Citations in Utah
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Utah.
Statistics for Utah (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Utah
Several residents reported that meals were cold, unappetizing, and sometimes insufficient, with observations confirming that food was served below recommended temperatures and appeared unappealing. Staff interviews revealed improper use of equipment to maintain food temperature due to shortages, and resident council minutes documented ongoing complaints about cold food.
A policy change restricted beverage options for residents, allowing only water between meals and limiting coffee and juice to meal times. The Dietary Supervisor confirmed that staff were instructed not to provide other beverages between meals, even upon request, due to cross contamination concerns. Residents expressed complaints about the new policy.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite having a wander guard alarm in place. Staff failed to respond appropriately to the alarm, did not verify the resident's location, and turned off the alarm without notifying others, resulting in the resident being unsupervised outside the facility for several hours.
A resident with multiple sclerosis and paraplegia, who was at high risk for falls and used an air mattress, was not provided with two-person assistance during a brief change. During care, the resident lost control and fell from the bed, resulting in bilateral femur fractures. Staff interviews revealed inconsistent understanding of assistance requirements for residents on air mattresses, and the care plan did not specify two-person assist for bed mobility at the time of the incident.
A resident who required 1:1 supervision while smoking was left unattended in the smoking area by a PRN PT who was unaware of the supervision requirement. The resident's clothing caught fire, leading to significant burn injuries and hospitalization. Another resident sustained burns to his hand while attempting to help. The DON confirmed that staff were unaware of the unsupervised situation and that supervision was not provided as required.
A resident with diabetes and dementia, who had a physician's order for a minced and moist diet due to swallowing difficulties, was given inappropriate snacks by nursing staff who were unaware of the updated diet order. The nurse relied on outdated report sheets that did not include diet texture information, leading to the resident choking and passing away after consuming the food.
A resident with severe dementia and urinary incontinence was left in a wet brief for approximately eight hours, leading to a rash and excoriation. The assigned CNA failed to perform required two-hour checks, gave conflicting accounts of care provided, and blocked staff from entering the room. Staff interviews confirmed that the resident was unable to communicate her needs and required frequent incontinence care, which was not provided, resulting in physical harm.
A resident with a history of brain hemorrhage and seizures experienced an unwitnessed fall and subsequently showed decreased responsiveness and vomiting. Despite these significant changes, nursing staff delayed notifying the medical provider and waited for the NP to arrive before arranging hospital transfer. The DON later confirmed that immediate physician notification was expected in such cases, and the family expressed concern over the delay. The resident was later found to have a new brain bleed and passed away.
A resident with a history of brain hemorrhage and multiple falls experienced an unwitnessed fall, after which staff initiated neurological checks but failed to document them properly and delayed notifying the medical provider about the resident's change in condition, including vomiting and decreased consciousness. The resident was not sent to the hospital until later in the day, where a brain bleed was diagnosed, and the resident passed away days later. Staff interviews revealed confusion about documentation and escalation procedures, contributing to harm.
The facility did not ensure that three residents with complex medical conditions were offered the COVID-19 vaccine or that their acceptance or refusal was documented. Record reviews and an interview with the DON confirmed the absence of required documentation for these residents.
Failure to Provide Palatable and Properly Heated Food
Penalty
Summary
Surveyors identified that the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for three of nineteen sampled residents. Multiple residents reported dissatisfaction with the quality and temperature of the food, including complaints that meals were cold, unappetizing, and insufficient. One resident stated that the food tasted very poor and that breakfast consisted only of toast and coffee. Another resident reported that the food was served cold, while a third resident described the lunch as unappealing and did not eat it. Observations during trayline service revealed that food items, including popcorn chicken, rice, and brussel sprouts, were served at temperatures below recommended levels and were cold to the taste. The appearance and texture of the food were also noted to be unappetizing, with brussel sprouts described as mushy and discolored, and the dessert having an unusual flavor combination. Further investigation revealed that the kitchen staff did not consistently use the proper equipment to maintain food temperature, as there were not enough bases/liners for all residents, leading to the use of hot pellets alone, which did not retain heat adequately. Staff interviews confirmed that the correct procedure was not always followed due to equipment shortages. Resident council meeting minutes from several months also documented ongoing complaints about cold food, indicating a pattern of unresolved issues related to food service quality and temperature.
