Whitney Rehabilitation Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamden, Connecticut.
- Location
- 2798 Whitney Avenue, Hamden, Connecticut 06518
- CMS Provider Number
- 075246
- Inspections on file
- 19
- Latest survey
- September 19, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Whitney Rehabilitation Care Center during CMS and state inspections, most recent first.
A resident with a Stage 3 pressure ulcer experienced worsening of the condition due to improper air mattress settings in an LTC facility. The resident's air mattress was set for a weight of 150 lbs, despite the resident weighing 104 lbs, causing discomfort and increased pressure on the wound. The facility failed to obtain a physician's order for the air mattress settings and did not implement a turning and positioning schedule, leading to the deterioration of the resident's wound.
The facility failed to provide palatable and properly prepared food, as reported by several residents. Issues included overcooked and bland food, lack of fresh produce, and improperly served items like melted ice cream and stale buns. The Food Service Director was aware of some issues but did not conduct formal audits, contrary to facility policy.
The facility's Dietary Department had several deficiencies, including undated open food items, unsanitary ice machine conditions, and improper storage of staff beverages. The Dietary Manager and staff failed to adhere to policies regarding food labeling, cleaning schedules, and storage practices.
The facility failed to ensure proper PPE use for residents on Enhanced Barrier Precautions and Transmission Based Precautions. Staff were observed not wearing gowns during high-contact care for residents with infections, despite clear signage and policies. Additionally, required signage for a resident on Covid-19 precautions was missing, and a dusty fan was found blowing on clean laundry.
The facility failed to follow physician orders for several residents, including not adhering to a positioning plan for a resident with dementia, not documenting daily weights for a resident with CHF, and not continuing anticoagulant therapy for a resident with DVT. Additionally, blood glucose monitoring was not performed for a diabetic resident, leading to a hypoglycemic episode.
A resident with osteoarthritis was verbally abused by an LPN during a confrontation over a medication cart. The LPN used profane and derogatory language, which was witnessed by another LPN who intervened. The incident was reported, substantiated, and led to the termination of the LPN's employment.
A facility failed to address a resident's advance directives upon admission. The resident, with moderately impaired cognition and requiring assistance with ADLs, had a living will specifying no life support systems, yet was recorded as a full code. Interviews with the DON and ADON confirmed that advance directives should have been addressed upon admission, but this was not done. The facility's policy required that a resident's choices regarding advance directives be honored and documented.
A resident was left wearing a hospital gown for several days due to delayed laundry return, impacting their dignity and participation in therapy. Despite being cognitively intact and requiring assistance with dressing, the resident's clothing was not returned for five days. The issue was reported to the laundry department, but the Director of Environmental Services was unaware until later, and the facility's policy for reporting missing items was not followed promptly.
The facility failed to notify responsible parties and physicians of significant changes in residents' conditions. A resident with cognitive impairment developed an open wound without notifying the responsible party. Another resident with CHF experienced a significant weight loss without physician notification. Additionally, a resident refused to wear a prescribed lumbar brace, and the physician was not informed. These actions were contrary to the facility's policies.
A resident with severe cognitive impairment and multiple health issues was not provided necessary grooming assistance, resulting in unshaven and disheveled appearance over several days. Staff interviews revealed inconsistencies in following the facility's grooming policy, with no refusals documented despite the resident's unmet grooming needs.
A facility failed to implement a physician's order for a resident's ambulation, leading to a deficiency. The resident, with a history of spinal issues, required a two-person assist for ambulation per the physician's order. However, the nurse aide did not ambulate the resident, believing it was the responsibility of physical therapy. The care card indicated a two-person assist was needed but did not specify that ambulation should occur, leading to documentation that ambulation was not applicable.
The facility failed to follow the posted menu and did not notify residents of meal substitutions. A resident was served breaded fish instead of their pre-selected barbecue spare rib sandwich. The Food Service Director conducted audits but found no inconsistencies, and only one in-service was provided to the Dietary Aide. Further observations showed manicotti was replaced with stuffed shells, and sherbet with ice cream, without notifying residents. The Resident Council confirmed meal tickets often did not match selections or served food.
