Clearstream Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hastings, Michigan.
- Location
- 240 E North St, Hastings, Michigan 49058
- CMS Provider Number
- 235281
- Inspections on file
- 18
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Clearstream Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Two residents with dementia and mental health conditions became involved in a physical altercation after one resident, who frequently wandered and picked up items, took a pair of gloves belonging to another resident. The second resident, who had a history of depression, suicidal ideation, and irritability, followed and forcefully grabbed the first resident’s arm, prompting the first resident to slap her in the face. Care plans did not address the first resident’s behavior of picking up others’ belongings or the second resident’s frustration with peers, despite known patterns of wandering, item-handling, and conflict with other residents. A family member witnessed the incident, and staff interviews confirmed the behavioral patterns that led to the conflict, which met the facility’s own policy definitions of physical abuse (hitting, slapping, grabbing).
A nurse administered a discontinued dose of Meloxicam to a resident after failing to reconcile the medication with the current physician order and not removing the outdated medication card from the cart. Multiple medication cards for both discontinued and current dosages were present, and audits of medication administration and storage did not consistently check for discontinued medications, leading to a medication error.
Surveyors found that medication carts were not properly managed, including missing narcotic count documentation, discontinued medications left accessible and administered to a resident, and an insulin pen in use without an open date. LPNs and other staff acknowledged lapses in following procedures for medication removal and labeling, and audits did not consistently check for discontinued medications.
The facility failed to maintain a sanitary environment in Resident #61's room and the spa room, with issues such as debris and stains. Additionally, the locked memory care unit's dining room did not provide a home-like atmosphere, as meals were served on trays, unlike the main dining room. Staff interviews revealed a lack of understanding regarding the differing meal service practices.
The facility failed to notify the provider of missed medication doses for two residents, one with atrial fibrillation and another with hypertension and a PEG tube. Medications were not reordered in time, leading to missed doses, and feeding tube orders were not in place, resulting in missed flushes. Staff interviews revealed systemic issues with medication reordering and communication.
The facility failed to provide adequate grooming for four residents with severe cognitive impairments, resulting in unkempt appearances and potential embarrassment. Observations showed these residents had noticeable facial hair that was not addressed, despite the facility's policy to improve appearance according to preferences. Staff interviews revealed a lack of awareness of residents' grooming preferences, and no documentation was provided to justify the lack of care.
The facility failed to provide residents with their food and beverage preferences, leading to incorrect items being served. Observations showed residents receiving beverages and nutritional supplements that did not match their meal tickets, such as being served Ensure Plus instead of Boost. Additionally, meals did not align with dietary needs or preferences, like serving regular jam to a diabetic resident. Staff interviews revealed these discrepancies were due to the dietary department providing available items rather than preferred ones.
A resident reported overhearing CNAs making derogatory comments about another resident's hygiene, which was not thoroughly investigated by the facility. Despite being cognitively intact, the resident's concerns were not adequately addressed by the Unit Manager or other staff, leading to a lack of communication and follow-up. The Director of Nursing was unaware of the incident, and grievance forms were not provided, indicating a failure in documentation and response to resident complaints.
A facility failed to update a resident's advanced directive and code status, despite requests from the designated patient advocate. The resident, unable to make medical decisions, was listed as Full Code, contrary to their signed directive and the advocate's request for DNR status. The advocate, living out of state, struggled with decision-making responsibilities and requested guardianship, which the facility did not initiate.
A facility failed to notify a resident's emergency contact of a change in condition, involving bruising and a laceration discovered during catheterization. The resident, who was moderately cognitively impaired with dementia and Alzheimer's, had their condition noted by a nurse, but the family was not informed, as confirmed by the DON.
A facility failed to prevent the misappropriation of a resident's narcotic medications, resulting in the loss of pain medication. An RN signed for a new Norco prescription but did not add it to the narcotic count sheet, leading to a discrepancy. The RN tested positive for opioids and oxycodone, and the facility concluded that the RN diverted the Percocet, as she could not provide a valid prescription for oxycodone and failed to follow proper procedures.
A facility failed to follow its abuse policy when staff did not report observations of potential sexual abuse of a resident with dementia and Alzheimer's disease. Despite noticing bruising and swelling in the resident's genital area, staff did not immediately inform the Nursing Home Administrator as required. The Administrator only learned of the injury weeks later, highlighting a lapse in the facility's reporting procedures.
A resident with dementia and muscle weakness experienced multiple falls due to the facility's failure to update the care plan with appropriate fall prevention interventions. Despite being at high risk for falls, the resident's care plan did not include the use of a fall mat, which was not consistently placed by the bed. Staff interviews confirmed the lack of documentation and communication regarding this intervention.
A resident with multiple pressure ulcers did not receive necessary care to prevent and treat her condition. Despite having a care plan that included the use of bilateral boots for offloading, these were not consistently applied. Observations showed the resident often without the prescribed boots, and staff interviews revealed a lack of adherence to the care plan. The MAR/TAR inaccurately indicated the boots were applied, contributing to the deficiency in pressure ulcer care.
