Evergreen Center For Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Stafford Springs, Connecticut.
- Location
- 205 Chestnut Hill Road, Stafford Springs, Connecticut 06076
- CMS Provider Number
- 075326
- Inspections on file
- 21
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Evergreen Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia and a history of falls, who required assistance with bed mobility, was directed by a nursing assistant to turn and grab a side-rail that was not locked. When the resident applied pressure, the side-rail lowered, causing the resident to fall from bed and sustain a head laceration and bruising. Staff interviews confirmed the side-rail was not properly secured before care was provided.
A medication error occurred when an LPN administered a full set of medications intended for one resident to another, failing to properly verify the resident's identity and not immediately notifying a registered nurse or provider after the error was discovered. The affected resident, who had a history of cardiac issues, experienced hypotension and required emergency intervention and hospital evaluation before returning to the facility in stable condition. The incident was not fully reported until later, and the nurse continued the medication pass before the error was recognized by supervisory staff.
A medication error occurred when an LPN administered a full set of medications intended for one resident to the wrong individual, failing to verify identity with the required identifiers and relying only on a photograph. The error led to a significant drop in blood pressure for the affected resident, who required clinical intervention and monitoring. The nurse did not immediately report the full extent of the error, and facility policy for resident identification was not followed.
The facility failed to ensure staff were knowledgeable about Enhanced Barrier Precautions (EBP) and proper PPE use. Observations revealed no enhanced barrier signs outside resident rooms, and staff interviews showed inconsistent understanding of EBP, with some unaware of the significance of orange dots indicating EBP. The facility's policy on infection prevention was not effectively communicated, particularly to third-shift staff, leading to inadequate implementation of precautions.
A facility failed to ensure proper communication and documentation for a resident's prosthetic discomfort, leading to frequent refusals without evaluation. Another resident's catheter use lacked a documented diagnosis, and a bruise on a resident's hand was not adequately assessed or documented after a rough transfer incident. These deficiencies highlight lapses in communication, documentation, and adherence to facility practices.
The facility failed to monitor hot water temperatures properly, resulting in excessively high temperatures in two residents' bathrooms. The maintenance staff did not follow the required procedures for checking and logging temperatures, leading to a deficiency in ensuring a safe environment.
A resident with anxiety and depression felt threatened and fearful after two incidents involving an LPN, where medication was mishandled and comments were made that caused distress. The resident reported these incidents to a nurse aide, but the concerns were not effectively communicated to supervisory staff, violating facility policy on reporting allegations of mistreatment.
The facility failed to create comprehensive care plans for two residents, one with urinary catheter needs and another with sensory deficits. Despite assessments indicating the need for care plans, the facility did not address the urinary difficulties of a resident with Benign Prostatic Hypertrophy or the hearing issues of a resident with cognitive communication deficits. Interviews revealed that these oversights were due to a failure to follow the facility's policy on maintaining current care plans.
A facility failed to update a resident's care plan to reflect their preference for how they wished to be addressed. The resident, who required maximum assistance and was cognitively intact, expressed dissatisfaction with being called by their first name, which was not documented in their care plan. Staff interviews revealed that the omission was due to forgetfulness, and the facility's policy of maintaining current care plans was not followed.
The facility failed to administer medications according to professional standards for two residents. An LPN left Ativan at a resident's bedside, leading to a missing dose, and another LPN administered an incorrect dose of Metformin to a different resident. Both actions violated the facility's medication policies.
A resident with a stage 2 pressure ulcer did not receive proper care as the facility failed to use positioning wedges as per the care plan. The resident, who required assistance to turn, was left in one position without the use of wedges, which were found unused in the closet. Nursing staff were unaware of the resident's specific needs, and the facility lacked a policy for using positioning aids.
A resident with severe cognitive impairment and mobility issues eloped from the facility due to inadequate supervision. The resident, who had recently developed the ability to self-propel in a wheelchair, was found outside after the receptionist left the desk unattended. The facility's policy required residents to be accounted for at all times, but there was no coverage for short absences, leading to the resident's brief elopement.
