Failure to Follow Care Plans Results in Resident Injuries
Summary
The facility failed to ensure that two residents received care in accordance with their comprehensive person-centered care plans, which required two staff members to assist with all activities of daily living. In the first instance, a Certified Nurse Assistant (CNA) provided care to a resident singlehandedly, despite the care plan indicating a need for two-person assistance. This resident, who was completely dependent on others for all activities of daily living and unable to communicate needs, suffered a left mid diaphysis femur fracture after being changed by the CNA without assistance. The CNA did not check the Kardex prior to providing care and was unaware that the resident required two-person assistance for all activities, not just transfers and showers. In the second instance, another CNA changed a different resident's diaper alone, even though the care plan and Kardex specified a two-person assist. This resident was also severely cognitively impaired and completely dependent on others for all activities of daily living. The CNA stated that they often changed the resident alone due to the nurse being busy and did not check the Kardex. The resident later exhibited a swollen leg and a noticeable change in leg alignment, leading to a diagnosis of a right comminuted mid shaft femur fracture. Both incidents highlight a failure to adhere to the facility's Safe Resident Handling policy, which mandates that the number of staff needed for care is indicated in the care plan and Kardex. The CNAs involved did not verify the care requirements before providing care, resulting in significant injuries to the residents. The facility's internal investigations confirmed these lapses in following the care plans, which contributed to the residents' injuries.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Immediate actions for investigation regarding resident #2 included resident assessment by Nurse Practitioner, statement collection from indicated staff, review of medical record, review of Central Monitor pulse oximetry-heart rate data and review of video surveillance. Corrective actions included review of all policies and procedures pertaining to safe positioning and handling, ADL care as well as Osteopenia. Re-evaluation of resident’s care plans by Rehabilitation Services including transfer and ADL care. Comprehensive Plan of Care reviewed and updated on return form ACF and reviewed with caregivers. Review found that resident was identified, and care planned for- at risk for fracture related to immobility and complexity of [DIAGNOSES REDACTED]. #6 was suspended from duty pending investigation with subsequent disciplinary action and remediation for non-compliance with 2-person assist. The resident’s mother was notified and further updated by DNS and Administrator regarding the occurrence, investigative conclusions and updates to plan of care. Immediate corrective actions for investigation regarding resident #3 addressed both non-compliance with 2 person assist, as well as safe positioning for urinary catheterization for contracted residents. Immediate remediation with disciplinary action for CNA #7. Rounds on all units to confirm placement of picture signage with the emoji (not words) of a hand holding up 2 fingers indicating 2-person assist. This emoji is referred to as “I Take 2.” Mandatory acknowledgement for Nursing staff in employee portal of ‘Safe Handling Advisory.’ Corrective action include- Review of all policies and procedures pertaining to safe positioning and handling as well as Osteopenia. Review and updates to Policy and Procedure for Urinary Catheters with additional requirement of alternate positioning needs for procedure to be specified in the plan of care and require a medical order. Re-evaluation of resident by Rehabilitation Services on return from ACF for review of Plan of Care, including positioning for catheterization, transfer and ADL care. Inservices were conducted with nursing staff on these updates to resident #3 plan of care. Parents were notified and updated by DNS and Administrator, they verbalized understanding of resident [MEDICAL CONDITION] diagnosis, active treatment with infusion therapy already in place and continued risk for fracture. They expressed appreciation for the detailed report including updates to ADL care and catheterization. 2) As a corrective action following investigation for resident #2, the policy and procedure for ADL care was revised. As an added safety intervention, ALL residents greater than 35lbs and fully dependent in ADL performance will be two-person assist for all ADL care that requires moving. Review of all 122 residents indicates that 81 residents require 2-person assist. Revision of CNA assignments on all shifts to identify teams for ADL care to facilitate consistent compliance with 2-person assist. Mandatory training with competency assessment for all Nurses and CNAs to include updates to policy and implementation of team assignments. All residents admitted to Sunshine are care planned on admission for risk for Osteopenia and fracture due to the complex medical diagnoses, decreased mobility and non-ambulatory status. Mandatory review inservice was conducted including competency with all Nursing Staff on Osteopenia and Risk for Fracture and Safe Positioning and Handling. Training included use/navigation of resident Kardex to identify resident needs, working together CNA with CNA or NURSE-CNA to ensure safety. In addition, in order to identify others at risk, related to this occurrence for resident #3, a re-evaluation of all Sunshine residents requiring intermittent catheterization was conducted with the Rehab team for need for alternate positioning needs for this procedure. 3) Two-person assist compliance audits were initiated and completed by Nurse Managers and off shift Supervisors. Audits will be continued monthly on all shifts, for a period of 12 months. 4) Monthly audit results and chart reviews will be reported in writing, at least quarterly, to the Administrator and Quality Committee, their findings and corrective actions for a period of not less than 12 months, with ensuing frequency as determined by the Quality Committee. 5) Initiated 10/20/2024 by the Director of Nursing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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