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Latest High Scope/Severity Citations
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Emergency exit doors on two units were found secured shut with zip ties and rolled gauze, preventing egress. Staff, including nurses, aides, and maintenance, were unaware of the obstructions, which were likely put in place to stop frequent alarms caused by high winds. The facility's policy required exits to remain unobstructed, but the deficiency was only discovered during a survey, placing residents in immediate jeopardy.
A resident with cognitive impairment and a history of agitation was allowed unsupervised access to a courtyard, where he climbed onto the facility's roof after becoming upset about a potential move to a secured unit. Staff observed the resident on the roof and called the fire department for assistance. Prior to the incident, increased agitation and unsafe behaviors had been noted, but the resident's care plan and supervision level were not updated accordingly. The facility also failed to complete required smoking assessments for another resident.
A resident with a full code status did not receive immediate or effective BLS/CPR when found unresponsive, as staff delayed initiating CPR while searching for code status, failed to use a backboard or Ambu-bag, and performed inconsistent chest compressions. Some staff lacked current BLS/CPR certification, and the emergency cart was not properly stocked, resulting in inadequate life-saving measures.
A resident with Alzheimer's disease and moderately impaired cognition was able to leave the facility multiple times without staff awareness or proper sign-out, including driving a personal vehicle offsite and becoming lost. The care plan did not initially address the resident's access to a vehicle or driving capability, and staff failed to implement adequate supervision or follow sign-out protocols, despite the resident's known cognitive deficits.
A resident with a history of substance abuse was repeatedly found in possession of illicit drugs and drug paraphernalia, and tested positive for multiple substances while under facility care. Despite documented incidents and hospitalizations, staff failed to consistently monitor, investigate, or implement effective interventions to prevent further drug use, and did not thoroughly document supervision or follow facility policy regarding contraband and substance abuse.
Emergency Exit Doors Obstructed with Zip Ties and Gauze
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by allowing emergency exit doors on two units to be secured shut with zip ties and rolled gauze, preventing egress. The facility's policy required that exit doors remain unlocked and unobstructed at all times to allow for rapid evacuation, and maintenance logs indicated that door operations were checked daily, with no mention of obstructions. However, on the day of the survey, observations revealed that the emergency exit doors on the short halls of two units were physically secured, blocking access to the outside. Multiple staff members, including nurses and aides, were unaware that the emergency exit doors were secured shut. Interviews revealed that the doors would frequently alarm due to high winds, which may have led to the use of zip ties and gauze to prevent the alarms from sounding. Despite this, there was no documentation or communication among staff or management regarding the application of these obstructions, and maintenance staff were also unaware of the situation. The Nursing Home Administrator and DON confirmed they were not aware that the emergency exit doors had been secured in this manner. The deficiency was identified during the survey, and it was determined that the facility's failure to ensure unobstructed emergency exits placed residents in immediate jeopardy of serious harm, as it would have prevented safe egress during an emergency.
Removal Plan
- Removed the zip ties and rolled gauze that secured the emergency exit doors shut
- Inspected all doors to ensure proper functioning
- Educated all staff on emergency doors and route of egress and the facility's policy that all emergency exit doors should be unobstructed
- Maintenance checks all exit doors for proper functioning
Failure to Prevent Accident Hazard Due to Inadequate Supervision of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment, alcohol-induced dementia, and a court-appointed guardian was not provided with effective supervision, resulting in a serious incident. The resident, who had a history of confusion, agitation, and impaired judgment, was allowed unsupervised access to an enclosed courtyard where he was considered a safe smoker. On the day of the incident, the resident became upset after being told by staff that he would be moved to a secured unit. Subsequently, he stacked patio furniture, climbed onto an awning, and then accessed the facility's roof. Staff observed the resident running and sitting on the edge of the roof, prompting the fire department to be called for his safe removal. Prior to this event, the resident had not exhibited wandering or exit-seeking behaviors, but staff had noted increased agitation and unsafe behaviors, including attempts to take his non-smoking roommate outside to smoke. Despite these observations and discussions with the guardian about escalating behaviors and the potential need for a higher level of care, the resident remained in the unsecured unit. The resident's care plan had not been updated to reflect the increased risk, and he was not placed under enhanced supervision or restricted from unsupervised courtyard access until after the incident occurred. Additionally, the facility failed to complete a smoking assessment on admission and quarterly for another resident to determine if independent smoking was safe or if supervision was required. The lack of timely reassessment and supervision for residents with cognitive impairment and behavioral changes contributed to the occurrence of the incident and the identified deficiency.
