Citations in New York
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New York.
Statistics for New York (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in New York
A CNA physically struck a resident with multiple chronic conditions after the resident became agitated and struck the CNA during care. The CNA responded by grabbing the resident's wrist, slapping their face, and using profane language. The incident was witnessed by staff, confirmed by video surveillance, and resulted in a red mark on the resident's cheek. The event was determined to be physical and verbal abuse, with psychosocial harm identified.
A resident with severe cognitive impairment and high fall risk was not provided with adequate fall prevention interventions, despite being identified as high risk. Staff observed the resident attempting to get out of bed prior to a fall that resulted in injury, but necessary safety measures such as frequent monitoring and use of floor mats were not consistently implemented or documented. Inconsistent communication and documentation among staff contributed to the resident sustaining harm from a fall.
A resident with significant risk factors for skin breakdown did not receive consistent pressure ulcer prevention interventions, including turning, repositioning, and heel offloading. Inadequate monitoring and documentation by staff led to the development of a Stage 2 pressure injury that progressed to an unstageable wound, as well as a deep tissue injury to the heel. Staff interviews confirmed lapses in following wound prevention protocols, resulting in actual harm.
Surveyors found that the facility did not have documented policies for Braden scale assessments, skin observation, admission assessments, or MDS assessments. The DON stated these were corporate issues and acknowledged the absence of such policies, while the administrator indicated that not every process required a policy.
A resident with severe cognitive impairment and mobility limitations was assessed by Physical Therapy as requiring maximum assistance for bed mobility, but the admission MDS documented the resident as dependent, creating a discrepancy. The facility did not have a policy for MDS assessments, and staff interviews highlighted inconsistencies in the assessment and care planning process.
A resident with severe cognitive impairment suffered a fall resulting in facial and head injuries. Facility staff attempted to notify a family representative but contacted the wrong person and left only a voicemail, with no documented follow-up or attempts to reach other listed contacts. The correct representative was not informed of the incident until they visited the facility over a month later, despite the facility's policy requiring timely notification after significant changes in condition.
Two residents with cognitive impairment did not have their care plans reviewed or updated in accordance with required assessment schedules. Although goals and interventions were documented, there was no evidence that these were evaluated for effectiveness or that updates were made based on recent assessments. Staff interviews revealed inconsistencies in care plan documentation and transfer of meeting notes within the electronic medical record system.
A maintenance staff member entered a resident's room without a valid work order and engaged in verbally abusive behavior, repeatedly and loudly accusing the resident of attempting to spit on a nurse manager. The resident, who was cognitively intact and had multiple medical conditions, denied the accusation and called 911 after feeling unsafe. Audio and video evidence, as well as staff interviews, confirmed the staff member's conduct was aggressive, disrespectful, and in violation of resident rights.
A resident with intact cognition alleged verbal and physical abuse by a staff member, including threatening statements and contact with an injured ankle. Although the incident was reported internally, the facility failed to notify the State Agency within the required two-hour timeframe, resulting in a deficiency for not adhering to mandated abuse reporting protocols.
A resident with complex medical conditions and impaired cognition was prescribed medications for constipation prevention, but staff failed to develop and implement a person-centered care plan addressing this risk. Instead, an outdated care plan was used, and interviews confirmed that required care planning procedures were not followed by nursing staff.