A facility failed to ensure pharmacist recommendations were reviewed and acted upon in a timely manner for a resident with PTSD and dementia. Despite severe cognitive impairment, recommendations for Naloxone and Clonazepam were delayed, with actions not taken until months later. A corporate nurse acknowledged the oversight, noting a transition of ownership contributed to the lapse.
The facility failed to maintain complete hospice documentation for two residents receiving hospice care. One resident with dementia and heart failure, and another with Alzheimer's disease, both lacked certification records in their clinical files. An LPN noted the absence of documentation and mentioned that hospice providers typically supply paperwork during visits, which is then recorded in hospice binders.
A resident with mobility issues reported being roughly handled by a nurse aide, resulting in bruising. The facility failed to ensure the resident was seen by social services within three days and did not report the incident to the state agency. The incident was not immediately reported by the resident due to fear of retaliation, and the facility's investigation could not substantiate the abuse.
The facility failed to complete Significant Change in Status MDS assessments on time for residents receiving hospice care. A resident with dementia and heart failure had their MDS assessment completed three days late, while two other residents with Alzheimer's and dementia had their assessments completed two days late. The MDS Director was unaware of the requirement to complete these assessments within 14 days of determining a significant change.
A resident with a history of heart failure and a fractured humerus felt scolded by a nursing assistant for frequently ringing the call bell during the night. The NA admitted to being short with the resident due to workload stress, which led to the resident feeling disrespected. The facility's policies on treating residents with dignity were not upheld.
A resident with diabetes was initially deemed competent to self-administer insulin via a pump. However, the resident experienced difficulties managing the pump, resulting in elevated blood sugar levels and requiring nursing intervention. Despite facility policy requiring re-evaluation upon a change in status, the resident was not reassessed, and the potential discontinuation of the insulin pump was not considered.
A resident with Type 1 Diabetes was discharged from an LTC facility without proper documentation regarding their insulin pump, which was crucial for their diabetes management. The discharge packet lacked details on blood sugar monitoring and insulin administration, despite the facility's policy requiring comprehensive discharge planning. The DON confirmed the omission of this critical information.
A facility failed to maintain an insulin pump for a resident with diabetes, as there was no documentation of the insulin infusion set being changed during the resident's stay. The resident, who had moderate cognitive impairment, was discharged from the hospital with instructions to continue using the insulin pump, but the facility did not ensure the infusion set was changed every 2-3 days as per the manufacturer's guidance.
A facility failed to ensure staff were trained in managing an insulin pump for a resident with diabetes. The resident, with moderate cognitive impairment, was unable to manage the pump on certain occasions. Staff, including LPNs, were not trained by the facility and relied on the manufacturer's manual for guidance. The facility's policy required re-evaluation of the resident's ability to self-administer medications, but this was not adequately addressed.
Failure to Ensure Side-Rail Was Locked Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with dementia, a history of falls, and osteoporosis, who required substantial assistance with bed mobility, was directed by a nursing assistant to turn onto their side in bed and grab the side-rail. The side-rail, which was intended to assist with bed mobility, was not locked into place at the time. As the resident grabbed the side-rail and applied pressure, it lowered unexpectedly, causing the resident to fall out of bed and sustain a head laceration and bruising to the knees and lower leg. The resident's care plan and kardex specified the use of padded side-rails and staff assistance for bed mobility, with the expectation that side-rails would be locked before use. During the incident, the nursing assistant had previously lowered the side-rail to change the bed linens and raised it again but failed to ensure it was securely locked. When the resident reached for the side-rail as instructed, the unlocked rail gave way, resulting in the fall and subsequent injuries. Interviews with facility staff confirmed that the expectation was for side-rails to be locked before providing care to residents who use them for mobility. The nursing assistant involved acknowledged not verifying that the side-rail was locked after raising it. Maintenance staff inspected all beds and found no mechanical issues with the side-rails, and staff education materials indicated that proper use and locking of side-rails were part of both initial and annual training.
