Citations in Texas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Texas.
Statistics for Texas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Texas
Two residents did not receive prescribed medications as ordered, including missed insulin and blood sugar checks for a diabetic resident attending an outside program, and a missed dose of Metoprolol for another resident with a gastrostomy tube. Nursing staff failed to notify the physician or ensure medication administration in accordance with facility policy, resulting in significant medication errors.
Surveyors found that a nurse left a medication cart unlocked while unattended, and two residents had medications (an inhaler and nystatin cream) unsecured in their rooms without proper assessment for self-administration or physician orders. Facility staff were unaware of the presence of these medications at bedside, and policies requiring secure storage and assessment for self-administration were not followed.
Staff failed to follow infection control protocols by not performing proper hand hygiene and not donning required PPE, such as gowns, during incontinent care, IV medication administration, and gastrostomy tube medication administration for residents on enhanced barrier precautions. These lapses occurred despite staff training and clear signage, affecting multiple residents with complex medical needs.
A resident with severe cognitive impairment and dementia was not provided with care plan meetings that included her representative, as required. The facility did not document or conduct quarterly care plan conferences, and the resident's representative confirmed she was never invited to participate. Staff interviews revealed that the responsibility for organizing these meetings was not fulfilled, resulting in the representative's exclusion from the care planning process.
A resident with a history of behavioral issues and cognitive impairment was struck in the head by another resident with psychiatric diagnoses and poor impulse control after a dispute involving a wheelchair. The incident was witnessed by a CNA, and records showed both residents had care plans addressing their behavioral risks, but staff intervention occurred only after the physical contact had taken place.
A resident with multiple mental health diagnoses was incorrectly coded on the MDS assessment as not having a serious mental illness or intellectual disability in the PASRR section, despite care plan documentation showing PASRR positivity and related services. Staff interviews confirmed the assessment should have reflected the resident's true status, and there was no specific policy for ensuring MDS accuracy.
A resident with a feeding tube and multiple medical conditions did not receive a scheduled enteral feeding as ordered by the physician. Staff interviews confirmed that the nurse responsible did not administer the feeding, despite care plan interventions and facility policy requiring adherence to physician orders for tube feedings.
A resident with COPD was observed receiving continuous oxygen therapy without a physician's order documented in the medical record. Nursing staff and administration were unaware of the missing order until notified by surveyors, despite facility policy requiring a physician's order specifying oxygen administration details.
Two CNAs did not change gloves or perform hand hygiene during incontinence care for a resident with multiple health conditions, despite being aware of facility policy and infection control requirements. Both staff handled the resident and personal items without proper glove changes or hand hygiene, as confirmed by interviews and policy review.
The facility employed a Food Service Supervisor who did not meet the required certification, education, or experience qualifications to serve as Director of Food and Nutrition Services. The FSS had not obtained certification as a dietary manager and lacked the necessary degree or experience, and the facility was aware of these deficiencies at the time of the survey.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors due to lapses in medication administration. One resident, a male with diagnoses including type 2 diabetes mellitus, schizophrenia, and hypertension, did not receive his ordered blood sugar checks or insulin for 21 out of 31 days in May. The resident attended an adult habilitation center Monday through Friday, where staff were not authorized to administer medications. Facility nurses documented the missed doses as the resident being away but did not notify the physician or ensure alternative arrangements for medication administration. The medical director and nursing staff were unaware that the resident was not receiving his prescribed blood sugar checks and insulin during his time at the center. Another resident, a male with a history of dysphagia, gastrostomy hemorrhage, muscle wasting, and hypertension, did not receive his scheduled dose of Metoprolol via gastrostomy tube at 4:00 p.m. on a specific date. The resident reported not receiving the medication, and the responsible nurse confirmed it was her duty to administer medications on time. The facility's policies require medications to be administered as ordered and for the physician to be notified if a dose is missed, but this protocol was not followed in this instance. Interviews with facility staff, including nurses, the medical director, the regional nurse consultant, and the administrator, confirmed that the expected practice was to administer medications as ordered and to notify the physician if a dose was missed. However, in both cases, the required medications were not administered as prescribed, and appropriate notifications were not made, resulting in significant medication errors for both residents.
Failure to Secure Medications and Assess Self-Administration
Penalty
Summary
Surveyors identified that a registered nurse failed to secure a medication cart when leaving it unattended to check a resident's blood sugar. The nurse admitted to forgetting to lock the cart and acknowledged responsibility for ensuring it was secured. Facility leadership, including the Regional Compliance Nurse and Administrator, confirmed that medication carts are expected to be locked when unattended to prevent unauthorized access. Additionally, a resident with COPD and asthma was observed multiple times with a labeled Albuterol inhaler on her dresser, which she reported using as needed and stated she brought from home. The medication was also found on the nurse's medication cart at one point, and the resident indicated she had informed someone at the facility about possessing the inhaler, though staff were unaware. The resident had not been assessed for self-administration of medication, and the inhaler was not secured as required by facility policy. Another resident was found with a tube of nystatin cream on her bedside table, which she stated was brought by her husband and used for itching. There was no physician order for the cream, and the resident had not been assessed for self-administration. Staff later instructed the resident to have the medication removed, but were initially unaware of its presence. Facility policy requires medications to be stored securely and only accessible to authorized personnel, and mandates assessment and physician order for self-administration, which was not completed in these cases.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not following proper infection control protocols during resident care. In one case, a CNA provided incontinent care to a female resident with dementia and congestive heart failure without changing gloves or performing hand hygiene between cleaning the resident's front and back areas. The CNA then touched clean items and assisted the resident to her wheelchair while still wearing the same contaminated gloves, only removing them and washing hands after completing all care tasks. Interviews confirmed that the CNA was aware of the correct procedures but did not follow them during the observed care. In another instance, an LVN administered IV medication to a male resident with sepsis and cellulitis, who was on enhanced barrier precautions (EBP), without donning a gown as required by the resident's care plan and facility policy. The LVN performed hand hygiene and wore gloves but omitted the gown, later stating that nervousness caused her to forget this step. The resident's care plan and EBP signage in the room clearly indicated the need for both gloves and gown during high-contact care activities, including IV medication administration. Additional deficiencies were observed with another male resident with quadriplegia and a feeding tube, also on EBP. An LVN administered medications via the resident's gastrostomy tube without wearing a gown, despite the presence of PPE supplies and EBP signage in the room. Furthermore, two CNAs provided personal care, including bathing, to the same resident without donning gowns. Both staff members acknowledged their training on PPE use and the importance of infection control, but failed to comply with established protocols during the observed care activities.
Failure to Involve Resident Representative in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident's representative was invited to participate in the development and review of the resident's person-centered care plan. The resident, an elderly female with dementia, muscle weakness, and anxiety, had been admitted to the facility several months prior. Her medical records indicated severe cognitive impairment, and her care plan included interventions to communicate with the resident and her family regarding her needs. However, there was no documentation in the electronic medical record that a care plan conference had been completed or uploaded since her admission. Interviews with the resident's representative confirmed that she had not been invited to any care plan meetings since the resident's admission. Facility staff, including the social worker, registered nurse coordinator, administrator, and MDS coordinator, acknowledged that care plan meetings should occur at least quarterly and that the social worker was responsible for ensuring these meetings were conducted. Despite this, the required care plan meetings had not taken place, and the representative had not been given the opportunity to participate in the resident's care planning process.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when one resident physically struck another in the head. Specifically, a male resident with a history of dementia, Alzheimer's disease, and behavioral problems, including physical aggression, was hit in the head by a female resident diagnosed with bipolar disorder, schizophrenia, and poor impulse control. The incident occurred in the day room when the male resident reportedly ran over the female resident's foot with his wheelchair, prompting her to hit him in the head. This event was witnessed by a CNA, who heard the altercation and observed the physical contact. Record reviews indicated that the male resident had documented short- and long-term memory problems and a history of behavioral issues, while the female resident had a care plan addressing her potential for physical behaviors and poor impulse control. The care plan for the female resident included interventions for immediate staff intervention in the event of physical behaviors toward others. Despite these documented risks and interventions, the physical altercation occurred, and staff intervention only took place after the incident had already happened. Interviews with staff and residents confirmed the occurrence of the incident, with the CNA stating she intervened immediately after hearing the altercation and witnessing the physical contact. The facility's policy states that residents have the right to be free from abuse, including abuse by other residents. However, the incident demonstrated a failure to prevent resident-to-resident abuse as required by facility policy and regulatory standards.
