Making CMS Citations Actionable for LTC Providers

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A facility failed to provide necessary supervision to prevent an avoidable accident involving a resident with severe cognitive impairment, a history of stroke, dementia, and dysphagia, who was on a pureed diet with nectar thick liquids. The resident required staff assistance with eating due to an inability to control the speed and quantity of food intake, as documented in the care plan, Kardex, and speech therapy notes. Despite clear instructions and repeated education to staff that the resident needed supervision during meals to prevent rapid, impulsive self-feeding and reduce the risk of aspiration or choking, a nurse aide left a meal tray in front of the resident and exited the room to deliver other trays. Shortly after the meal trays were distributed, another nurse aide found the resident unresponsive and not breathing, with food in his mouth. Nursing staff initiated CPR and called EMS, who arrived and took over resuscitation efforts. The resident was transported to the hospital, where he was intubated after a second cardiac arrest and admitted to the ICU. Hospital records and the death certificate confirmed that the cause of death was airway occlusion by a bolus of food. Interviews with staff, including nurse aides, nurses, the speech therapist, the DON, the administrator, the nurse practitioner, and the medical director, confirmed that the resident was known to require supervision during meals due to impulsive eating behaviors and high risk of choking. The nurse aide who left the tray was new, had not previously worked with the resident, and had been incorrectly informed by other aides that the resident could feed himself without assistance. The failure to provide required supervision directly led to the resident being left alone with food, resulting in choking and subsequent death.

Removal Plan

• Resident #132 was provided with his breakfast tray by Nurse Aide #8, who walked out of the resident's room.
• The charge nurse completed a Risk Management and Situation Background Assessment Recommendation (SBAR). The Administrator, Director of Nursing, Medical Director, and Responsible Party were all notified.
• Resident #132's diet consistency, supervision needs, and feeding requirements were reviewed by the Director of Nursing and Administrator. The Registered Dietician confirmed that Resident #132 was appropriate for a puree diet with thickened liquids, with staff supervision required during meals.
• A root cause analysis was determined by the Administrator, Director of Nursing, and Eastern Regional Administrator that Nurse Aide #8 did not provide resident supervision during meal. Nurse Aide #8 was suspended pending investigation.
• Nurse Management/designee reviewed all residents' kardex and audited the assistance level required while feeding. It was concluded that 9 residents were dependent on staff for feeding and 7 residents required supervision of staff.
• DON #1/designee completed observation rounds during lunch and dinner meals on the identified residents that needed feeding assistance with no other concerns identified.
• Nurse Management initiated a facility-wide education for all licensed nurses/NAs on meal delivery and feeding assistance, focusing on proper resident identification, verification of correct diet orders, and adherence to required supervision levels during meals.
• Licensed nurses/NAs were educated on utilizing the kardex to locate information needed to determine supervision required with feeding.
• No licensed nurses/NAs are permitted to work without education in meal tray delivery until they have completed this required education.
• All licensed nurses/NAs were educated by Nurse Management or the Administrator via phone or with one-on-one in-service.
• The only staff that pass resident meal trays are NAs/licensed nurses.
• This training has been added to the orientation program for all licensed nurses/NAs.
• The Director of Nursing, Nurse Manager, and Administrator will conduct audits of resident meal tray delivery. These audits include validation of accurate meal tickets, correct resident identification, and confirmation that residents receive the correct diet with the required level of assistance as indicated on the resident Kardex and diet order.
• Audits are done two meals per day, five days per week for six weeks. Any concerns identified will be addressed and corrected immediately.
• Results of these audits will be reviewed during the QAPI meeting to determine whether additional monitoring is needed.
• The Administrator is responsible for ensuring completion and oversight of this Plan of Correction.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A cognitively impaired resident with a known history of wandering and a moderate risk for elopement, as documented in their care plan and risk assessments, was able to exit a secure second-floor unit despite wearing a wander guard device. The resident was first found by an LPN on the facility's first floor, asking another resident for directions. The LPN returned the resident to the second-floor common area but did not notify the assigned nurse or other second-floor staff of the incident. This lack of communication meant that staff were unaware of the resident's attempt to leave the secure unit earlier in the day. Later that afternoon, the resident pushed open a stairwell door on the second floor, proceeded down the stairs, and exited the facility through an exterior door. The stairwell door alarm sounded, but the unit secretary silenced the alarm without thoroughly checking the area or confirming the whereabouts of the resident. The unit manager was consulted for the alarm code but also did not investigate the cause of the alarm. As a result, the resident was able to leave the facility unsupervised and was not immediately detected as missing. It was not until several hours later, after staff noticed the resident was missing during rounds, that a search was initiated. The search was initially conducted by a single LPN and later expanded with additional staff, but facility administration and the DON were not notified until much later. The facility's elopement protocol was not enacted until several hours after the resident had left the premises. The resident was eventually found outside on facility grounds, having sustained injuries that required hospitalization. The failure to provide adequate supervision, respond appropriately to alarms, and enact the elopement protocol in a timely manner constituted a deficiency and resulted in an Immediate Jeopardy situation.