Medication Error Due to Failure in Resident Identification and Timely Notification
Penalty
Summary
A medication error occurred when a licensed nurse administered a set of prescribed medications intended for one resident to the incorrect resident. The nurse prepared the medications for the intended resident at the doorway of a shared room but then approached the wrong resident and failed to verify the resident's identity using the identification bracelet, relying instead on a verbal confirmation and a photo in the medical record. The nurse did not inform the resident of the medications being administered. After the medications were given, the resident questioned the absence of a specific medication, prompting the nurse to realize the error. At this point, the nurse could not locate a supervisor and instead informed another nurse, but did not fully disclose the extent of the error. The resident who received the incorrect medications had a history of cardiac conditions, including hypertension, heart failure, and atrial fibrillation, and was prescribed different medications than those administered. Following the error, the resident experienced a significant drop in blood pressure and required immediate interventions, including fluids, medication for hypotension, and positioning. The resident was subsequently transferred to the emergency department for further evaluation and treatment, where additional fluids were administered and poison control was consulted. The resident returned to the facility later that day in stable condition. The facility's policies required verification of resident identity using multiple identifiers and immediate notification of a registered nurse and provider in the event of a medication error. However, the nurse failed to follow these protocols, both in verifying the resident's identity and in promptly notifying the appropriate clinical staff and provider about the error. The incident was not fully reported until after the nurse had continued the medication pass, and the full extent of the error was only discovered later by supervisory staff.
Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A medication error occurred when a licensed nurse administered a full set of prescribed medications intended for one resident to the incorrect resident, who was the roommate. The nurse prepared the medications at the doorway of the shared room and, upon entering, asked the resident if she was the intended recipient. The resident affirmed, but the nurse failed to verify the resident's identity using the identification bracelet and relied solely on a photograph in the medical record, which she mistakenly believed matched the intended resident. The nurse did not inform the resident of the medications being administered and only realized the error when the resident inquired about a medication not included in the cup. The resident who received the incorrect medications had a history of cardiac conditions, including hypertension, heart failure, and atrial fibrillation, and was prescribed different medications than those administered. After ingesting the medications, the resident experienced a significant drop in blood pressure and required immediate clinical intervention, including fluids, repositioning, and close monitoring. The error was not immediately reported to supervisory staff, and the nurse continued with the medication pass for other residents before the full extent of the error was discovered. Interviews and documentation revealed that the nurse did not follow facility policy, which required verification of resident identity using at least two identifiers, such as the name band and photograph, prior to medication administration. The nurse also failed to communicate the full scope of the error to supervisory staff promptly, resulting in a delay in appropriate response. The facility's policies clearly outlined the steps for medication administration and resident identification, which were not adhered to in this incident.
Inadequate Staff Knowledge on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that all staff members were knowledgeable in identifying residents requiring Enhanced Barrier Precautions (EBP) and proficient in utilizing proper personal protective equipment (PPE) while providing care for these residents. During the survey, it was observed that there were no enhanced barrier signs outside resident bedroom doors. Interviews with staff revealed a lack of understanding and inconsistent practices regarding the use of PPE for residents on EBP. For instance, a charge nurse indicated that orange dots on resident room plates signified the need for EBP, but a nursing assistant was unaware of this and did not use gowns while providing care. Another nursing assistant was observed not wearing a gown when exiting a room with an orange dot, despite the resident being dependent on care. The facility's policy on Precautions to Prevent Infection indicated that EBP involves targeted gown and glove use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms. However, the policy was not effectively communicated or implemented among staff, particularly those on the third shift, who found it difficult to attend in-service training. The Infection Preventionist stated that no signage was required outside resident rooms, as visitors were not expected to provide high-risk direct care. Despite this, the lack of clear communication and training led to staff being unaware of which residents required EBP and the necessary precautions to take, as evidenced by the interviews and observations during the survey.