A resident with renal disease, diabetes, and depression did not receive quarterly statements for their Resident Trust Account over the past year. The Business Office Manager, new to her role, was unaware of her responsibility to send these statements, believing Corporate handled it. Upon inquiry, she learned she was responsible, leading to the deficiency.
A resident with no fluid restriction repeatedly requested a water pitcher overnight, but the facility failed to resolve this grievance over several months. Despite acknowledging the issue and planning to order more pitchers, the facility did not ensure availability from 11:00 PM to 7:00 AM, contrary to its grievance policy.
A facility failed to accurately code the MDS for a resident requiring a PASRR Level II assessment. The resident, diagnosed with schizophrenia, depressive episodes, and dementia, was not identified as having a serious mental illness in the MDS, despite a PASRR Level II assessment indicating such. The error was discovered during a review with a social worker, who noted the resident was not listed for Level II coding, and the facility lacked a PASRR policy.
The facility failed to ensure consistent documentation of ADL care for a resident with a history of fractures and osteoarthritis, with a low completion rate of POC documentation. Additionally, the facility did not document meal consumption for another resident with impaired cognition and a femur fracture. Interviews revealed a lack of monitoring and awareness among staff, and the facility lacked specific documentation policies.
A resident with Alzheimer's disease wandered off the property and was found three miles away. The facility failed to investigate the incident promptly or report it to the state agency. Staff interviews revealed a lack of awareness and communication, and the resident knew the code to the elevator, allowing access to the main entrance. The facility's policy for immediate notification and investigation was not followed.
Improper Air Mattress Setting Leads to Worsening Pressure Ulcer
Penalty
Summary
The facility failed to properly set and monitor an air mattress for a resident, leading to the worsening of a pressure ulcer. The resident, who had diagnoses including type 2 diabetes mellitus, anemia, and hyponatremia, required extensive assistance for transfers, toileting, and bed mobility. The resident's care plan included the use of an air mattress for a Stage 3 pressure ulcer on the left buttock, but it did not specify the correct settings for the mattress. Additionally, there was no documentation of a turning and positioning schedule, and the nurse aide care card lacked directives for turning and positioning. Observations and interviews revealed that the air mattress was set incorrectly at 150 lbs, despite the resident weighing 104 lbs. The resident expressed discomfort and pain due to the mattress feeling too firm, akin to sitting on rocks. The nursing staff, responsible for monitoring and setting the air mattress, failed to adjust it according to the resident's weight. A physician's order for setting and monitoring the air mattress was not in place, which should have been obtained when the air mattress was first initiated. The wound physician noted that the pressure ulcer had worsened, with increased depth, tunneling, and undermining, indicating that the wound had been exposed to more pressure. The physician attributed the worsening condition to the air mattress being set too firm, which increased pressure on the wound. The facility's air mattress policy required observing the mattress each shift to ensure proper functioning and settings, which was not adhered to in this case.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Interviews with residents revealed dissatisfaction with the taste and quality of the food, noting that cold food was not served cold and there was a lack of fresh fruits and vegetables. A taste tray evaluation found that the broccoli stems and manicotti were overcooked, mushy, and bland. The Food Service Director acknowledged the overcooking of broccoli and admitted to not conducting audits on food quality, although he performed undocumented demonstrations with cooks. During a Resident Council meeting, multiple residents reported issues such as uncooked rice, inedible fish, stale burger buns, melted ice cream, and wilted salads. The facility's policy stated that food should be prepared to conserve nutritive value and enhance flavor and appearance, which was not adhered to in these instances.