Failure to Provide Beverages Consistent with Resident Needs and Preferences
Penalty
Summary
The facility failed to provide beverages consistent with resident needs and preferences and sufficient to maintain hydration. A sign posted in the resident elevator announced a policy change restricting beverage availability, stating that only water would be provided between meals and that coffee and juice would only be served at meal times. Residents were informed that if they wanted beverages other than water between meals, they would need to provide their own, with vending machines planned for future installation. The Dietary Supervisor confirmed that this policy was implemented due to concerns about cross contamination from residents bringing their mugs to the kitchen, and that kitchen staff were instructed not to provide beverages other than water between meals, even if residents requested them. The Dietary Supervisor also acknowledged that residents had complained about the change since its implementation.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, including dementia and a history of alcohol dependence, was assessed as high risk for wandering and elopement. The resident had a documented history of increased wandering, previous elopement attempts, and impaired decision-making skills. The care plan included interventions such as the use of a wander guard alarm system, staff education on elopement policy, and engagement in purposeful activities. Despite these measures, the resident was able to exit the facility unsupervised and was missing for several hours. On the day of the incident, the resident exited the building, triggering the wander guard alarm. A staff member turned off the alarm without notifying other staff or verifying the resident's location. Other staff members assumed the resident was accounted for and did not physically check on him when the alarm sounded. The resident was later found outside the facility and returned by staff. Interviews revealed that staff were aware of the resident's elopement risk and the protocol for responding to wander guard alarms, which included verifying the location of all residents with wander guards and notifying staff via walkie talkies. However, these protocols were not followed during the incident. Documentation and interviews indicated that the resident had previously eloped, both before and after the implementation of the wander guard. The facility's policy stated that alarms are not a replacement for necessary supervision and that staff must respond to alarms promptly. The failure to respond appropriately to the wander guard alarm and to verify the resident's whereabouts resulted in the resident's unsupervised exit from the facility.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall and Fractures
Penalty
Summary
A resident with multiple sclerosis, paraplegia, a history of falls, and other significant medical conditions was admitted and later readmitted to the facility. The resident was using an air mattress and had bilateral side rails to assist with bed mobility. The care plan specified a two-person assist for transfers but did not include a two-person assist for bed mobility, despite the resident's high risk for falls and use of an air mattress. On the day of the incident, a CNA was providing a brief change for the resident. During the process, the resident rolled to her left side, let go of the positioning bar to grab her catheter, and subsequently lost control, sliding off the bed. The CNA attempted to hold the resident but was unable to prevent the fall, as the resident lost control from her hips down. The resident sustained scratches on her face and was later found to have bilateral femur fractures, requiring hospital admission. Interviews with staff revealed inconsistent understanding of the requirements for two-person assistance for residents on air mattresses. Some CNAs believed that the need for assistance depended on the resident's individual ability, while others relied on shift reports or personal observation. The DON confirmed that the resident should have had a two-person assist for bed mobility due to the air mattress, but this was not reflected in the care plan at the time of the incident.
Failure to Supervise Smoking Resident Results in Fire and Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two of seven sampled residents. One resident, who had a physician's order and care plan requiring one-to-one supervision while smoking due to a seizure disorder and potential for injury, was left unattended in the designated smoking area by a PRN physical therapist. The therapist, who was not aware of the supervision requirement, left the resident with cigarettes and a lighter and returned inside the facility. There were no other staff present in the smoking area at the time. While unsupervised, the resident's shirt caught on fire. Another resident attempted to extinguish the flames with his hand but was unsuccessful, resulting in burn injuries to his own hand. A third resident alerted staff by shouting for help. Staff responded by bringing a smoking blanket and a fire extinguisher, and the nurse used the blanket to put out the flames. The fire department arrived within 5-10 minutes, and the resident who caught fire was transported to the hospital with significant burn injuries. The second resident sustained burns to his fingers while trying to help. The facility's investigation confirmed that the resident who required supervision was left alone due to a lack of communication and understanding of the care plan by the PRN therapist, who primarily worked at another facility. The Director of Nursing acknowledged that the staff were unaware of the resident being left unsupervised and that the required supervision was not provided, resulting in injuries to both residents involved.
