Autumn Care Of Myrtle Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, North Carolina.
- Location
- 5725 Carolina Beach Road, Wilmington, North Carolina 28412
- CMS Provider Number
- 345507
- Inspections on file
- 25
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Autumn Care Of Myrtle Grove during CMS and state inspections, most recent first.
A nurse physically restrained a cognitively impaired resident by holding her arms down during incontinence care, resulting in the resident screaming, sustaining bruises, scratches, and pain that required medication. The incident was witnessed by two nurse aides, who also observed the nurse cursing and spitting at the resident and placing a pillow over her face. The resident, who had a history of combative behaviors and required non-restrictive interventions, was left with visible injuries and increased anxiety following the event.
A nurse failed to administer prescribed as-needed pain medication to a cognitively impaired resident with chronic pain after the resident exhibited combative behaviors, including spitting. Instead of attempting to calm or reapproach the resident, the nurse left the room, wasted the medication, and did not reassess or attempt to provide pain relief later in the shift. Facility leadership confirmed this constituted neglect.
Two nurse aides failed to immediately report an incident in which a nurse physically restrained, cursed at, and spit on a resident with severe dementia during care, resulting in the nurse completing her shift and remaining assigned to the resident. The delay in reporting prevented timely investigation and removal of the accused staff, contrary to facility abuse prevention policies.
Two residents did not receive care in accordance with their comprehensive care plans: one resident with a feeding tube did not have a care plan developed for tube care as indicated by the MDS assessment, and another resident with severe cognitive impairment and a history of falls did not have bilateral fall mats in place as ordered and care planned after a room transfer. The DON and Administrator confirmed these deficiencies during observations and interviews.
Staff failed to discard expired insulin pens and did not record an opened date on an in-use insulin pen on a medication cart. Multiple insulin pens were found past their discard date, and one Lantus pen was missing an opened date despite partial use. Nurses were responsible for checking and labeling insulin, but these steps were missed.
Staff failed to follow infection control protocols by not donning required PPE when providing care to two residents on transmission-based precautions for wound care. In one case, a medication aide entered a resident's room on contact precautions without gloves or a gown, and in another, a nurse aide provided high-contact care to a resident on Enhanced Barrier Precautions wearing only gloves. Both incidents occurred despite posted signage, available PPE, and prior staff training.
A mechanical lift was left unattended in a hallway, creating an accident hazard that resulted in a cognitively impaired resident with a history of falls tripping over the equipment while ambulating independently. The resident sustained a minor injury, and staff interviews confirmed that the lift should have been stored in the utility room when not in use.
A resident with a surgically placed j-tube experienced tube dislodgement that was not immediately reported to a physician. Instead, a nurse inserted an indwelling urinary catheter tube into the site without a physician order, after a nurse aide failed to report finding the tube on the floor. The nurse only notified the DON and provider after the replacement tube also became dislodged, resulting in the resident being sent to the hospital for surgical intervention. Staff interviews confirmed that proper notification and procedures were not followed.
A nurse failed to provide appropriate care when a resident's recently placed j-tube became dislodged, inserting a urinary catheter into the site without a physician's order and without recognizing the need for hospital treatment. The tube became dislodged again, and the resident was later sent to the hospital for surgical reinsertion. Facility policy did not permit nurses to replace j-tubes, and the incident resulted in a deficiency related to improper management of enteral feeding tubes.
An agency LPN, lacking documented training and competency in jejunostomy tube (j-tube) care, improperly replaced a dislodged j-tube with a urinary catheter tube without physician orders or appropriate guidance, after failing to recognize the need for hospital treatment. The facility's orientation and competency verification processes for agency nurses did not include specific instruction on j-tube care, leading to this deficiency for a resident requiring specialized feeding tube management.
Over a six-month period, the facility did not address or communicate follow-up on concerns raised by the Resident Council, including issues with meal tickets, food quality, staffing during mealtimes, and menu item availability. Despite concern forms being completed and meeting minutes signed by the Administrator, there was no evidence of follow-up or resolution, leading to resident frustration and a lack of documented action by facility management.