Staff-to-Resident Physical and Verbal Abuse Incident
Penalty
Summary
On 12/08/2025, a certified nurse aide (CNA) was observed on video surveillance striking a resident in the face, resulting in a red mark on the resident's cheek. The incident occurred after the resident, who had a history of alcoholic cirrhosis, chronic kidney disease, and chronic obstructive pulmonary disease, became agitated and attempted to self-transfer from a recliner. The resident, who was moderately cognitively impaired and known to display verbal and physical aggression, struck the CNA during an attempt to reposition them. In response, the CNA grabbed the resident's wrist and slapped them in the face. The CNA was also witnessed using profane language directed at the resident during the altercation. Multiple staff interviews confirmed the sequence of events, with several staff members hearing or witnessing the slap and the use of inappropriate language. The CNA admitted to reacting physically after being struck by the resident and acknowledged that their response was inappropriate. The incident was immediately reported by the CNA to the supervising nurse, and the resident was subsequently assessed for injuries. The red mark on the resident's cheek resolved by the following day, and no additional injuries or changes in behavior were documented in the days following the incident. The facility's abuse prevention policy defined physical abuse as the willful infliction of injury, including hitting and slapping. The investigation concluded that physical abuse had occurred, as the CNA's actions met the definition of abuse. The incident was corroborated by video evidence and staff interviews, which consistently described the CNA's response as unacceptable and constituting physical and verbal abuse. The resident was monitored for psychosocial harm, and although no lasting injury or behavioral changes were documented, the event was determined to have caused psychosocial harm according to the reasonable person concept.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as high risk for falls. The resident, who had diagnoses including cerebral infarction, aphasia, altered mental status, and severe cognitive impairment, was assessed as a high fall risk based on the facility's fall risk assessment protocol. Despite this, the resident's care profile did not reflect fall precautions, and interventions such as 30-minute safety checks and floor mats were either not implemented or not documented as required by facility policy. Staff interviews revealed that the resident was observed attempting to get out of bed prior to the fall, with half of their body hanging off the bed, but this observation did not result in additional interventions or updates to the care plan. The resident was dependent for bed mobility and transfers, and staff had varying perceptions of the resident's ability to move or self-transfer. On the night of the incident, the resident was found on the floor with injuries including a swollen eye, hematoma, and a scratch, after reportedly attempting to get out of bed to retrieve belongings. The facility's documentation and communication regarding fall risk interventions were inconsistent, with some staff unaware of the resident's increased risk and others noting that required safety measures were not in place or not documented. The facility's fall risk intervention protocol required immediate implementation of prevention measures for residents with high fall risk scores, but the resident's care plan and care profile were not updated accordingly. The lack of documentation and failure to implement or communicate appropriate interventions contributed to the resident sustaining actual harm from a fall. The deficiency was substantiated by observations, record reviews, and staff and representative interviews, which highlighted lapses in supervision, care planning, and adherence to established safety protocols.
Failure to Prevent and Manage Pressure Ulcers Resulting in Actual Harm
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers and to ensure that a resident did not develop avoidable pressure ulcers. A resident with multiple risk factors, including dementia, a recent hip fracture, and diabetes, was admitted with a blanchable area of moisture-associated skin damage to the coccyx/buttocks and was dependent for bed mobility. Despite being identified as at moderate risk for pressure ulcers on the Braden Scale, there were no documented interventions such as turning and repositioning or heel offloading at admission, and the care plan did not include these risk reduction measures. The resident's care records showed inconsistent implementation and documentation of skin observations and heel offloading. Certified nurse aide accountability records indicated that skin checks were not signed as completed on multiple occasions, and heel offloading was not consistently performed as ordered. The resident subsequently developed a Stage 2 pressure injury on the left buttocks, which later progressed to an unstageable wound, and a deep tissue injury to the right heel. These injuries were attributed to the lack of consistent preventive interventions, such as turning, repositioning, and heel offloading, as well as inadequate monitoring and documentation by staff. Interviews with facility staff, including the DON, RNs, LPNs, and nurse practitioners, revealed gaps in communication and implementation of wound prevention protocols. Staff acknowledged that interventions like heel offloading and turning were not automatically initiated for high-risk residents and that orders and protocols were not always followed or documented. The facility's own wound management policy required comprehensive risk reduction measures, but these were not consistently applied, resulting in actual harm to the resident.
Lack of Required Clinical Assessment Policies
Penalty
Summary
The facility administrator failed to ensure the effective and efficient use of facility resources to attain or maintain the highest practicable well-being of each resident, as evidenced by the inability to provide requested facility policies during an abbreviated survey. Specifically, the DON stated there were no documented facility policies for Braden scale assessments, skin observation, admission assessments, or Minimum Data Set (MDS) assessments. The DON indicated that the absence of these policies was a corporate issue and acknowledged the lack of documentation. The administrator reportedly informed the DON that not every process in the facility required a policy. These findings were based on record review and interviews conducted during the survey.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status for one out of three residents reviewed. Specifically, a resident admitted with diagnoses including dementia, an intracapsular fracture of the right femur, and type 2 diabetes mellitus was evaluated by Physical Therapy and found to require maximum assistance for bed mobility. However, the admission Minimum Data Set (MDS) documented the resident as dependent for bed mobility, which did not align with the Physical Therapy evaluation. The facility also lacked a policy related to the MDS assessment process. Further review of the resident's care plan indicated a self-care performance deficit due to activity intolerance, confusion, and disease processes, with interventions focused on encouraging participation in self-care. Interviews with nursing staff revealed that the rehabilitation department completed the functional assessment section of the MDS, which was then signed off by nursing. Staff noted that the resident was coded as dependent for bed mobility and questioned the absence of turning and positioning orders or heel elevation. Attempts to interview the Physical Therapist involved were unsuccessful.