Failure to Provide Diet Consistent with Physician Orders Results in Resident Harm
Penalty
Summary
A resident with diagnoses including type 2 diabetes and vascular dementia, and a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition, had a physician's order for a minced and moist texture diet with thin consistency due to recent swallowing complications such as coughing and vomiting up food. Despite this order, the resident was provided with a cheese stick and pretzels as a snack after a low blood sugar reading. Both food items were not appropriate for the prescribed diet texture. The nurse, who was training a new nurse at the time, was unaware of the resident's updated diet order. The nurse report sheet only documented how residents took their pills and did not include information about diet texture. The updated diet order was present only in the primary care provider's orders and was not reflected in the nurse report sheet or the treatment/medication administration records. The nurse did not receive any information during shift report about changes to the resident's diet or new swallowing difficulties. After the resident consumed some of the provided snack, staff found the resident choking and unresponsive. Despite attempts to clear the airway and perform the Heimlich maneuver, the resident passed away. The facility's investigation determined that the incident occurred because the nurse did not have access to the resident's texture restrictions at the point of care, as this information was not readily available or communicated to nursing staff.
Resident Left in Wet Brief for Extended Period Resulting in Skin Breakdown
Penalty
Summary
A deficiency occurred when a resident with severe dementia and urinary incontinence was left in a wet brief for an extended period, resulting in a rash and excoriation to the groin area. The resident was unable to communicate her needs and relied on staff for incontinence care. On the evening in question, the assigned CNA failed to perform the required two-hour checks and did not change the resident's brief for approximately eight hours. When oncoming staff arrived, they found the resident saturated with dried and wet urine up to her shoulders, and the nurse confirmed the resident's condition and documented skin breakdown. Multiple staff interviews revealed that the CNA assigned to the resident gave conflicting accounts of when care was last provided, initially claiming to have changed the resident multiple times, then admitting she had not done so since the afternoon. The CNA also blocked other staff from entering the resident's room and yelled at a coworker who confronted her about the lack of care. Other CNAs and nurses stated that routine practice was to check and change residents at least every two hours, and that leaving a resident in a wet brief could quickly lead to skin breakdown or infection. The facility's policy required regular incontinence care and monitoring to prevent neglect and harm. Staff interviews confirmed that the resident never refused care and that there were standing orders for frequent checks due to her incontinence and cognitive impairment. The failure to provide timely incontinence care directly resulted in physical harm to the resident, as evidenced by the documented skin issues and the observations of multiple staff members.
Failure to Immediately Notify Physician After Resident's Change in Condition Post-Fall
Penalty
Summary
A deficiency was identified when the facility failed to immediately consult with a resident's physician following a significant change in the resident's physical status after a fall. The resident, who had a complex medical history including traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, epileptic seizures, and obstructive hydrocephalus, experienced an unwitnessed fall in the early morning hours. Initial assessment by staff indicated the resident was alert and reported no pain, and the physician, DON, and family were reportedly notified. However, subsequent documentation and interviews revealed that the resident exhibited a decrease in level of consciousness and episodes of vomiting, which were not promptly communicated to the medical provider. Nursing staff continued neurological checks and observed that the resident was less responsive than her baseline, requiring manual opening of her eyes for pupil assessment. Despite these concerning signs, the nurse on duty waited for the Nurse Practitioner (NP) to arrive later in the morning before taking further action, citing previous family concerns about hospital transfers and the resident's DNR status. The NP, upon being notified and assessing the resident, immediately recognized the need for hospital evaluation due to the resident's lethargy and vomiting, and arranged for transfer to the emergency room. Interviews with facility staff confirmed that there was a delay in notifying the medical provider about the resident's change in condition, particularly the decrease in responsiveness and vomiting following the fall. The DON stated that such changes should have prompted immediate physician notification. The family expressed concern that the resident was not sent to the hospital promptly, especially given her history of brain bleeds and falls. The resident was later found to have suffered a catastrophic new brain bleed and passed away several days after the incident. The facility's internal investigation did not address the failure to respond to the resident's change in condition.