Nursing staff failed to follow Enhanced Barrier Precautions by not wearing gowns while providing tracheostomy and gastrostomy tube care to two residents with indwelling devices. Despite posted signage and available PPE supplies, nurses performed high-contact procedures with only gloves and masks, contrary to facility policy and infection control protocols.
A nurse administered 2 units of sliding scale insulin to a resident with a blood sugar of 103, despite a physician order specifying no insulin for levels below 150. The error occurred after the nurse became distracted by multiple aides and was only realized after the resident's family questioned the need for insulin. The incident was reported to the DON, and the resident did not experience any adverse effects.
A resident with chronic kidney disease and symptoms of UTI did not have an ordered urinalysis and C&S completed because the urine sample, though collected and entered into the EMR and lab website, was not recorded in the lab book used for lab pickups. This omission resulted in the sample not being collected by the lab and no test results being available, as confirmed by staff interviews.
Two residents experienced deficiencies in medical record documentation, including incomplete incident reporting for a resident with a feeding tube and inaccurate medication administration records for a diabetic resident. In both cases, a nurse failed to accurately document care provided, including not recording actual medication administration and leaving required forms incomplete, despite expectations from the DON for thorough and accurate recordkeeping.
A resident with a recent knee replacement fell and exhibited signs of a fracture, including severe pain and inability to bear weight. Despite these symptoms, staff failed to assess and report the condition, attributing the pain to dementia-related behaviors. The fracture was only identified after a family member raised concerns, leading to a delayed diagnosis and treatment.
A resident experienced inadequate pain management following a total knee replacement and a subsequent fall. Despite high pain levels and difficulty bearing weight, staff failed to communicate these issues to the medical provider, attributing the pain to dementia. The resident was later found to have a femur fracture, highlighting a lack of thorough pain assessment and communication within the facility.
A cognitively impaired resident in an LTC facility was sexually abused by another resident with a history of inappropriate behavior. The victim, unable to consent or protect himself, was found with the perpetrator's hand inside his brief. Despite the perpetrator's known history, the facility failed to update care plans or implement effective interventions, leading to the incident.
A severely cognitively impaired resident exited an LTC facility unsupervised after a receptionist unlocked the door, assuming the resident could go outside alone. The resident, who had a history of dementia and falls, was found over an hour later in the parking lot, posing a high risk of harm. The facility failed to provide adequate supervision, as the resident was not previously identified as an exit-seeker.
A resident with a history of stroke and dysphagia experienced severe health complications after a facility failed to follow a physician's order to hold tube feeding following vomiting. The order was not correctly entered into the electronic MAR, leading to continued feeding and subsequent respiratory distress. The resident was hospitalized with aspiration pneumonitis and acute hypoxic respiratory failure.
A facility failed to accurately document the administration of Hydrocodone-Acetaminophen for a resident. The medication was signed out on the declining count sheet but not documented in the MAR. Attempts to contact the responsible nurses were unsuccessful, as one nurse went on leave, another was an agency nurse no longer at the facility, and a third was suspended. The DON acknowledged the issue, revealing inaccuracies in the MARs and missing narcotic count sheets.
The facility failed to maintain a clean and safe environment, with a black greenish substance and foul odor found around commodes in multiple rooms, and broken or missing bathroom door thresholds posing safety hazards. Interviews revealed a lack of communication and responsibility among staff, with no documentation of maintenance follow-up or cleaning schedules.
A long-term care facility failed to obtain and record accurate weights for several residents, leading to significant discrepancies in their weight records. This affected the monitoring and management of residents with complex medical conditions, such as diabetes and congestive heart failure. Staff interviews revealed a lack of consistency and communication regarding weight changes, highlighting gaps in adherence to the facility's weight policy.
A resident on immunosuppressive therapy did not receive monthly CBCs as ordered due to a failure in the lab requisition process. The facility's transition to a new electronic medical record system led to a missed step in notifying the lab vendor, resulting in no CBCs being documented from December to July. The Nurse Practitioner was unaware of the order and relied on external lab results, while the Director of Nursing confirmed the new process but was unaware of the specific order.