Deficiencies in Prosthetic Care, Catheter Documentation, and Bruise Assessment
Penalty
Summary
The facility failed to ensure proper communication and documentation regarding the use of prosthetic devices for a resident with a history of cerebrovascular accident and amputations. The resident, who was cognitively intact, expressed discomfort with the prosthetic devices, leading to frequent refusals to wear them. Despite these refusals being documented in the nursing assistant flow sheets, there was no corresponding documentation in the nursing notes, and the physical therapy department was not informed of the discomfort. This lack of communication and documentation resulted in the prosthetic devices not being evaluated for fit and comfort, as the physical therapist was unaware of the resident's discomfort. In another case, the facility failed to document a diagnosis supporting the use of an indwelling urinary catheter for a resident with benign prostatic hypertrophy. Although the resident was admitted with a catheter and had orders for its use, the facility's records did not contain a diagnosis justifying the catheter's continued use. This oversight was identified during a review with the Director of Nursing Services and other staff, who acknowledged the absence of a documented diagnosis in the resident's medical records. Additionally, the facility did not adequately assess and document a bruise on a resident's hand, which was reported after an incident involving a nurse aide. The resident, who had a history of stroke and mobility issues, reported being roughly handled during a transfer, resulting in a bruise. The facility's investigation could not substantiate abuse, but the incident highlighted a failure to follow the facility's practice of assessing and documenting bruises for size, color, and pain. The lack of timely assessment and documentation of the bruise was noted during interviews with facility staff.
Failure to Monitor Hot Water Temperatures
Penalty
Summary
The facility failed to adhere to hot water temperature monitoring requirements, leading to excessively high water temperatures in resident bathrooms. Observations on the memory care unit revealed that the hot water temperature in two residents' bathrooms exceeded the acceptable limit set by the Centers for Medicare and Medicaid Services, with temperatures recorded at 124.4 and 129.4 degrees Fahrenheit. The maintenance staff was notified, and upon rechecking, the temperatures remained above the acceptable range. The Director of Maintenance was informed and acknowledged the issue, indicating that the system would be flushed and the hot water turned off to ensure resident safety. Further investigation revealed that the facility's hot water temperature monitoring policy was not being followed. The Director of Maintenance admitted that the water temperatures were taken daily but not at varied times as required, and the time of testing was not documented. Additionally, there was no evidence of daily checks and logging of the mixing valve, nor was there documentation of weekly calibration of the tester. The facility policy required immediate action if temperatures exceeded the state's maximum level, but the logs and policy review indicated lapses in compliance with these procedures.
Failure to Report Resident's Allegations of Feeling Unsafe and Fearful
Penalty
Summary
The facility failed to implement policies that ensured allegations of feeling unsafe and being fearful of retaliation were reported for Resident #194. Resident #194, who was cognitively intact and had a history of depression and anxiety disorder, reported feeling threatened and fearful after two incidents involving LPN #5. On one occasion, LPN #5 left Ativan at the resident's bedside, which went missing, and later administered a second dose after the resident requested it. The resident felt threatened by LPN #5's comment that it would not happen again, fearing potential poisoning in retaliation. On another occasion, the resident questioned the dose of Eliquis administered by LPN #5, who allegedly responded in a manner that made the resident feel threatened and fearful of a blood clot, leading the resident to take the medication. The resident reported these incidents to NA #7, who acknowledged the resident's distress but did not effectively communicate the resident's fears of safety and retaliation to the appropriate supervisory staff. The Director of Nursing and RN #5, the nursing supervisor, were not informed of the resident's allegations of mistreatment over the weekend. The facility's policy required immediate separation of the resident from the alleged abuser and notification of administrative staff or the nursing supervisor, which was not followed in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a urinary catheter. The resident, diagnosed with Benign Prostatic Hypertrophy, was admitted with a history of using intermittent and indwelling catheterization for urinary elimination. Despite the Minimum Data Set (MDS) assessment indicating the need for a care plan due to urinary incontinence, the facility did not create one. Progress notes detailed the resident's urinary difficulties, including high post-void residuals and the need for catheterization, but these issues were not addressed in a care plan. Interviews with the Director of Nursing Services (DNS) and other staff revealed that the oversight was due to a failure to follow the facility's policy on maintaining current care plans. Another resident with a cognitive communication deficit and anxiety also lacked a person-centered care plan addressing their sensory needs. The resident, who required assistance with daily activities and had moderate hearing difficulty, was noted to have malfunctioning hearing aids. Despite recommendations from an audiologist for new hearing aids, the care plan did not reflect any interventions for the resident's communication or sensory needs. Interviews with the DNS confirmed that the interdisciplinary team did not update the care plan to address the resident's hearing deficit, contrary to the facility's expectations for customized and updated care plans.