Inaccurate MDS Assessment Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with significant mental health diagnoses. Specifically, the MDS for a female resident with a history of bipolar disorder, schizophrenia, delusional disorder, and anxiety disorder was incorrectly coded in the PASRR (Preadmission Screening and Resident Review) section. The assessment marked that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite documentation in the care plan indicating that the resident was PASRR positive and receiving habilitation coordination and independent living skills training. Interviews with facility staff, including the MDS Coordinator, Regional Reimbursement Specialist, Regional Compliance Nurse, and Administrator, confirmed that the MDS should have been marked to reflect the resident's PASRR status. The Administrator acknowledged that monitoring of MDS accuracy was done through random audits or spot checks but could not recall the last audit performed. There was no specific policy or procedure in place regarding MDS assessment accuracy, and the facility relied on the RAI manual for guidance.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident who required enteral feeding via a gastrostomy tube. The resident, a male with diagnoses including dysphagia, gastrostomy hemorrhage, and muscle wasting, had physician orders for Nutren 2.0 to be administered through his PEG tube with specified flushes. The comprehensive care plan identified risks such as aspiration, weight loss, and dehydration, and included interventions to administer tube feeding as ordered. However, on a specified date, the resident did not receive his scheduled feeding, as confirmed by his own report and subsequent staff interviews. Interviews with nursing staff and facility leadership confirmed that it was the nurse's responsibility to administer the enteral feeding as ordered and that failure to do so could result in weight loss and other complications. The facility's policy assigned responsibility for tube feeding administration to the nursing service department. The deficiency was identified through record review and interviews, which established that the resident's enteral feeding was not administered according to physician orders on the specified date.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of COPD who was receiving oxygen therapy had a corresponding physician's order in her medical record. The resident was observed on multiple occasions using oxygen via nasal cannula, with the oxygen concentrator set at 2 liters per minute. The resident reported wearing oxygen at all times due to her COPD. Review of the resident's care plan indicated she was to receive oxygen therapy, but it did not specify the number of liters to be administered. Additionally, the physician order summary did not contain an order for oxygen, and the admission MDS had not yet been completed. Interviews with nursing staff and facility administration revealed that the lack of an oxygen order was not identified until brought to their attention by the surveyor. The charge nurse responsible for the resident's care and the regional compliance nurse both confirmed that an order should have been present in the electronic medical record. The facility's policy on oxygen administration requires a physician's order specifying the amount and method of oxygen delivery, which was not followed in this case.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to follow proper infection prevention and control protocols during incontinence care for a resident who was dependent for toileting and had multiple diagnoses, including diabetes mellitus, heart failure, anemia, anxiety disorder, malnutrition, and chronic obstructive pulmonary disease (COPD). During the observed care, the resident had a bowel movement and was wet. CNA A cleaned the resident's front, including the penis, while CNA B cleaned the buttocks. Both CNAs did not change gloves or perform hand hygiene between tasks, and subsequently put a clean brief on the resident and handled the resident's personal belongings without changing gloves or sanitizing their hands. Interviews with both CNAs revealed that they were aware of the requirement to change gloves and perform hand hygiene but chose not to do so, citing reasons such as working quickly and feeling nervous under observation. The facility's Infection Preventionist and Director of Nursing (DON) confirmed that staff are expected to change gloves and perform hand hygiene after cleaning a resident, as per facility policy. The facility's hand hygiene policy, last updated in January 2025, emphasizes the importance of hand hygiene in preventing the spread of healthcare-associated infections and requires all personnel to adhere to these practices.
Unqualified Food Service Supervisor in Food and Nutrition Services
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, as required by regulations. Specifically, the Food Service Supervisor (FSS) did not possess the necessary certification, education, or qualifications to serve as the Director of Food and Nutrition Services. The FSS was not a certified dietary manager or certified food service manager, did not have an associate's or higher degree in food service management or hospitality, and lacked two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. Although the FSS had completed a course of study in food safety management, he had not yet taken the exam to become a certified dietary manager and was therefore not eligible for certification at the time of the survey. Interviews with facility staff confirmed that the FSS assumed the position without meeting the required qualifications, and the Administrator was aware of this deficiency. The FSS consulted periodically with a registered dietitian, but the dietitian was not employed full-time by the facility. The lack of appropriately qualified leadership in the food and nutrition service could impact the facility's ability to ensure food safety and adequate nutrition for residents, as required by federal regulations and the Food Code.
Some of the Latest Corrective Actions taken by Facilities in Texas
- Re-educated the Chief Operating Officer on governing-board responsibilities for oversight of care, services, and vendor payments (L - F0837 - TX)
- Re-educated nurses and medication aides on medication-administration and error-reporting policies through one-on-one meetings and memos (L - F0837 - TX)
- Implemented ongoing Medication-Pass Observations to monitor administration accuracy (L - F0837 - TX)
- Established contingency procedures for internet or phone outages, including Hot-spot use and pharmacy-printed MAR/TAR backups (L - F0837 - TX)
- Initiated regular conference calls among DON, HR Director, CEO/COO, and future administrator to review vendor payments and supply needs (L - F0837 - TX)
- Directed all departments, maintenance, and laundry staff to monitor supply levels and promptly report low inventory to HR for replenishment (L - F0837 - TX)
- Added annual van registration and insurance checks to the maintenance checklist with administrator review during QAPI (L - F0837 - TX)
- Delivered abuse/neglect-prevention training to the Administrator and all staff, including new hires and agency personnel, using verbal instruction and post-tests (K - F0835 - TX) (K - F0600 - TX)
- In-serviced all team members on the 24-hour compliance hotline for reporting unresolved concerns (K - F0835 - TX)
- Posted compliance-hotline notices near the time clock and in breakrooms to encourage anonymous reporting (K - F0835 - TX)
- Required Regional and Clinical leaders to attend EMR meetings to ensure timely interventions for identified resident issues (K - F0835 - TX)
- Provided clinical-team education on two-hour rounding for residents needing assistance (K - F0600 - TX)
- Implemented daily IDT rounding to identify and address concerns for residents unable to communicate (K - F0600 - TX)
- Delivered one-on-one education to CNA staff on obtaining assistance rather than refusing assigned care (K - F0600 - TX)
Failure to Appoint Administrator and Maintain Essential Services
Penalty
Summary
The facility failed to ensure that a governing body appointed a state-licensed administrator responsible for managing the facility, resulting in a prolonged period without an administrator. During this time, the only administrative staff present were the DON and Human Resource Director, who reported that the facility had not been paying vendors, leading to the disconnection of essential services such as telephone, internet, and food deliveries. Staff members were forced to use their personal funds to purchase basic supplies for residents, including food, hygiene products, and laundry supplies, as the facility was unable to maintain regular operations due to unpaid bills. Multiple interviews with staff, including the DON, maintenance director, dietary manager, and others, revealed that the lack of an administrator and insufficient financial support from the governing body resulted in significant operational disruptions. The facility's phone and internet services were disconnected, making communication with families and healthcare providers difficult. The van used for resident transportation lacked insurance and current registration, causing residents to miss important medical appointments. Essential services such as laundry and food preparation were compromised, with staff reporting the use of cold water for laundry due to a broken hot water heater and the need to substitute menu items because of insufficient food supplies. Residents and their representatives expressed concerns about the absence of an administrator and the impact on care, including delays in hospice placement and missed medical appointments. The facility's inability to pay vendors also affected maintenance, with necessary repairs and services being delayed or denied. The cumulative effect of these failures led to the identification of Immediate Jeopardy, as the lack of oversight and resources placed residents at risk of decreased quality of life and care.
Removal Plan
- Re-educate the Chief Operating Officer (COO) on the governing board responsibility to ensure management and operation of the facility, with emphasis on oversight of facility care and services and vendor payments.
- Meet to review and make payments or payment arrangements for outstanding vendor invoices, including telephone/internet, van insurance, van registration, and fire/security services.
- If the internet is out, staff will use Hot spots for internet access; if Hot spots are not working, the DON will obtain paper-printed MARs and TARs from the pharmacy.
- The Social Worker will call each family to share the mobile phone number if/when needed.
- The Activity Director will complete resident interviews to identify residents affected by phone interruption and share with them the availability of mobile phone if needed.
- The Human Resource Director will contact the facility's vendors to share the phone number if/when required.
- Meet to review the facility's outstanding invoices and ensure vendor payments.
- The Director of Nursing (DON) will complete a Medication Error Form for each of the identified residents with medication errors, including communication with providers and corrective actions.
- The Chief Nursing Officer (CNO) will confirm completion of Medication Error Forms.
- The DON will re-educate nurses and certified medication aides on policies for administering medications and medication errors, using one-on-one meetings and memos, and will complete Medication Pass Observations.
- Provide education regarding obtaining MARs and TARs from the pharmacy if no internet is available, and Hot spots will be available for use.
- Post the facility administrator's vacant position and continue active recruitment, with a sign-on bonus.
- Communicate all items needed for resident care to the DON and HR Director, who will participate in conference calls with the CEO and COO to ensure vendor payments and supply needs.
- Continue conference calls with the new administrator once onboarded, and review minutes during QAPI to determine supply needs.
- Educate staff to communicate supply needs to HR, who will ensure supply is replenished before items run out.
- Educate laundry staff to notify HR when chemical supply is low.
- The Maintenance Director will monitor supply levels and communicate needs to HR.
- Department heads will monitor supplies and communicate needs to HR.
- Reimburse staff for out-of-pocket expenses per usual procedures, and HR will instruct staff not to purchase items for the facility in the absence of the administrator; all purchases will be made by the administrator and/or HR Director after the conference call.
- Add annual van registration and insurance to the annual maintenance checklist, and the administrator will review the checklist during QAPI.
- Hold an ad-hoc QAPI meeting, and notify the Medical Director of the deficient practice and removal plan; review action items during QAPI, with meeting minutes maintained.
Significant Medication Errors Due to Order Transcription and Administration Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving anticonvulsant medications. In the first case, a male resident with epilepsy and severe cognitive impairment was admitted with an order for phenytoin sodium extended-release capsules, 300 mg at bedtime. However, due to a transcription error by an LVN, the order was entered as 900 mg at bedtime, resulting in the resident receiving a triple dose for seven consecutive nights. This error was not identified during the daily morning meetings where new admission orders were supposed to be reviewed by the ADONs and DON. The resident subsequently developed symptoms consistent with phenytoin toxicity, including altered mental status, ataxia, and slowed speech, and was sent to the hospital where a toxic phenytoin level was confirmed. In the second incident, a female resident with a seizure disorder and moderate cognitive impairment had an order for carbamazepine to be administered as 400 mg in the morning and 100 mg at bedtime. The medication was only available in 200 mg tablets, and on at least one occasion, the resident received 200 mg at bedtime instead of the ordered 100 mg. Nursing staff were inconsistent in their administration practices, with one LVN stating she did not break tablets before crushing them, while another reported cutting the tablet in half. The resident's care plan did not address carbamazepine use, and the MAR reflected the incorrect administration. Both incidents revealed failures in medication reconciliation, order transcription, and verification processes. Staff interviews indicated a lack of consistent review and double-checking of new admission orders, as well as discrepancies between medication orders, MARs, and actual medication administration. The facility's policies required verification of medication orders and reconciliation with hospital records, but these procedures were not effectively implemented, leading to significant medication errors for the residents involved.