Dietary Department Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards in the Dietary Department, as evidenced by several deficiencies observed during a tour. Open food items in the walk-in freezer and refrigerator were not dated, with some items like chicken patties showing signs of freezer burn. The ice machine and its scoop were found in unsanitary conditions, with the scoop stored in a visibly soiled holder and the machine's vents covered in dust. Additionally, the dish room had dirty ceiling vents, and an uncovered garbage can was found on the clean side of the dish area. Staff practices also contributed to the deficiencies. The Dietary Manager acknowledged that whoever opened food items was responsible for labeling them with an open date, but this was not consistently done. The ice machine had not been cleaned for the current month, and the Dietary Manager indicated that maintenance was responsible for cleaning the vents, but it was their responsibility to notify maintenance when cleaning was needed. Furthermore, staff beverages were improperly stored in the kitchen refrigerator, which was against facility policy, and the Dietary Aide could not justify this action.
Inadequate PPE Use and Signage in LTC Facility
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was used for residents on Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP). For Resident #32, who had an ileal conduit and was on EBP for Clostridium Difficile (C-Diff) and Methicillin Resistant Staphylococcus (MRSA), a nurse aide was observed emptying the urinary bag wearing gloves but not a gown, despite signage indicating the need for both. The nurse aide admitted to forgetting to don the gown, although she had received education on EBP. Similarly, Resident #36, who had a feeding tube and a history of extended spectrum beta lactamase (ESBL) resistance infection, was on EBP. A nurse aide was seen performing incontinent care wearing gloves but not a gown, despite being aware of the EBP requirements. The aide misunderstood the need for PPE during incontinent care, which was clarified by the Infection Preventionist, who confirmed that PPE should have been worn. For Resident #74, who had an unhealed pressure ulcer and was on EBP for wound care, a registered nurse conducted wound care without wearing a gown, contrary to the facility's policy. Additionally, Resident #76, diagnosed with Covid-19, was on TBP, but the required signage to alert staff and visitors of PPE needs was missing from the resident's door. The Infection Control Nurse was responsible for the signage but denied removing it. Furthermore, a tour of the laundry room revealed a fan with heavy dust accumulation blowing on clean laundry, indicating a lapse in maintenance and cleanliness protocols.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to adhere to physician's orders for Resident #32, who was diagnosed with conditions including macular degeneration, cataracts, cerebral infarction, and dementia. The resident required substantial assistance for daily activities and was supposed to be positioned out of bed according to a 24-hour positioning plan. However, observations revealed that the resident was often left in bed, contrary to the plan. Nursing progress notes lacked documentation on the resident's comfort, positioning, or pain as required by the physician's order. Interviews with staff indicated a misunderstanding or disregard for the positioning plan, with one nurse aide admitting to keeping the resident in bed based on personal preference rather than the resident's needs or orders. For Resident #69, who had diagnoses including chronic systolic congestive heart failure, the facility failed to document daily weights as ordered by the physician. Although the electronic medication administration record indicated that weights were completed, the actual weights were not recorded in the clinical record. Interviews with staff revealed a lack of communication and documentation processes, with nurse aides responsible for weighing residents but not documenting the results. The failure to update care cards and assignment sheets with the daily weight requirement further contributed to the oversight. Resident #153, with a history of deep vein thrombosis, did not receive the prescribed anticoagulant therapy due to an error in medication order transcription. The facility's policy required following the inter-agency patient referral form for medication orders, but the Lovenox order was incorrectly given an end date, leading to a lapse in administration. Interviews with advanced practice registered nurses and licensed practical nurses highlighted a lack of clarity and verification in the medication ordering process. Additionally, Resident #173, who had diabetes, did not receive necessary blood glucose monitoring due to an inadvertent discontinuation of the order. This oversight resulted in missed monitoring instances and a subsequent hypoglycemic episode requiring hospital transfer.