A long-term care facility failed to protect residents from the misappropriation of Hydrocodone-Acetaminophen tablets. Two residents, both cognitively impaired, had discrepancies in their medication records, with missing tablets and incomplete documentation. Nurse #6 was implicated in both cases, leading to her indefinite suspension. The facility's inadequate handling and documentation of narcotic medications resulted in this deficiency.
The facility failed to maintain accurate records for controlled drugs, specifically Hydrocodone-Acetaminophen, for two residents. Missing declining count sheets and discrepancies in medication administration records were identified, with no system in place to reconcile narcotic documents. Attempts to contact responsible nurses were unsuccessful, and staff interviews confirmed the lack of proper documentation and reconciliation processes.
The facility failed to ensure a safe environment in the 700-hall by using a floor scrubber with a broken squeegee, leaving water puddles without wet floor signs. Staff interviews confirmed the issue, and budget constraints prevented equipment repair. The absence of signage posed a fall risk.
The facility failed to date two insulin pens, Lantus and Novolog, on a medication cart, which should be discarded 28 days after opening. A nurse, not typically assigned to the cart, was unaware of the missing dates and did not administer the pens. The DON confirmed the requirement for dating insulin pens upon opening.
A resident with severe cognitive impairment was flicked on the forehead by a Medication Aide during care, compromising her dignity. The incident occurred while two Nurse Aides were cleaning the resident after she smeared feces in her room. Witnesses reported the flicking action, which the Medication Aide claimed was a joke. The resident expressed surprise but was not hurt or afraid. The facility investigated the incident, and the Administrator confirmed the action was inappropriate.
Resident Physically Restrained and Injured During Care by Nurse
Penalty
Summary
A cognitively impaired resident with severe vascular dementia, psychotic disturbance, anxiety, delusional disorder, depression, and chronic pain was subjected to physical restraint by a nurse during incontinence care. The resident, who had a history of combative behaviors such as hitting, scratching, and rejecting care, required two-person assistance for personal care. During an episode of care, a nurse entered the room while two nurse aides were assisting the resident and proceeded to hold the resident's arms down, crossing them over her body to restrict movement. The nurse used a technique previously employed in an emergency department setting, despite not being familiar with the facility's policies and procedures regarding restraints in LTC settings. The nurse's actions were witnessed by two nurse aides, who reported that the nurse also cursed and spit at the resident, further escalating the resident's agitation. The nurse placed a pillow over the resident's face, though it was not held down, and the aides removed it. The resident screamed during the restraint and subsequently developed bruising and scratches on her hands, wrists, and forearm, as well as pain that required as-needed pain medication. The nurse aides recognized the actions as abusive and reported the incident, though one aide delayed reporting due to being in shock. Medical assessments following the incident documented new bruising, scratches, and complaints of pain in the resident's hands and wrists. The resident expressed fear and stated that her hand was broken and hurt. X-rays were performed, revealing no fractures, but the resident continued to experience pain and anxiety, requiring additional medication. Staff interviews confirmed that the nurse's actions constituted physical restraint and were not in accordance with the resident's care plan, which emphasized non-restrictive interventions and re-approaching the resident if care was refused.
Neglect Due to Withholding of Pain Medication Following Resident Behavioral Symptoms
Penalty
Summary
A deficiency occurred when a nurse failed to protect a resident's right to be free from neglect by withholding prescribed as-needed pain medication. The resident, who had severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder, depression, and chronic pain due to peripheral neuropathy, requested pain medication. The nurse documented that the resident exhibited behaviors such as scratching, biting, and spitting when she entered the room. In response, the nurse left the room without attempting to calm the resident or reapproach, and did not administer the ordered pain medication. The nurse subsequently wasted the medication and did not attempt to administer it later in the shift, nor did she reassess the resident's pain. The nurse acknowledged being aware of the resident's combative and agitated behaviors but chose not to tolerate them, resulting in the resident not receiving pain relief as ordered. Documentation showed the resident had reported a pain level of 6 out of 10, but there was no record of the pain medication being given during the relevant shift. Interviews with facility leadership confirmed that the nurse's actions were inappropriate and constituted neglect. The Director of Nursing and the Nurse Practitioner both stated that pain should have been addressed and the medication administered as ordered, regardless of the resident's behavioral symptoms. The failure to provide pain relief as requested and ordered, and the lack of further assessment or intervention, led to the finding of neglect for this resident.
