Carolton Chronic & Convalescent Hospital Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfield, Connecticut.
- Location
- 400 Mill Plain Rd, Fairfield, Connecticut 06824
- CMS Provider Number
- 075034
- Inspections on file
- 18
- Latest survey
- April 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Carolton Chronic & Convalescent Hospital Inc during CMS and state inspections, most recent first.
The facility did not accurately submit required PBJ staffing data, resulting in a report that incorrectly showed no licensed nurses present for several days. Although schedules confirmed licensed staff were on duty, the staff member responsible for PBJ data entry could not be reached to clarify the error, and leadership was unaware of the cause.
The facility did not promptly report multiple allegations of abuse involving residents with cognitive and physical impairments to the Administrator, State Agency, or Police as required by policy. Incidents included resident-to-resident aggression and a claim of a staff member pushing a resident, with delays or failures in documentation, notification, and escalation by staff and resident representatives.
The facility did not promptly investigate or report multiple allegations of abuse involving residents with cognitive impairments and behavioral concerns. Staff failed to document incidents, notify administration, or remove involved personnel as required by policy, resulting in delayed reporting to the State Agency and incomplete investigations.
Surveyors found that personal care items such as bedpans and urinals were left unlabeled and uncovered in shared bathrooms, contrary to facility policy, with staff unable to explain the lapse. Additionally, a resident with significant health needs experienced consistently inadequate hot water in their bathroom due to a longstanding plumbing issue that had not been addressed, requiring staff to bring in warm water from other rooms for care.
Licensed staff failed to document the administration and effectiveness of controlled pain medications for several residents, with medications being signed out and administered but not recorded in the MAR or nurse's notes. Staff also borrowed controlled medications from other residents' supplies without proper authorization or documentation, and medications were left unsupervised at the bedside for a resident who was not authorized to self-administer, contrary to facility policy.
Multiple residents with respiratory conditions did not have their oxygen and nebulizer tubing labeled or dated to indicate when they were last changed, and staff were unclear about who was responsible for this task. Some residents received oxygen at flow rates lower than prescribed by their physicians, and care plans did not always address oxygen therapy management. Facility policy did not specify the frequency or responsibility for tubing changes, contributing to these deficiencies.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including staff plating food without beard restraints, food being prepared next to an open garbage can, and numerous opened and undated food items in storage areas. The kitchenette refrigerator/freezer was found soiled and contained expired and unlabeled food, with missing temperature logs and inconsistent cleaning practices. These findings reflect failures to follow facility policies and professional standards for food safety.
Surveyors observed multiple failures in infection control practices, including staff not wearing required PPE during high-contact care, not performing hand hygiene before and after glove changes or when exiting rooms, improper posting of transmission-based precaution signage, and incorrect handling of soiled linen. These deficiencies were noted during care of residents with indwelling devices, pressure ulcers, and active infections, and were confirmed through staff interviews and review of facility policies.
The facility did not appoint a qualified Infection Preventionist, as the designated LPN had not completed the required infection prevention training and did not meet the job qualifications, including holding an RN license and relevant experience. The IP began the training months after assuming the role, and only partially completed the required modules, contrary to facility policy.
A resident with a history of a left tibia fracture and chronic pain was given a 50mg dose of Morphine Sulfate Oral Solution instead of the prescribed 5mg dose, due to administration of the wrong concentration. The error occurred when an RN supervisor provided the medication from a locked cabinet, bypassing standard verification procedures, and an LPN administered it without checking the label against the order. No adverse effects were observed in the resident at the time.
A resident with anxiety, CHF, and IBS, who was cognitively intact and dependent on staff, repeatedly reported concerns about staff interactions and care to nursing staff. Despite these ongoing complaints, there was no documentation in the grievance log, no updates to the care plan, and no formal investigation or notification to the grievance officer, contrary to facility policy. Staff interviews confirmed a lack of awareness and follow-up on the resident's grievances.
Two residents did not have comprehensive care plans addressing their specific needs: one with frequent urinary and occasional bowel incontinence was not assessed or provided a toileting program, and another with severe dysphagia and tube feeding did not have NPO status documented in the care plan or nurse aide assignments, despite facility policy requiring this information.