Failure to Notify Correct Family Representative After Resident Injury
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a significant change in the resident's physical condition. Specifically, after a resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and altered mental status, experienced a fall resulting in injuries to the face, eyes, and head, the facility did not promptly inform the correct family representative. The initial attempt to notify was made by calling the first contact listed on the resident's face sheet, but this was not the correct representative, and only a voicemail was left. There was no documented evidence of follow-up attempts or efforts to contact other listed representatives when the initial call was not returned. Interviews with staff revealed that the wrong contact was repeatedly called, and the correct representative was not informed of the incident until they visited the facility over a month later. The care plan for the resident included interventions to ensure safety and communication, but these were not effectively implemented regarding family notification. The facility's own policy required notification of family or significant others in the event of an accident or incident, but this was not followed, as evidenced by the lack of timely and appropriate communication with the designated representative.
Failure to Review and Update Cognitive Care Plans as Required
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed, updated, and revised for two out of three residents reviewed for care planning. Specifically, one resident with severe cognitive impairment and another with moderate cognitive impairment had care plans for impaired cognition that had not been reviewed or updated in accordance with the most recent comprehensive or quarterly assessments. The care plans contained goals and interventions, but there was no documented evidence that these were evaluated for effectiveness or that goals were met, as required by facility policy. Interviews with facility staff revealed that the responsibility for updating cognitive care plans typically falls to the Social Worker, who stated that updates are supposed to occur quarterly, annually, and with any significant changes. However, discrepancies were noted between the dates of care plan reviews in the electronic medical record and the actual care plan meeting documentation. The Social Worker and DON acknowledged that care plan updates were not consistently reflected in the system, and meeting notes were not always properly transferred to the care plan documents.
Verbal Abuse by Maintenance Staff Toward Resident
Penalty
Summary
A deficiency occurred when a maintenance staff member engaged in verbally abusive behavior toward a resident. The incident began after the resident had expressed care concerns from the previous evening and had an interaction with a unit manager, during which the resident was told they could leave against medical advice if they wished to be discharged. Shortly after, the maintenance staff member entered the resident's room without a work order or valid reason, rapidly knocked, and confronted the resident in a loud and disrespectful manner, repeatedly accusing the resident of attempting to spit on the unit manager. This confrontation was captured on an audio recording made by the resident and corroborated by facility video footage. The resident, who had diagnoses including a left leg fracture, muscle weakness, and obesity, was cognitively intact and able to communicate effectively. During the incident, the resident remained calm and denied the accusations, while the maintenance staff member insisted on the claim and stated that the resident needed to be removed from the facility. The resident subsequently called 911, reporting that they felt unsafe due to the staff's behavior. Multiple staff interviews confirmed that the maintenance staff member's tone was loud, aggressive, and accusatory, and that their actions were considered verbally abusive and unprofessional. Facility policy and New York State regulations require that residents be protected from all forms of abuse, including verbal abuse. The investigation revealed that the maintenance staff member acted outside their scope of duties, entered the resident's room without proper cause, and failed to treat the resident with dignity and respect. The staff member's behavior was acknowledged by facility leadership and other staff as inappropriate, undignified, and in violation of resident rights.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of staff-to-resident verbal and physical abuse within the required two-hour timeframe to the State Survey Agency and other appropriate authorities. According to the facility's policy, all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made. In this case, an incident involving a resident and a staff member was reported to the facility Administrator via email, but the report to the State Agency was not made until several days later, well beyond the required timeframe. The Administrator acknowledged awareness of the allegation but did not submit the report as required, citing forgetfulness. The incident involved a resident with intact cognition who alleged that a staff member entered their room, made threatening statements, and made physical contact with the resident's injured ankle. The resident called emergency services, and law enforcement responded to the facility. The facility's investigation concluded that verbal abuse had occurred. Despite these findings and the facility's established policy, the delay in reporting the allegation constituted a failure to comply with regulatory requirements for timely reporting of abuse.