Verbal Abuse Incident Involving Resident and LPN
Penalty
Summary
The facility failed to protect Resident #106 from verbal abuse by a staff member, resulting in a substantiated incident of mistreatment. Resident #106, who was diagnosed with osteoarthritis and was alert, oriented, and self-mobile in a wheelchair, was involved in a verbal altercation with LPN #12. The incident occurred when Resident #106 allegedly moved LPN #12's medication cart, prompting LPN #12 to engage in a verbal exchange with the resident. During this exchange, LPN #12 used profane and derogatory language towards Resident #106, calling the resident an 'idiot' and a derogatory term. LPN #11 witnessed the incident and intervened by stepping between the two parties. The facility's documentation and interviews confirmed that LPN #12 admitted to swearing at Resident #106, and the incident was reported to the RN supervisor. The Director of Nursing Services (DNS) acknowledged that the verbal exchange should not have occurred, and staff are prohibited from swearing at residents regardless of provocation. The facility's Abuse/Retaliation Prohibition Policy defines verbal abuse as the use of disparaging and derogatory language towards residents. The incident was substantiated, and LPN #12's employment was terminated as a result.
Failure to Address Advance Directives Upon Admission
Penalty
Summary
The facility failed to address advance directives timely for a resident upon admission. Resident #375, who was admitted with diagnoses including hypothyroidism and a femur fracture, had moderately impaired cognition and required assistance with activities of daily living (ADLs). The resident's clinical record included a living will that specified the resident did not want life support systems such as artificial respiration, cardiopulmonary resuscitation, and artificial means of providing nutrition and hydration. Despite this, the resident was recorded as a full code. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that advance directives should have been addressed upon admission, but this was not done for Resident #375. The facility's policy on advanced directives, dated March 31, 2023, required that a resident's choices regarding advanced directives be honored and documented in the care plan and face sheet. The DON and ADON were unable to explain why the advance directives were not addressed during the resident's admission.
Resident's Dignity Compromised Due to Delayed Laundry Return
Penalty
Summary
The facility failed to ensure the timely return of laundry for a resident, resulting in the resident having to wear a hospital gown for several days. The resident, who was cognitively intact and required assistance with dressing, reported not receiving their clothing back from the laundry for five days. This situation was observed during a Resident Council meeting and further confirmed during interviews with the resident and staff. The resident expressed discomfort and dissatisfaction with wearing a hospital gown, which affected their participation in physical therapy sessions. The issue was reported to the laundry department by a nurse aide, but the Director of Environmental Services was not aware of the missing clothing until several days later. The department was experiencing staffing shortages, and the regular employee responsible for handling such issues had left. The facility's policy required staff to report missing items to supervisors, who would then inform the social worker or administration, but this process was not followed in a timely manner. The social worker was only informed of the issue on the same day as the surveyor's observation, despite the nurse aide being aware of the problem earlier.
Failure to Notify Responsible Parties and Physicians of Resident Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident's development of an open area requiring treatment. Resident #36, who had a history of stroke and was severely cognitively impaired, developed a superficial open area on the right great toe. Despite the facility's policy requiring notification of changes in status, there was no documentation that the responsible party was informed of this condition from the time it was identified until it was resolved. The wound nurse indicated that it was the responsibility of the nurse or unit manager to notify the responsible party, but this did not occur. In another instance, the facility did not notify the physician of a significant weight loss in a resident with congestive heart failure. Resident #69, who was moderately cognitively impaired and had chronic heart failure, experienced a weight loss of more than 3 pounds in one day. The facility's policy required notification of such weight changes, but the physician or APRN was not informed. The APRN confirmed that she would have expected to be notified to assess the situation further. Additionally, the facility failed to notify the physician of a resident's refusal to wear a prescribed lumbar brace. Resident #476, who had multiple vertebral compression fractures, was observed multiple times without the brace, which was required when out of bed. Despite the resident's refusal being reported to an LPN, there was no documentation of physician notification until after surveyor inquiry. The facility's policy required physician notification if a refusal was of significant importance, which was not initially followed.