Removal Plan
- Licensed nurse completed a head-to-toe assessment, vital signs and neurological check on Resident #235 and findings revealed no abnormalities noted. Attending physician was notified and no new orders were given.
- Director of Nursing and/or Designee completed medication reconciliations to ensure that medications are given as ordered and documented on the MAR.
- Director of Nursing and/or designee conducted a review of all residents' changes in conditions, changes in level of care and signs and symptoms that possibly could have been medication toxicity. None was identified.
- Director of Nursing and/or designee conducted a review of all admissions/readmissions and ER visits to ensure medication orders are reconciled.
- Director of Nursing and/or designee conducted a toxicity Monitoring orders for all drugs with narrow therapeutic range and were added to EMAR.
- DON and/or Designee completed 100% medication reconciliation and MAR to Cart audit to ensure that medication on hand matches order and are administered as ordered.
- All licensed nurses were re-educated by the Director of Nursing or designee on the following: Abuse/Neglect and Exploitation, Medication Administration Policy and Seven Rights of medication administration, Medication Reconciliation, Change of Condition-signs/symptoms of medication toxicity and Md/RP notifications, Clinical Admission Process in EMR, 2 nurse verification on all new admission/readmission orders.
- 100% licensed nurses were re-educated on the following: Medication Administration Policy and Seven Rights of medication administration, Medication Reconciliation on new and medication order changes, Verification of medication label prior to medication administration.
- Licensed nurses who are out on PTO/ FMLA/ Leave of Absence will have the re-education completed prior to the start of their next scheduled shift.
- Newly hired licensed nurses will receive this training during orientation prior to providing care to residents. The training will include the above-stated educational components.
- Admission/readmission/new and medication order changes will be reviewed during the morning clinical meeting to ensure orders have been reconciled with hospital records and verified with physician. New and medication order changes will be reviewed to ensure medication is administered as ordered to include verification of medication label to match physician's orders. Review will also ensure that monitoring of adverse effects is ordered, completed, and documented and physician is notified for abnormal findings.
- Weekend RN and/or ADON will complete and review Medication reconciliation for admission/readmissions/new orders/medication order changes over the weekend.
- Director of Nursing will monitor compliance with medication administration policy and the seven rights of medication administration.
- Director/Designee will monitor compliance each weekday morning of new admission/readmission reconciliation completion and review medication order listing report to ensure new and changed medications are administered as ordered.
- Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/or designee reviews the order listing and medication reconciliation process is followed during clinical meetings.
- An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal.
Failure to Prevent Resident Drug Use and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with multiple complex medical and behavioral diagnoses, including COPD, multiple sclerosis, bipolar disorder, and legal blindness. The resident had a moderate cognitive impairment and required partial to moderate assistance with most activities of daily living. Despite being on parole for drug use and a sex offense, and after staff were informed by the resident's parole officer that he was bringing drugs into the building to sell to other residents, the facility did not implement effective interventions to prevent further incidents. The resident was found exhibiting signs of an overdose, including weakness, limpness, pinpoint pupils, confusion, and difficulty talking, and was subsequently transported to the hospital, where he tested positive for marijuana. Prior to this event, the resident had failed drug screenings, and the facility was aware of ongoing concerns about drug use among residents, as reported by multiple residents and staff. The facility did not have a care plan addressing the resident's behavior related to substance abuse, and there was no evidence of a thorough investigation or reporting to the state agency when drug use was suspected or confirmed. Interviews with residents and staff revealed that the smell of marijuana and reports of drug use were common, particularly during smoke breaks and in resident rooms. The Administrator and DON acknowledged awareness of these issues but did not take sufficient action to investigate, report, or prevent the introduction and use of nonprescription drugs within the facility. The facility's policy prohibited illegal drug use, but it was not effectively enforced, and staff were not in-serviced on recognizing or reporting signs and symptoms of drug use prior to the incident.
Removal Plan
- Resident #2 was assessed for signs or symptoms of drug use. MD was notified. Resident was drug tested.
- All residents will be in-serviced on the facility policy regarding illegal drug use.
- All residents will be assessed upon return from any leave from the facility for signs and symptoms of illegal drug use to include limpness on both sides of body, pinpoint pupils, confusion, and difficulty talking.
- All nursing staff will be in-serviced to perform and document the assessment upon return and if any signs and symptoms are noted the Administrator and DON will be notified, and the facility will follow the illegal drug use policy.
- The DON/designee will monitor the documentation for each resident return to ensure the assessments are complete.
- Resident is being discharged pending acceptance.
- The DON/designee will monitor the effectiveness of assessments completed of residents.
- QAPI meeting will be held and findings will be discussed.
- A pre/posttest will be completed by staff on signs/symptoms of drug use and ongoing.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Failure to Prevent and Address Resident Sexual Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement effective written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of a male resident with a history of sexually inappropriate behaviors. This resident, who had diagnoses including dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, was admitted without a care plan addressing his known sexually inappropriate behaviors. Despite documentation from a previous facility recommending placement in a male-only locked unit due to sexual aggression, the facility did not initially identify or address these behaviors upon admission. The resident engaged in sexually inappropriate conduct, including inappropriately touching a student visitor during an activity, making female residents uncomfortable with sexual gestures, and repeatedly being sexually inappropriate with staff. Multiple residents and staff reported feeling uncomfortable or unsafe due to the resident's actions, and these concerns were communicated to facility leadership. However, the facility did not implement effective interventions or services to address the resident's behaviors, nor did they in-service staff on how to properly handle such behaviors to prevent further incidents. The facility's leadership, including the DON and Administrator, failed to recognize or act upon the resident's history and ongoing behaviors. They did not conduct a full investigation or report the incident involving the student to the state agency or law enforcement, as required by policy. Additionally, the facility's abuse prevention policy was not fully implemented, and staff were not adequately trained or informed about handling sexually inappropriate behaviors beyond routine or initial training. These failures resulted in an Immediate Jeopardy situation, as residents and visitors were placed at increased risk for abuse and neglect.
Removal Plan
- The DON, Social Services Director, and designee(s) interviewed/assessed all residents for potential abuse by conducting safe surveys on each resident.
- Resident evaluated by primary care provider and provided a medication update.
- Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted. Psyche consult provided.
- Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible.
- IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions.
- Care plan revisions and interventions communicated to front line staff caring for resident.
- Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident.
- Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes.
- Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies.
- Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting.
- Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect.
- DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Process will be ongoing.
- In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Process will be ongoing.
- The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect. In-service will be ongoing.
- QAPI meeting will be held monthly, and findings discussed.
- The DON will monitor the effectiveness of interventions will be ongoing.
- A pre/posttest on abuse and neglect will be ongoing.
- The facility is still looking for proper placement of resident.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Failure to Prevent and Address Resident's Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to ensure a resident was free from abuse, neglect, and exploitation, specifically by not providing appropriate interventions and services to address the resident's ongoing sexually inappropriate behaviors. The resident, a male with dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, had a documented history of sexually inappropriate behavior at a previous facility, including recommendations for placement in a male-only locked unit. Upon admission, the facility did not care plan for these behaviors, and staff were unaware of the resident's history, despite clinical notes indicating prior sexual aggression. The deficiency was further evidenced when the resident inappropriately touched a student visitor during an activity, an incident that was reported to the DON and Administrator. However, the facility did not conduct a full investigation, report the incident to the state agency, or notify law enforcement. Interviews with other residents and staff revealed ongoing discomfort and reports of sexually inappropriate behaviors by the resident toward both staff and other residents, which had been reported to facility leadership without effective intervention. The care plan was not updated in a timely manner, and interventions such as 1:1 supervision were inconsistently implemented and not maintained. Additionally, the facility's abuse prevention policies and staff training were insufficient to address the specific risks posed by the resident's behaviors. Staff were not in-serviced on abuse/neglect and sexually inappropriate behaviors following the incident, and there was a lack of documentation and communication regarding interventions. The facility's failure to identify, investigate, and implement effective measures to prevent further incidents placed residents and visitors at risk of harm.
Removal Plan
- The DON, Social Services Director, and designee(s) interviewed/assessed all residents for potential abuse by conducting safe surveys on each resident.
- Resident evaluated by primary care provider and provided a medication update.
- Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted. Psych consult provided.
- Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible.
- IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions.
- Care plan revisions and interventions communicated to front line staff caring for resident.
- Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident.
- Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes.
- Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies.
- Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting.
- Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect.
- DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Process will be ongoing.
- In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Process will be ongoing.
- The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect. In-service will be ongoing.
- QAPI meeting will be held monthly, and findings discussed.
- The DON will monitor the effectiveness of interventions will be ongoing.
- A pre/posttest on abuse and neglect will be ongoing.