Failure to Initiate Person-Centered Care Plan for Constipation Risk
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a newly admitted resident with multiple complex medical diagnoses, including chronic pulmonary embolism, coronary heart disease, moderate pericardial effusion, and small cell lung cancer complicated by superior vena cava syndrome. The resident, who had moderately impaired cognition, was prescribed medications to prevent constipation, specifically MiraLAX and Senna, as per physician's orders. However, there was no documented evidence that a care plan addressing the risk for constipation was created or implemented for this resident. Interviews with facility staff revealed that the admitting nurse did not initiate a new care plan upon the resident's admission and instead retrieved an outdated care plan from a previous admission. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that a current care plan for constipation risk was not in place and acknowledged that it was the responsibility of the admitting nurse and other nursing staff to ensure care plans were completed. This failure was found during an abbreviated survey and was cited as noncompliance with facility policy and regulatory requirements.
Some of the Latest Corrective Actions taken by Facilities in New York
- Revised the admissions and readmissions policy to mandate RN assessments of height, weight, shoulder and chest circumferences (L - F0689 - NY)
- Retrained all CNAs and licensed nurses on the updated admissions and lift/transfer policies, requiring completion before their next shift (L - F0689 - NY)
Failure to Assess and Document Proper Sling Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents, resulting in actual harm. A resident with vascular dementia, dysphagia, chronic kidney disease, and severely impaired cognition was readmitted to the facility after hospitalization for acute respiratory failure. Upon readmission, there was no documented assessment by a registered nurse or therapist to determine the resident's transfer status or the appropriate sling size for mechanical lift use, despite the resident's unsteady gait and poor balance. The care plan and care card did not include instructions for mechanical lift use, sling size, sling type, or loop configuration. On the day of the incident, two certified nursing assistants attempted to transfer the resident using a mechanical lift after determining the resident was too weak for a walker transfer as indicated on the care card. They selected an extra-large full-body sling, which did not fit the resident's body size, and used it because it was the only available sling on the unit. The staff did not verify the resident's weight or ensure the sling was appropriate for the resident's size. During the transfer, the resident slipped through the sling, fell, and sustained a subdural hematoma and orbital fracture. The investigation revealed that several slings in the facility lacked visible size labels, and there were non-manufacturer slings in circulation. Interviews with staff indicated inconsistent practices regarding who determines transfer status and sling selection, with some staff believing certified nursing assistants could make these decisions independently. Training on sling selection and mechanical lift use was found to be inadequate, with at least one certified nursing assistant reporting incomplete hands-on training. Documentation of sling size and type in care plans was lacking, and there was confusion among staff about proper procedures for assessing residents and updating care plans after admission or readmission.
Removal Plan
- Revise the facility policy on resident admissions and readmissions to include a registered nurse assessment which addresses a resident's height, weight, shoulder circumference, and chest circumference.
- Retrain all certified nursing assistants and licensed nursing staff on the admissions and lift/transfer policies and attest that all remaining nursing staff will complete mandatory training prior to their next scheduled shift.
- Reassess all residents identified as needing a full mechanical lift for transfers and assign an appropriate lift sling.
Failure to Prevent Elopement and Inadequate Supervision of Residents
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents identified as being at risk for elopement or accidents. One resident with Alzheimer's dementia, severely impaired cognition, and a history of repeated falls was assessed as high risk for elopement and was equipped with a wander detection device. Despite multiple prior incidents where this resident was found in or near stairwells and exit doors with alarms sounding, the resident was able to exit the facility undetected on two separate occasions. On both occasions, staff were either occupied providing care to other residents or did not fully investigate the source of the alarm, resulting in delayed recognition that the resident was missing. Documentation of required 15-minute checks was incomplete, and there was no evidence of additional interventions being implemented after the first elopement. Staff interviews revealed confusion about alarm response protocols, with some staff silencing alarms without fully searching the area or notifying supervisors as required by facility policy. Another resident with severely impaired cognition, multiple comorbidities, and independent use of a motorized scooter was allowed to move freely throughout the facility and its grounds. The resident was assessed as low risk for elopement and did not have a wander detection device. On one occasion, the resident left the facility grounds undetected and traveled approximately four miles away to a fast-food restaurant, where they were later found and returned by family. There was no documented plan to monitor or account for the resident's whereabouts when they left the building, and staff were unaware of specific monitoring expectations for residents using scooters independently on the grounds. The facility did not require the resident to notify staff or sign out when leaving the unit, and there was no restriction or supervision in place for off-campus mobility. Facility policies required staff to monitor residents' whereabouts, respond promptly to alarms, and notify supervisors in the event of a missing resident or elopement. However, staff interviews and documentation revealed inconsistent adherence to these protocols, including failure to expand searches beyond immediate areas, inadequate communication among staff, and incomplete documentation of supervision. These failures resulted in residents exiting the facility undetected, placing them at risk for serious harm and triggering Immediate Jeopardy and Substandard Quality of Care findings.
