management training to be eligible for rehire.
- All new hires receive training on dementia and care of wandering/behavioral residents during orientation and thereafter.
- Unsupervised courtyard access was restricted for residents with wandering or unsafe behaviors.
- Designated staff monitor the courtyard during resident use.
- Routine environmental rounds are conducted to identify elevated surfaces and climbing risks.
- Behavioral escalation triggers are incorporated into care planning.
- Nurse managers are to be notified immediately for new agitation, pacing, wandering, or exit-seeking behavior; a wandering assessment is completed, wander guard placed, provider and responsible party notified, and care plan updated.
- Residents with new wandering or exit-seeking behaviors are discussed in clinical meetings.
- The DON is responsible for ensuring wandering assessments, notifications, wander guard initiation, and care plan updates are completed.
- A list of exit-seeking/wandering residents is updated and reviewed by the DON and Social Worker.
- Resident wandering assessments and nursing documentation are audited by the DON/ADON to identify residents with increased agitation, exit-seeking, or wandering behavior.
- Audits ensure residents with these behaviors have wander guards and appropriate care plan interventions.
- Audit results are discussed at the clinical At-Risk IDT Meeting and presented to the QAPI Committee for review and revision as needed.
- All residents are assessed for wandering and exit-seeking and with any significant change in condition.
- Education on facility processes for residents with increased agitation, pacing, exit-seeking, or wandering behavior is provided to all staff and reviewed.
Failure to Properly Disinfect Shared Blood Glucose Meters
Penalty
Summary
Facility staff failed to properly clean and disinfect shared blood glucose meters before and after each use, as required by both facility policy and the manufacturer's instructions. Observations revealed that staff used alcohol wipes instead of EPA-registered disinfectant wipes, and in some cases, did not disinfect the meters at all prior to use. This practice was observed during blood glucose checks for two residents, both of whom were identified as having bloodborne pathogens, including hepatitis C. The blood glucose meters were not labeled for individual resident use and were stored in a manner that allowed for potential cross-contamination. Nursing staff, including a nurse and the Assistant Director of Nursing (ADON), demonstrated a lack of knowledge regarding the correct disinfection procedures. The nurse stated he was trained to use alcohol for cleaning, and the ADON admitted she was unaware that the meter needed to be cleaned both before and after each use. Both staff members had previously received training on blood glucose meter disinfection, but failed to follow the correct procedures during observed care. The facility's policy and the manufacturer's guidelines both specified the use of EPA-registered disinfectant wipes with a required contact time, which was not followed. The deficiency was identified during direct observation and interviews, which confirmed that the improper cleaning and disinfection of blood glucose meters occurred while caring for residents with known bloodborne pathogens. The facility's monitoring systems failed to detect or correct these lapses in infection control, and staff continued to use shared meters without proper disinfection, increasing the risk of cross-contamination and exposure to bloodborne infections among residents.
Removal Plan
- Removed and discarded prior blood glucose meters that were being utilized for multi-resident use.
- Placed individual blood glucose meters in a zipped plastic bag with resident's name identifier to prevent cross contamination.
- Blood glucose meters are removed from the zipped plastic bag prior to entering the resident room, then cleaned, disinfected, and air-dried per EPA-registered disinfectant wipe manufacturer's recommendation before and after use.
- Blood glucose meters are stored in each resident's respective medication cart.
- Applied residents' names to the individual blood glucose meters.
- Upon resident discharge, blood glucose meter is disinfected with EPA-registered disinfectant wipe and stored in medication room.
- All new admissions and residents with new blood glucose meter testing orders will be given a new blood glucose meter by the nurse receiving the order and/or admitting nurse.
- Nurse and/or admitting nurse will label the blood glucose meter and baggy with resident's name and place it in their respective medication cart.
- Education provided to all Licensed Nurses on the specific resident use of blood glucose meters, storage, cleaning, and disinfecting using proper EPA-disinfecting wipe.
- Licensed Nurses who have not received the education will be removed from the schedule until the education has been completed.
- Education related to cleaning, disinfecting, and storage of individual blood glucose meters will be added to the general orientation of newly hired Licensed Nurses.
- Administrator and/or Director of Health Services is responsible for ensuring all Licensed Nurses are educated.
- Licensed nurses who are scheduled to work will receive in-person education and complete return demonstration of cleaning and disinfecting blood glucose meters.
- Licensed Nurses who are not scheduled to work will receive over the phone education with return demonstration review by Director of Health Services prior to next scheduled shift.
- Administrator and/or Director of Health Services maintains the employee roster of those who have been educated and who require review.
- Facility contacted the local health department regarding the infection control breach.