Removal Plan

• A headcount was performed to confirm that all residents were accounted for.
• Resident #2 was located and sent to the hospital for evaluation.
• Regional Plant Operations reviewed all doors and locking mechanisms and addressed variances.
• Nursing administration reviewed residents on wanderguard for appropriate orders and care plans.
• Elopement binders were reviewed to ensure that all residents at elopement risk were included.
• All staff were educated on procedures for elopement drill and announcement of Code Yellow.
• All staff were educated on the facility policies on wandering and elopement, and safety checks and supervision.
• Nursing staff were educated on rounding at the start of their shift and every 2 hours.
• Elopement drills were conducted.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate and appropriate information was communicated to the receiving health care provider during an emergent discharge. When a resident experienced a significant change in condition requiring emergency transfer to an acute care facility, an LPN incorrectly identified the resident and sent the individual to the hospital with another resident's identifiers and medical record. As a result, the resident was registered at the hospital under the wrong name and date of birth, and medical care was provided under the incorrect identity for approximately two hours. The error was discovered when the hospital contacted the facility to clarify the resident's identity. Record review showed that the resident who was actually transferred had a history of chronic obstructive pulmonary disease and congestive heart failure and was in severe respiratory distress at the time of transfer, requiring intubation. The incorrect medical record and identifiers were provided to EMS, and the resident was unable to correct the information due to decreased consciousness. The Director of Nursing Services confirmed that the wrong medical record was sent and acknowledged the resident's history of respiratory compromise. The incident resulted in the resident's representative not being contacted for consent for intubation, as the hospital had contacted the wrong representative based on the incorrect identifiers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Licensed nursing staff failed to demonstrate the necessary competencies and skills to meet resident needs during an emergency transfer. Specifically, an LPN incorrectly identified a resident experiencing a significant change in condition and reported the wrong resident to the on-call provider. The LPN also sent the incorrect medical record and patient identifiers with the resident during transfer to the hospital, resulting in the hospital treating the resident under another individual's information for approximately two hours. The facility's policy required nursing staff to collect and organize pertinent information and accurately report the resident's current symptoms and status to the physician, which was not followed in this instance. The resident involved had a history of chronic obstructive pulmonary disease and congestive heart failure and was admitted to the hospital's Intensive Care Unit requiring intubation after presenting with altered mental status, excessive sputum, and cool skin. The LPN did not provide a verbal report to the hospital at the time of transfer, and the Director of Nursing Services was unable to provide evidence that the LPN was competent with the facility's protocol for acute condition changes. This series of actions and omissions resulted in the resident being at risk for delayed or inappropriate treatment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to promptly report a critical laboratory result to the ordering practitioner for a resident with multiple complex medical conditions, including cancer, end-stage renal disease requiring hemodialysis, heart failure, and acute kidney failure. The resident had a critical low blood glucose value of 42, which was identified after blood was drawn at dialysis. The laboratory notified the facility of this result, but the nurse on duty was unable to reach the physician and only sent a text message, receiving no response. No further escalation was attempted, and the Medical Director was not contacted as required by facility policy. The resident had exhibited a change in condition, including confusion and cold extremities, on the evening prior to being found unresponsive. Staff had difficulty obtaining vital signs, particularly oxygen saturation, and these issues were reported among the care team. Despite these signs and the critical lab value, there was no documented evidence that the physician was promptly notified or that additional monitoring or interventions were initiated in response to the abnormal findings. The resident was later found unresponsive and was pronounced deceased by EMS. Interviews and record reviews revealed that staff were aware of the abnormal findings and the facility's policies required immediate physician notification for critical lab results and changes in condition. However, the nurse did not follow the escalation protocol when the physician could not be reached, and there was a lack of timely and effective communication among the care team regarding the resident's deteriorating status. The failure to report the critical lab result and adequately respond to the change in condition constituted the identified deficiency.