Failure to Provide Timely Care and Physician Notification After Resident Fall
Penalty
Summary
A resident with a complex medical history, including traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, epileptic seizures, and obstructive hydrocephalus, experienced an unwitnessed fall in the early morning hours. The resident was found on the bathroom floor by her husband and was initially assessed as alert, with no pain or apparent neurological deficits. Neurological checks were initiated, and the physician, DON, and family were notified via text. However, documentation of the neurological assessment following the fall could not be located in the medical record. Throughout the morning, the resident exhibited a change in condition, including episodes of vomiting and decreased level of consciousness. Staff noted that the resident was more lethargic than usual and required assistance to open her eyes for neurological checks. Despite these concerning symptoms, the resident was not immediately sent to the hospital. The nurse practitioner was notified later in the morning and, upon assessment, determined that the resident needed to be transported to the emergency room. The resident was sent to the hospital by a non-emergent ambulance, where she was diagnosed with a brain bleed and subsequently passed away four days later. Interviews with facility staff revealed inconsistencies in the process for documenting and escalating care for residents with changes in condition following a fall. Staff were unclear about the handling and storage of neurological check forms, and there was a delay in notifying the medical provider of the resident's deteriorating condition. The facility's investigation did not address the resident's change in condition, and the lack of timely intervention and documentation contributed to the finding of harm for the resident.
Failure to Document COVID-19 Vaccine Offer and Refusal
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine and that their acceptance or refusal was properly documented. During interviews and record reviews, it was found that for three out of five sampled residents, there was no documentation indicating whether the COVID-19 vaccine was offered or refused for the year 2024. The residents involved had significant medical conditions, including quadriplegia, protein-calorie malnutrition, anxiety disorder, type 2 diabetes mellitus, morbid obesity, schizoaffective disorder, major depressive disorder, dementia, and adult failure to thrive. The Director of Nursing confirmed that there was no documentation available to show that these residents were offered or refused the vaccine, and stated that a refusal form should be completed if a resident declines vaccination.
Some of the Latest Corrective Actions taken by Facilities in Utah
The facilities implemented several corrective actions to address the safety and supervision deficiencies.
- The facility assessed the resident for injuries, contacted police upon suspicion, and updated care plans as needed. Staff received training on abuse prevention and elopement protocols. (J - F0600 - UT)
- The Director of Nursing audited residents with medical devices to ensure proper care planning and staff training. Staff were trained on safe transfers and accident prevention, including appropriate transfer techniques. The Administrator ensured transportation staff were trained and competent in securing residents during transport. (J - F0726 - UT) (J - F0689 - UT)
- The facility partnered with an organization to provide training and new protocols for resident transport. Transportation staff were reeducated on proper securement procedures and underwent competency evaluations. The Quality Assurance Performance Improvement Committee approved the updated driver safety program and implemented ongoing audits. (G - F0689 - UT)
- The facility audited residents' transfer statuses to ensure appropriate equipment was used. Staff received re-education on changes in condition, appropriate lifts, and safe transfer methods. Department heads conducted spot checks to verify compliance with transfer protocols. (G - F0689 - UT)
Failure to Provide Timely Care and Monitoring for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, leading to deficiencies in care. Resident 46 experienced ongoing emesis and abdominal pain, but the facility did not ensure timely monitoring or intervention. Despite receiving a stat order for an ultrasound, the facility delayed contacting the contracted radiology provider, resulting in a significant delay in obtaining the ultrasound. The resident continued to experience symptoms without adequate assessment or communication with the physician, ultimately leading to the resident's death. Resident 46 had a complex medical history, including hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder. Despite these conditions, the facility staff failed to document and communicate the resident's change in condition effectively. Multiple staff members observed the resident's deteriorating condition, including vomiting and abdominal pain, but there was a lack of coordinated response and communication with the medical team. Similarly, Resident 298, who had a history of dementia, hypertension, and acute kidney failure, did not receive timely diagnostic testing for a suspected deep vein thrombosis. The facility canceled a scheduled appointment and failed to ensure the ultrasound was performed promptly. This lack of timely intervention and communication with healthcare providers contributed to the deficiency in care for both residents.
Removal Plan
- The community management team implemented a morning Standup meeting with Nursing to get report from previous day's activities/concerns. If changes in condition are noted from communication notes, DON or ADON will verify MD team had been notified and if notification has not been made will do so at that time. Consultants will attend morning meetings when in-person and participate in random morning meetings when offsite to ensure compliance.