Removal Plan
- Resident #120 was placed on enhanced supervision and restricted from unsupervised courtyard access after the incident.
- Resident #120 was reassessed and changed from a safe smoker to a supervised smoker.
- Resident #120 was relocated to a room closer to the nurses' station for increased observation.
- All residents with cognitive deficits and physical capabilities were assessed for wandering, change in behavior, increased agitation, and problematic behaviors.
- Wander guard transmitters were placed on all residents identified as having the ability to wander.
- The Interdisciplinary Team reviewed all residents to identify those with wandering or exit-seeking behavior.
- Staff members were assigned as wandering resident monitors on duty to monitor wandering residents and points of egress.
- All staff received in-service training on supervision of wandering residents, continuous observation, escalation of concerns, and environmental risk identification.
- Staff were instructed to relocate residents displaying exit-seeking or wandering behavior to the secure unit and notify the DON for evaluation.
- All employees were re-hired by new ownership and required to complete dementia and behavior management training to be eligible for rehire.
- All new hires receive training on dementia and care of wandering/behavioral residents during orientation and thereafter.
- Unsupervised courtyard access was restricted for residents with wandering or unsafe behaviors.
- Designated staff monitor the courtyard during resident use.
- Routine environmental rounds are conducted to identify elevated surfaces and climbing risks.
- Behavioral escalation triggers are incorporated into care planning.
- Nurse managers are to be notified immediately for new agitation, pacing, wandering, or exit-seeking behavior; a wandering assessment is completed, wander guard placed, provider and responsible party notified, and care plan updated.
- Residents with new wandering or exit-seeking behaviors are discussed in clinical meetings.
- The DON is responsible for ensuring wandering assessments, notifications, wander guard initiation, and care plan updates are completed.
- A list of exit-seeking/wandering residents is updated and reviewed by the DON and Social Worker.
- Resident wandering assessments and nursing documentation are audited by the DON/ADON to identify residents with increased agitation, exit-seeking, or wandering behavior.
- Audits ensure residents with these behaviors have wander guards and appropriate care plan interventions.
- Audit results are discussed at the clinical At-Risk IDT Meeting and presented to the QAPI Committee for review and revision as needed.
- All residents are assessed for wandering and exit-seeking and with any significant change in condition.
- Education on facility processes for residents with increased agitation, pacing, exit-seeking, or wandering behavior is provided to all staff and reviewed.
Failure to Provide Timely and Effective BLS/CPR to Full Code Resident
Penalty
Summary
Facility staff failed to provide proper and effective Basic Life Support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code when found unresponsive, pulseless, and not breathing. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately call a code blue or initiate CPR upon discovering the resident's condition. Instead, staff delayed action while attempting to verify the resident's code status, and there was confusion and lack of clarity among staff regarding the resident's code status and the location of this information in the medical record. Chest compressions were not started until approximately 12 minutes after the resident was found unresponsive. When CPR was eventually initiated, it was performed on the resident's bed without first placing the resident on a firm, flat surface or using a backboard, which was available in the facility. Staff did not consistently perform continuous and uninterrupted CPR, and there were inconsistencies in the rate and quality of chest compressions. Additionally, staff failed to use the Ambu-bag for rescue breathing, instead placing a non-rebreather mask on the resident, which is not appropriate during CPR. EMS personnel arriving at the scene observed these deficiencies and had to move the resident to the floor to continue CPR. Interviews and record reviews revealed that some staff members lacked current BLS/CPR certification, and there were discrepancies in staff knowledge regarding proper CPR procedures, including compression rates and the use of equipment. Documentation and staff statements indicated that the emergency cart was not properly checked or restocked, resulting in missing essential equipment such as the Ambu-bag. These failures resulted in the resident not receiving timely and effective life-saving measures as required by their full code status.