Failure to Update Resident Care Plan with Preferences
Penalty
Summary
The facility failed to update the care plan of Resident #342 to reflect their preferences, specifically regarding how they wished to be addressed. Resident #342, who has diagnoses including Acute Embolism and Thrombosis, Paraplegia, and anxiety disorder, was identified as cognitively intact and requiring maximum assistance with dressing and bathing. Despite this, the care plan dated 11/7/24 did not include the resident's preference for how they wanted to be addressed, which was a concern expressed by the resident in a grievance logged on 11/11/24. The grievance indicated that the resident was unhappy with being called by their first name by a staff member. Interviews with staff revealed that RN #3 acknowledged the omission, stating that the resident's preference should have been included in the care plan for the benefit of all staff, not just those who had direct communication with the resident. RN #3 admitted forgetting to update the care plan. Additionally, NA #8, who provided care to Resident #342, reported that the resident expressed concerns about another staff member during their interaction. However, NA #8 did not engage further beyond providing care and was subsequently removed from the resident's assignment and received an in-service. The facility's policy requires that care plans be kept current by all disciplines, but this was not adhered to in this instance.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for Resident #194, who had a history of depression and anxiety disorder. On 11/16/24, LPN #5 prepared Ativan for Resident #194 but left the medication at the bedside when the resident indicated it was too early to take it. Upon returning, the medication was missing, and the resident reported not having taken it. A second dose was administered after the initial dose was unaccounted for. The facility's policy clearly stated that medications should not be left at the bedside, and the Director of Nursing Services confirmed this expectation. Additionally, the facility failed to follow the five rights of medication administration for Resident #74, who had diagnoses including Type 2 diabetes mellitus and Parkinson's disease. On 11/20/24, LPN #1 administered only one tablet of Metformin instead of the prescribed two tablets. LPN #1 admitted to not being familiar with the resident and not reading the physician's order carefully. The facility's active Medication Pass policy required medications to be administered safely and per physician's orders.
Failure to Use Positioning Wedges for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for a resident who was at risk for pressure ulcers and had developed a stage 2 pressure ulcer on the right buttocks. The resident, who was cognitively intact and required partial/moderate assistance to roll, was not turned using the appropriate offloading device as per the care plan. The care plan specified repositioning every 2 hours with positioning wedges, but observations and interviews revealed that the wedges were not used, and the resident was left in one position without assistance. Nursing staff were unaware of the resident's specific positioning needs, and the wedges were found stored in the resident's closet, unused. The resident expressed an inability to turn without assistance and indicated that staff had not used the wedges for positioning. Interviews with nursing staff revealed a lack of awareness and communication regarding the resident's care plan and positioning needs. The facility did not have a policy for the use of positioning wedges and air mattresses, contributing to the deficiency. The wound care nurse acknowledged the importance of using wedges for effective pressure offloading but noted that the resident did not like using them, leading to the consideration of an air mattress as an alternative.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from eloping. The resident, who had diagnoses including hemiplegia, hemiparesis, TIA, and cerebral infarction, was severely cognitively impaired and dependent on assistance for all activities of daily living. Despite these conditions, the resident was found outside the facility self-propelling in a wheelchair. This incident occurred after the resident had been discharged from occupational therapy, having reached their goals, and was noted to have recently developed the ability to self-propel short distances. The deficiency occurred when the receptionist left the front desk unattended for a brief period, during which the resident managed to exit the building. The facility's elopement policy required residents to be accounted for at all times, but there was no expectation for desk coverage during short absences like bathroom breaks. Staff interviews revealed that the resident had not previously attempted to elope, and the incident was unexpected. The resident was quickly returned to the building by staff who noticed the elopement through a window.