Staff did not consistently provide required fingernail care for two residents dependent on assistance, resulting in long and dirty nails despite care plans and policies mandating weekly nail care. Additionally, a resident with severe physical impairments and incontinence was left without timely assistance after soiling, despite repeated calls for help and facility policy requiring regular incontinence care. Staff interviews confirmed these lapses in care and communication.
A resident with multiple diagnoses and a documented interest in activities such as bingo, reading, and music was not provided with opportunities to participate in these activities as outlined in their care plan. Staff did not ensure the resident was prepared for activities, failed to escalate issues when the resident was not ready, and did not document refusals or provide alternative engagement, resulting in the resident not participating in preferred activities.
A resident with severe cognitive impairment and a pressure ulcer required an air mattress set at a specific setting per physician order, but staff failed to ensure the mattress was set and monitored correctly. The air mattress was found set at a lower setting than ordered, and nursing staff had signed off on checks without verifying the correct setting, resulting in a deficiency in pressure ulcer care.
A resident with Parkinson's disease and other conditions experienced frequent urinary and some bowel incontinence, but did not receive a required assessment or individualized care plan to address continence. Despite being cognitively intact and aware of toileting needs, the resident was not offered a toileting program and had to wear incontinence briefs due to delays in staff assistance. Facility documentation and staff interviews confirmed that necessary assessments and care planning were not completed as required by policy.
A resident receiving nutrition via g-tube was observed lying flat in bed while tube feeding was infusing, despite orders and policy requiring the head of bed to be elevated to prevent aspiration. An agency nurse aide, who had not received facility orientation, lowered the bed without pausing the feeding, and staff interviews revealed a lack of specific instruction and training for agency personnel regarding this care requirement.
Controlled medications were repeatedly borrowed from one resident's supply to administer to others when needed medications were unavailable, as confirmed by multiple staff interviews and documentation reviews. Limited staff access to the automated medication dispensing system and late admissions contributed to this practice, which was also noted by the pharmacy consultant.
Failure to Accurately Submit PBJ Staffing Data
Penalty
Summary
The facility failed to submit accurate Payroll-Based Journal (PBJ) staffing data for four specific days, as required by CMS. The PBJ report for the second quarter indicated that there were no licensed nurses present 24 hours a day on those dates. During interviews, the Administrator was unaware of the issue and deferred responsibility to the Director of Nursing Services (DNS), who stated that another staff member was responsible for PBJ data entry but could not explain the discrepancy. The DNS later provided staff schedules confirming that licensed nursing staff were present on all shifts for the days in question. Attempts to interview the staff member responsible for PBJ data entry were unsuccessful. Facility documentation and interviews confirmed that the required staffing information was not accurately reported, despite the presence of licensed staff.
Failure to Timely Report Alleged Abuse and Incidents to Authorities
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft to the Administrator, State Agency, and Police as required by facility policy for three residents reviewed. In one case, a resident with cerebral palsy and adjustment disorder reported that another resident with Alzheimer's disease grabbed their neck and pushed their wheelchair, leading to a retaliatory act where the first resident ran over the other's feet. This incident was not documented in the care plans or reported to the appropriate authorities until the surveyor brought it to the attention of the Director of Nursing Services (DNS). The DNS admitted to delaying the report to the State Agency and not notifying the police, contrary to facility policy, and was unaware of the incident until informed by the surveyor. Interviews revealed that the social worker and charge nurse were also unaware or did not report the incident, and the resident's representative had not been informed. Another resident with dementia and depression alleged that a nurse aide pushed them into the bathroom, but was unable to identify the aide. The resident reported the incident to their representative, who did not escalate the concern, believing it may have been a misunderstanding. The charge nurse was aware of the resident's ongoing complaints about a mean and bossy aide but did not report these concerns to administration. When the resident later told an RN about being pushed, the RN conducted an informal investigation but did not report the incident to the DNS, nor did she document the event or collect staff statements. The DNS only became aware of the allegation when notified by the surveyor and subsequently delayed reporting to the State Agency. A review of facility documentation, including care plans and nursing notes, failed to show any record of the alleged incidents for the residents involved. The facility's abuse policy requires immediate reporting of any alleged or witnessed abuse to the nursing supervisor, department heads, administrator, police, and state authorities within two hours. The failure to follow these procedures resulted in delayed or absent reporting and documentation of abuse allegations, as well as a lack of timely notification to the appropriate authorities.
