Failure to Ensure Staff Competency and Proper Resident Transfers
Summary
The facility failed to ensure that all nursing staff, including agency staff, received proper orientation and competency verification before providing care to residents. Specifically, Nurse Aide (NA) #1 transferred a resident using a sit-to-stand mechanical lift, contrary to the resident's care plan, which required a total mechanical lift with two-person assistance. This improper transfer resulted in the resident's foot slipping, causing the resident to be lowered to the floor and subsequently lifted manually by NA #1 and NA #2 without using the appropriate mechanical lift. The resident later suffered an acute fracture of the left hip, underwent surgery, and was eventually discharged to hospice care, where they expired shortly after. The incident highlights a significant lapse in ensuring that staff were adequately trained and aware of the resident's specific care requirements as outlined in their care plan and Kardex system. The competency checklist for NA #1 from the agency indicated previous training and experience in patient transfers but lacked specific information on using mechanical lifts. NA #1 admitted to not receiving orientation or education on resident transfers or lift equipment from the facility and was unaware of how to access resident care plans or the Kardex system. NA #2, who assisted NA #1, also did not provide proper guidance on the required transfer method for the resident. The Director of Nursing (DON) and the Scheduler failed to verify NA #1's competency in using mechanical lifts before allowing her to provide care, relying instead on a general skills checklist from the staffing agency. Interviews with various staff members, including the DON, Scheduler, and other nurses, revealed a lack of consistent orientation and competency verification for agency staff. The DON acknowledged that agency staff were given only basic resident care information and were expected to seek guidance from nursing staff if needed. The Administrator admitted that the incident was avoidable if the staff had followed the care plan, indicating a systemic issue in ensuring that all staff, including agency staff, were adequately trained and aware of the specific care needs of residents. This deficiency in staff training and competency verification directly led to the resident's fall and subsequent injury.
Removal Plan
- Director of Nursing and/or their designee completed education with facility licensed nurses and C.N.A.'s on lift competency with return demonstration. Licensed agency nurses and C.N.A.'s were educated on proper lift competency with return demonstration. Education was also provided on where licensed nurses and C.N.A.'s can locate current lift status.
- Director of Nursing and/or their designee educated all licensed nurses and C.N.A.'s, including agency staff on location of resident care guides.
- All new facility licensed nurses and C.N.A.'s will receive education from the unit managers on the location of the resident care guides during their orientation. Unit Managers were notified of this responsibility.
- All licensed nurses and C.N.A.'s from an agency are required to come in prior to their first shift to receive lift training and review facility policies. This training is completed by the Director of Nursing and/or their designee. The nursing scheduler is responsible for scheduling agency staff for this orientation. The nursing scheduler notified the agencies of this requirement. Each agency staff is now required to read through facility policies and procedures related to resident care which are located at each nurse's station in the Agency Orientation book. They are to acknowledge understanding of these policies by signing the Policy Acknowledgement Sheet. Agency staff are required to complete lift competency prior to working, this is completed by the Director of Nursing and/or their designee. The facility is requiring the agency to provide the skills checklist of each agency staff member for review prior to working. The Director of Nursing and/or their designee will review the skills check list to ensure that they have the skills to meet the needs of our residents.
- The Director of Nursing and/or their designee completed lift competencies with return demonstration for all licensed nurses and C.N.A.'s and agency staff.
- New hires will be educated Director of Nursing and/or designee on facility policies and lift competencies upon hire.
- The facility made the decision to have an ad hoc QAPI (Quality Assurance and Process Improvement) committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice for a period of 12 weeks.
- The Director of Nursing and/or their designee will audit five (5) agency staff, licensed staff and C.N.A.'s, to the location of the care guides for the residents.
- The Director of Nursing and/or their designee will audit five (5) facility and agency C.N.A.'s weekly for 12 weeks observing lift transfers. Any negative observations will be corrected immediately.
- Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and or their designee for review and/or revision as needed for three (3) months.