Removal Plan
- Quality Assurance Nurse (QA) and the RN on duty review the current residents' care profile in the facility's electronic health record (EHR) system, Code Status.
- QA and the RN verify the residents' Code Status via POLST forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status.
- A copy of the list of Full Code residents is made readily available to staff at the nurse's station for reference and is updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed.
- DON/Designee provides in-service education to nursing staff regarding the availability of the list of residents who are Full Code.
- DON checks the Emergency Cart (EC) and ensures that CPR backboard is available.
- RN and/or Designated Licensed Nurse conduct inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This is validated by the DON and/or Designee.
- RN and/or Designated Licensed Nurse conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard.
- DON initiates in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly.
- DON initiates in-service to RNs, LVNs, and CNAs regarding providing rescue breathing, not placement of a non-rebreather mask.
- DON provides continued in-services for all of the facility's RNs, LVNs, and CNAs.
- DON initiates in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly.
- Director of Staff Development (DSD) reviews employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date.
- Identified CNA attends the CPR certification training and is put on temporary suspension until CPR certification is received as part of Direct Care Staff competency.
- Identified LVN that does not have a current CPR/BLS certification is placed on suspension and is not permitted to return to work without an active certification for CPR/BLS.
- Clinical Nurse Consultant provides 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards.
- DON/Designee provides in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- DON/Designee provides in-service to LVN 2 upon returning to work. LVN 2 is not on the schedule until education/reeducation is provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation.
- DON/Designee provides in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- A Certified CPR instructor provides mandatory re-education and training for all Licensed Nurses and CNAs which is also attended by the DON and DSD with return demonstration conducted.
- A series of ongoing CPR Certification Training sessions is provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training.
- A Code Blue drill is initiated and continues weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR.
- An RN is designated as the team leader for Code Blue emergencies.
- Additional CPR training is provided by a Certified CPR Instructor to provide mandatory re-education and training for all Licensed Nurses and CNAs with return demonstration.
- Any Licensed Nurses or CNAs are not permitted to work directly with patients if they do not complete the Certified CPR refresher course.
- Director of Staff Development (DSD)/Designee maintains a log for all Direct Care Staff of their active Certification for BLS/CPR.
- DSD/Designee notifies staff with BLS/CPR certification expiring within a month.
- DSD/Designee presents to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification.
- No Direct Care Staff are permitted to work directly with patients without an active BLS/CPR certification.
- QAA Committee reviews audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions.
Failure to Supervise Cognitively Impaired Resident with Vehicle Access
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for a resident with Alzheimer's disease and moderately impaired cognition. The resident, who had a history of forgetfulness and required assistance with activities of daily living, was able to leave the facility multiple times without staff awareness or proper sign-out procedures. On several occasions, the resident left the premises in a personal vehicle, including one incident where he traveled to another city and another where he was found lost and returned by police. Despite these incidents, the resident's care plan did not initially include interventions addressing his access to a vehicle or his ability to drive. The facility's records showed that the resident's cognitive impairment and diagnosis of Alzheimer's were known, and staff were aware that he required supervision and cues for safety. However, after the resident left the facility and drove significant distances without staff knowledge, there were no immediate updates to his care plan to address the risk associated with his access to a vehicle. Interviews with staff and family confirmed that the resident was able to leave the facility unsupervised, and staff were not consistently verifying sign-out and return procedures. The resident's responsible party and staff expressed concerns about his ability to drive safely due to his cognitive deficits. The facility's policy required assessment and care planning for residents at risk of elopement or unsafe wandering, but these measures were not effectively implemented for this resident. Staff interviews revealed gaps in communication and understanding of protocols related to resident supervision and sign-out procedures. The lack of timely interventions and supervision allowed the resident to repeatedly leave the facility and operate a vehicle, despite clear risks associated with his medical condition and cognitive status.