A resident with multiple health conditions and a high fall risk experienced two falls due to staff failing to use prescribed assistive devices during transfers. Despite training, a CNA did not use a slide board or gait belt, leading to the resident being found on the floor on separate occasions.
A facility failed to provide timely emergency physician services for a resident with multiple health conditions who had not voided for 13 hours after returning from the hospital. Despite multiple attempts to contact the resident's physician and the facility's on-call provider, no immediate medical intervention was provided, leading to significant urinary retention. The facility lacked a contingency plan for emergency care when the resident's independent physician did not respond.
Two residents experienced medication administration errors, leading to a 12% error rate. A resident received an incorrect dose of Depakote due to an incomplete order, and another resident missed a dose of Symbicort inhaler because it was not available. The LPN failed to follow the facility's medication administration policy, which requires verifying orders before administration.
The facility failed to properly label, date, and store medications in the medication cart. An opened insulin lispro pen was found without an open date, and in the stock meds area, an opened bottle of Mucus ER and Cetirizine 10 mg were also missing open dates. RN FF confirmed that nurses were supposed to label medications with open dates, but this was missed. The DON reported that night shift staff were expected to review medication carts to ensure proper labeling.
The facility failed to implement Enhanced Barrier Precautions for two residents, one with a urinary catheter and another with a feeding tube. Observations showed a lack of signage and PPE, and staff did not consistently use gloves and gowns during care activities, despite the requirements. This resulted in potential cross-contamination risks.
The facility failed to prevent elopement for two residents and ensure safe mechanical lift transfers for another, resulting in Immediate Jeopardy. One resident expressed a desire to leave and was not reassessed for elopement risk, while another with a known history of elopement was found outside. Additionally, a resident was injured during a lift transfer due to improper equipment maintenance and staff training.
The facility failed to protect residents from abuse, resulting in incidents where a resident physically assaulted another, and another resident engaged in inappropriate sexual behavior. Despite care plans, interventions were insufficient, leading to emotional distress and physical harm. The facility's policy on abuse was not adequately enforced, contributing to these deficiencies.
A resident with dementia and other health issues fell from a mechanical lift and sustained a head injury. A CNA moved the resident back to bed without waiting for a nurse's assessment, contrary to facility policy and guidelines. The resident was later hospitalized and returned with stitches and a hematoma. Staff interviews confirmed the breach in protocol.
A resident with severe cognitive impairment and limited mobility was injured during a transfer when a CNA failed to use the prescribed sit-to-stand lift, resulting in a laceration requiring sutures. The CNA did not check the care plan and manually transferred the resident, leading to the injury.
A resident with dementia experienced two unwitnessed falls resulting in head trauma, but the facility failed to notify the physician. The resident was on hospice care, and facility staff assumed the hospice nurse would inform the hospice physician. However, the hospice nurse expected the facility to notify the resident's physician directly. A follow-up visit note lacked any mention of the falls, highlighting a communication breakdown.
A facility failed to prevent physical abuse between two residents with dementia, resulting in repeated incidents of aggression. Despite known triggers and a history of aggression, the facility lacked consistent supervision and effective interventions, leading to physical altercations. Staff interviews highlighted insufficient dementia training and inadequate supervision, particularly during weekends and evenings.
A resident with dementia experienced a right hip fracture that was not reported as an injury of unknown origin by the facility. The fracture was discovered after the resident complained of pain, but the facility attributed it to a previous fall without proper documentation or timely reporting. Interviews and records indicated a lack of immediate pain or injury signs post-fall, leading to a delay in investigation.
A resident with dementia experienced two falls in one night, but the facility failed to document a complete post-fall assessment. Although the resident initially showed no abnormalities, a hip fracture was discovered two days later when the resident complained of leg pain. The lack of documentation delayed necessary interventions.