Penalty
Resources
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The facility failed to ensure staff competency in medication administration when an LPN administered Metoprolol to a resident with interstitial lung disease, heart failure, and hypertension without obtaining required vital signs beforehand, despite a physician order to hold the drug for SBP < 100 or HR < 50 and a facility policy and completed competency indicating vital signs must be taken prior to preparing parameter-based medications. This issue was identified in 1 of 5 nurses observed and was determined to have the potential to affect all residents and increase the risk of harm.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
A resident with severe cognitive impairment, multiple cardiac diagnoses, and full code status experienced respiratory distress and became unresponsive, but nursing staff failed to provide competent emergency care in accordance with facility policies. An RN could not determine that the crash cart oxygen tank was empty, did not know how to connect the suction machine, and could not state that a backboard was needed for CPR; competency records showed no evaluation for suction use, vital signs, or emergency response. An LVN reported the resident became weak and was breathing slowly, but did not initiate ventilation, was unable to document vital signs, and paramedics found that staff were not performing CPR, no backboard was in place, and the oxygen regulator delivered only up to 8 L/min. Facility policies required prompt assessment and intervention for respiratory and cardiac symptoms, immediate CPR by trained licensed staff when an individual is unresponsive and not breathing normally, and accurate documentation, as well as sufficient, competent nursing staff, which were not met in this event.
The facility failed to ensure that a CMT had demonstrated competency in resident identification during medication administration and did not complete the required quarterly medication aide evaluations. Despite only one documented evaluation and no evidence of competency in verifying resident identity, the CMT was scheduled to pass medications and entered the wrong room, administering clozapine 150 mg and melatonin 3 mg intended for another resident to a frail, elderly resident with CHF and Afib. The resident, who weighed 79.2 pounds, subsequently developed tachycardia, shortness of breath, altered mental status, profound hypothermia, a small pleural effusion, and aspiration pneumonia, was admitted to the hospital for comfort measures only, and later died. The DON acknowledged that quarterly evaluations were required and could not provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
The facility failed to ensure that staff had required behavioral health competencies and ready access to policies and procedures. Activity assistants assigned to a behavioral health Special Treatment Program entered the unit to assess residents and revise care plans without documented completion of the facility’s required ProACT behavioral health training, despite a policy mandating such training for all staff performing direct care or daily duties on behavioral health units. In addition, multiple CNAs, LVNs, a RT, and unit managers were unable to locate or identify key facility policies, including those for ventilator weaning and resident showers, and reported relying on others or personal experience rather than written P&P. A professional reference cited in the report emphasized that policies must be reviewed, updated, and accessible to guide staff actions and protect resident rights.
An LVN independently removed a resident’s PICC line used for IV antibiotics, despite facility policy and Texas Board of Nursing guidance that only an RN may perform PICC insertion or removal. The resident, who had multiple cardiac conditions and moderate cognitive impairment, reported that the line was removed at the facility and denied pain or complications, and surveyors observed an intact, non-infected site. Documentation and staff interviews confirmed that the LVN performed the removal alone under a provider discontinue order, while the RN, ADON, DON, and Administrator all acknowledged that PICC removal is outside LVN scope and should be done by an RN.
Failure to Follow Vital Sign Parameters Before Administering Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nurse was competent in medication administration according to physician orders and facility policy. The facility’s Medication Administration policy, revised 9/10/25, required that when medications had vital sign parameters, vital signs must be taken prior to preparing the medication. Resident #21, admitted with interstitial lung disease and heart failure, had a physician’s order for Metoprolol Succinate ER 12.5 mg by mouth in the morning for hypertension, with instructions to hold the dose for systolic blood pressure (SBP) less than 100 or heart rate less than 50. On 3/30/26 at 9:35 AM, LPN #2 administered the resident’s medications, including Metoprolol, and only checked the resident’s blood pressure after the medication was given, contrary to the order and policy requiring vital signs beforehand. The CNO confirmed that the nurse should have checked the resident’s vital signs before administering the medication. Review of LPN #2’s oral medication administration competency form showed she had completed training, including the requirement that vital sign parameters be taken per facility practice before pouring medication, yet this was not followed in practice. This failure was identified for 1 of 5 nurses observed during medication administration and was determined to have the potential to affect all residents in the facility and increase the risk of harm to residents.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