Failure to Assist Resident with Grooming
Penalty
Summary
The facility failed to provide necessary assistance for grooming to Resident #32, who was severely cognitively impaired and required substantial assistance for daily activities. The resident had diagnoses including macular degeneration, cataracts, cerebral infarction, and dementia, and was identified as needing maximal assistance for eating, toileting, and transfers. Despite the care plan indicating the need for assistance with bathing, dressing, personal hygiene, and grooming, observations over three days showed the resident was unshaven and had disheveled hair. Interviews with staff revealed inconsistencies in the understanding and execution of the facility's grooming policy. A nurse aide admitted difficulty using a disposable razor and did not report the issue to a nurse, contrary to the policy. Another aide and an LPN confirmed that residents should be shaved daily or as needed, with refusals reported to a nurse. However, no refusals were documented for Resident #32, indicating a lapse in communication and adherence to the grooming policy, which aims to maintain residents' dignity and ensure socially acceptable grooming.
Failure to Implement Physician's Order for Resident Ambulation
Penalty
Summary
The facility failed to implement a physician's order for ambulation for a resident with a history of wedge compression fracture, osteoarthritis, and thoracolumbar fusion. The resident was cognitively intact and required assistance with activities of daily living due to decreased mobility. The care plan indicated the resident needed a one-person assist for ambulation using a rolling walker, but a physician's order later required a two-person assist. Despite this, the nurse aide responsible for the resident did not ambulate the resident, believing that physical therapy was responsible for this task. The nurse aide followed the Resident Care Card, which indicated a two-person assist was needed for ambulation but did not specify that ambulation should occur. Consequently, the nurse aide documented that ambulation was not applicable, as she believed the responsibility lay with physical therapy. Interviews with the rehabilitation director and therapists revealed that orders for ambulation were not specific in terms of frequency or location, and the facility's practice was for nursing staff to assist with ambulation as needed, without explicit direction in the physician's order.
Failure to Follow Posted Menu and Notify Residents of Meal Substitutions
Penalty
Summary
The facility failed to adhere to the posted menu and did not provide prior notification to residents when meal substitutions were made. During an observation of the lunch meal, a resident who had pre-selected a barbecue spare rib sandwich was instead served breaded fish, despite the barbecue spare rib sandwich being available. This inconsistency was noted despite previous complaints from the Food Committee about meal tickets not matching what was served. The Food Service Director (FSD) had conducted audits in April 2024 but found no inconsistencies, and no further audits were completed after that month. Additionally, the FSD provided only one in-service to the Dietary Aide responsible for checking meal tickets, but could not recall the content of the training. Further observations revealed that manicotti was listed on the menu, but stuffed shells were served instead, and sherbet was substituted with ice cream halfway through service without notifying residents. The FSD attributed these errors to a mistake in removing the wrong item from the freezer and an unexplained shortage of ice cream. During a Resident Council meeting, it was confirmed that meal tickets often did not reflect the residents' selections or the food served. These findings highlight a failure in the facility's dietary services to follow the posted menu and communicate changes to residents, leading to dissatisfaction and confusion among the residents.
Failure to Provide Quarterly Resident Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly statements for residents with a Resident Trust Account, specifically affecting one resident with intact cognition and diagnoses including renal disease, Diabetes Mellitus, and depression. The resident reported not receiving quarterly banking statements for the past year after a change in bookkeeping staff. The Business Office Manager, who assumed her role in April, was unaware of her responsibility to send these statements, mistakenly believing that Corporate was responsible. Upon inquiry, she discovered that she was indeed responsible for providing the statements, which had not been sent due to this misunderstanding.