Failure to Prevent Resident-to-Resident Physical Altercation Over Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident physical abuse when two residents engaged in a physical altercation. One resident with Alzheimer’s disease and generalized anxiety disorder, who was severely cognitively impaired with a BIMS score of 0/15, frequently walked around the unit and picked up items in her environment. Her care plan identified that she spent time walking around the unit picking up sensory items and directed staff to offer cues and prompts as needed, but there was no care plan addressing her behavior of picking up other residents’ belongings. On the day of the incident, this resident walked by another resident in the dining area and picked up a pair of gloves that were next to the second resident, then walked away carrying the gloves. The second resident involved had unspecified dementia, major depressive disorder, and a history of suicidal ideation, with a BIMS score of 12/15 indicating moderate cognitive impairment. Her care plan identified risk for psychosocial well-being concerns related to suicidal ideation and included an intervention to remove residents to a calm, safe environment when conflict arises, but there was no care plan addressing her frustration with peers. A family member witness reported that after the first resident picked up the gloves and began walking down the hall, the second resident followed, forcefully grabbed the first resident’s arm, and pulled back in a way that caused the first resident to turn around. In response, the first resident slapped the second resident on the side of the face, after which the second resident appeared angered and verbally stated that she had been slapped. Staff interviews and documentation further described the residents’ behaviors and the circumstances leading to the altercation. An LPN stated that the first resident frequently explored her environment by picking up items and did not have the capacity to consider ownership of the items she handled. A CNA reported that the second resident felt frustrated by the actions of other residents and would respond by yelling at them. A progress note documented that the second resident had been upset about a disagreement with another resident over her gloves, and a later psychiatric evaluation noted that she argued with another resident and had current symptoms including anxiety, depression, and irritability. The facility’s Resident Rights, Abuse and Neglect policy defined physical abuse to include hitting, slapping, and grabbing, and the reasonable person concept was applied to determine that neither resident would want to be grabbed forcefully by the arm or slapped in the face, establishing that the resident-to-resident physical contact constituted abuse that the facility failed to prevent.
Medication Administration Error Due to Failure to Remove Discontinued Medication
Penalty
Summary
A deficiency occurred when a nurse failed to follow professional standards of nursing practice during medication preparation and administration for a resident. The nurse retrieved and administered Meloxicam 7.5 mg from a medication card that had been discontinued, instead of the current order for Meloxicam 15 mg once daily. The discontinued medication card was not removed from the medication cart after the physician changed the order, leading to the administration of the incorrect dose. The nurse did not reconcile the medication dosage against the physician order prior to administration. Interviews with facility staff revealed that there were multiple medication cards for both the discontinued and current dosages in the cart, and that audits of medication administration and cart storage were performed without consistently checking for discontinued medications. Documentation of medication pass audits was incomplete, lacking details such as dates, resident names, or specific medications observed. Professional standards, including the six rights of medication administration, were not consistently followed, resulting in a medication error for the resident.
Medication Labeling, Storage, and Administration Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. On one medication cart, the narcotic count sheets were not verified for the current day, with the last entry recorded the previous night. The Assistant Director of Nursing (ADON) confirmed that narcotic counts should be performed and documented at each shift change, but the responsible LPN had not completed the count and cited the absence of a log sheet as a possible reason. Additionally, another LPN admitted to not having counted narcotics that day. Further observations revealed that a resident was administered Meloxicam 7.5 mg, which had been discontinued per physician orders and replaced with a 15 mg dose. The discontinued medication remained in the cart alongside the new medication, and the LPN acknowledged the error after reviewing the orders. Another issue was found with an insulin pen in a medication cart that was in use but lacked an open date, which the LPN attributed to forgetting to date it. Audits performed by the ADON and Unit Manager (UM) focused on medication administration and storage, but the UM reported not regularly checking for discontinued medication cards, and insulin pens were not always dated upon opening.
Deficiencies in Sanitation and Dining Environment
Penalty
Summary
The facility failed to maintain a sanitary and orderly environment in two specific areas: Resident #61's room and the spa room between C and D hall. Observations revealed that Resident #61's room had a windowsill track littered with dead bugs, dust, and debris, a cracked and chipped tile sill, and a headboard with veneer pulled away, leaving a large gap. Additionally, a window curtain had a noticeable stain. Resident #61, who was cognitively intact, expressed dissatisfaction with the room's condition, comparing it unfavorably to her home environment. In the spa room, a padded shower chair was found with stuck-on and smeared brown debris, and the supply cabinet had black-spotted debris on the inside walls, indicating a lack of cleanliness and maintenance. The facility also failed to provide a home-like dining environment in the locked memory care unit's dining room. Observations showed that residents in this unit were served meals on trays placed on dining tables, which contrasted with the main dining room where meals were served directly on the table without trays. Interviews with staff, including the Dietary Director, DON, and a CNA, revealed a lack of awareness and understanding of why meals were served differently in the locked memory care unit. The facility's policy emphasized creating a pleasant dining atmosphere, which was not adhered to in the memory care unit, potentially leading to an institutionalized dining experience for residents.
Failure to Notify Provider of Missed Medication Doses
Penalty
Summary
The facility failed to maintain professional standards of nursing practice by not notifying the provider of missed medication doses for two residents. Resident #6, who was admitted with atrial fibrillation, missed a morning dose of Symbicort inhaler because the medication was not reordered in time. The LPN responsible did not notify the facility's medical doctor, believing it was unnecessary. This oversight was attributed to a common issue where staff were not diligent in reordering medications, leading to missed doses. Resident #338, admitted with hypertension and a PEG tube, also experienced missed medication doses. Upon readmission, the facility did not have the resident's medications available, including Coreg, due to a failure in ordering them. Additionally, there were no feeding tube orders in place, resulting in missed flushes for the PEG tube. The LPN involved did not verify the orders with a second nurse, as required, and the Unit Manager was not informed of the missing orders. Interviews with facility staff, including the DON and pharmacists, revealed systemic issues with medication reordering and communication. The facility's policy required nurses to reorder medications when there were 7 doses remaining and to notify providers of missed doses, but these procedures were not consistently followed. The pharmacy confirmed that urgent medications could be delivered the same day if requested, but this option was not utilized, leading to the deficiencies observed.