- The facility is still looking for proper placement of resident.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Failure to Provide Timely and Appropriate Respiratory Care During Acute Distress
Penalty
Summary
A facility failed to provide safe and appropriate respiratory care to a resident with significant respiratory needs, resulting in a deficiency. The resident, a male with diagnoses including heart failure, renal failure requiring dialysis, COPD, and respiratory failure, was admitted with orders for oxygen therapy and inhaled medications. During incontinence care, the resident developed respiratory distress, with oxygen saturation dropping to 66% while on 5 liters of oxygen via nasal cannula. Despite clear signs of distress, including labored breathing, use of accessory muscles, and rapid respirations, there was a delay in nursing intervention and escalation of care. Staff responses were inconsistent and did not align with professional standards or the resident's care plan. The nurse assigned to the resident did not enter the room until several minutes after being notified, and upon assessment, left the resident multiple times to call the physician rather than staying at the bedside. The nurse administered a nebulizer treatment, but the resident's oxygen saturation remained critically low, and the nurse did not immediately call emergency services. Other staff, including the wound care nurse and ADON, were not fully aware of the resident's status or the duration of his distress. The DON was present in the nurse station but did not assess the resident directly, and there was confusion among staff regarding when to call 911 and the use of available respiratory equipment such as a bi-pap machine. Interviews revealed gaps in staff knowledge and adherence to protocols for acute respiratory events. The facility lacked a rapid response policy, and staff were unclear about the threshold for activating emergency services. The resident remained in respiratory distress for approximately 40 minutes before receiving effective intervention with a non-rebreather mask and transfer to the hospital. The failure to promptly recognize and respond to the resident's acute respiratory needs, as well as to follow established care plans and professional standards, led to the identification of a deficiency by surveyors.
Removal Plan
- Notify Medical Director.
- Conduct emergent QAPI meeting.
- Re-educate staff on Professional Standards of Respiratory Care process.
- Provide one-on-one education to LVN A regarding acceptable standards of practice for residents in respiratory distress. Continue weekly education for LVN A for four weeks, monitored for understanding and implementation of knowledge.
- Educate all licensed nursing staff and certified nurse aides regarding acute change in condition including residents experiencing respiratory distress.
- Audit all patients that require respiratory treatment to ensure care plans and standards of practice are updated and followed.
- Educate new staff upon hire and monthly for 3 months on providing respiratory care according to professional standards of practice.
- Contract Respiratory Therapist to conduct ongoing monthly training and education for all licensed nurses to ensure professional standards of practice are followed for respiratory care needs.
- QAPI team to implement best practices including notifying 911 to transfer a resident to the hospital for respiratory distress with oxygen saturation below 70% and prompt immediate interventions and notification of Medical Doctor for any resident showing signs of respiratory distress.
- Monitor all current patients and newly admitted patients that require respiratory care for appropriate treatment and services.
Failure to Notify and Document Resident's Refusal of Nutrition and Hydration
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including a recent stroke, heart disease, and ataxia, was admitted to the facility and subsequently refused all meals and hydration from dinner on the day of admission through breakfast two days later. Despite this refusal, there was no documentation in the resident's progress notes regarding the lack of nutrition or hydration, nor was there evidence that the practitioner or responsible party (RP) was notified of the resident's ongoing refusal. The care plan was updated only after the resident was sent to the emergency room, and meal intake documentation was limited to entries indicating 0-25% consumption, with no option to record 0% intake. Interviews with staff revealed that the certified nursing assistant (CNA) informed the charge nurse of the resident's refusal to eat or drink, but the charge nurse did not document these refusals or notify the practitioner or RP. The nurse stated she became busy and did not complete the required documentation or notifications. Nurse practitioners who saw the resident during this period were not informed of the missed meals and were unaware of the resident's poor intake until after the resident was found to be lethargic and was sent to the hospital. The responsible party was only notified when the resident was being transferred to the emergency room, and expressed that earlier notification could have allowed them to intervene. Upon arrival at the hospital, the resident was diagnosed with acute encephalopathy, acute renal failure, and profound dehydration, requiring admission for further treatment. The facility's own policy required notification of the physician and RP in cases of significant changes in intake or nutritional status, but this was not followed. Multiple staff, including the director of nursing, administrator, and medical director, confirmed that the expected protocol was not adhered to, and that the lack of communication and documentation contributed to the resident's decline.
Removal Plan
- Resident #1 no longer resides in the facility.
- DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends.
- Residents identified with low or declining intake (25% or less) were immediately evaluated by nursing. NP/MD and RP notifications initiated.
- Care plans updated accordingly by DON/Designee.
- DON/Designee will in-service Licensed nursing/licensed agency staff re-educated and directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations. This will be added to licensed nurses' general orientation for new hires.
- DON/Designee will in-service CNAs/Agency CNA re-educated and directed to notify charge nurse of missed meals or poor intake (<25%), accurate documentation and communication expectations. This will be added to CNAs general orientation for new hires.
- Mandatory in-services will be completed with all current and oncoming nursing staff prior to start of shift worked.
- Competency for License staff and CNAs/Agency CNAs validation conducted on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses/CNAs general orientation for new hires.
- Administrator was in-serviced on department head meal manager schedule and details by Texas Area President.
- Department Heads will be in-serviced by administrator on meal manager requirements.
- DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily for a period to ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool.
- Any issues will be reported to the QAPI Committee meeting.
- Ad hoc QAPI to review the deficiency and the process for POR will be completed.
Failure to Notify Responsible Party and Practitioners of Resident's Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's responsible party and practitioners when there was a significant change in the resident's physical status, specifically a deterioration in health. The resident, a male with a history of cerebral infarction, hypertension, neoplasm-related pain, heart disease, ataxia, and myocardial infarction, was admitted to the facility and subsequently refused to eat or drink from dinner on his admission day through breakfast two days later. Despite this refusal, there were no entries in the resident's progress notes regarding the lack of nutrition or hydration, nor any documentation that practitioners or the responsible party were notified of the situation. Staff interviews revealed that the CNA informed the charge nurse about the resident's refusal to eat or drink, and both attempted to encourage intake without success. However, the charge nurse did not document these refusals in the electronic medical record, citing being busy, and did not notify the responsible party or practitioners. The nurse also mistakenly believed the resident was his own responsible party. Practitioners who saw the resident during this period were not informed of the missed meals, and documentation in the point-of-care system only allowed for a 0-25% intake range, not a true 0% intake, further obscuring the severity of the issue. The responsible party was only notified when the resident was being sent to the emergency room after being found lethargic with low vital signs. Upon hospital evaluation, the resident was diagnosed with acute encephalopathy, acute renal failure, and profound dehydration. Interviews with facility leadership confirmed that there was an expectation for staff to notify management, the responsible party, and practitioners when a resident refused meals or hydration, but this did not occur in this case. The facility's own policies required prompt notification in such circumstances, but these were not followed, resulting in a significant lapse in care and communication.
Removal Plan
- Resident #1 no longer resides in the facility.
- DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends. Residents identified with low or declining intake (<25%) were immediately evaluated by nursing. NP/MD and RP notifications initiated. Care plans updated accordingly by DON/Designee.
- DON was in-serviced by Regional Nursing to notify MD/NP and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations with return demonstration.
- DON/Designee will in-service licensed nursing staff/licensed agency re-educated and directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations. This will be added to licensed nurses' general orientation for new hires.
- Mandatory in-services will be completed with all current and oncoming nursing staff prior to start of shift worked.
- DON/Designee will complete competency validation conducted for licensed nurses/licensed agency on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses' general orientation for new hires.
- Administrator was in-serviced on department head meal manager schedule and details by Texas Area President.
- Department Heads will be in-serviced by administrator on meal manager requirements.
- DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily to ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool.
- Any issues will be reported to the QAPI Committee meeting monthly.
- Administrator will lead Ad hoc QAPI to review the deficiency and the process for POR.
Failure to Provide Timely Behavioral Health Services and Protect Residents from Harm
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of bipolar disorder and a history of aggressive behaviors received timely and necessary behavioral health care and services. Despite physician orders for psychiatric evaluation and management issued on two separate occasions, there was a significant delay in the resident being seen by psychiatric services. The resident exhibited escalating behaviors, including yelling, threatening, and physical aggression towards staff and other residents, which were documented in progress notes. The care plan included interventions for managing mood and behaviors, but these were not effectively implemented, and the resident did not receive psychological therapy as indicated in the MDS assessment. The resident's aggressive behaviors culminated in an incident where she scratched another resident with her fingernails during an outburst, resulting in injuries to the other resident's thigh. Documentation showed that the resident had a pattern of verbal and physical aggression, including threats with utensils and physical altercations. Staff interviews confirmed that the resident had ongoing behavioral issues since admission, and there was a lack of timely psychiatric intervention despite multiple referrals and physician orders. The delay was attributed to issues with the psychiatric service provider, including staff turnover and insurance problems, but there was no evidence of follow-up or alternative arrangements to ensure the resident's behavioral health needs were met. The other resident involved in the altercation had moderate cognitive impairment and required substantial assistance with activities of daily living. He sustained injuries as a result of the incident and expressed dissatisfaction with his care following the altercation. The facility's failure to implement behavioral health interventions and protect residents from harm was further evidenced by the lack of documentation of behavioral monitoring and the absence of timely psychiatric evaluation, despite clear indications and orders for such services.
Removal Plan
- Resident #1 was assessed and noted to be stable.
- An audit of Resident #1's current list of medications was performed by the Administrator to ensure all current medications were delivered and available in the facility.
- Resident #1 will be seen by Psych services for follow up and intervention (personal safety).
- Resident #1's care plan was updated with current psych diagnosis and interventions as well as specific behaviors and interventions.
- One on one monitoring has been placed for Resident #1 when near other residents until stable per psych NP recommendation or transfer out of the facility.