Failure to Timely Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to respond appropriately to allegations of abuse involving three residents. In the first case, a resident with cerebral palsy and anxiety reported that another resident with Alzheimer's disease and agitation had grabbed their neck and pushed their wheelchair, leading to a retaliatory act where the first resident ran over the other's feet. This incident was not documented in the care plans or nursing notes, and the Director of Nursing Services (DNS) was unaware of the event until informed by a surveyor. The incident was not reported to the State Agency immediately, and the investigation summary was delayed. Additionally, the involved residents' representatives were not notified, and staff members who were aware of the incident did not escalate it to administration as required by policy. In another instance, a resident with dementia and depression alleged that a nurse aide had pushed them into the bathroom. The resident was unable to identify the aide, but consistently described the aide as mean and bossy. The allegation was not reported to the DNS or administration by the staff who were aware of the resident's concerns. The resident's representative also failed to report the concern, believing it may have been a misunderstanding. When the DNS was finally informed by a surveyor, the incident had not been documented in the care plan or nursing notes, and the staff member involved was not identified or removed from duty as required by facility policy. Across both cases, the facility did not follow its abuse policy, which requires immediate initiation of a thorough investigation, removal of the involved staff member, and timely reporting to the State Agency. Documentation was lacking, and there were delays in both internal and external reporting. Statements from involved staff were incomplete or missing, and the required investigation steps were not followed promptly or thoroughly.
Improper Storage of Personal Care Items and Inadequate Hot Water in Resident Bathroom
Penalty
Summary
Surveyors observed that personal care items, including bedpans, urinals, and toilet hats, were not stored in accordance with facility policy in multiple shared bathrooms. These items were found unlabeled, uncovered, and wedged inside metal racks or railings, sometimes in contact with walls or with other objects such as clothing. Staff interviews revealed that nurse aides were responsible for labeling, covering, and storing these items, but could not explain why the policy was not followed. The infection prevention nurse and the director of nursing both confirmed the expectation for proper storage and labeling, but were unable to account for the observed lapses. Additionally, a resident with a diagnosis of malignant neoplasm of the bladder and blindness was found to have inadequate hot water in their bathroom sink. Multiple temperature checks over several days showed the hot water was consistently far below acceptable levels, requiring staff to bring in warm water from other rooms for bathing. Interviews with maintenance staff and the administrator revealed a longstanding issue with the hot water supply to this room, stemming from an improper connection made during a renovation years prior. The problem had persisted because a repair was never scheduled, and the water would only become hot after running for an extended period or by manipulating water flow in other areas. The facility's failure to ensure proper storage of personal care items and to maintain safe and comfortable water temperatures in resident bathrooms resulted in an environment that did not meet standards for cleanliness, comfort, and safety. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and records.
Failure to Document Controlled Medication Administration and Improper Medication Handling
Penalty
Summary
Licensed nursing staff failed to document the administration of controlled pain medications, including the resident's pain level and the effectiveness of the medication, as required by professional standards. For multiple residents with chronic pain and cognitive impairments, controlled substances such as Oxycodone and Tramadol were signed out on the controlled substance disposition record and administered, but these administrations were not recorded on the Medication Administration Record (MAR) or in the nurse's notes. Pain assessments often indicated a pain level of zero prior to administration, and there was no documentation of complaints of pain, the administration itself, or the medication's effectiveness in the clinical record. Interviews with the LPN responsible for these administrations revealed that omissions in documentation were oversights, and the EMR system was designed to prompt for effectiveness documentation, which was not completed. Additionally, the facility failed to ensure that controlled medications for pain and anxiety were available for residents as ordered, resulting in staff borrowing medications from other residents' supplies. Controlled Substance Disposition Records showed multiple instances where medications were removed from one resident's supply and given to another, without documentation of physician orders authorizing this practice. Interviews with nursing staff and the DNS confirmed that borrowing medications occurred due to limited access to the automated medication dispensing system and staffing limitations, and that this practice was recognized as poor and not in line with facility policy or pharmacy consultant recommendations. Furthermore, a resident who did not wish to self-administer medications was observed with unsupervised medications left at the bedside by an LPN, who admitted to leaving medications with the resident upon request and without a physician's order. The facility's policy prohibits leaving medications unattended and requires staff to observe residents consuming their medications. The DNS confirmed that leaving medications at the bedside for unsupervised self-administration is unacceptable practice.