Failure to Provide Adequate Grooming for Residents with Cognitive Impairments
Penalty
Summary
The facility failed to provide adequate grooming care for four residents who were dependent on staff for activities of daily living, resulting in unkempt appearances and potential feelings of embarrassment. Observations revealed that these residents, all with severe cognitive impairments, had noticeable facial hair that was not addressed by the staff. Despite the facility's policy to improve residents' appearance in accordance with their preferences, there was no documentation to explain why the grooming was not performed. Resident #12 was observed multiple times with long white facial hairs on her chin, and no documentation was provided to justify the lack of shaving. Similarly, Resident #14 had facial hair resembling a mustache and chin hairs, with a family member confirming that the resident would not have wanted facial hair. Resident #17 had a visible mustache and debris in her hair, while Resident #53 had long chin hairs. All these residents were observed over several days with the same grooming issues. Interviews with staff, including the Director of Nursing and a Registered Nurse, revealed a lack of awareness regarding the residents' preferences for facial hair grooming. The staff prioritized completing baths over addressing facial hair, and there was no documentation of refusals or preferences for grooming. The facility's shaving policy, adopted in 2018, emphasized improving residents' appearance according to their preferences, but this was not adhered to in these cases.
Failure to Provide Resident Food and Beverage Preferences
Penalty
Summary
The facility failed to consistently provide residents with their food and beverage preferences, leading to incorrect items being served to 12 residents out of a census of 88. Observations revealed that residents were often given beverages and nutritional supplements that did not match their meal ticket preferences. For instance, Resident #17 was repeatedly served a red beverage instead of apple juice and a Vanilla Ensure Plus instead of Chocolate Boost, which was specified on her meal ticket. Similarly, Resident #53 and others were served Ensure Plus instead of Boost, despite the nutritional differences between these products. In several instances, residents were served meals that did not align with their documented preferences or dietary needs. Resident #2, who preferred sweet breakfasts, was served only one portion of French toast instead of the double portion noted on her meal ticket. Resident #64, who disliked broccoli, was served it despite her meal ticket specifying alternative vegetables. Additionally, Resident #24, a diabetic, was served regular jam instead of the sugar-free condiments she preferred, and was given oatmeal instead of Fruit Loops on a day when Fruit Loops were requested. Interviews with staff, including the Dietary Director, revealed that the discrepancies were due to the dietary department providing what was available rather than what was preferred or ordered. The Dietary Director acknowledged that the facility's policy was to provide substitutes from the same food group and nutritionally equivalent, but this was not consistently followed. The report highlights that the residents in the locked memory care unit were unable to express their dissatisfaction, which could impact their nutritional intake.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the interactions between staff and residents. Resident #54, who was cognitively intact with a BIMS score of 15/15, reported overhearing CNAs making derogatory comments about a resident's hygiene, which she found upsetting. Despite reporting this to the Unit Manager (UM) CC, no thorough investigation was conducted to address the issue or identify the resident involved. Interviews with staff revealed a lack of communication and follow-up on the reported concerns. Social Services Director (SSD) GG admitted to not investigating Resident #54's previous complaints, assuming they were being handled by the nursing team. UM CC acknowledged speaking to the CNAs about keeping their voices down but did not report the incident to higher management or investigate further. The Assistant Director of Nursing (ADON) was aware of the complaint but did not pursue it, believing UM CC had resolved the issue. The Director of Nursing (DON) was unaware of the incident until the survey, indicating a breakdown in communication and reporting within the facility. The facility also failed to provide grievance forms for Resident #54, suggesting a lack of documentation and follow-up on resident complaints. Previous issues with CNA P's behavior were noted, but no corrective actions were mentioned in the report.
Failure to Update Advanced Directive and Code Status
Penalty
Summary
The facility failed to ensure that Resident #338's advanced directive information was updated and accurate, which could potentially lead to the resident's preferences for medical care not being followed. Resident #338 was admitted with a diagnosis of hypertension and had designated a family member, FM RR, as their patient advocate. The resident had signed a form indicating they did not want life-sustaining treatment under certain conditions. However, despite being listed as a Full Code at the facility, FM RR had requested a change to Do Not Resuscitate (DNR) status, which was not processed by the facility. FM RR, who was responsible for making medical decisions due to the resident's inability to participate in complex decision-making, expressed difficulty in fulfilling this role due to living in another state. FM RR had informed the facility of the desire to change the code status to DNR and later requested the facility to obtain a guardian for the resident. Despite these requests, the facility did not send the necessary paperwork to FM RR to change the code status, nor did they initiate the process for guardianship. The Social Services Director confirmed awareness of these issues but could not explain why the paperwork was not sent or why the guardianship process was not started.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for a resident who was moderately cognitively impaired with diagnoses of dementia and Alzheimer's disease. On March 15, 2025, a progress note indicated that the resident had bruising and swelling on the labia and a laceration above the urethra, discovered during a catheterization procedure. Despite these findings, the nurse on duty did not inform the family or emergency contact. The Assistant Director of Nursing was informed, but the family was still not contacted. The Director of Nursing confirmed that the resident's emergency contact was not notified of the bruising and tear when they were found.