- Resident #2 was assessed after the event involving Resident #1, revealing no signs of distress or emotional agitation.
- Training of staff and audits of all residents identified as in need of behavioral health services as well as abuse and neglect were initiated by the Administrator.
- A spreadsheet was created with the identification of the services and if services were needed.
- The facility is verifying comprehension on staff training by following up after education based on a random selection.
- Staff will not be allowed to work their shifts until this Inservice and training has been completed.
- The Administrator will be responsible for the direct Inservice of her staff.
- All residents who have diagnoses or demonstrated signs of behavioral health concerns have the potential to be impacted by this deficient practice.
- The Administrator is directing the review of all residents with Behavioral Health diagnoses to identify unmet behavioral or psychiatric needs.
- All open psychiatric referrals were verified and re-submitted or scheduled.
- Review of all residents with Behavioral Health Diagnosis was started and completed by DON, ADON, Administrator.
- Creation of spreadsheet identifying unmet behavioral or psychiatric needs. Any other residents identified will be referred to psych as well. Responsible: DON, Admin, Social Worker.
- A review of their medications will be completed as well. The Psychiatrist will assist with any referrals or review of concerns that were identified with this audit.
- A review is scheduled for the Psychiatrist and Attending Physician on the medications as it relates to any current behaviors or events since the last Dose Reduction Review.
- The Regional Director of Operations has educated the Administrator, DON and ADON on behavioral care and services for the residents for the facility and comprehension will be verified at this same time.
- The administrator has created an audit tool to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders on behavioral health matters.
- Audits will be conducted by the DON daily for two weeks, weekly for two weeks and monthly for two months.
- A spreadsheet was created for the audit to be conducted and documented.
- Any negative findings will be reported to the administrator for immediate correction.
- The Medical Director was notified of the deficiency (F740) and an Ad-Hoc QAPI meeting was held to discuss the findings.
- All findings will be reported to the QAPI team for QAPI.
Failure to Provide Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for a resident with significant risk factors, including complete paraplegia, muscle weakness, and a history of sepsis related to a sacral wound. The resident was admitted with a stage IV pressure ulcer to the sacrum and an unstageable pressure area on the left heel. Despite physician orders for specific wound care treatments and the need for weekly skin assessments, the facility did not complete weekly skin assessments or consistently provide ordered treatments to the resident's wounds over a period of several weeks. Documentation revealed that the resident did not receive wound care treatments as ordered on multiple occasions for both the sacral wound and the left heel. The treatment administration records showed missed treatments, and there was a lack of weekly skin assessments following the initial admission assessment. The wound care doctor was not made aware of the pressure area on the left heel, and the wound care nurse had left the facility, leaving gaps in wound care oversight. The resident's wounds worsened during this period, with the sacral wound increasing in size and the left heel developing into a full-thickness open wound with necrotic tissue. Interviews with staff confirmed that weekly skin assessments were not performed, and treatments were not administered as ordered. The resident reported not receiving care to the left heel and was unaware of the wound due to paralysis. The nurse responsible for documenting treatments admitted to mistakenly signing off on treatments that were not performed. Observations confirmed the presence of an old, dated dressing on the left heel and significant deterioration of the wound. Facility policies required regular skin assessments and documentation, which were not followed, leading to the identification of an Immediate Jeopardy situation.
Removal Plan
- Resident #1 received a head-to-toe assessment including skin by the DON, findings of a worsening left heel were relayed to Medical Director and new orders received to clean wound with normal saline, pat dry, apply alginate with silver and cover with non-adherent dressing daily.
- Findings were relayed to the Medical Director.
- Emotional Distress Assessment completed for Resident #1 by the Social Worker with no emotional distress observed.
- Resident #1's Care Plan was updated by Corporate MDS Nurse regarding wound care and observations to be performed by staff. All nursing staff were in-serviced including PRN, agency staff and all newly hired staff prior to their shift.
- Charge nurses on staff conducted a 100% skin audit on 78 residents overseen by the DON. Charge nurses were in-serviced on proper skin assessment by the DON prior to the conduction of assessments. No other residents were identified as having unidentified skin issues.
- Administrator/DON initiated Staff in-service for ALL NURSING STAFF on Prevention of Pressure Ulcers, Pressure Ulcers/Skin Breakdown - Clinical Protocol & Abuse and Neglect. DON trained by VP of Clinical Services prior to start of in-service. If staff are unable to attend any of the in-services, they will be required to complete them before starting their assigned shift to include PRN staff, agency staff and any new hires.
- The Medical Director has been involved in developing the Plan of Removal. These conversations are considered a part of the QA process.
- A QAPI meeting was held with attendance of the Company President, Director of Nursing & VP of Clinical Services.
- This plan will be monitored through completion by corporate staff.
- Plan of Removal completion with continuation of oncoming staff and follow up.
Failure to Prevent Accidents Due to Inadequate Supervision and Implementation of Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for three residents. One resident, with moderate cognitive impairment and mobility issues, was able to leave the facility unsupervised and was returned by a community member after being found at a gas station over a mile away. Staff interviews revealed that the resident was last seen during a smoke break, and there was a lack of awareness among staff regarding the resident's whereabouts until he was brought back. Documentation showed that the resident was assessed as high risk for elopement, but interventions were limited to routine monitoring, and staff did not consistently monitor or supervise the resident as required. Another resident, with severe cognitive impairment and a history of stroke, was identified as high risk for elopement based on assessments and physician notes. However, the care plan did not include information or interventions related to this risk, and multiple staff members were unaware of any residents being high elopement risks. This lack of communication and failure to update care plans and inform staff resulted in inadequate supervision and increased the risk of elopement for this resident. A third resident, with a history of falls and moderate cognitive impairment, was not provided with required fall prevention interventions. Despite physician orders for a low bed and fall mat, the resident's bed was not in the lowest position and the fall mat was not in place at the time of a fall that resulted in a left hip fracture. Staff interviews confirmed that the interventions were not implemented, and the care plan did not specify these requirements. The incident report and staff statements indicated a lack of consistent implementation and monitoring of fall prevention measures for this resident.
Removal Plan
- Resident was discharged to a secured facility.
- All entrances to the facility have been key-pad locked and residents are not allowed out of the facility without an assigned staff member being with them.
- One resident who is high risk for elopement was placed on 1:1 monitoring until secure placement is located.
- All resident elopement assessments were completed, and high risk residents were identified.
- High risk resident's care plan was formulated and any resident care plans requiring updates were done.
- Administrator in-serviced department heads and facility staff on interventions for the identified high risk resident, including 1:1 monitoring, updated care plan, and Kardex update.
- Staff not available in person were contacted by phone and verbally in-serviced.
- Staff are informed that the administrator/designee will notify staff through the above measures and through an in-service if any other resident is deemed high risk for elopement.
- PRN, agency staff, and new hires will be educated on this process as they are assigned to work.
- Administrator will interview staff on their understanding and retention of education given to them on elopement and where to find information on residents at high risk for elopement.
- Regional Nurse will monitor new admission elopement assessments for high risk residents to validate that interventions are in place and communication is in the EMR system.
- Administrator will document this on an audit form.
- Regional nurse in-serviced the administrator and the director of nursing on reviewing any new admission elopement assessments to identify a resident scoring ten or more.
- Ensuring that any new staff are educated to the interventions of a resident deemed high-risk for elopement.
- Initial comprehension of education with the administrator and the DON was completed by questioning on understanding of the training by the regional nurse consultant.
- Regional nurse will document compliance using an audit form.
- Ad.Hoc QAPI meeting was completed with the IDT and the medical director to discuss this plan of removal.
- Resident's fall care plan interventions and Point of Care Kardex were reviewed and updated to reflect the resident's current condition.
- Regional Nurse Consultant/ADON reviewed the facility fall assessment report to identify residents at risk of falls and to validate that current interventions are in place on the resident care plan and Point of Care Kardex.
- RNC and the ADON reviewed all facility residents to validate that their fall interventions were care planned and that the Point of Care Kardex was updated to list the fall interventions.
- Audit was documented utilizing the PCC Fall Assessment score report.
- Additional residents were identified as at risk for falls. Each had a care plan developed with interventions added to their POC Kardex.
- RNC/administrator educated facility staff regarding where to find the information for fall interventions.
- Staff not receiving the initial education will receive it before starting their next assigned shift.
- Nurses were instructed to review the care plan, and CNAs were instructed to review the Point of Care Kardex.
- Interdisciplinary team were given a list of resident fall interventions by the RNC, to refer to while making rounds on their regularly assigned residents before the morning stand-up meeting and reporting any concerns during that meeting.
- IDT manager on duty will make rounds on the weekend to identify and immediately resolve concerns with fall interventions.
- Administrator verified the initial comprehension of staff training by questioning staff and documenting it on an audit form.
- Administrator and the RNC will document these tasks on a facility created audit form for record keeping purposes.
- RNC will review falls to ensure that the care plan is updated with a new intervention and that those interventions, if applicable, are carried over to the Point of Care Kardex.
- Any concerns will be corrected immediately and re-education given to the management team.
- Education understanding will be completed by the administrator by questioning the facility staff about where they can find the fall intervention information.
- RNC will complete education understanding with the management IDT by questioning them regarding IDT rounds and identifying problems with fall interventions specifically.
- Ad.Hoc QAPI meeting was held with the medical director and the IDT to discuss this plan of removal.