- The nursing team implemented a new shift communication form that will be relayed at shift change with oncoming nurse for concerns/follow-up items still pending at shift change. All forms will be left in the drawer at nurse's station for management review at the next morning standup meeting. Consultants will provide training on this process.
- A new CNA communication program/sheets implemented as a way for CNAs to communicate with oncoming shift and report to nurse. Sheets will be collected daily and reviewed during the daily standup meeting with department managers. Consultants will provide education and training on this process.
- Nursing implemented a new Communication and Follow-Up book that will remain at the nursing station. The book is a duplicate copy book with highlights and follow-up items from the previous day. The original will be removed and reviewed at daily manager Standup meeting. Consultants will provide education and training on this process.
- Communication improvements made between the building and MD team by adding the DON and Administrator to the secure messaging app between the MD group and Facility. Areas of concern or issues that arise will be addressed in the manager stand-up meeting.
- Representatives from the consulting organization reviewed and assessed the facility's policies and procedures regarding changes in resident condition. The consultants provided the community with a change of condition policy to adopt. The consultants provided education and training with licensed nursing and nursing assistants.
- Facility in coordination with the consulting organization, the consultants will complete record reviews of all residents to ensure no resident has experienced a change in condition not previously identified. Any findings of change of condition will be reported to the resident's attending physician and the resident's representative. This information will be communicated with the DON and Administrator at the manager stand-up meeting.
- The consultants ongoing will review daily progress notes to ensure documented changes of condition are timely identified and action steps are taken with resident changes of condition.
Resident Found in Locked Therapy Room with Alleged Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an Immediate Jeopardy citation. A resident with a history of dementia and cognitive impairments was found missing by staff, and after a search, was discovered exiting a locked therapy room. The resident made statements indicating that a male staff member engaged in sexual actions with her. The therapy room was inaccessible to staff, and the resident was found pale, nauseated, and disoriented, with therapy paperwork in hand. Interviews with staff revealed that the therapy room was locked, and the resident was missing for approximately 20 minutes. Staff observed the resident exiting the therapy room, appearing sick and disoriented. The resident later disclosed to staff that she and a male staff member attempted to engage in sexual activity, which was reportedly consensual according to the resident. However, the resident's cognitive impairments raised concerns about her ability to consent. The male staff member, a Physical Therapy Assistant, was found in the facility after hours, contrary to previous instructions. Staff reported that the therapy room was usually unlocked, and the male staff member's presence in the facility after hours had been a concern. The facility's failure to ensure the safety and security of the resident, as well as the lack of access to the therapy room, contributed to the deficiency.
Removal Plan
- Resident and staff member were separated.
- Police contacted upon suspicion.
- Resident assessed; no injury noted.
- Notification to Physicians, POA, Incident reported by administrator to DHS, APS, Ombudsman.
- Resident interviewed with administrator.
- Hospital evaluation completed, no trauma noted.
- Resident care plan reviewed and updated as needed.
- Provider to assess/evaluate residents including medication review.
- Social Services wellness visits to be completed for resident and PRN.
- Behavioral health visit requested with local mental health provider.
- Therapy staff member was immediately placed on administrative leave, facility keys/badge provided to administrator.
- Therapy staff member was questioned and released by the police, pending potential charges.
- Employee file was reviewed.
- Therapy staff member will not return to the facility.
- Regional Director of Operations spoke to Therapy Regional Director and informed him that staff are not to stay in the facility after normal business hours without the approval of the facility administrator.
- Facility will ensure the therapy staff working in the facility have background checks (DACS) that are connected to the facility.
- All residents interviewed by administrator/designee to assess potential for abuse/neglect allegations.
- Locks will be removed from all doors and/or Master Key accessible to charge nurse on medication cart.
- Staff Members will not remain in the facility after normal business hours without the approval of the facility administrator.
- Administrator, DON and RNC reviewed Abuse & Neglect Policy.
- Administrator, DON and IDT were educated by RNC regarding Abuse & Neglect Policy.
- Administrator/DON/designee will complete Abuse & Neglect education with all staff.