Failure to Provide Overnight Water Pitchers
Penalty
Summary
The facility failed to resolve a grievance regarding a resident's request for a water pitcher to be available overnight. The resident, who was cognitively intact and independent with eating and oral hygiene, expressed concerns during multiple Resident Council meetings about the unavailability of water pitchers from 11:00 PM to 7:00 AM. Despite the facility's documentation of plans to order more water pitchers and address the issue, the resident's request was not fulfilled over several months. The facility's grievance policy requires prompt resolution of complaints, but this was not achieved in this case. The resident's medical history included anemia, cervical disc disorder, and peripheral vascular disease, and there was no fluid restriction in place. The facility's failure to provide a water pitcher overnight persisted despite repeated mentions in Resident Council meetings and the facility's acknowledgment of the issue. The Assistant Director of Nursing Services confirmed that while water was offered in cups at night, the facility had not yet implemented a system to ensure water pitchers were available overnight, as initially promised.
Inaccurate MDS Coding for PASRR Level II
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for a resident who required a Preadmission Screening and Resident Review (PASRR) Level II assessment. The resident, who had diagnoses including schizophrenia, depressive episodes, and dementia, was identified as severely cognitively impaired and required extensive assistance with daily activities. Despite the PASRR Level I assessment indicating the need for a Level II assessment due to schizophrenia, the MDS did not reflect the resident's status as having a serious mental illness as determined by the state Level II PASRR process. The deficiency was identified during an interview and clinical record review with a social worker, who acknowledged that the PASRR documentation in the clinical record included a Level II assessment completed in 2015. However, the resident was not listed for Level II coding, leading to an incorrect MDS assessment. The facility did not provide a policy for PASRR when requested, indicating a lack of procedural guidance in ensuring accurate assessments for residents with serious mental illnesses.
Inadequate Documentation of ADL Care and Meal Consumption
Penalty
Summary
The facility failed to ensure consistent documentation by the Nurse Aide (NA) related to the provision of Activity of Daily Living (ADL) care for Resident #61, who had diagnoses including a wedge compression fracture, osteoarthritis, and a history of breast cancer. The resident was cognitively intact and required assistance with ADLs. However, the Point Of Care (POC) documentation from 6/20/24 to 8/29/24 showed a low completion rate of 29.4% for documenting bed mobility, transfers, toileting, and personal hygiene. Interviews revealed that charge nurses and unit managers were not adequately monitoring the POC documentation, and the Licensed Practical Nurse (LPN) was unaware of the requirement to check NA documentation. The facility lacked a policy for NA documentation, ADL documentation, and POC documentation. Additionally, the facility failed to ensure a complete and accurate medical record for Resident #375, who was admitted with diagnoses including hypothyroidism and a femur fracture. The resident had moderately impaired cognition and required assistance with ADLs. The facility did not document the meals consumed by the resident on 2/22 and 2/23/2024 for breakfast and lunch. The Director of Nursing Services (DNS) acknowledged the failure to document meal consumption and could not explain why it was not done. The facility's undated Documentation Policy indicated that NAs are responsible for completing the residents' flow sheet.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an incident where a resident with Alzheimer's disease and adjustment disorder wandered off the property unattended. Despite being identified as a low risk for wandering, the resident left the facility and was found three miles away by a family member. The facility did not initiate a Facility Reported Incident form or an investigation until nearly three months after the incident occurred. Staff interviews revealed that the resident had been able to exit the facility without staff awareness, and there was no immediate notification to the state agency as required by policy. On the day of the incident, the resident expressed a desire to go home and refused to wear a wander guard. One-to-one supervision was initiated, and the resident was added to the wanderer/elopement list. However, the clinical record lacked documentation of an immediate investigation or reporting to the state agency. Interviews with staff, including the Nursing Supervisor, LPN, and Receptionist, indicated a lack of awareness and communication regarding the resident's elopement. The Director of Nursing (DON) was not fully informed about the resident's whereabouts and the extent of the elopement until much later. The facility's exit doors required a code to open, but the resident knew the code to the elevator, which allowed access to the first floor and main entrance. The Maintenance Assistant and Administrator confirmed that the code had not been changed for an extended period, and there was no schedule for changing it. The facility's Elopement Assessment policy required immediate notification and investigation, which was not followed in this case, leading to a significant delay in addressing the incident and reporting it to the appropriate authorities.
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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