Failure to Ensure Proper Respiratory Care and Tubing Management
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for residents requiring oxygen and nebulizer therapy. For multiple residents with diagnoses such as acute respiratory failure, hypoxia, COPD, and congestive heart failure, observations revealed that oxygen and nebulizer tubing were not labeled or dated to indicate when they were last changed. Staff interviews indicated a misunderstanding of responsibility, with some believing the oxygen vendor was responsible for changing and labeling tubing weekly, while the vendor clarified that the facility was responsible for this task. Review of facility policy and the vendor contract confirmed that the facility, not the vendor, was responsible for changing and labeling respiratory supplies, but the policy did not specify the required frequency or responsible party for tubing changes. Additionally, the facility failed to administer oxygen therapy according to physician orders. In several cases, residents were observed receiving oxygen at flow rates lower than those prescribed by their physicians. For example, one resident with a physician order for 2-3 liters per minute was found receiving only 1.5 liters per minute, and staff had to adjust the setting after this was identified. Another resident with a titration order to maintain oxygen saturation above 92% was also observed on a lower flow rate, though their saturation was within the target range at the time of observation. Care plans for some residents did not include interventions or focus areas related to the administration and management of oxygen therapy, despite active physician orders for such care. The facility's oxygen policy was reviewed and found lacking in guidance regarding the frequency of tubing changes and assignment of responsibility for this task. These deficiencies were identified through observations, record reviews, and interviews with staff, the DNS, and the oxygen vendor.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's main kitchen and a kitchenette. Dietary aides were seen plating food without wearing required beard restraints, contrary to facility policy. Additionally, a dietary aide was cooking fish fillets on a stove grill directly adjacent to an open, uncovered, and full industrial-sized garbage can. These actions were acknowledged by the Director of Food Services as violations of established procedures for maintaining sanitary conditions during food preparation and service. Further inspection of the dry storage, refrigerator, and freezer areas revealed several opened and undated food items, including various types of pasta, rice, fish fillets, broccoli, and orange juice. The Director of Food Services confirmed that all opened food items should have been labeled with the date they were opened, as per facility policy. The ice cream freezers were found to be missing thermometers, despite temperature logs being maintained, and the Director of Food Services could not explain how temperatures were recorded without thermometers present. In the kitchenette of the main dining room, the refrigerator/freezer unit was found to be soiled, malodorous, and contained expired and unlabeled food items, including milk cartons, eggnog, pitchers, and a bottle with an unknown liquid. The microwave and coffee maker were also dirty, and the floor was stained and littered with debris. The temperature log for the refrigerator/freezer was missing, and staff interviews revealed inconsistent practices regarding temperature monitoring and responsibility for maintaining cleanliness and food safety in the kitchenette.
Infection Control Deficiencies: PPE Use, Hand Hygiene, and Precaution Signage
Penalty
Summary
Multiple deficiencies in infection prevention and control were identified during observations and record reviews for several residents. Staff failed to consistently wear required personal protective equipment (PPE), such as gowns and gloves, when providing high-contact care to residents on Enhanced Barrier Precautions (EBP) or contact precautions. In one instance, a nurse aide provided incontinent care to a resident with a gastrostomy tube without donning an isolation gown, despite clear signage and available supplies. Additionally, signage for transmission-based precautions was not always correctly posted, as seen with a resident on contact precautions for Clostridium difficile, where only EBP signage was displayed instead of the required contact precautions signage. Hand hygiene practices were not followed according to facility policy and standard precautions. During wound care and dressing changes for residents with pressure ulcers, staff failed to perform hand hygiene before donning gloves, between glove changes, and after glove removal. In several cases, staff reapplied gloves multiple times without hand hygiene, and in one instance, left the resident's room without performing hand hygiene. These lapses were acknowledged by the staff involved and confirmed by interviews with the infection preventionist and director of nursing, who stated that hand hygiene should have been performed at each required step. Improper handling of soiled linen was also observed. A nurse aide was seen carrying visibly soiled linen and a soiled brief in the hallway, then removing gloves and accessing clean linen without performing hand hygiene. Facility policy requires hand hygiene after handling soiled materials and before handling clean items. These failures to adhere to infection control protocols were observed across multiple staff members and resident care situations, as documented in the facility's own policies and confirmed through staff interviews.