Misappropriation of Resident's Narcotic Medications
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medications for a resident, resulting in the loss of the resident's pain medication. The issue was identified when the Director of Nursing (DON) received a call from the facility pharmacy about a discrepancy involving 20 unaccounted Percocet pills prescribed to a resident. An audit of medication carts and narcotic drawers was conducted, but the missing medication could not be located. The investigation revealed that a Registered Nurse (RN) had signed for a new Norco prescription for the resident but failed to add it to the narcotic count sheet, which should have reflected 35 scripts instead of 34. The RN was the last to document the administration of Percocet to the resident and tested positive for opioids and oxycodone during a drug test. Despite providing an undated script for Norco, the RN could not explain the missing narcotic card and narcotic sheet or why the Norco script was not logged onto the shift-to-shift count sheet. The facility concluded that the RN had diverted the Percocet from the resident, as she was unable to provide a valid prescription for oxycodone and did not follow procedure with the addition of the Norco script to the narcotic count log. The investigation included interviews with the RN and a Licensed Practical Nurse (LPN), as well as a review of the narcotic count logs and medication administration records. The Consulting Pharmacist confirmed the discrepancies in the documentation and noted that the RN had signed for the delivery of the Norco prescription and was the last to document the administration of Percocet. The facility's disciplinary action report for the RN indicated a previous violation of department policies and procedures related to medication documentation.
Failure to Report Observations of Potential Abuse
Penalty
Summary
The facility failed to operationalize its abuse policy and procedure for a resident who was moderately cognitively impaired with diagnoses including dementia and Alzheimer's disease. The deficiency occurred when staff did not report observations of potential sexual abuse to the Nursing Home Administrator immediately. On a specific date, a progress note indicated that the resident had bruising and swelling in the genital area, which was not reported to the Administrator as required by the facility's policy. The Nursing Home Administrator only became aware of the injury weeks later when informed by the Assistant Director of Nursing. Interviews with staff revealed that the Licensed Practical Nurse who observed the injury did not report it to the Abuse Coordinator but instead informed the oncoming nurse. The Registered Nurse who also observed the injury did not notify the Administrator or the Abuse Coordinator, only discussing it with the Assistant Director of Nursing. The facility's policy mandates that all allegations and suspicions of abuse must be reported immediately to the Administrator or their designee, which was not followed in this case. The facility's abuse training records showed that the involved staff had received training on reporting requirements, yet failed to adhere to them.
Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to update and revise the person-centered care plan in a timely manner with appropriate interventions for the prevention of falls for a resident. The resident, a male with diagnoses including lack of coordination, muscle weakness, dementia, and Alzheimer's disease, was identified as being at high risk for falls. Despite this, the care plan did not include necessary interventions such as the use of a fall mat, which was not consistently placed by the resident's bed as required. The resident experienced multiple falls, including one incident where he was found on the floor after attempting to self-transfer from bed to wheelchair. Observations revealed that the fall mat, which was supposed to be a part of the resident's fall prevention strategy, was not in place during these incidents. Interviews with staff, including a CNA and an LPN, confirmed that the fall mat was not listed as an intervention in the resident's care plan or kardex, indicating a lack of communication and documentation. The Director of Nursing (DON) acknowledged the oversight and noted that the interdisciplinary team met weekly to review falls and care plans, but the necessary updates had not been made for this resident. The failure to include and implement the fall mat intervention in the care plan contributed to the resident's repeated falls, highlighting a deficiency in the facility's care planning and communication processes.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to provide necessary care and services to prevent, treat, and promote healing of pressure ulcers for a resident with multiple pressure ulcers and chronic venous hypertension. The resident had several pressure ulcers, including a stage 3 ulcer on the right buttock, an unstageable ulcer on the left ankle, and a stage 3 ulcer on the left heel. Despite having a care plan that included interventions such as the use of bilateral boots for offloading pressure, these interventions were not consistently implemented. Observations revealed that the resident was often left in a supine position without the prescribed bilateral boots for offloading, which were intended to prevent further skin breakdown. The resident reported that staff had not assisted her in getting out of bed since her admission and that she was not taken to the bathroom despite being continent. The resident's legs and feet were frequently observed without the necessary offloading devices, and her wounds were not properly managed, as evidenced by purulent drainage and multiple open sores on her lower legs. Interviews with staff indicated a lack of adherence to the care plan, as the intervention for bilateral boots was not documented in the resident's kardex, and staff failed to apply the boots consistently. The Medication Administration Record/Treatment Administration Record (MAR/TAR) inaccurately indicated that the boots were applied, despite observations to the contrary. The facility's failure to implement the care plan and document refusals or changes in the resident's condition contributed to the deficiency in pressure ulcer care.
