Failure to Provide Required Patient Identification Wristbands
Penalty
Summary
The facility failed to provide wristband identification tags or any other means of identification for two of three sampled patients, as required by regulation and the facility's own policy. Patient 7, who was admitted with diagnoses including diabetes mellitus type 2 and chronic pain syndrome, was found during observation to have no wristband or other identification while lying in bed. Patient 7's Minimum Data Set (MDS) indicated moderately impaired cognition and a need for maximum assistance with several activities of daily living. Both the patient and the Director of Staff and Development (DSD) confirmed the absence of an identification wristband, with the DSD acknowledging the necessity of such identification, especially during medication administration and emergencies. Patient 8, admitted with diabetes mellitus type 2 and cognitive impairment, was also observed without a wristband or any other form of identification. The MDS for Patient 8 showed severely impaired cognition and total dependence on staff for all activities of daily living. The DSD confirmed that Patient 8 did not have any identification wristband or alternative means of identification. The Director of Nursing (DON) further stated that all patients, particularly those who are nonverbal or confused, should have wristband identification at all times to ensure proper identification before care and treatment. A review of the facility's policy and procedure titled "Admission, Discharge and Transfer" indicated that wristbands or ankle bands must be worn by residents at all times to ensure proper identification prior to receiving medication, treatment, or special services. Despite this policy, the observations and interviews confirmed that both Patient 7 and Patient 8 were not provided with the required identification, constituting a failure to meet the licensure requirement.
Plan Of Correction
Patient Identification How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, patients 7 and 8 were immediately provided with wristbands after it was identified that they were without one. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. - All residents are at risk of being affected. - On 9/26/25, a facility-wide resident identification wristband audit was conducted by the Administrator Assistant. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. - On 9/24/25, the Admissions Department received in-service training on the proper placement of identification wristbands for all admitted residents, conducted by the Administrator Assistant. - From 10/13/25-10/15/25, all staff received in-service training on resident identification wristbands, conducted by the Administrator Assistant. - Starting 10/13/25, the Administrator Assistant will perform random weekly checks of five residents for 3 months using an audit form to ensure proper use of identification wristbands. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The Administrator Assistant will be reporting the results of the monitoring to the QA committee monthly for 3 months for review and recommendations and to ensure substantial compliance is sustained. Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.