Failure to Appoint Qualified Infection Preventionist with Required Training
Penalty
Summary
The facility failed to hire a qualified Infection Preventionist (IP) in accordance with its own policy and regulatory requirements. The IP, an LPN, assumed the role over four months prior to the survey but had not completed the required specialized infection prevention training at the time of the survey. The IP only began the mandatory training several months after starting the position, completing a portion of the required modules online, but had not finished the full curriculum. The delay in obtaining the necessary training was attributed to a misunderstanding about the training format and the demands of the position. Review of the facility's job description for the Infection Preventionist Nurse revealed that the position required a current RN license, two years of professional nursing experience in LTC, and at least three years in nursing administration or a comparable management role with infection control training and APIC interaction. The IP in the role did not meet these qualifications, as she was an LPN and had not completed the required training. The Director of Nursing Service (DNS), who oversaw the IP, held an infection prevention certificate but was not the designated IP according to facility policy.
Significant Medication Error Due to Incorrect Morphine Sulfate Dose
Penalty
Summary
A significant medication error occurred when a resident with a history of a displaced spiral fracture of the left tibia and chronic pain was administered an incorrect dose of Morphine Sulfate Oral Solution. The physician's order specified Morphine Sulfate 10mg/5ml, with a dose of 2.5 ml by mouth every 4 hours as needed for moderate pain. However, the resident was given a 50mg dose instead of the ordered 5mg dose, due to the administration of Morphine Sulfate 100mg/5ml solution rather than the prescribed concentration. This error was identified after the medication was administered, and the resident was closely monitored, with no apparent adverse effects noted at the time of evaluation. The error was facilitated by a breakdown in medication storage and verification procedures. The Morphine Sulfate 100mg/5ml was not stored in the Omnicell automated dispensing cabinet due to a barcode issue, and was instead kept in a locked cabinet in the nursing supervisor's office. On the day of the incident, the RN supervisor removed the medication from the locked cabinet and provided it to an LPN without verifying the medication order or the concentration of the medication. The LPN, in turn, did not check the label on the medication against the physician's order before administration, assuming it was correct. Facility policy required a three-way check to compare the medication to the medication administration record and the prescription label, as well as verification of the correct medication and dose prior to administration. Both the RN supervisor and the LPN failed to follow these procedures, resulting in the administration of the incorrect dose. The incident was documented as a medication administration error, as the resident received a different dosage than specified by the original order.
Failure to Promptly Address and Resolve Resident Grievances
Penalty
Summary
A deficiency occurred when the facility failed to promptly address and resolve a resident's grievances regarding care and staff interactions. The resident, who was cognitively intact and dependent on staff for transfers, bed mobility, and toileting, reported to a nurse that certain evening shift employees spoke to them in a mean tone and acted independently without involving the resident. Despite these concerns being communicated, there was no documentation of grievances for this resident in the facility's grievance log, and the care plan did not reflect the resident's accusatory behaviors or interventions to address them. Nurses' notes over several days documented accusatory statements by the resident about staff and care, but these were not followed up with investigations or reported to the grievance officer as required by facility policy. Interviews with facility staff, including the Director of Nursing Services (DNS), LPN, and Social Worker (SW), revealed a lack of awareness and follow-up regarding the resident's repeated complaints. The DNS acknowledged that although the resident had previously reported complaints about staff behavior, no formal investigation was initiated, and nothing was documented. The SW, who served as the grievance officer, was unaware of the resident's ongoing concerns and stated that he would have followed up if informed. Facility policy required that all grievances be reported, investigated, and resolved in writing, but this process was not followed for the resident's repeated allegations, resulting in a failure to honor the resident's right to voice grievances without discrimination or reprisal.