- Education including post-test initiated for all facility staff on Abuse/Neglect.
- All employees will be educated at start of their next shift or if no scheduled shift by all staff meeting.
- The DON/designee will review incidents of sexually inappropriate behavior to ensure appropriate interventions are implemented and no trends are noted.
- The Administrator/designee will conduct random resident & staff interviews to ensure the Abuse & Neglect Policy have been followed and allegations have been investigated and reported.
- The facility administrator/designee will do random facility visits during off hours to ensure that only staff clocked in and assigned to be working are in the facility and that the charge nurse has a Master Key to all locked doors in the facility.
- The Administrator/designee will review employee files (including contracted therapist) to ensure they have completed abuse training, verification of license and background checks (DACS) is connected to the facility.
- Medical Director was informed of the incident and QAA Review & Recommendations.
- Results will be reported to the QAA committee from monitoring and follow-up.
Failure to Prevent Sexual Abuse and Elopement
Penalty
Summary
The facility failed to prevent an instance of sexual abuse between two residents and neglected to provide the necessary supervision to prevent the elopement of another resident. Resident 269, who had severe cognitive impairment and a history of wandering, was found naked from the waist down on top of Resident 270, who was also cognitively impaired and nonverbal. The incident occurred when the staff responsible for monitoring the memory care unit were occupied with other tasks, leaving the residents unsupervised. This lack of supervision allowed Resident 269 to enter Resident 270's room and engage in inappropriate behavior, which was only discovered when therapists were searching for Resident 269 for a therapy session. The facility's failure to monitor Resident 269's wandering behavior and provide adequate supervision directly led to the incident of sexual abuse, which was verified by the facility's investigation. In a separate incident, Resident 17, who had a history of wandering and severe cognitive impairment, eloped from the facility. The resident was found and returned by a police officer. The facility's records indicated that Resident 17 had been assessed as a high risk for wandering and required frequent safety checks. However, the facility failed to implement a coordinated plan to supervise the resident's whereabouts, leading to the elopement. The receptionist, who was assisting another resident outside, believed that Resident 17 eloped through the front door during this time. The facility's lack of a coordinated plan and failure to monitor Resident 17's wandering behavior resulted in the resident's elopement. Both incidents were determined to be noncompliant and constituted immediate jeopardy. The facility's failure to prevent the sexual abuse of Resident 270 and the elopement of Resident 17 highlighted significant lapses in supervision and monitoring of residents with known wandering behaviors and cognitive impairments. These deficiencies were identified through interviews, record reviews, and witness statements, which documented the events leading to the incidents and the facility's inadequate response to the residents' needs for supervision and safety.
Removal Plan
- Resident was assessed for injury; no injuries were found.
- Facility representative spoke with family who reported that she had done this type of thing at home.
- Resident was determined to be a high risk for further elopements and would need to be moved to the secure unit. Resident was transferred to the secure unit to prevent further elopements.
- IDT reviewed the elopement.
- A training was conducted for the all staff meeting. Clinical training topics included labs, abuse reporting, and elopement prevention.
- Facility IDT met to review elopement process.
- Elopement binder was created for all high-risk residents on Cambridge.
- CNA Coordinator was given instructions to create tools for the staff, including a task sheet to alert staff of high-risk behaviors for residents and elopement sheets for the elopement binder.
- CNA Coordinator was given responsibility to round at least twice daily to verify the unit was running smoothly and that staff had the tools they needed to care for the residents.
- Administrator/Designee began holding meetings with CNA coordinator regarding the flow of the unit, communication, and the competency of the supervising staff on the unit.
- QAPI committee reviewed the events and identified the need for further interventions for elopement/abuse prevention.
- QAPI committee began creating care kits for memory care residents to decrease boredom, exit seeking, and help residents who were up at night.
- Residents were separated, and the abuse investigation was initiated.
- The police were notified, CMS was notified.
- The resident was placed on 1:1 with the intention to remain until the investigation was complete and interventions could identify how to prevent recurrence.
- The victim was moved off the unit.
- An internal meeting was held to review the investigation with the Regional Nurse Consultant, the Director of Clinical Services, the Corporate LCSW, the Facility Administrator, and Director of Nursing.