Removal Plan

• RN A initiated CPR immediately after being notified by CNA B that no vital signs could be obtained. 911 was called and EMS assumed care upon arrival. When EMS determined the presence of post-mortem changes and pronounced death, the resident was respectfully prepared, and family/representatives were notified according to facility protocol.
• RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition. During this education, the DON/designee reviewed the Handoff Communication policy to clarify expectations of correctly rounding residents at end and beginning of the shift.
• CNA B and LVN B were provided with 1:1 education by DON/designee on how to obtain vital signs according to vital signs policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with both employees to clarify when immediate notification with licensed nurse or RN supervisor and/or physician notification is required for abnormal vital signs.
• LVN B received 1:1 education from the DON/designee on the proper steps for reporting critical lab results and abnormal vital signs in accordance with the facility's Change of Condition policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with LVN B to clarify when immediate physician notification is required for critical labs and abnormal vital signs. The training education of LVN B reinforced the requirement to contact the Medical Director when the attending physician or NP is not available, ensuring timely escalation and resident safety.
• Inservice training was provided by DON/designee with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed.
• Inservice training was provided by DON/designee with all licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Education included: completing change of condition evaluation for residents, notifying physicians for any change of conditions, notifying the party responsible for change of conditions, notifying Medical Director in case of attending physician not answering calls, reporting critical and abnormal lab results to physician or covering physician, reporting abnormal vital signs to physicians or covering physicians, performing walking rounds at beginning and end of shift where doorway check only are not permitted unless preferred by the patient.
• A root cause analysis (RCA) revealed multiple system-level factors that contributed to the poor medical event follow up which includes handoff communication issue, monitoring follow up, training and possible competency gaps and timely physician notification. The RCA identified the root cause as the proper communication and handoff follow up for identified care issues and physician notification for changes of conditions for any medical events.
• The NHA will oversee corrective actions and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, medication administration pass audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action.
• Any new issues found during medical record audits and medication pass administration audit will be presented to the QAPI team members for immediate action. The DON will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
• All residents were identified to be at risk for the identified deficient practice. A random audit of all in-house patients was completed by DON/designee and found a total of 8 residents have abnormal vital signs that needed to be reported to physicians. A random audit of all vital signs taken for all residents completed by DON or designee showed that there was a total of 8 residents potentially affected by the deficient practice. The assigned licensed nurse completed a review of the abnormal vital signs and was reported to the attending physician. A random audit of all vital signs taken for NOC shift when incident happened was completed by DON or designee using the exception report from EMR and showed that there was a total of 8 residents meeting criteria. The following reviews and interventions were conducted by the 8 residents: BP monitoring parameters for 1 resident that is not on antihypertensive medication were added after the physician was notified; BP monitoring parameters for 1 resident that is below 100 SBP after the physician was notified; PR parameter for 1 resident that is not on any ACE, ARBs, Calcium or beta blocker was added after physician notification; 2 resident triggered as abnormal but after review is within normal limits of resident range of BP; 3 residents had over 100 PR but have medications administered.
• Training in change of condition, monitoring and reporting will be included for new hires and will be reviewed yearly by DON and DSD during the annual performance review. The annual training calendar will include change of condition monitoring for its annual in-service for licensed nurses and CNAs.
• The ADON/designee will conduct a random audit of residents with change of condition to determine that physicians were notified following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
• The ADON/designee will conduct a random audit of residents with change of condition to determine that monitoring occurred for 72 hours following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
• A random verification of licensed nurses' knowledge and training will be conducted by ADON/designee using a mock change of condition drill to test responses of nurses on what conditions including abnormal vital signs will be reported to physicians. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
• RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition.
• CNA B and LVN B were provided 1:1 education by DON/designee on how to obtain vital signs.
• LVN B was provided 1:1 education by DON/designee on reporting critical lab and reporting abnormal vital signs and on contacting Medical Director in case attending physician is not available.
• Inservice training was provided by DON/designee with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed.
• Inservice training was provided by DON/designee with all LNs. Staff will not be allowed to provide direct care until training has been completed. Education included: completing change of condition evaluation for residents, notifying physicians for any change of conditions, notifying the party responsible for change of conditions, notifying Medical Director in case of attending physician not answering calls, reporting critical and abnormal lab results to physician or covering physician, reporting abnormal vital signs to physicians or covering physicians, performing walking rounds at beginning and end of shift where doorway check only are not permitted unless preferred by the patient.