Failure to Address Pharmacist Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were provided to the physician for review and response for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD) and dementia with psychotic disturbance. The resident had severe cognitive impairment as indicated by the Comprehensive Significant Change Minimum Data Set (MDS) assessment. Despite consultant progress notes identifying recommendations for the prescriber to review the physician's order for Naloxone and to add a stop date for Clonazepam, these recommendations were not addressed in a timely manner. Specifically, recommendations made on 2/21/2024, 6/20/2024, and 7/21/2024 were not acted upon until 10/23/2024. During an interview and record review, a corporate nurse acknowledged the oversight and noted that pharmacy recommendations should be reviewed and signed by the physician. However, due to a transition of ownership in June 2024, there was a lapse in addressing these recommendations. The facility's policy requires that pharmacist recommendations be submitted to the Director of Nursing Services and followed up on to ensure appropriate action is taken within a reasonable timeframe. The failure to adhere to this policy resulted in sporadic entries and a lack of timely response to the pharmacist's recommendations.
Incomplete Hospice Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the completeness of hospice notes for two residents receiving hospice care. Resident #12, diagnosed with dementia and heart failure, had severe cognitive impairment as indicated in a quarterly Minimum Data Set (MDS) assessment. This resident elected hospice services on November 5, 2024, and the care plan required coordination with the hospice provider to review the effectiveness of care. However, the clinical record lacked certification records for this resident. Similarly, Resident #91, diagnosed with Alzheimer's disease and receiving palliative care, elected hospice services on December 18, 2023. The care plan for this resident included interventions for comfort and coordination of care. During a review on November 21, 2024, it was identified that certification records were also missing for this resident. An LPN acknowledged the absence of documentation and mentioned that hospice providers usually visit the facility and provide paperwork, which is then entered into hospice binders containing notes from the hospice nurse.
Failure to Report and Follow Up on Allegation of Mistreatment
Penalty
Summary
The facility failed to ensure that a resident was seen by social services within three days following an allegation of mistreatment, as per the facility's practice. Additionally, the facility did not report the allegation of mistreatment to the appropriate state agency. The resident involved, who was admitted with diagnoses including hypothyroidism, hyperlipidemia, hypertension, osteoarthritis, and a history of stroke, reported that a nurse aide roughly handled them during a transfer, resulting in bruising on the resident's hand. The incident occurred when the resident, who required assistance with mobility and self-care, rang the call bell for help to use the bathroom. The nurse aide allegedly grabbed the resident's hand and feet to transfer them to a wheelchair, which the resident claimed led to bruising. The resident did not report the incident immediately due to fear of retaliation, and it was only brought to attention after a physical therapist noticed the bruising and reported it to the nursing staff. Interviews with facility staff revealed that the social worker was aware of the incident but did not follow up with the resident within the required timeframe. Furthermore, the social worker did not report the incident to the state agency, citing workload as a reason. The facility's investigation could not substantiate the abuse, but the care plan was updated to require two staff members for assistance with the resident's care.
Late Completion of Significant Change MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to ensure that staff accurately coded the Minimum Data Set (MDS) assessments to reflect significant changes in the status of residents receiving hospice care. Resident #12, diagnosed with dementia and heart failure, elected hospice services on November 5, 2024. However, the Significant Change in Status MDS assessment, which should have been completed within 14 days of the determination of a significant change, was not completed by November 21, 2024, making it three days late. Similarly, Resident #91, with Alzheimer's disease and receiving palliative care, elected hospice services on December 18, 2023. The MDS assessment for this resident was completed two days late on January 3, 2024. Resident #101, also diagnosed with dementia and receiving palliative care, elected hospice services on February 18, 2024. The MDS assessment for this resident was completed two days late on March 5, 2024. An interview with RN #6, the MDS Director, revealed a lack of awareness and training regarding the requirement to complete a significant change MDS within 14 days after the determination of a significant change. RN #6 mistakenly believed the facility had 14 days after setting the Assessment Reference Date to complete the MDS. This misunderstanding led to the late completion of the significant change MDS assessments for Residents #12, #91, and #101.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, as evidenced by an incident involving a nursing assistant (NA) and a resident. The resident, who was alert and oriented, had a history of a fractured humerus, heart failure, and localized edema, and required maximal assistance for toileting. On the night in question, the resident's family member reported that the resident felt scolded by the NA for frequently ringing the call bell between 1 AM and 2 AM. The NA admitted to being short with the resident due to the frequent calls for assistance with toileting, talking, and repositioning, and acknowledged that she may have scolded the resident, although she denied yelling. The incident was documented in a facility Reportable Events Form, and the resident confirmed feeling scolded during an interview. The NA's statement indicated she was overwhelmed with her workload that night, which included caring for new arrivals to the unit. The facility's Employee Code of Ethics and Resident Rights Policy emphasize treating residents with care, courtesy, respect, and dignity, which was not upheld in this instance. The deficiency was identified through clinical record review, facility documentation review, and interviews.