Failure to Develop Comprehensive Care Plans for Incontinence and NPO Status
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. For one resident with Parkinson's disease, bipolar disorder, and major depressive disorder, the clinical record and nurse aide documentation showed frequent urinary incontinence and occasional bowel incontinence. Despite this, the care plan did not address the resident's incontinence, and no assessment for incontinence was found in the medical record. Interviews with nursing staff confirmed that an assessment and care plan should have been completed, and a toileting program should have been considered, but these actions were not taken. The resident reported being aware of the need to urinate or have a bowel movement but required staff assistance for toileting due to mobility limitations. The resident wore an adult incontinence brief at all times because of delays in receiving help from staff and indicated that a toileting program had not been offered. Facility policy required a thorough assessment and care planning for residents with incontinence, but this was not followed in this case. For another resident with severe dysphagia, gastrostomy status, and a history of pneumonitis due to aspiration, the care plan failed to specify the resident's NPO (nothing by mouth) status, despite physician orders and nutrition evaluations indicating tube feeding as the sole source of nutrition. The written nurse aide assignment also did not indicate the NPO status, and staff interviews revealed that nurse aides relied on these assignments for care information. Facility policy required clear communication and documentation of NPO status, but this was not reflected in the care plan or assignment sheets at the time of the survey.
Failure to Provide Timely Nail and Incontinence Care
Penalty
Summary
Staff failed to provide adequate fingernail care for two residents who were dependent on staff for personal hygiene. One resident with dementia and chronic medical conditions was observed on multiple occasions to have very long fingernails with dark debris underneath, despite physician orders and care plans directing weekly nail assessments and care on shower days. Interviews with staff confirmed that nail care was their responsibility and there was no directive from the family to restrict staff from performing this care. Similarly, another resident with Alzheimer's disease and limited mobility was observed to have long, dirty fingernails, and reported having requested nail care from staff without receiving it. Staff interviews confirmed that nail care should be performed on shower days or as needed, and facility policy supported this expectation. In a separate incident, a resident with cerebellar ataxia, epilepsy, functional quadriplegia, and a feeding tube, who was fully dependent on staff for all ADLs and incontinent, was left without timely assistance after being incontinent. The resident was observed calling for help for approximately an hour, using the call bell multiple times, and communicating the need for incontinence care. Staff responded through the intercom but did not enter the room or provide assistance for an extended period, with one staff member stating the resident would need to wait due to other duties. When care was finally provided, the resident was found to have a wet brief. Interviews with staff revealed a lack of communication and follow-through to ensure the resident's needs were met, despite care plans and policy requiring incontinence care every 2-3 hours and as needed. These deficiencies were identified through direct observation, review of clinical records, facility documentation, and staff interviews. The facility's own policies and care plans outlined the required standards for nail and incontinence care, but these were not consistently followed, resulting in unmet care needs for the residents involved.
Failure to Provide Activities of Interest to Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide activities of interest to a resident with diagnoses including cerebellar ataxia, epilepsy, mild anxiety, and depression. The resident, who was dependent on staff for mobility and personal care, had a care plan specifying enjoyment of activities such as bingo, reading, music, and pet therapy, with interventions to offer these activities and ensure access to an activity calendar and activity cart. Despite these documented preferences and interventions, observations showed the resident was often in bed, either awake in a dark room or watching TV, and had not attended bingo in a long time. Interviews revealed that the resident liked bingo but was not consistently prepared in time to attend, and staff did not escalate the issue or provide alternative activities as outlined in the care plan. Further review indicated that the recreational staff did not routinely offer activities to the resident, often due to the resident's closed door, and there was a lack of documentation regarding activity refusals or efforts to engage the resident. The recreation therapist acknowledged not escalating the issue when the resident was not ready for activities, and 1:1 interactions were infrequent and not well-documented. Facility records confirmed the resident had not participated in or refused bingo during the review period, and the facility's policy required meaningful activities to support residents' social, emotional, and physical needs, which was not met in this case.