Failure to Immediately Report and Protect Resident Following Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse policies and procedures regarding the immediate reporting of an allegation of staff-to-resident abuse and the protection of the resident involved. According to the facility's abuse policy, all staff are required to report any allegations, suspicions, or incidents of abuse or neglect to the Administrator or Abuse Coordinator immediately, but no later than two hours after the event. In this incident, two nurse aides witnessed a nurse physically restrain a resident, curse and spit at the resident, and place a pillow over the resident's face during incontinence care. Both aides acknowledged awareness of the abuse policy and recognized the actions as abuse, but neither reported the incident until the following day when they returned for their next shift, well beyond the required reporting timeframe. The resident involved had severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder, depression, and chronic pain with peripheral neuropathy. During the incident, the resident became agitated, screamed, and attempted to resist care, leading to the nurse's inappropriate actions. The nurse aides reported feeling shocked and needing time to process the event, which contributed to their delay in reporting. As a result of the delayed reporting, the accused nurse was able to complete the remainder of her shift and continued to be assigned to the resident, contrary to the facility's policy that requires immediate removal of staff accused or suspected of abuse. The deficiency was further evidenced by the fact that the incident was not reported to the administration until the next day, delaying the initiation of an investigation and the removal of the accused nurse from duty. The resident was later assessed and found to have discoloration and a small scratch on her right wrist. The failure to immediately report the abuse and protect the resident was confirmed through staff interviews and record review, demonstrating noncompliance with the facility's established abuse prevention policies.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required. For one resident admitted with a gastrostomy (feeding) tube and documented cognitive impairment, the Minimum Data Set (MDS) assessment indicated the need for a care plan addressing the feeding tube. However, a review of the medical record over an eleven-month period revealed that no such care plan was created. The MDS nurse was unaware of the omission, attributing responsibility to a previous nurse who was no longer employed, and the Director of Nursing confirmed that care plans should have been developed according to guidelines. For another resident with severe cognitive impairment, hemiplegia, and a history of falls, the care plan and physician orders required bilateral fall mats to be placed on both sides of the bed. After a fall, the care plan was updated to include this intervention. However, following a room transfer, only one fall mat was present, and the resident was unable to locate the second mat. Observations confirmed the absence of the required fall mat, and both the DON and Administrator acknowledged that the care plan was not being followed as written.
Expired Insulin Pens and Missing Opened Date on Medication Cart
Penalty
Summary
Facility staff failed to properly manage insulin pens on one of four medication carts reviewed for medication storage. Specifically, four insulin pens (three Insulin Lispro/Humalog and one Insulin Glargine/Lantus) were found on the 700-hall medication cart with expiration dates that had passed according to the manufacturer's guidelines, which require pens to be discarded 28 days after opening. Additionally, one Insulin Glargine (Lantus) pen was found in use without an opened date recorded, despite 60 of 300 units having been administered. Interviews with staff revealed that medication aides were not responsible for administering insulin and therefore did not check for expired insulin, while nurses were expected to check for expired medications and record opened dates on insulin pens. The Unit Manager and DON both confirmed that nurses were responsible for checking medication carts for expired medications at least weekly, and that insulin pens should be checked daily and prior to use. The expired insulin pens and the pen lacking an opened date were not identified or discarded as required.