- Medical Director was notified of the infection control breach.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A severely cognitively impaired resident with a primary diagnosis of toxic encephalopathy, along with other significant medical conditions such as cardiac arrest, atherosclerotic heart disease, and chronic kidney disease, exited the facility without staff knowledge for over two hours. The resident, who required partial to moderate assistance with most activities of daily living and was known to be confused and unsteady on his feet, was last seen in his room by a nurse aide at approximately 9:30 AM. Video footage later revealed that the resident walked unassisted through the lobby and out the front door while the receptionist was present but engaged in conversation with a visitor. The receptionist did not recognize the resident as a resident and did not intervene as he exited the building. After leaving the facility, the resident walked along a heavily trafficked road, fell, and was assisted by strangers who transported him to a fire station 20 miles away. The facility staff became aware of the resident's absence only after a family member arrived for a visit and could not locate him. A search was initiated, and law enforcement was notified. The resident was eventually found and transported to the hospital, where he was noted to have abrasions and swelling consistent with a fall. Interviews with staff and family confirmed that the resident was consistently confused, required supervision for ambulation, and was not safe to walk unassisted. The facility's risk assessment and care plan for the resident did not identify wandering or elopement risk, as there was no prior history of such behaviors. However, the resident's cognitive impairment, confusion, and poor balance were documented. Staff interviews indicated that the resident typically remained in his room and had not previously attempted to leave the facility. The front entrance was unlocked due to the presence of a receptionist, but there was no effective process in place to ensure that residents could not exit unnoticed, especially when staff were unfamiliar with all residents or distracted.
Removal Plan
- A head count was completed by Nurse Supervisor #1 for 100% of residents. All residents in facility were accounted for with no issues identified.
- The Director of Nursing reviewed clinical alerts dashboard and nursing notes for all residents for the past 30 days to identify any exit seeking behaviors. No issues identified.
- The Director of Nursing audited 100% of residents wandering risk assessments. All residents with low wandering risk were reviewed for changes in condition/function that may put them at risk to exit the facility. No issues identified.
- Risk assessments are completed upon admission by the admitting nurse, quarterly and any time a change of condition is noted by staff nurse or nurse manager.
- All residents at high-risk for wandering charts were reviewed by the Director of Nursing to ensure that they had appropriate wander prevention strategies in place to include wander guard bracelet in place and functioning properly, daily battery checks and every shift placement checks were present on the MAR and that care plan was current and appropriate interventions were on the care plan.
- The Nurse Supervisor checked 100% of current residents with wander guards for placement and function by observing that wander guard was on resident's person and utilized the wander guard checker device to ensure proper function. No issues were noted.
- All exit doors were checked by the Director of Nursing and Nurse Supervisor #1 to ensure they were functioning properly.
- Staff interviews were initiated for all staff by the Director of Nursing to identify any exit seeking behaviors. Interviews identified no other new onset of exit seeking behaviors.
- The QA Nurse Consultant rechecked all entrance/exit doors to include door with wander guard system, squealer boxes and on/off switches for mag lock doors (doors with keypad entry/exit) and all were functioning properly. No issues were identified.
- A Quality Assurance Performance Improvement meeting held with the Interdisciplinary Team members to discuss incident findings and plan to correct.
- The Director of Nursing began education of all full time, part time, and as needed staff including agency on the following topics: Elopement Prevention and Missing Person Policy. Education included what to do if resident was exhibiting wandering/exit seeking behaviors especially for those residents who normally stayed in their rooms. Staff educated to stop and communicate with the resident and redirect, ensure safety of the resident and immediately notify the nurse.
- The Administrator will ensure that any of the above identified staff who did not complete the in-service training will not be allowed to work until the training is completed.
- This in-service was incorporated into the new employee facility orientation for the above identified staff and will be provided by the Staff Development Coordinator during orientation and prior to working in patient care areas.
- The Administrator educated all receptionists that all visitors will need to sign in and out and wear a badge to identify them as a visitor when entering the facility through main entrance designated for visitor entry.
- All other exit doors are locked with signage above directing visitors to go to the main entrance to enter and exit the facility.
- All receptionists and nurses were educated by the Administrator that receptionists are to lock the main entrance door upon leaving front desk for any reason and nurses are to let visitors into and out of facility in receptionist's absence from receptionist area.
- Receptionists were educated to have all persons exiting facility to be identified prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility to ensure they are not a resident displaying exit seeking behaviors.
- If the person is noted to be a resident, receptionist is to maintain resident safety and immediately notify nurse assigned to resident to come assist resident.
- The Administrator will ensure that any newly hired receptionist or nurse will receive this education prior to working and this in-service was incorporated into the new employee facility orientation for the above identified staff.
- Visitors will be required to sign in and out and wear visitor badge while in the facility.
- Receptionists were educated that they are to lock the main entrance door upon leaving front desk area for any reason and if no one is available to provide coverage until they return, they are to notify nursing staff via phone that they will be leaving front desk area prior to leaving.
- Upon hearing doorbell ringing, nurses are to go to front entrance area and let visitor into the facility, have visitor sign in and provide them with a visitor's badge.
- For visitors leaving facility, nurse is to identify person prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility.
- A receptionist is scheduled to work 7 days a week. In the event that there is no receptionist available, facility front entrance doors will be locked and nurses on duty will be responsible for allowing visitors entry or exit to facility.
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