Failure to Reassess Resident's Self-Administration Capability
Penalty
Summary
The facility failed to reassess a resident's ability to self-administer medication after a change in the resident's status. The resident, who had a diagnosis of diabetes and was using an insulin pump, was initially assessed and deemed competent to manage the pump. However, on two consecutive days, the resident was unable to manage the insulin pump, and there were concerns noted, although specifics were not documented. The resident's blood sugar levels were significantly elevated on these days, requiring intervention from the nursing staff. Despite the facility's policy requiring re-evaluation of a resident's ability to self-administer medication upon a change in status, the resident was not reassessed when difficulties were identified. The facility's policy also indicated that the right to self-administer medication could be withdrawn if the resident could no longer safely perform the task. The Director of Nurses and Assistant Director of Nurses acknowledged that the resident should have been re-evaluated and that discontinuation of the insulin pump should have been considered.
Failure to Include Insulin Pump Information in Discharge Instructions
Penalty
Summary
The facility failed to ensure that the discharge instructions for a resident included critical information about the use of a specialized device, specifically an insulin pump, which was necessary for the resident's diabetes management. The resident, who had a diagnosis of Type 1 Diabetes and was using an insulin pump during a hospital stay, was discharged to a home care setting without the necessary documentation regarding the insulin pump. The discharge packet did not include details such as the frequency of blood sugar monitoring, insulin type, frequency, route, or the presence of the insulin infusion pump, which are essential for the resident's ongoing care. The deficiency was identified through a review of clinical records, facility documentation, and interviews. The Director of Nurses confirmed that the nurse responsible for completing the discharge paperwork failed to include information about the insulin pump. The facility's discharge planning policy requires collaboration with social services to create a viable discharge plan, but in this case, the necessary information was omitted, leading to an incomplete discharge packet for the resident.
Failure to Maintain Insulin Pump for Resident with Diabetes
Penalty
Summary
The facility failed to ensure proper maintenance of a medical device for a resident with diabetes who was using an insulin pump. The resident was discharged from the hospital with instructions to continue using the insulin pump, and the insulin infusion set was due to be changed on specific dates according to the manufacturer's guidance. However, the clinical record did not show any evidence that the insulin infusion set was changed during the resident's stay at the facility. The resident had a moderate cognitive impairment and required supervision with activities of daily living. Despite having a physician's order allowing the resident to self-administer the insulin pump, there was no documentation to confirm that the infusion set was changed as required. The Director of Nursing Services acknowledged the lack of documentation supporting the change of the insulin infusion set, which was supposed to occur every 2-3 days as per the manufacturer's instructions.
Lack of Staff Training on Insulin Pump Management
Penalty
Summary
The facility failed to ensure that staff were trained and competent in managing and monitoring a specialized medical device, specifically an insulin pump, for a resident with diabetes. The resident was identified as having moderate cognitive impairment and required supervision with activities of daily living. Despite being deemed capable of self-administering the insulin pump, there were documented instances where the resident was unable to manage the device, leading to concerns that were not clearly specified. The facility's policy required re-evaluation of the resident's ability to self-administer medications if there was a change in status, but it appears this was not adequately addressed. Interviews with staff, including LPNs and the Director of Nursing, revealed that the facility did not provide training on the insulin pump. Instead, staff were expected to refer to the manufacturer's instructions. On one occasion, an LPN had to fill and insert a new insulin cartridge using the user manual, as she had not received training from the facility. The lack of training and reliance on the manual indicates a gap in ensuring staff competency in managing the resident's insulin pump, which is critical for the resident's well-being.
Latest citations in Connecticut
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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