- Director of Nursing conducted an in-service with facility staff on Abuse Prevention with a post-test validation.
- The perpetrator was reviewed by the Behavioral Health Facility Committee to validate interventions were effective and further abuse prevented.
- Corporate LCSW provided a training with the Social Services Department on Sexual Intimacy in the LTC setting, Assessing Capacity to Consent, Care Planning, and appropriate Documentation.
- Corporate LCSW came to the facility and assessed the Perpetrator and reviewed the interventions in place.
- Cameras were set up to enhance visibility in the unit for staff.
- Computers in the unit were connected to be able to view halls for when CNAs were busy in rooms.
- Facility reviewed staffing patterns on the unit to validate that there was proper supervision on the unit.
- An investigation was conducted and found that the abuse program was not being run in accordance with facility policy and procedure.
- The administrator was terminated.
- A facility manager took over the facility with significant oversight of the RVP/Designee.
Inadequate Staff Training Leads to Resident Injury
Penalty
Summary
The deficiency involved a failure to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care for a resident, leading to a series of incidents that compromised the resident's well-being. A resident was transported in a facility van without proper securement of their wheelchair, resulting in the resident falling backward and sustaining a hyperextension injury to the neck. This incident led to a diagnosis of central cord syndrome and edema at the C6 and C7 levels of the cervical spine. The facility's failure to provide adequate training for staff responsible for transporting residents was a significant factor in this incident. Following the transport incident, the resident's care continued to be compromised. Upon returning to the facility, the resident's cervical collar, which was ordered to be worn at all times, was removed by CNAs during grooming and bathing. This removal occurred without proper supervision or understanding of the potential risks, as the CNAs were not adequately trained or informed about the necessity of the cervical collar. The resident was then unsuccessfully transferred to bed, resulting in the resident being assisted to the floor, further indicating a lack of competency in safe transfer techniques among the staff. The report highlights that the facility did not conduct proper orientation and training for newly hired nurse assistants and CNAs, which contributed to the inadequate care provided to the resident. The CNAs involved in the incidents were not properly trained on the use of medical devices such as the cervical collar, nor were they adequately supervised during critical care activities. This lack of training and supervision was a direct cause of the deficiencies observed, leading to the resident's compromised safety and well-being.
Removal Plan
- The Director of Nursing/Designee to do an audit of all residents to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place.
- The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs.
- The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff.
- The Director of Nursing to provide training to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material.
- The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport.
- Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed.
- The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents.
- The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe.
- The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards.
- All Staff will receive training by Director of Nursing/Designee prior to their next working shift.
- The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed.
- The facility to review the 24-hour report in daily stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing.
Facility's Failure to Ensure Resident Safety Leads to Multiple Incidents
Penalty
Summary
The facility failed to ensure a safe environment for its residents, resulting in multiple incidents of harm and immediate jeopardy. One significant incident involved a resident who was improperly secured in a wheelchair during transport in the facility van, leading to a fall that caused a hyperextension injury to the cervical spine, resulting in central cord syndrome. The resident's condition was further compromised when CNAs removed the cervical collar during grooming and bathing, which was against the medical order for the collar to be worn at all times. This lack of adherence to safety protocols and inadequate staff training on securing residents during transport and handling medical devices contributed to the resident's injury and subsequent complications. Additionally, the facility experienced several other incidents indicating a failure to maintain a hazard-free environment and provide adequate supervision. These included a resident sustaining a fractured hip after multiple falls, another resident tripping over a broken structural column, and a resident being unsafely discharged and found wandering. There were also instances of residents eloping from the facility, a resident being injured by another resident with a razor, and a resident being hit by a meal cart. These events highlight the facility's systemic issues in identifying and mitigating accident hazards and ensuring resident safety. The facility's deficiencies were compounded by inadequate staff training and oversight. The CNA Coordinator responsible for the transport incident had not received proper training on securing residents in the transport vehicle. Furthermore, the facility's documentation practices were insufficient, as evidenced by the lack of monitoring orders for the cervical collar and incomplete incident reports. These deficiencies underscore the need for comprehensive staff training and robust safety protocols to prevent future incidents and ensure resident well-being.
Removal Plan
- The Director of Nursing/Designee to do an audit of all residents to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place.