Failure to Use Assistive Devices Leads to Resident Falls
Penalty
Summary
The facility failed to ensure the safety of Resident #33, who has a high risk for falls due to multiple health conditions, including the absence of a right leg above the knee, multiple sclerosis, blindness in the left eye, and muscle wasting. The resident's care plan indicated the use of a slide board for transfers, but this was not consistently followed by the staff. On two separate occasions, the resident was found on the floor after attempted transfers by a CNA, indicating a lack of adherence to the prescribed safety measures. On the first incident, the CNA attempted to pivot transfer the resident from the bed to a wheelchair without the resident's assistance, resulting in the resident sliding to the floor. The CNA reported using a gait belt, but the resident was described as dead weight and did not assist during the transfer. The bed was positioned higher than the wheelchair to facilitate a safe transfer, but the lack of proper technique and assistive device use led to the fall. In the second incident, the resident explicitly stated that the CNA did not use the slide board and attempted to lift him independently, which resulted in the resident being lowered to the floor. The resident reported that the slide board was usually placed against the footboard of his bed, but it was not utilized during the transfer. Despite the CNA having completed training for fall prevention and the use of assistive devices, the failure to follow the care plan and use the slide board contributed to the resident's fall risk and subsequent incidents.
Failure to Provide Timely Emergency Physician Services
Penalty
Summary
The facility failed to ensure that emergency physician services were utilized for a resident who was moderately cognitively impaired and had multiple diagnoses, including morbid obesity, anxiety disorder, metabolic encephalopathy, COPD, and chronic respiratory failure. After returning from a hospital stay, the resident had not voided for approximately 13 hours, and facility staff made several attempts to contact the resident's physician and the facility's on-call medical provider without success. The facility's nurse practitioner was unable to provide an order for catheterization because the resident was not under their care. The Director of Nursing acknowledged that there was no plan in place for residents under the care of the independent physician if he did not respond to calls. The resident eventually received a straight catheterization, which relieved 600cc of urine, indicating significant urinary retention. The lack of timely physician response and the absence of a contingency plan for emergency care contributed to the deficiency, as the resident did not receive prompt medical intervention for a potentially serious condition.
Medication Administration Errors Result in 12% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12% error rate. This deficiency was observed in two residents. Resident #338, who was readmitted to the facility, did not receive the correct dosage of Depakote due to an incomplete medication order that lacked a specified dose. The LPN administered a 125 mg dose instead of the prescribed 500 mg. Additionally, the morning dose of Coreg was omitted because it was not available. The LPN documented the administration of Depakote under an order that did not specify the dose, which was confirmed by the DON during a review of the MAR. The DON acknowledged the error and confirmed that the LPN did not follow the rights of medication administration. Resident #6 did not receive the morning dose of Symbicort inhaler because it was not available, as it had not been reordered. The LPN noted the absence of the inhaler and omitted the dose. The facility's policy requires that medications be administered as prescribed by the attending physician, and any discrepancies in dosage or schedule should be verified against the physician's orders. The failure to adhere to this policy contributed to the medication errors observed.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label, date, and store medications in the medication cart, as observed during a survey. An opened insulin lispro (Humalog) pen was found in the top shelf of the cart without the date it was opened, although it was labeled with the resident's name. Additionally, in the stock medications area of the cart, an opened bottle of Mucus ER and an opened bottle of Cetirizine 10 mg were found without open dates. Registered Nurse (RN) FF confirmed that the nurses were supposed to label the insulin pens and other medications with the date they were opened, but this was missed. The Director of Nursing (DON) reported that the night shift nursing staff were expected to review the medication carts to ensure all medications were labeled with open dates, and that nurses should label medications when they are opened. This oversight in labeling and dating medications could potentially lead to decreased efficacy of medications and exacerbate medical conditions.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to effectively implement Enhanced Barrier Precautions (EBP) for two residents, R7 and R338, which resulted in potential cross-contamination risks. For R7, the medical records indicated the presence of a urinary catheter, but there was no documentation of EBP being implemented until several days after the catheter was inserted. Observations revealed that there was no signage or personal protective equipment (PPE) available at R7's room, and staff, including the Unit Manager, handled the catheter tubing without wearing gloves or gowns. The Director of Nursing later confirmed that R7 should have been placed on EBP due to the urinary catheter. For Resident #338, who had an enteral feeding tube, there was a sign indicating the need for EBP, but staff did not consistently adhere to these precautions. A Certified Nursing Assistant was observed assisting the resident without wearing a gown, despite the requirement for both gloves and gowns for direct care activities. An LPN confirmed that the resident was on EBP due to the feeding tube, highlighting a lapse in adherence to infection control protocols.