Failure to Ensure Competent Nursing Response During Resident Respiratory/Cardiac Emergency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nursing staff possessed and demonstrated the competencies required to provide emergency care consistent with facility policies and resident assessments. A resident with a POLST indicating full code and full treatment status was admitted for long-term care with diagnoses including diabetes mellitus, congestive heart failure, dementia, and atrial fibrillation. The resident’s MDS showed severe cognitive impairment and dependence on staff for all ADLs, and the care plan identified potential for cardiac distress related to cardiac conditions, directing staff to monitor for symptoms such as dyspnea, shortness of breath, tachycardia, and to promptly notify the physician if symptoms occurred. Physician orders also included PRN oxygen 2–5 L via nasal cannula for shortness of breath or oxygen saturation below 92%. Surveyors found that nursing staff lacked critical emergency response skills and did not follow the facility’s CPR and oxygen administration policies when the resident became unresponsive with difficulty breathing. RN 1 was observed to be unable to determine that the oxygen tank on the crash cart was empty and could not demonstrate how to connect the suction tubing to the suction machine, and later stated not knowing how to check if the oxygen tank was empty or how to connect the suction machine. RN 1 also could not verbalize that a backboard was needed during CPR. Review of RN 1’s competency records showed no skills and competency evaluation for use of a suction machine, vital signs, or emergency response. The DON reported that RN 1 had a language barrier and that she paired RN 1 with experienced LVNs due to RN 1’s comprehension and communication needs. During the resident’s decline, LVN 2 reported that the resident had been stable earlier and had eaten 100% of dinner, but later was weak and breathing slowly. LVN 2 attempted to take vital signs but was unable to document the results and stated that paramedics initiated CPR upon arrival. The Paramedic Captain reported that, on arrival, facility staff were not performing CPR, a backboard was not in place, and the oxygen valve regulator connected to the oxygen tank delivered only up to 8 L/min. LVN 2 stated she was not aware that ventilation could be provided when a resident was unresponsive and breathing slowly and acknowledged inaccuracies in documentation times. Facility policies required assessment of symptoms such as shallow breathing and vital signs during oxygen therapy, immediate initiation of CPR by licensed staff certified in CPR when an individual is unresponsive and not breathing normally (unless a DNR is present), and accurate, time-specific documentation of procedures and treatments. The facility’s staffing policy required sufficient numbers of nursing staff with appropriate skills and competency, which was not met for the involved licensed nurses.
Failure to Ensure CMT Medication Competency and Required Quarterly Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Certified Medication Technician (CMT) had the required competencies and quarterly evaluations to safely administer medications, as required by Rhode Island regulations. State regulations mandate that medication technicians must complete a State‑approved course, demonstrate competency in drug administration, and receive quarterly evaluations by the Director of Nursing (DON) or RN designee, with documentation placed in personnel files. The facility’s own assessment stated that department‑specific training and competencies are completed throughout employment to ensure staff can safely and competently provide the required care. However, review of the CMT’s personnel record showed she was hired as a CMT/Nursing Assistant and had only one medication administration evaluation since hire, with no evidence of the four required quarterly evaluations. Record review of the CMT’s “Medication Administration Competency” document showed no evidence that she had demonstrated competency in identifying a resident prior to medication administration. Despite this, she was scheduled to administer medications periodically. On the evening in question, the CMT entered the wrong room and administered medications intended for another resident to Resident ID #1, without verifying the resident’s identity and missing all patient identifiers. The medications administered in error included clozapine 150 mg and melatonin 3 mg, which were prescribed for another resident. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. Following the medication error, a provider note documented that the CMT had administered the wrong medications by entering the wrong room and failing to verify identity, and that the clozapine dose was of significant concern given the resident’s low body weight of 79.2 pounds. The resident subsequently presented to the hospital with elevated heart rate, shortness of breath, and altered mental status, was found to have profound hypothermia, a small left pleural effusion, and aspiration pneumonia, and was admitted for inpatient comfort measures only. The resident later expired. The DON acknowledged that medication aide evaluations are required at least quarterly and was unable to provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