- The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs.
- The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff.
- The Director of Nursing to provide training to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material.
- The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport.
- Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed.
- The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents.
- The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe.
- The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards.
- All Staff will receive training by Director of Nursing/Designee prior to their next working shift.
- The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed.
- The facility to review the 24-hour report in daily stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing.
Resident Injury Due to Improper Securement During Transport
Penalty
Summary
The facility failed to ensure that a resident received the necessary supervision and assistance devices to prevent an accident during transportation. Specifically, a resident was not properly secured in a facility vehicle, leading to the resident sliding out of their wheelchair and sustaining a femur fracture. The incident occurred when the transportation driver had to brake suddenly, and it was later revealed that the lap belt was not secured on the resident. The resident involved had a medical history that included diabetes mellitus type 2, hypotension, muscle weakness, and required assistance with personal care and mobility. The resident used a wheelchair and had moderately impaired cognition, as indicated by a BIMS score of 11. On the day of the incident, the resident was being transported back from a doctor's appointment when the accident occurred, resulting in injuries that required hospitalization. The transportation driver admitted to neglecting to secure the lap belt, although the wheelchair was harnessed at four points. The incident was reported to the Survey State Agency, and the facility's investigation confirmed the oversight in securing the resident properly. The resident was evaluated by a facility nurse and emergency medical services were called, leading to the resident's transport to an acute care hospital where a left femur fracture was diagnosed.
Removal Plan
- The facility entered into an agreement with an organization to implement and provide training and new protocols to transport facility residents.
- All staff who performed transportation services for the facility were reeducated on proper securement of residents during transport, which included training videos produced by the contracted organization.
- Transportation staff attested to the completion of the training by signing training records.
- Transportation staff were required to complete a post-training test.
- All staff members who performed transportation services were required to read and sign the Fleet Safety Program book.
- Staff members were interviewed regarding safety during transportation.
- Administrative staff interviewed residents to determine if there were additional concerns about safety during transportation.
- The facility's Quality Assurance Performance Improvement (QAPI) Committee approved the updated driver safety training program.
- The transportation supervisor will audit the transport of each driver daily for 2 weeks, followed by audits on 3 random days of the week for 1 week, with an audit 1 day per week for 1 week.
- The transportation supervisor will perform ongoing random audits.
- The transportation supervisor or designee will validate transportation driver's pre and post-securement, documenting the results every week for 4 weeks then bi-weekly for 2 weeks, and 3 random audits every month thereafter.
- The transportation supervisor will report any trends or concerns to the QAPI committee for review for 90 days.
- Any discrepancies will be addressed at time of discovery.
Inadequate Supervision and Improper Transfer Method Result in Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices for a resident, leading to an accident. Resident 217, who had a history of cerebrovascular accident, right bundle branch block, heart failure, and major depressive disorder, was dependent on staff for transfers due to his inability to stand. Despite this, on a specific date, CNA 4 used a sit-to-stand device to transfer the resident, contrary to the care plan that required a Hoyer lift with two-person assistance. During the transfer, the resident was unable to bear weight, causing his arms to move upward, but the transfer was completed without immediate signs of pain. Subsequently, the resident was found to have a swollen and bruised left shoulder, which was later diagnosed as a fracture of the left humeral surgical neck. The facility's investigation revealed that the injury likely occurred during the improper transfer by CNA 4. The resident's condition, compounded by his non-verbal status due to the cerebrovascular accident, meant he could not communicate pain effectively, delaying the recognition of the injury. The facility's documentation and communication were also found lacking. The weekly skin assessment inaccurately reported no skin issues, despite bruising being observed earlier. Additionally, the bruising was not reported to management until two days after it was first noticed. This delay in reporting and the initial use of an inappropriate transfer method contributed to the harm experienced by the resident.
Removal Plan
- Audit all residents with current sit to stand transfers to ensure the current lift being used is appropriate for the resident status.
- Perform re-education 1:1 in huddles or over the phone regarding change of condition, bruising, range of motion, and which lift is appropriate for resident current condition.
- Complete audits with department heads on spot checking rooms to ensure staff members are using the appropriate lift with two-person transfer.
- Make unit managers aware of any changes with therapy evaluation with the lifts.
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