Failure to Prevent Elopement and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure the safety and prevent elopement for three residents, resulting in Immediate Jeopardy. Resident #100 and Resident #101 left the premises without staff knowledge and were later found in the community. Resident #100, who had a history of expressing a desire to leave the facility, was not reassessed for elopement risk despite showing signs of exit-seeking behavior. The facility's elopement policy was not followed, as door alarms were not functioning properly, and staff were not immediately responsive to alarms. Resident #101, who had a known history of elopement risk, was found outside the facility without staff knowledge, indicating a failure in monitoring and supervision. Additionally, the facility failed to minimize the risk of injury during mechanical lift transfers for Resident #106. The resident fell during a transfer when the sling clips became detached from the lift, resulting in a head injury. The facility did not conduct routine inspections of the mechanical lift slings, and the sling used did not have a manufacturer's tag, making it impossible to determine its age or condition. The CNA involved in the transfer was not aware of the requirement for two staff members to assist with transfers, further contributing to the incident. The facility's inaction in maintaining proper safety protocols and equipment checks led to these deficiencies. The lack of reassessment for elopement risk, failure to ensure door alarms were functioning, and inadequate training and equipment maintenance for mechanical lift transfers were significant factors in the incidents involving Residents #100, #101, and #106.
Removal Plan
- All licensed nurses present in the facility were re-educated on warning signs of elopement, reassessing residents to determine their risk of elopement and development of an elopement care plan and communicating new resident needs related to elopement to the interdisciplinary team. Non licensed staff were educated on resident warning signs for elopement and need to report signs to the nurse immediately.
- Plan put in place to educate every staff member prior to their next working shift.
- Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement as well as a functioning personal alarm.
- Facility confirmed all door alarms and personal safety alarms were in working order and were monitored for functionality daily.
- Resident #101 was placed on 15-minute checks until a personal safety alarm was placed on him.
- Facility ensured the door codes were changed.
- Facility ensured elopement drills will be conducted on a weekly basis.
- Facility ensured signs were posted to educate visitors on the need to avoid assisting any resident through a door and to have staff escort visitors out of the building.
- Facility ensured the elopement book was reviewed and up to date.
- Facility reviewed the elopement policy and deemed it was appropriate.
- Facility ensured all windows were functioning properly.
- Facility ensured behavior tracking orders for elopement tendencies were added to all residents at risk.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving four residents. Resident #102, who was severely cognitively impaired, physically assaulted Resident #103. Despite having a care plan in place to manage potential aggression, Resident #102 exhibited wandering, abusive language, and threatening behavior prior to the assault. The incident occurred when Resident #102 struck Resident #103 multiple times, causing emotional distress and physical pain. Staff intervention was delayed, and Resident #103 was left emotionally upset and physically bruised. In another incident, Resident #107, also severely cognitively impaired, engaged in inappropriate sexual behavior by grabbing Resident #108 in the dining room. Resident #107 had a history of socially inappropriate behavior, yet the care plan interventions were insufficient to prevent the incident. Resident #108, who was moderately cognitively impaired, experienced significant emotional distress and fear following the incident, leading her to request a change in her living arrangements to avoid further encounters with Resident #107. The facility's failure to implement effective interventions and monitor residents' behaviors contributed to these incidents of abuse. The facility's policy on abuse and neglect was not adequately enforced, as evidenced by the lack of preventive measures and timely staff response to the residents' aggressive and inappropriate behaviors. These deficiencies highlight the facility's inability to maintain a safe environment free from abuse for its residents.
Failure to Follow Post-Fall Protocols
Penalty
Summary
The facility failed to ensure proper post-fall care and assessment for a resident, resulting in the potential for serious injury. The facility's policy required that a resident not be moved until a nurse evaluated their condition after a fall. However, after a resident fell from a mechanical lift and sustained a head injury, a Certified Nursing Assistant (CNA) panicked and moved the resident back to bed without waiting for a nurse's assessment. This action was contrary to the facility's policy and the guidelines published by the American Association of Post-Acute Care Nursing, which emphasize the importance of assessing for spinal column injuries and other significant injuries before moving a resident. The resident involved had a history of cerebral infarction, major depressive disorder, unspecified dementia, and anxiety disorder, and required maximal assistance for transfers. After the fall, the resident was sent to the hospital and returned with stitches and a hematoma. Interviews with staff confirmed that the resident was moved before a proper assessment was conducted, which could have worsened the injuries. The Director of Nursing reiterated the importance of leaving a resident in the position they were found until assessed by a nurse to prevent complications.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to the care plan for a resident, resulting in an injury. The resident, who was severely cognitively impaired and had limited physical mobility, was supposed to be transferred using a sit-to-stand lift as per her care plan. However, a CNA attempted to transfer the resident from her bed to a wheelchair without using the recommended equipment or a gait belt. During this manual transfer, the resident sustained a laceration on her right lower leg, which required sutures. The incident occurred when the CNA responded to the resident's call to go to the bathroom. Without checking the care plan, the CNA stood the resident up and twisted her into the wheelchair, leading to the injury. The CNA admitted to not using the sit-to-stand lift or a gait belt during the transfer. The Director of Nursing confirmed that the transfer was conducted incorrectly, as the sit-to-stand lift should have been used according to the care plan.