Removal Plan
- The facility's immediate plan was reviewed and accepted.
- 85% of staff had been educated on elopement risk and wander detection device door alarm response. The remaining staff will be educated prior to the start of their next shift or upon return from their leave.
- Staff education was verified onsite during interviews. Multiple staff including nursing, maintenance, housekeeping, and activities were interviewed.
- Staff were able to report content of education, confirmed the day they received the education, and the facility staff who presented the education.
Failure to Prevent Resident-to-Resident Abuse Resulting in Harm, Injury, and Death
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, resulting in multiple incidents of actual harm, serious injury, and death. In one case, a resident with severe cognitive impairment and a history of major depressive disorder was physically assaulted by their roommate, who had recently been admitted with a history of aggressive and paranoid behavior. The facility did not conduct effective monitoring or develop a baseline care plan for the new admission to identify and address potential aggressive behavior. There was no documented psychiatric consult or evidence of a completed psychotherapy evaluation, and staff failed to implement appropriate interventions despite the resident's recent psychiatric emergency department stay and medication orders for behavioral health issues. The assault resulted in the resident being found bleeding from the head and subsequently dying after hospital transfer. Another incident involved a resident with moderately impaired cognition and a history of wandering behavior who entered another resident's room and was struck with a cane, resulting in an acute right hip fracture. The care plan for the wandering resident did not include specific interventions for monitoring or preventing such behavior, and documentation of staff rounds was inconsistent or lacking. Staff interviews revealed that rounds were conducted but not always documented, and there was no clear system for monitoring or intervening in resident wandering or aggression, despite known behavioral risks. A third incident occurred when a resident with severe cognitive impairment was struck in the face with a walker by another resident who also had severe cognitive impairment and a history of wandering and combative behavior. The care plans for both residents lacked detailed interventions for monitoring or preventing aggressive or intrusive behaviors. Staff and supervisory interviews indicated that responsibility for monitoring residents was not clearly defined or consistently implemented, and there was insufficient documentation of behavioral monitoring and interventions. These failures resulted in immediate jeopardy to resident health and safety.
Removal Plan
- Policy and Procedure on Abuse, Mistreatment and Neglect was reviewed with no revision.
- An Audit was done. The Director of Nursing and Assistant Director of Nursing assessed 70 residents on the third floor with no injuries or signs of abuse. No additional concerns were identified.
- Facility admission policy was revised.
- The facility developed a policy titled Resident Rounding-Nursing. It is the policy for all nursing staff that states they are responsible for completing regular rounds of their assigned areas and the facility's common areas, at the start of their shift, twice during the shift, and at the end of their shift, to monitor resident well-being, maintain a safe environment, and respond promptly to resident needs.
- The facility policy titled Nursing/Rehabilitation/Maintenance was reviewed/revised to include storage for equipment (including wheelchair/footrests) not being used.
- Facility-wide inspection was conducted by the therapy department to assess durable medical equipment in residents' rooms that could present a potential safety hazard. Concerns will be addressed accordingly to ensure safety.
- Three Hundred and Fifty-Eight resident wheelchairs were checked for potential safety hazards. No concerns were found.
- In-service conducted on Rounding, Call Bells, and Daily Tasks. Lesson plan and sign-in sheets were reviewed/confirmed for staff in-service conducted on Rounding, Call Bells, and Daily Tasks.
- An Audit done of all new residents admitted within the 30 days prior to the date of the incident was reviewed by the Regional Nurse/Designee to determine if there were any documented or known behavioral concerns with an adjunct target behavior care plan with individualized monitoring in place. Three residents were admitted on psychoactive medications with physical aggression, anxiety and mood changes. Behavior care plans were developed.