Failure to Prevent Neglect and Ensure Timely Care for Resident
Penalty
Summary
The facility failed to administer care in a manner that enabled effective and efficient use of its resources to maintain the highest practicable well-being of a resident. The administrator did not ensure that staff refrained from willful abuse and neglect, as evidenced by staff not assisting a resident out of bed at a reasonable time, causing her to miss breakfast and lunch on a regular basis. The resident was consistently left in bed for most of the day, despite care plans and interdisciplinary team agreements specifying she should be up in her wheelchair between 6:00 AM and 7:30 AM daily to eat meals and reduce her risk for aspiration pneumonia. The resident, an elderly female with rheumatoid arthritis, dysphagia, acquired neck deformity, and adult failure to thrive, was dependent on staff for transfers and required to be in her wheelchair to feed herself due to physical limitations. Multiple records, including care plans, progress notes, and video evidence, showed repeated instances where she was not assisted out of bed until the afternoon, resulting in missed meals and prolonged periods in soiled linens. Staff interviews confirmed that some aides refused to enter her room due to personal conflicts or perceptions of her being a difficult resident, and this refusal was tolerated by facility leadership. The resident experienced significant weight loss over several months, and both she and her family reported feelings of neglect and lack of dignity. Observations and interviews with staff, the resident, and her family revealed a pattern of neglect, with staff failing to follow the care plan and not providing timely assistance. Staff acknowledged that the resident was often not gotten up before breakfast, and some admitted to avoiding her room. Leadership interviews indicated awareness of the issue, with the administrator and others noting that staff were allowed to refuse care assignments. The facility's own policies required prevention and identification of neglect, but these were not followed, resulting in the resident missing meals, remaining in bed for extended periods, and experiencing psychosocial and physical harm.
Removal Plan
- Regional Director of Operations in serviced Administrator on Abuse/Neglect.
- Regional Director of Operations and Director of Clinical Services will attend EMR meetings to ensure any resident issues identified have appropriate interventions.
- Administrator in-serviced all team members on compliance 24-hour hot line where team members can report any concerns and or if administration is not taking corrective action or putting interventions in place to ensure residents are being cared for by staff appropriately.
- Compliance hotline notifications will be posted by time clock and breakrooms.
- Administrator trained by Regional Director of Operations.
Failure to Protect Resident from Neglect and Missed Care
Penalty
Summary
The facility failed to ensure that a resident was protected from psychosocial abuse and neglect, as evidenced by repeated failures to assist her out of bed at a reasonable time, resulting in her missing breakfast and lunch and remaining in a soiled brief for extended periods. The resident, who had diagnoses including rheumatoid arthritis, dysphagia, acquired deformity of the neck, and adult failure to thrive, was dependent on staff for transfers and required to be in her wheelchair to feed herself due to physical limitations. Her care plan specifically directed staff to get her out of bed between 6:00 AM and 7:30 AM daily and to ensure she was up for all meals, but this was not consistently followed. Multiple observations, interviews, and record reviews revealed that the resident was often left in bed until the afternoon, missing meals and personal care. Video evidence and staff interviews confirmed that on several occasions, she was not assisted out of bed until after 1:00 PM, and her call light was left unanswered for hours while she remained in soiled conditions. Staff acknowledged that some aides refused to enter her room due to perceptions of her being a 'difficult' resident, and this led to her care needs being neglected. The resident herself reported feeling hungry, neglected, and tired of being left in her own waste, and her family members corroborated these accounts, stating that the neglect was ongoing and not limited to isolated incidents. Documentation showed a significant weight loss over several months, and staff interviews confirmed that the resident's care plan was not being followed after an initial period of compliance. Staff also admitted to avoiding her room and not providing timely assistance, with some stating they would not go in due to previous accusations made by the resident. The administration was aware that staff were refusing to care for her and that she was missing meals and personal care, but failed to ensure consistent adherence to her care plan and basic care standards.
Removal Plan
- Facility team members were in serviced on Abuse/Neglect for all team members including new hires, PRN, vacation, Agency and Leave of Absence. Education will be provided through verbal in servicing and post-test will be given to ensure retention of education. DON/ADON were provided training on Abuse/Neglect by RDO/RDCS.
- Skin assessment was completed on Resident #1. Skilled Wound Care Physician will conduct an onsite visit.
- Interviewable residents were interviewed by IDT team to inquire if residents had any concerns with any basic care not being met.
- Weight loss summary report was reviewed for all significant weight losses for those residents who are not able to be interviewed to validate that residents who need assistance with meals did not sustain weight loss due to lack of required assistance with meal service and review meal intake documentation.
- Clinical team was in serviced on importance of Q2 hour rounding on residents requiring assistance to ensure their needs are being met.
- One on one education completed with CNA C regarding assisting residents or finding assistance to provide care for residents in need. All staff assigned to resident hall were in serviced that they cannot refuse to go into resident room as assigned. Administrator trained by Regional Director of Operations.
- Daily rounding will be conducted by the IDT team for all assigned residents to address any concerns and identify any issues for those residents unable to communicate.
- Ad HOC QAPI meeting with MD conducted to discuss the plan of correction for compliance.
Failure to Ensure Proper Bed Rail Installation, Assessment, and Maintenance
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for three residents reviewed for bed rail use. Specifically, the facility did not have the manufacturers' recommendations and specifications available or follow them for installing and maintaining bed rails, resulting in a large gap in one resident's bed rail. Observations revealed that a bed rail was loose and had a gap of approximately 14 to 18 inches between the mattress and the rail, and staff reported that the issue had persisted for 2-3 months without being properly reported or addressed. The Director of Plant Operations was unaware of the issue until surveyor intervention and did not maintain documentation or a log of maintenance requests or repairs, nor did he have the manufacturer manuals for the beds or bed rails. Additionally, the facility failed to develop care plans that addressed the risk of entrapment and did not implement interventions to prevent entrapment for residents with a history of falling out of bed. Care plans for these residents did not include the risk of entrapment, and bed mobility assessments indicated that bed rails were not recommended for use, yet the rails remained in place. Multiple incident reports documented repeated falls from bed for these residents, and consent forms for bed rail use were present but not aligned with current assessments or care plans. The facility also did not provide maintenance and monitoring of bed rails according to manufacturer specifications or recommendations. There was no evidence of regular, documented inspections, and staff were not consistently trained on the proper procedures for reporting broken or malfunctioning bed rails. The lack of proper installation, assessment, and maintenance of bed rails placed residents at risk for entrapment, serious injury, or death, as directly stated in the report.
Removal Plan
- The Director of Plant Operations changed the bed for resident #70 with properly operating bed rails.
- The Charge Nurse reassessed resident #70 for bed mobility and the bed mobility assessment for resident #70 was updated. The use of side rails was recommended per assessment.
- The Charge Nurse reassessed resident #102 for bed mobility and the bed mobility assessment for resident #102 was updated. The use of side rails was not recommended per assessment.
- The Director of Plant Operations removed the assist bar for resident #102 per recommendations from assessment.
- The Charge Nurse reassessed resident #87 for bed mobility and the bed mobility assessment for resident #87 was updated. The use of one bed rail for turning and repositioning recommended per assessment.
- The Director of Plant Operation removed the right bed rail from resident #102's bed.
- The Director of Plant Operations was educated according to Manufacturers Guidelines on proper installation of bed rails.
- The Director of Plant Operations conducted a Bed Rail Entrapment Assessment throughout the building to identify any bed rail posing a risk of entrapment.
- The Executive Director of Operation obtained the manufacturer's guidelines for each type of bedrail in the facility, and they are compatible for use with the beds that we have.
- Any non-compliant bed rail was either fixed or replaced to meet assessment standards and proper installation according to the manufactures guide.
- The Director of Plant Operations will complete the Bed Rail Entrapment Assessment.
- The Director of Clinical Operations and/or designee will conduct an audit of bed mobility assessments to ensure proper evaluation and documentation.
- If the bed mobility assessment indicated that bed rails were not needed, they were removed by the Director of Plant Operations.
- The Director of Clinical Operations and/or designee will lead training sessions to ensure team members understand proper procedures for identifying and addressing bed rail concerns.
- Team members must immediately report malfunctioning, broken, or non-working equipment to their Supervisor and the Director of Plant Operations via phone and on maintenance log.
- New team members will be educated regarding reporting any broken equipment during orientation.
- The Executive Director completed educational training with the Director of Plant of Operations regarding the completion of the Bed Rail Entrapment Assessment per company policy.
- Nursing staff and department managers educated on acceptable gaps for zone 1 and zone 3.
- Nursing staff will document on the licensed medication administration record the checks have been completed.
- Any gaps larger than 4-3/4 will be reported to the on-call phone and the maintenance log.
- Documentation will be completed on the company form for the assessment.
- The Executive Director of Operations completed educational training with the Director of Plant Operations on the manufacturer's guidelines on bed rails installation for the Medline (FCE1232RSRN) and Joerns beds (F14SC).
- Charge nurses must accurately complete bed rail assessments and determine if rails are suitable for resident use.
- Charge Nurses educated on how to accurately complete bed rail assessments.
- New charge nurses will be educated regarding completing an accurate bed rail assessment during orientation according to manufacturers' recommendation.
- If an assessment indicates bed rails are recommended, the team member must notify both the Director of Clinical Operations and the Director of Plant Operations immediately.
- New charge nurses will be educated regarding immediate notification to the Director of Clinical Operations and the Director of Plant Operations during orientation.
- The Director of Clinical Operation and/or Designee will complete training on accident/incident prevention, including types of interventions put into place to prevent any further fall.
- The Clinical Reimbursement Coordinator will conduct an audit of resident care plans, ensuring appropriate documentation of bed rail concerns.
- Care plans will be updated to specify bed rail risks and potential entrapment hazards.