Failure to Ensure Behavioral Health Training and Staff Access to Policies and Procedures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff working in the behavioral health Special Treatment Program (STP) had the required behavioral health training, and that clinical and direct care staff could locate and reference facility policies and procedures. A complainant reported that Activity Assistants (AAs) were required to enter the STP to assess residents’ activity needs without having the required behavioral health training. The STP Director stated that all employees who worked in the STP were required to complete behavioral health training to ensure staff and resident safety. Review of the facility’s behavioral health training record with the Director of Staff Development showed that AA 1 and AA 3 were not listed as having completed the training, and AA 2 had only participated in the first day of a two‑day behavioral health training program. AA 1, AA 2, and AA 3 confirmed they were required to enter the STP for activity assessments and care plan revisions; AA 1 and AA 3 reported they had requested behavioral health training due to safety concerns but had not received it, despite having worked at the facility from several months to over two years. Further review of training documentation with the DON and Administrator confirmed that only AA 2 appeared on the training list, and that AA 1 and AA 2 had completed only day one of the behavioral health training, with no evidence of completion of day two. There was no documentation of any behavioral health training for AA 3 or AA 4. The facility’s policy titled “ProACT Training & Certification,” dated 8/28/2025, stated that Generations Healthcare provides Professional Assault Crisis Training (ProACT) to all staff involved in direct patient care within behavioral health units, including program staff, nursing staff (RN, LVN, CNA), STP staff, and ancillary staff responsible for daily job duties on behavioral health units where they may interact with behavioral health residents. The policy required all applicable staff providing direct patient care or completing daily job duties on behavioral health units to complete ProACT de‑escalation and restraint training within 90 days of hire. The deficiency also includes the inability of multiple staff members to locate or identify facility policies and procedures (P&P), including those related to ventilator weaning and resident showers. A Unit Manager stated that P&P could be found on the computer but was unable to locate a ventilator weaning policy. A Respiratory Therapist reported not knowing where facility P&P were kept, stated that P&P used to be in a binder whose location he did not know, and was unable to state the current ventilator weaning policy, relying instead on personal experience. Several CNAs and LVNs reported they did not know where P&P were stored and indicated they would ask a nurse or manager if they had questions. Another Unit Manager stated she could ask medical records for P&P. A professional reference from the American Association of Post‑Acute Care Nursing, cited in the report, described that policies should be reviewed annually, revised as regulations change, and stored with documentation of review dates and revision histories, and that policies ensure regulatory expectations are met, resident rights are protected, and staff actions are guided with clarity and consistency.
LVN Removed PICC Line Outside Scope of Practice
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses possessed and adhered to the appropriate competencies and scope of practice for resident care, specifically related to the removal of a Peripherally Inserted Central Catheter (PICC) line. A male resident with chronic systolic congestive heart failure, chronic atrial fibrillation, ischemic cardiomyopathy with pacemaker, venous insufficiency, and a history of pulmonary thromboembolism was admitted and had an active care plan for completion of an antibiotic regimen via PICC line. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 11. The care plan documented the use of a PICC line for antibiotic therapy, and the resident later reported that his PICC line had been removed at the facility a couple of weeks prior to the survey. On the date of the incident, a progress note completed by an LVN documented that the resident’s midline was discontinued per MD order using aseptic technique, with the catheter measured, tip intact, pressure applied, and a pressure dressing placed. The LVN documented that the resident tolerated the procedure well and was resting comfortably afterward. During interview, the resident confirmed that he had a PICC line that was removed at the facility, did not recall who was present during the removal, and denied pain or discomfort during or after the procedure. Observation of the site by surveyors showed no swelling, signs of infection, redness, or scabbing at the extraction site. Interviews with staff established that the LVN removed the PICC line independently, without RN presence or oversight, despite acknowledging that LVNs at the facility were only allowed to change PICC dressings and that PICC removal was not within LVN scope of practice. The LVN stated that RNs were responsible for pulling PICC lines and that removal required a provider order. The RN, ADON, DON, and Administrator each stated that only an RN could remove a PICC line per facility policy and Texas Board of Nursing standards, and that LVNs were not allowed to remove PICC lines. The ADON reported learning of the incident by reviewing progress notes and confirmed that the LVN had removed the line under discontinue orders from the NP, with no RN present. The DON confirmed she became aware that the LVN had removed the PICC line and informed the LVN that this was outside LVN scope of practice. Review of the Texas Board of Nursing position statement showed that insertion and removal of PICC lines or midline catheters is beyond the scope of practice for LVNs, confirming that the LVN practiced outside her scope when she removed the resident’s PICC line.
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