Removal Plan
- Resident #1 received a head-to-toe assessment.
- Resident #1 was placed on 1:1 monitoring.
- The physician was notified and lab orders were obtained with no abnormalities noted.
- The care plan was updated with updated interventions of 1:1 monitoring, documenting exit seeking behaviors, and laboratory studies were completed.
- The vehicle belonging to Resident #1 which was on the premises was removed by resident's Relative Z and moved to her premises.
- Resident #1 has not driven a vehicle.
- The employee monitoring the reception desk was suspended and returned to work.
- Staff member was provided with 1:1 education on following proper out on pass process.
- Nursing administration conducted a facility wide audit of all current residents to determine if any residents were operating personal vehicles that were on the facility's premises.
- The facility completed an audit of all residents wandering evaluations.
- No new residents found at risk for wandering/elopement.
- The center developed and implemented a process to ensure safe and proper leaves of absence for residents: the center developed and implemented a Front Door Safety & Sign-Out Procedure.
- Staff members who assist with front desk reception duties were educated on the new process of Front Door Safety & Sign-Out Procedure to include competency check off.
- The facility initiated 100% reeducation on Elopement Protocols and the supervision of residents and ANE.
- The facility initiated 100% reeducation with the Charge Nurses on the process of Front Door Safety & Sign-Out Procedure.
- The training of direct care staff was completed in person or via telephone.
- Those that were not scheduled completed reeducation prior to accepting assignment for the next scheduled work.
- Verification of 100% of direct care staff education was verified by the Director of Nursing/ designee.
- Employee roster was utilized to validate completion.
Failure to Monitor and Investigate Resident Illicit Drug Use
Penalty
Summary
The facility failed to implement an effective system to monitor and investigate how a resident with a known history of substance abuse was able to obtain and use illicit drugs while residing in the facility. Despite the resident being cognitively intact and having no independent outside pass privileges, there were multiple documented incidents where the resident was found in possession of illicit substances and drug paraphernalia, and subsequently tested positive for cocaine, fentanyl, and opiates. Staff discovered a white powdered substance and a crack pipe in the resident's room on more than one occasion, and hospital records confirmed the resident's admission of drug use within the facility. There was a lack of consistent documentation and follow-through regarding the monitoring and supervision of the resident after each incident. Although the resident's care plan and behavior contract addressed substance abuse, there were no additional interventions documented after repeated hospitalizations for drug use. The facility's own policies required immediate assessment, drug screening, and restriction of passes, but there was no evidence of a thorough investigation into how the drugs were obtained or brought into the facility. Staff interviews revealed uncertainty about the process for handling contraband, inconsistent communication, and a lack of clarity regarding the involvement of law enforcement or addiction specialists. Furthermore, there was insufficient documentation of frequent monitoring and supervision of the resident following each incident, as required by facility policy. Staff did not consistently document monitoring on various shifts, and there was no evidence of a substance abuse assessment, psychiatric evaluation, or referral for addiction treatment after the resident's repeated positive drug screens and hospitalizations. The facility's failure to investigate the source of the drugs and to implement effective interventions contributed to the ongoing risk and ultimately resulted in the resident requiring multiple hospital transfers due to drug use while in the facility.
Removal Plan
- Regional Director of Operations in-serviced the Administrator regarding the facility's Resident Possession & Use Policy and the Illicit Drug Use Program.
- Administrator will be responsible for overseeing the Social Service Director in ensuring all residents identified with a history of substance abuse and drug seeking behaviors are closely monitored with appropriate and effective interventions.
- Regional Nurse Consultant in-serviced the Director of Nursing regarding the facility's Resident Possession & Use Policy and also the Illicit Drug Use Program.
- Director of Nursing will be responsible for overseeing nursing staff in ensuring all residents identified with a history of substance abuse and drug seeking behaviors are closely monitored with appropriate and effective interventions.
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