- The Director of Clinical Operations notified the Medical Director of immediate jeopardy and reviewed bed rail policy and procedure.
- This practice will be reviewed with the QA Committee to ensure no changes are needed to the current policy.
- All actions outlined in this plan will be monitored for ongoing compliance, reinforcing our commitment to providing a safe environment for residents.
Failure to Prevent Accident Hazards and Inadequate Supervision of Smoking and Sharp Objects
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident, who had a history of seizures and required assistance with daily activities, sustained a cigarette burn on his thigh after dropping a cigarette while smoking. Documentation showed that he was assessed as an unsafe smoker and required supervision and a smoking apron, but on observation, he was not wearing the apron while smoking under supervision. There was no evidence that the incident was reported to the state, and staff interviews revealed a lack of awareness and follow-up regarding the incident and required interventions. Another resident, diagnosed with multiple sclerosis and assessed as an unsafe smoker, was allowed to sign out and smoke in an unsafe area without supervision and kept cigarettes, a vape, and a lighter in his possession. Staff interviews indicated confusion about the resident's supervision requirements and the facility's smoking policy, with some staff believing the resident could make his own decisions despite being deemed unsafe. Observations confirmed that the resident was unsupervised while smoking and vaping, and staff were unaware of the full extent of his access to smoking materials. Additional deficiencies included a resident assessed as a safe smoker who was observed smoking on the side of a residential street after signing out, and another resident with severe cognitive impairment who also signed herself out to smoke in an unsafe area. Furthermore, a resident with moderate cognitive impairment and dependence on staff for personal hygiene was found to have seven disposable razors stored insecurely in his room, accessible on top of his mini refrigerator. Staff acknowledged that razors should not be left in resident rooms and should be disposed of in sharps containers after use, but the razors remained accessible for an extended period.
Removal Plan
- Residents #22, #48, and #32 will be supervised when in an unsafe area. The physician was notified of both the smoking and residents leaving safe supervised area.
- All smoking assessments were audited for accuracy and care plan updated as indicated. Residents #22, #48, and #32 were reassessed and evaluation determined they are safe smokers and able to vape safely. Resident #25 was reassessed and evaluation determined he is an unsafe smoker.
- All smokers were reassessed, and changes made to safe or unsafe smoking, including vaping as indicated.
- Assessments completed by Corporate Clinical Specialist and Corporate Case Mix. Residents assessed to be unsafe will be supervised and smoking supplies will be held at the nurse's station. Residents assessed to be a safe smoker will be able to smoke unsupervised at their leisure in the designated smoking area.
- An emergency care plan meeting was conducted with residents (#22, #48, #32, and #25) regarding safe supervision and smoking policy, to include vaping. Residents #22, #48 and #32 were informed they can smoke only in the smoking area of the facility. Resident #25 was informed that he remains an unsafe smoker and must be supervised. All smoking residents were educated in regards to the smoking area of the facility and informed that location is the only place they can smoke. Care plans updated as indicated to include education regarding safety plan and pedestrian safety.
- Ombudsman notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn.
- Medical Director notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn.
- Corporate Clinical Specialist in-serviced Administrator and ADON regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, smoking assessment accuracy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz.
- Facility Administrator and ADON in-serviced all staff regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz. Staff will not be allowed to work until completion.
- Corporate Clinical Specialist in-serviced staff on residents that are safe smokers and those that are not, and how to find that information.
- Corporate Clinical Specialist, or designee, in-serviced licensed nurses on completing smoking risk assessment accurately as related to current health concerns/conditions, resident capabilities, and resident smoking material preference (cigarettes and/or electronic cigarettes). In-service included that Licensed Nurses are responsible for completing the smoking assessments upon admission, change of condition, and quarterly.
- The above training regarding Accident/Hazard Supervision, specifically in regard to safe smoking and safe supervision will be implemented into new hire orientation.
- To monitor compliance, residents will be monitored by the DON/designee through observations and communication with staff daily and monthly.
- DON/designee will review smoking assessments weekly and monthly.
- The QA committee will meet weekly to review compliance with the plan of action. If no further concerns are noted, the facility will continue to be monitored as per the routine facility QA committee.
Failure to Prevent and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that further incidents were prevented during the investigation process. Specifically, three residents were involved in multiple altercations, both verbal and physical, with one resident repeatedly instigating arguments, making inappropriate comments, and engaging in physical aggression toward other residents. Despite documented behavioral issues and previous incidents, the facility allowed the alleged perpetrator to remain in the facility and have direct contact with other residents, including those who had previously been involved in altercations with him. The records show a pattern of behavioral problems, including verbal aggression, inappropriate touching, and physical altercations involving the same resident. This resident had a history of mental health diagnoses, including bipolar disorder and impulse disorder, and had been the subject of multiple care plan interventions and counseling referrals. However, the interventions implemented were not sufficient to prevent further incidents, as the resident continued to have direct contact with others and was involved in additional altercations, including kicking another resident and engaging in fights during smoke breaks and in the dining area. Other residents and staff reported ongoing issues with this resident, describing him as an instigator who frequently caused disruptions and conflicts. The facility's documentation and interviews indicate that, although some assessments and care plan updates were made following incidents, there was a lack of effective action to prevent further abuse or mistreatment while investigations were ongoing. The facility did not ensure the separation of the alleged perpetrator from potential victims, and there was insufficient evidence of thorough investigation or immediate protective measures. This failure resulted in an Immediate Jeopardy situation, as residents remained at risk for further harm due to the continued presence and actions of the resident with a history of aggressive and inappropriate behavior.
Removal Plan
- All staff in-serviced by Executive Director of Operations/Director of Clinical Operations and/or designee on Prevention, Identification and Reporting/Investigation of Abuse. All staff not present at time of in-service will not be permitted back to work until in-service is complete.
- The Executive Director of Operations/Director of Clinical Operations were in-serviced by the Regional Director of Clinical Operations on Prevention, Identification and Reporting/Investigation of Abuse.
- Resident #3 was placed on one-to-one monitoring.
- Discharge Planning initiated to family for Resident #3. Family agreed by phone to discharge resident to their care. Resident remained on one-to-one monitoring until discharge.
- Safe Surveys were conducted by Director of Resident Support Services and/or designee with all residents cognitively able to participate. Action taken based on survey results included: Resident #3 was on one-on-one monitoring; resident with wound care concern no longer in facility; resident who reported CNA roughness was reinterviewed, care plan and tasks updated, and one-on-one in-service to be completed with CNA.
- All residents identified as at risk for physically aggressive behaviors were reviewed by the Clinical Resource Coordinator/Assistant Director of Clinical Operations to ensure they had an accurate care plan, appropriate interventions and appropriate Psych Services or Counseling Services.
- The Director of Clinical Operations/Assistant Director of Clinical Operations/Executive Director of Operations will monitor EMR documentation including the 24-hour report, incident reports and alerts, and Grievances to identify potential abuse or situations requiring further investigation during morning meeting.
- Abuse allegations will be reported and investigated according to company policy and THHS regulations.
- Potential abuse or situations requiring further investigation will be documented on a Grievance form.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in multiple resident-to-resident altercations and incidents of physical and verbal aggression. Several residents with varying degrees of cognitive and physical impairment were involved in these incidents. For example, one resident with bipolar disorder, impulse disorder, and Parkinson's disease was involved in multiple altercations, including fighting with another resident in the smoking area, being hit with a walker by a different resident in the dining room, and kicking a resident with severe cognitive impairment during breakfast. These events were often preceded by arguments, verbal aggression, or behaviors such as instigating conflicts and making inappropriate comments. Another resident with vascular dementia and hemiplegia was involved in a physical altercation in the smoking area, where both he and another resident ended up on the ground after an argument escalated. The care plans for these residents included interventions such as monitoring for signs of danger, psychological evaluations, and staff supervision, but these measures were not effective in preventing the altercations. In one case, a resident with severe cognitive impairment and hemiplegia was threatened and grabbed by another resident, and later kicked by a different resident, despite care plan interventions intended to prevent such incidents. Interviews with residents and staff revealed a pattern of ongoing behavioral issues, with one resident frequently instigating arguments and being verbally aggressive toward others. Staff and residents reported that this individual had a history of behavioral problems, including being physical with other residents and making inappropriate comments. Despite being aware of these behaviors and having care plans in place, the facility did not prevent repeated incidents of abuse and altercations among residents, leading to the identification of an Immediate Jeopardy situation.
Removal Plan
- All staff in-serviced by Executive Director of Operations (EDO)/Director of Clinical Operations (DCO) and/or designee on the following topics: Prevention, Identification and Reporting/Investigation of Abuse; How to Immediately Protect Residents when abuse is suspected; Possible Interventions to Assist with De-escalation after an Incident. All staff not present at time of in-service will not be permitted back to work until in-service is complete.
- Resident #3 was placed on one-to-one monitoring. Discharge Planning initiated to family. Resident remained on one-to-one monitoring until discharge.
- Safe Surveys were conducted by DRSS and/or designee with all residents cognitively able to participate. Action taken based on survey results, including care plan and task updates and one-on-one in-service for CNA as needed.
- All residents identified as at risk for physically aggressive behaviors were reviewed by the CRC/ADCO to ensure they had an accurate care plan, appropriate interventions and appropriate Psych Services or Counseling Services.
- The DCO/ADCO/EDO will monitor EMR documentation including the 24-hour report, incident reports and alerts, and Grievances to identify potential abuse or situations requiring further investigation during morning meeting.
- Abuse allegations will be reported and investigated according to company policy and THHS regulations. Potential abuse or situations requiring further investigation will be documented on a Grievance form with any investigation documentation attached.