Failure to Notify Physician After Resident Falls
Penalty
Summary
The facility failed to immediately notify the resident's physician of a change in condition for a resident who experienced two unwitnessed falls with known head trauma. The resident, who had been admitted to the facility with dementia, fell twice on the same night. The first fall was documented by a registered nurse, who noted the resident was found kneeling with their forehead on the floor, but vital signs were stable and the resident denied pain. The resident was then placed in a wheelchair and moved to a common area for observation. Shortly after, the resident fell again, resulting in a raised bump on the right temple. Despite these incidents, the facility did not notify the resident's physician. Interviews revealed that the facility staff believed it was the responsibility of the hospice nurse to communicate with the hospice physician, as the resident was a hospice patient. However, the hospice nurse reported that the facility declined an offer for a nurse visit to examine the resident after the falls. The hospice nurse also indicated that the facility nurse was expected to contact the resident's physician directly. A follow-up visit note from the resident's provider did not mention the falls, indicating a lack of communication and assessment regarding the resident's condition after the incidents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically involving two residents, Resident #104 and Resident #105. Resident #105, who has a history of dementia and psychosis, was involved in two incidents of physical aggression towards Resident #104 within an eight-day period. The first incident occurred when Resident #105 placed her hands on Resident #104's shoulders and squeezed them, reportedly because Resident #104 was making comments about her. The second incident involved Resident #105 bending back Resident #104's fingers, resulting in redness and pain, although an X-ray showed no fractures. Resident #105's care plan indicated a potential for physical aggression due to cognitive impairments and poor impulse control. Despite interventions such as providing a private room and activities to keep her engaged, there was a lack of consistent supervision and interaction, particularly from the activities department. Observations noted that Resident #105 was often left alone in her room without engagement, and staff were not always present to intervene during incidents. Resident #104, also diagnosed with dementia, was known to make inappropriate comments, which often triggered Resident #105's aggressive behavior. Staff interviews revealed that there was insufficient dementia-specific training and a lack of adequate supervision, especially during weekends and evenings. The facility's failure to ensure consistent supervision and effective interventions contributed to the repeated incidents of resident-to-resident abuse.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to recognize and report an injury of unknown origin for a resident, resulting in a lack of timely reporting and potential delay in investigation. The resident, who had dementia, was admitted to the facility and later complained of right hip pain. An X-ray revealed an impacted intertrochanteric fracture with varus deformity. Despite the fracture being identified, the facility did not report it as an injury of unknown origin because they attributed it to a fall that occurred earlier. The Director of Nursing (DON) and Nursing Home Administrator (NHA) both indicated that the fracture was linked to a fall on the resident's right side. However, there was no documentation of a post-fall assessment or evidence showing when the interdisciplinary team determined the fracture was due to the fall. The incident report from the fall noted no immediate pain or discomfort, and subsequent notes indicated no changes in the resident's condition until the pain was reported two days later. Interviews with staff revealed that the resident initially showed no signs of injury or pain following the fall. The resident's records showed stable vital signs and no pain complaints immediately after the incident. The fracture was only identified after the resident experienced pain and difficulty walking, leading to an X-ray. The facility's delay in correlating the fracture to the fall and lack of immediate reporting to the state contributed to the deficiency.
Incomplete Post-Fall Assessment Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of post-fall assessments for a resident, leading to potential insufficient follow-up and lack of necessary interventions. The resident, who had been admitted with a diagnosis of dementia, experienced two falls on the same night. The first fall was documented in the nurse's notes, indicating that the resident was found kneeling with their forehead touching the floor, with stable vital signs and no pain reported. The resident was then placed in a wheelchair and moved to a common area for observation. Shortly after, the resident fell again, resulting in a raised bump on the right temple. Despite these incidents, the post-fall neurological check record indicated no abnormalities or changes in the resident's range of motion. However, the Director of Nursing (DON) later reported that a post-fall nursing assessment had not been documented in the resident's health record. This lack of documentation led to a delay in identifying a hip fracture, which was discovered when the resident complained of right leg pain and was unable to bear weight two days after the falls. The deficiency highlights the importance of accurate and complete medical documentation to ensure proper follow-up and intervention.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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