Failure to Monitor and Set Air Mattress as Ordered for Pressure Ulcer Care
Penalty
Summary
A resident with a history of Alzheimer's disease, dementia, and a pressure ulcer to the left buttocks was identified as requiring a pressure-reducing air mattress set at a specific setting of 280, as ordered by the physician and outlined in the care plan. Despite these orders, observations revealed that the air mattress was set at 160 instead of the required 280. Nursing staff, including an LPN, had signed off on the Treatment Administration Record (TAR) indicating the mattress was checked, but were unaware of the correct setting and had not verified it against the physician's order. The discrepancy was only discovered after the LPN reviewed the order and adjusted the setting accordingly. Further interviews with nursing staff and the Director of Nursing Services confirmed that the air mattress should have been set and monitored at the correct setting every shift, as per facility policy and physician orders. The facility's policies required pressure relief mattresses to be checked for proper function every shift, but this was not consistently done. The failure to maintain the correct air mattress setting and to verify compliance with physician orders contributed to the deficiency in pressure ulcer care for the resident.
Failure to Assess and Care Plan for Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to provide appropriate treatment and services to restore or maintain bowel and bladder continence for a resident with diagnoses including Parkinson's disease, bipolar disorder, and major depressive disorder. The resident was identified as having intact cognition, required substantial assistance with mobility and transfers, and was dependent on staff for toileting. Despite frequent urinary incontinence and some episodes of bowel incontinence documented over a 30-day period, there was no evidence that a toileting program had been attempted or that a comprehensive assessment for incontinence had been completed. The resident reported awareness of the need to urinate or have a bowel movement but had to wear an adult incontinence brief at all times due to delays in staff assistance, and indicated that a toileting program had not been offered. Review of facility documentation and interviews with nursing staff and the DNS confirmed that an incontinence assessment should have been completed upon admission or with changes in continence status, and that a care plan and toileting program should have been developed based on the assessment. The care plan did not address the resident's incontinence, and the required assessments were missing from the medical record. Facility policies directed that residents with incontinence should receive thorough assessments and individualized care plans, but these steps were not followed for this resident.
Failure to Maintain Head of Bed Elevation During Tube Feeding
Penalty
Summary
A resident with diagnoses including cerebellar ataxia, COPD, severe malnutrition, and a gastrostomy tube (g-tube) was observed receiving tube feeding while lying flat in bed, contrary to physician orders and facility policy. The care plan and physician's order required the head of the bed to be elevated to 45 degrees during and after tube feedings to prevent aspiration, and the facility's aspiration policy directed that the head of bed should be up 30-45 degrees at all times during tube feeding. During observation, a nurse aide from an agency lowered the resident's bed to a flat position while the tube feeding was infusing, and only stopped when prompted by the surveyor. The nurse aide admitted to not having received a facility orientation and was unaware of the specific requirement to keep the head of bed elevated during tube feeding. Interviews with facility staff revealed that agency nurse aides were assumed to be competent and were not provided with formal facility training, relying instead on agency verification and brief unit tours. The LPN on duty acknowledged that she did not specifically instruct the agency nurse aide to pause the tube feeding before lowering the bed. The Director of Nursing Services (DNS) stated that agency staff were expected to follow facility policies, but the facility did not provide formal training for them. The failure to ensure the head of bed was elevated during tube feeding represented a lack of appropriate care to prevent complications for the resident.
Failure to Maintain Adequate Medication Availability and Secure Dispensing Practices
Penalty
Summary
The facility failed to ensure that medications, specifically controlled substances, were available to meet the needs of each resident. Documentation review revealed multiple instances where controlled medications such as Lorazepam, Oxycodone, and Tramadol were borrowed from one resident's supply to administer to another resident. These borrowings were recorded on Controlled Substance Disposition Records, with some entries lacking clear identification of the recipient. Interviews with nursing staff confirmed that when a medication was needed immediately and not available, the nursing supervisor would obtain the medication from another resident's supply. Additionally, it was noted that not all shifts had staff authorized to access the after-hours automated medication dispensing system (Pyxis), which further contributed to the practice of borrowing medications. The Director of Nursing Services (DNS) acknowledged awareness of this practice and identified limited access to the Pyxis system and late-day admissions as contributing factors. The facility's pharmacy consultant also observed and reported the borrowing of controlled medications during routine inspections, emphasizing that first doses should not be obtained from other residents. Facility policy requires only authorized and trained nursing personnel to access the automated medication dispensing system, but gaps in staff authorization and access were identified as root causes for the deficiency.
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The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
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