- Facility policy on Behavioral Health and Dementia was revised to include that the facility will ensure a designated behavior health monitor will be assigned each shift to observe for residents having behaviors such as combative, aggressive impulsive and or assaultive behaviors. Any behaviors negatively affecting others will be documented on the behavioral monitoring log including interventions attempted. All behaviors will be reported to the Registered Nurse for follow up including documentation and notification to physician and psychiatry as needed. The Registered Nurse Supervisor will review and sign the behavior monitoring log each shift.
- Staff members received in-service on resident-to-resident abuse/prevention.
- The facility completed in-service of all admission staff on changes to the admission policy, including a need to conduct a thorough review of the Patient Review Instrument prior to acceptance of the hospital referral.
- Facility staff members including Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants were interviewed and stated they received in-service on documentation, reporting of resident's behavior, equipment storage including wheelchair footrests, resident to resident abuse prevention and call bell with no concerns identified.
- The remainder of the staff who did not receive in-services will be in-serviced prior to starting their duties. Staff on vacation or off duty will be in-serviced before going to the unit.
Failure to Provide Adequate Supervision and Aspiration Precautions During Meals
Penalty
Summary
A deficiency occurred when a resident with a history of aspiration pneumonia, hyperphagia, and dysphagia, who was on aspiration precautions and required 1:1 supervision during meals, was left unattended in the dining room. The resident's care plan and Kardex did not fully document the required aspiration precautions or specialized feeding techniques, and staff were not consistently informed or aware of the specific supervision and assistance needed. The resident was served a ground diet with honey thick liquids, but was able to access inappropriate food consistency from another resident's plate due to lack of supervision. During the meal, there were no licensed nurses present in the dining room, and certified nurse aides did not provide the required 1:1 supervision. The resident was observed on surveillance video reaching for and consuming food from a neighboring plate, then displaying signs of distress, including waving arms and banging on the chest, which went unnoticed by staff present in the dining room. Dietary and housekeeping staff saw the resident in distress but did not intervene or notify nursing staff. The resident remained unattended for an extended period, and was later found unresponsive. Interviews with staff revealed confusion and lack of communication regarding responsibility for supervision and the specific needs of the resident. The speech language pathologist had documented and verbally communicated the need for 1:1 supervision and specialized feeding strategies, but these were not incorporated into the care plan or visible to all staff. The lack of adequate supervision and failure to follow aspiration precautions directly led to the resident choking and subsequently being pronounced deceased after resuscitation efforts.
Removal Plan
- All staff were educated on Aspiration Precautions, Dining Supervision, and Notification of Change in Condition.
- The facility attestation documented 87% of staff were educated with a plan to educate the remaining staff prior to the beginning of their next work assignment.
- Staff interviews verified understanding and retention of education provided.
Failure to Administer Anticoagulant on Admission Leads to Harm
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility following a hospital stay for a left femoral fracture. The hospital discharge summary and medication reconciliation order report both indicated that the resident was to receive Eliquis, an anticoagulant, at a specified dose. However, upon admission, the medication was not ordered, and the resident did not receive any anticoagulant therapy during their stay at the facility. The admitting nurse accessed the hospital records and noted the medication reconciliation order form but did not review the discharge summary or clarify questions about the anticoagulant order. The nurse placed the medication reconciliation form on the nurse practitioner's desk without notifying them of any concerns. The nurse practitioner reviewed and signed off on the orders entered into the computer but did not compare the discharge summary and medication reconciliation order form against the orders entered. A third nurse, responsible for the final check, only reviewed the orders in the medical record and did not reference the original hospital documents. As a result, the omission of the anticoagulant was not detected by any of the staff involved in the admission process. The resident subsequently developed edema in the lower extremity and was sent to the hospital, where a deep vein thrombosis was diagnosed. Interviews with facility staff revealed that the established protocols for medication reconciliation and double-checking high-risk medications, such as anticoagulants, were not followed. The failure to clarify and verify the resident's medication orders led to the resident not receiving a critical medication, resulting in actual harm.
Removal Plan
- Educate nursing staff to not view or print the discharge summary or medication reconciliation order form until a resident is discharged from the hospital.
- Transcribe medication from the discharge summary or medication reconciliation order form by the admitting nurse for each new admission or re-admission.
- Review medication orders by the advanced practice provider.
- Review medication orders by a second nurse.
- Review medication orders by the Director of Nursing.
- Review medication orders by a licensed pharmacist.
- Provide staff education based on an education outline.
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