Failure to Timely Obtain UA and Administer Antibiotic for UTI Leading to Immediate Jeopardy
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not obtaining a urine specimen and not initiating ordered antibiotic treatment in a timely manner for a suspected urinary tract infection (UTI). The resident had dementia, encephalopathy, urinary incontinence, bipolar disorder, anxiety, and painful urination, and was assessed as moderately impaired for decision making. The resident’s care plan directed staff to call the physician as needed for agitation, confusion, and changes in eating habits. A physician order was written to obtain a urinalysis (UA) to rule out a UTI and to treat if indicated. Although the order was entered into the electronic system by an assistant director of nursing, staff did not promptly obtain the urine specimen, and there were communication failures among nurses regarding responsibility for collecting the sample. Some nurses reported they were told a urine sample was needed, while others stated they were never informed, and no one notified the physician or APRN when the specimen was not obtained within the expected timeframe. When the urine specimen was eventually collected, the lab report showed a critical result indicating a positive UTI that required antibiotic treatment. An order for an oral antibiotic was created and appeared on the Medication Administration Record (MAR) to be given four times a day for five days. However, progress notes documented that the medication was “not available” and that staff “could not locate” the antibiotic. Nursing staff gave conflicting accounts about whether the pharmacy had been called, whether the emergency medication kit was checked, and whether the antibiotic had been pulled from the emergency dispensing cabinet. Pharmacy staff reported there was no record of the antibiotic being pulled from the emergency kit and that the first request to order the antibiotic was received by phone days after the critical lab result. One nurse admitted signing off doses on the MAR as given when they had not been administered, and another nurse stated the resident did not receive the antibiotic due to lack of communication. During this period, multiple staff and a visitor observed significant changes in the resident’s condition. A visitor reported that the resident, who was usually walking and talking, was instead in bed moaning, scratching, and appearing to be in pain, and was told by an LPN that the resident had not eaten or drunk anything for a couple of days and needed IV antibiotics. The visitor requested that the resident be sent to the hospital. CNAs and nurses reported that the resident had been walking when first admitted but later was not walking and was reported to be “hurting a lot.” The APRNs and the medical director stated they expected urine samples to be collected the same day or within 24–48 hours of the order and expected to be notified if staff could not obtain specimens or if lab results were out of range, but they were not informed of the delays or the lack of antibiotic administration. The medical director and APRNs assumed the ordered antibiotic was being given. The resident was ultimately transferred to the hospital and admitted to the intensive care unit with diagnoses including septic shock, respiratory failure, strep pneumonia, acute kidney failure, leukocytosis, and metabolic acidosis, and was later pronounced deceased. The facility’s own abuse/neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and the surveyors determined that the failures to timely obtain the UA and to timely provide ordered antibiotic treatment constituted neglect under this policy and under federal requirements for freedom from abuse, neglect, and exploitation. The survey also identified systemic communication and process issues that contributed to the deficiency. Staff reported that lab orders placed in the electronic MAR would “fall off” after 24–48 hours, so if nurses were not verbally informed of pending labs, they might not know a specimen was needed. Several nurses stated they were never told that a urine sample was required for the resident, while others said they had been told but did not escalate the issue when they could not obtain the specimen. One RN learned of the urine order only through a group text message on her personal phone. APRNs reported having repeated problems with the facility not completing physician orders, to the point that one APRN began scanning and emailing orders to multiple leaders because orders were written three or four times without being carried out. The administrator, who was not a nurse, stated she was unsure how nurses communicated lab orders and indicated that nurses should contact the physician if an antibiotic was not available the same day it was ordered. These documented failures in following physician orders, obtaining ordered labs, administering ordered medications, and communicating critical information led surveyors to cite the facility at Immediate Jeopardy level under 42 CFR §483.12 for failure to protect the resident from neglect. The hospital records confirmed that the resident was admitted to the intensive care unit with septic shock, respiratory failure, strep pneumonia, acute kidney failure, leukocytosis, and metabolic acidosis, and that the resident died shortly thereafter. A visitor reported being told that the resident’s UTI had become septic and that the resident was in organ failure, had pneumonia, and strep, which was consistent with the hospital documentation reviewed by the surveyor. Adult Protective Services contacted the facility administrator and requested that the resident be sent to the hospital. The facility’s own policies on abuse, neglect, exploitation, resident rights, and medication administration required that residents receive necessary care and that medications be administered according to orders and within required time frames. The survey findings concluded that the facility’s failure to timely obtain the ordered UA, failure to timely initiate and provide the ordered antibiotic, and failure to communicate and act on critical lab results constituted neglect that caused or was likely to cause serious injury, harm, impairment, or death, resulting in an Immediate Jeopardy citation at scope and severity level K under the federal regulation for freedom from abuse, neglect, and exploitation.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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