- All staff in-serviced on the Grievance process and utilizing the Grievance form to document the potential abuse or situation and the investigation.
- The Medical Director was made aware of the immediate jeopardy and involved in the development of the plan to remove during an abbreviated QA. Next scheduled QA meeting set.
- Monitoring of the Plan of Removal will be conducted through personal observation, through completion by Regional President of Operation and Regional Director of Clinical Services.
Failure to Notify Physician and Assess Resident with Abnormal Vitals and Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident reviewed for quality of care. Specifically, the facility did not document assessments or notify the physician when the resident's vital signs were abnormal over several days, despite clear parameters in the physician's orders for when to hold antihypertensive medications and when to notify the physician. The resident's blood pressure and heart rate were repeatedly below the specified thresholds, and antihypertensive medications were held accordingly, but there was no documentation of physician notification or further assessment. Additionally, staff and the resident's family expressed concerns about the resident's lethargy and fatigue throughout the week, but these concerns were not adequately addressed or escalated. The resident involved was an elderly female with a history of multiple fractures, hypertension, atrial fibrillation, chronic pain, and repeated falls. Upon admission, she required assistance with mobility and activities of daily living and had occasional urinary incontinence. During her stay, her blood pressure and heart rate were frequently low, and she exhibited increasing lethargy and fatigue, as noted by therapy staff, family, and in some nursing documentation. Despite these symptoms and abnormal vital signs, there was no evidence that the physician was notified or that further interventions were implemented until the resident's condition became critical. On the day her condition significantly worsened, the resident's family measured a critically low blood pressure and alerted nursing staff, who then assessed the resident and found her to be lethargic and minimally responsive. Only at this point was the physician notified, and the resident was transferred to the hospital, where she was diagnosed with sepsis from a urinary tract infection. Interviews with staff revealed inconsistent understanding and application of protocols for notifying the physician of abnormal vital signs and changes in condition, and the facility did not have a policy on blood pressure assessments. The deficiency was identified as Immediate Jeopardy due to the failure to ensure timely treatment and care in accordance with orders and standards of practice.
Removal Plan
- Inform the Medical Director of the Immediate Jeopardy.
- In-service licensed staff on notifying physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
- Train staff on notifying the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, assessing a resident for change of condition, and notifying physician of change in conditions.
- Review all patients for documented low blood pressure. If a patient is noted to have blood pressures outside of the specified order parameters, notify the MD or NP. If neither are available, or in an emergent situation, contact emergency services (911).
- In-service ADON, Administrator, Medical Records, and Wound Care Nurse on notifying physician of change of condition and assessing the patient for change in condition and identifying a major decline or improvement in the resident's status.
- Initiate staff (LVN, RN, CNA) in-servicing on notifying of changes in condition and quality of care. Any staff who have not received in-servicing will not be permitted to work until in-servicing has been completed. In-servicing will be on-going for PRN, new staff, staff on leave, agency (if applicable).
- If a CNA obtains abnormal vital signs they will notify their charge nurse immediately. Charge nurse will then re-assess resident and re-take vital signs. The physician is to be notified of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
- Notify the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, based upon direction of the medical director.
- Define abnormal vital signs as: Systolic BP less than 90, Diastolic less than 50, Systolic greater than 180, Diastolic greater than 100, Heart rate less than 50, Heart rate greater than 130.
- ADON/DON/designee will review the exception report for low blood pressures with systolic blood pressures less than 90 and diastolic less than 50. Review will occur daily for 2 weeks, then 5 times weekly for 6 weeks, then 3 times weekly for 4 weeks.
Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident representative when there was a significant change in the resident's condition or a need to alter treatment. Specifically, the facility did not notify the physician when the resident's vital signs were abnormal over several days, despite documentation and reports from staff and family that the resident was lethargic and fatigued. The resident was ultimately sent to the hospital after the family alerted a nurse to critically low blood pressure, where the resident was diagnosed with sepsis from a UTI. The resident involved was an elderly female with a history of multiple medical conditions, including fractures, hypertension, chronic pain syndrome, atrial fibrillation, repeated falls, and reduced mobility. Her care plan did not include a focus on urinary incontinence, risk for UTI, or hypertension. Medication administration records showed that antihypertensive medications were held multiple times due to low blood pressure, but there was no documentation that the physician was notified of these abnormal readings. Staff interviews revealed that the resident was observed to be lethargic and fatigued throughout the week, with these concerns reported by both staff and family, but not escalated to the physician. Interviews with facility staff, including the DON, nurses, and CNAs, indicated a lack of clarity and consistency regarding when to notify the physician of abnormal vital signs and changes in condition. The facility's policy required prompt notification of the physician and resident representative for significant changes, but this was not followed. The physician confirmed he was not notified of the abnormal vital signs prior to the resident's transfer to the hospital. The failure to notify the physician and the resident's representative of significant changes in condition was identified as a deficiency by surveyors.
Removal Plan
- Inform the Medical Director of the Immediate Jeopardy.
- In-service licensed staff on notifying physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
- Train staff on notifying the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, assessing a resident for change of condition, and notifying physician of change in conditions.
- Review all patients for documented low blood pressure. If a patient is noted to have blood pressures outside of the specified order parameters, notify the MD or NP. If neither are available, or in an emergent situation, contact emergency services (911).
- In-service ADON, Administrator, Medical Records, and Wound Care Nurse on notifying physician of change of condition and assessing the patient for change in condition and identifying a major decline or improvement in the resident's status.
- Initiate staff (LVN, RN, CNA) in-servicing on notifying of changes in condition and quality of care. Any staff who have not received in-servicing will not be permitted to work until in-servicing has been completed. In-servicing will be on-going for PRN, new staff, staff on leave, agency (if applicable).
- If a CNA obtains abnormal vital signs they will notify their charge nurse immediately. Charge nurse will then re-assess resident and re-take vital signs. The physician is to be notified of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
- Notify the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, based upon direction of the medical director.
- Define abnormal vital signs as: Systolic BP less than 90, Diastolic less than 50, Systolic greater than 180, Diastolic greater than 100, Heart rate less than 50, Heart rate greater than 130.
- ADON/DON/designee will review the exception report for low blood pressures with systolic blood pressures less than 90 and diastolic less than 50. Review will occur daily for 2 weeks, then 5 times weekly for 6 weeks, and then 3 times weekly for 4 weeks.
Failure to Prevent and Document Double Dosing of Narcotic Medications
Penalty
Summary
A deficiency occurred when three residents received double doses of their scheduled narcotic pain medications due to failures in medication administration and documentation. Specifically, a medication aide administered narcotic pain medications to three residents but did not sign off the administration in the electronic medical record (EMR), only on the narcotic count sheet. The aide wrote the medication administration on a piece of paper and gave it to the nurse on the next shift, who subsequently forgot about the note and, seeing the medications still due in the EMR, administered a second dose to each resident. Both staff members acknowledged they had been trained that the person administering the medication is responsible for signing off in both the EMR and the narcotic count sheet. The residents involved had complex medical histories, including dementia, chronic pain, and other significant diagnoses. The double dosing of narcotic medications was not documented in the residents' progress notes, and there was no follow-up monitoring of the residents for adverse effects after the error. Additionally, responsible parties for the residents were not notified of the medication errors, and the errors were not included in the 24-hour report to inform subsequent shifts. The facility's policy required prompt reporting of medication errors, detailed documentation, and close monitoring of affected residents, none of which were followed in this incident. Interviews with facility staff, including the DON, administrator, and medical director, confirmed that the required documentation, monitoring, and notifications were not completed. The medical director expressed concern about the lack of follow-up monitoring, stating that vital signs and respiratory status should have been checked due to the risk of narcotic overdose. The failure to adhere to established medication administration and error reporting protocols led to the identification of an Immediate Jeopardy situation by surveyors.
Removal Plan
- Responsible parties for Residents #1, #2, and #3 were contacted and made aware of the med errors.
- The Medical Director was made aware of past med error.
- Missed Medication Report was pulled to ensure no other residents were administered narcotics twice.
- Review of all Narcotic sheets was completed to ensure that there were no double doses of narcotics based on the sign out sheets and comparing to nurse notes and EMARs.
- ADONs are reviewing count sheets daily to ensure no double doses have been administered.
- The Chief Operating Officer and Director of Clinical Operations educated the DON and Administrator with a posttest to show understanding.
- The Director of Nurses provided training to the nurses and medication aides on duty with a post test to show understanding.
- Training for nurses and med aides on duty was provided with a post test to show understanding.
- Training was concluded for all staff on-site.
- Training will be concluded for those not present; they will be educated and required to pass a post test before they take their next assignment.
- New hires will receive training from the DON or designee during new hire orientation.
- The person who made the error(s) received an in-service and a disciplinary action.
- Residents with med errors were assessed and all notifications were made and documented by the ADON and CHARGE NURSE.
- Ad-Hoc QAPI meeting was held to discuss medication errors and failure to document; in-services over administering medications, medication errors, and notifications and reviewed post test for administering medications.
- Missed Medications report will be run during daily stand-up meeting to review medications that were missed.
- Any medication errors, the staff member will be contacted and an in-service and disciplinary action (where necessary) will be initiated.
- All nursing staff who administer medications will be given reminder education over the policy and procedures by the DON or Nurse Managers that will be initiated immediately following the med error until all staff who administer medications has received re-education.
- The ADONs are reviewing count sheets to ensure no one has been double dosed or that a dose has been missed and not documented in the EMAR. This is part of their morning routines.
- Missed Medication Report will be run prior to daily stand-up meeting by the DON. This will be an ongoing process.
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