F0838

J

Failure to Maintain Facility Assessment and Ensure Supervisory Coverage Resulting in Impaired Nurse Providing Care and Missed Medications

Picayune, Mississippi Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain and update a facility-wide assessment that accurately identified staffing, supervisory, and coordination-of-care needs by shift, including contingency planning for the absence of supervisory nursing staff. The facility assessment, dated in November 2024, identified residents requiring medication administration, supervision, and safety monitoring but was not updated annually as required. It did not specify staffing and supervisory needs by shift, nor did it include safeguards or contingency plans for when required nursing staff, including supervisory staff, were absent. The Administrator acknowledged that staffing decisions were generally based on census and daily schedules and could not explain how the facility assessment was used to determine supervisory coverage or continuity of care when staffing changes occurred. The DON also could not identify a contingency plan in the assessment for staffing needs when there was a staff call-off.

On the night shift beginning at 7:00 PM on 12/29/25, the scheduled charge nurse called in sick, and no replacement charge nurse was designated. As a result, there was no licensed nurse assigned as charge nurse to supervise staff, coordinate care, or respond to unsafe conditions on that shift. During this same shift on Station B, an LPN assigned to provide care and administer medications was impaired and unable to safely perform nursing duties. Camera footage reviewed by the DON showed the LPN at the nurse’s station and at the medication cart for an extended period, swaying, stumbling, appearing under the influence, repeatedly falling asleep, and failing to complete the medication pass. Staff statements described the LPN crying loudly, going to the bathroom frequently, falling asleep standing up and at the medication cart, and being unable to stay awake to pull or pass medications.

Because there was no designated charge nurse and no clear contingency plan, staff relied on informally notifying the nurse on the other unit, and the DON was not contacted until 1:30 AM. The impaired LPN remained in the facility and under the care of residents until approximately 3:00 AM. Medication Administration Record (MAR) and audit reviews showed that multiple residents on Station B did not have medications documented as administered or had medications documented as given late. For example, one resident with dementia and a severely impaired BIMS score of 3 had no documentation of receiving a scheduled bedtime dose of Donepezil. Another cognitively intact resident with cerebral infarction, hyperlipidemia, glaucoma, diabetes mellitus, and insomnia had no documentation of receiving scheduled evening and bedtime medications, including Crestor, Latanoprost, Novolog, and Trazodone. A resident with hemiplegia following cerebral infarction, diabetes, neuropathy, cough, and seizure disorders had no documentation of receiving any scheduled evening medications, including Keppra and Lacosamide. A resident with senile degeneration of the brain, dementia, hypertension, depression, and neuropathy had no documentation of receiving scheduled evening medications, including Clonidine, Duloxetine, and Gabapentin. Medication administration audit reports for Station B showed 25 residents with missed medication administrations and 5 residents with late medications during this period. The situation was determined to be Immediate Jeopardy beginning at 7:00 PM on 12/29/25 due to the lack of supervisory licensed nurse coverage and the continued care by an impaired nurse.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director; individual pots of coffee will be made in the kitchen and temperatures monitored by the Dietary Department to ensure coffee served is at or below 140°F.
• Coffee temperature logs were created to document the staff member who tested the coffee temperature and the time; logs will be turned into the Administrator daily.
• Training for all staff prior to their next scheduled shift; no staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse (topics include accidents/supervision and immediate interventions, abuse/neglect reporting and investigation, hot liquids policy, notification of Administrator/DON of unusual occurrences/high-risk events and timely notification, charge nurse delegation/duties and assignment process, impaired charge nurse escalation, updated facility assignment grid including designated charge nurse, and medication administration documentation).
• All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
• Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• The Facility Assessment was updated by the Administrator to include a contingency plan for absence of supervisory nursing staff and to adequately identify staffing needs by shift and building.
• The facility's Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and Charge Nurse Delegation; the Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs, with none found.
• Emergency QAA Committee meeting held with interdisciplinary attendance (Medical Director via telephone) to review the Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy and discuss the incident, actions taken, training, and monitoring.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator regarding the incident involving LPN #1.
• LPN #2 was reported to the agency that she works for and is not allowed to work at this facility.