Failure to Follow Infection Control Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures in two separate instances involving staff members providing care to residents on transmission-based precautions. In the first instance, a medication aide entered the room of a resident who was on contact precautions due to a wound infection, without donning the required personal protective equipment (PPE), specifically gloves and a gown. Despite a clearly posted sign on the resident's door and a stocked PPE cart outside the room, the aide proceeded to take the resident's blood pressure without the necessary protective attire. The aide later stated she was unaware of the resident's contact precaution status and did not notice the sign, although she acknowledged having received infection control training and understanding the requirements for contact precautions. In the second instance, a nurse aide provided high-contact care activities, including changing bed linens, assisting with activities of daily living, and transferring a resident with a surgical wound and a lower leg dressing, who was on Enhanced Barrier Precautions (EBP). The nurse aide wore gloves but failed to wear a gown, as required by the facility's EBP policy for high-contact care activities. A sign indicating the need for gloves and a gown was posted on the resident's door, and PPE supplies were available at the entrance. The nurse aide admitted to not reading the entire EBP sign and believed a gown was only necessary for wound care, not for other high-contact activities, despite having received training on EBP protocols. Both incidents were confirmed through staff interviews, review of facility policies, and direct observation. The residents involved had active wound care needs, with one on antibiotics for a wound infection and the other requiring daily and periodic wound dressings. The failures to follow established infection control protocols occurred despite the presence of clear signage, available PPE, and prior staff training.
Mechanical Lift Left in Hallway Causes Resident Fall
Penalty
Summary
A deficiency occurred when a mechanical lift, not in use, was left unattended in the hallway by a staff member. This created an accident hazard, resulting in a cognitively impaired resident with Alzheimer's disease, dementia, agitation, and a history of falls, tripping over the lift while ambulating independently. The resident had poor safety awareness, impaired memory, confusion, and was at high risk for falls, as documented in her care plan and assessments. The incident led to a minor injury, with the resident sustaining a small amount of blood from her left nostril after the fall. Staff interviews and record reviews confirmed that the mechanical lift was supposed to be stored in the utility room when not in use, and that staff had been educated on fall hazards and the importance of maintaining clear hallways. Despite these protocols, the lift was left in the hallway, directly contributing to the resident's fall. The resident continued to ambulate independently and required frequent redirection due to her severe cognitive impairment and impulsivity.
Failure to Immediately Notify Physician and Inappropriate Tube Replacement
Penalty
Summary
A facility failed to immediately notify a physician when a resident's jejunostomy tube (j-tube) became dislodged. The resident, who had a history of stroke, dysphagia, and was severely cognitively impaired, relied on the j-tube for nutrition and medication administration. On the day of the incident, a nurse aide observed a tube on the bathroom floor but did not report it to the nurse. Hours later, the assigned nurse discovered the j-tube was missing and, without contacting the physician, inserted an indwelling urinary catheter tube into the j-tube site, following advice from the wound nurse who was unaware it was a j-tube. There was no physician order for this action. The nurse was not aware that the tube was a j-tube rather than a gastrostomy tube and did not recognize the need for immediate hospital transfer or physician notification. The nurse only notified the DON after the replacement tube became dislodged a second time, at which point the DON instructed her to contact the provider and send the resident to the hospital. The resident was subsequently transferred to the hospital, where surgical intervention was required to replace the j-tube. Interviews with facility staff, including the nurse, nurse aide, wound nurse, DON, nurse practitioner, and medical director, confirmed that the nurse did not follow proper protocol for physician notification and tube replacement. The medical director and nurse practitioner both stated that it was inappropriate and unsafe for a nurse to replace a j-tube in the facility, especially without a physician's order, due to the risk of serious complications. Documentation review showed that the physician was not notified until after the second dislodgement and inappropriate tube replacement had occurred.
Removal Plan
- The DON, Assistant Director of Nursing (ADON), and Unit Managers re-educated Licensed Nurses and Nurse Aides (NA) on Resident Change in Condition Policy with emphasis on changes that require immediate physician notification and documentation.
- Nurse Aides were educated to notify the charge nurses if any devices, such as enteral feeding tubes, were displaced or not in resident at time of care.
- The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty.
- New Licensed Nurses, Agency Nurses, and Nurse Aides will be educated by the DON or ADON during the orientation process.
- The Director of Nursing will review the Facility Activity Report for any Interact SBAR, Interact Nursing Home to Hospital Transfer Forms, or any Events in the morning Clinical Morning Meeting, which will be held seven days a week, to verify prompt and/or immediate notification is communicated to the Physician and/or Provider.
- If notification to the physician has not occurred, the DON will notify the physician at that time.
Improper Replacement of Dislodged Jejunostomy Tube by Nursing Staff
Penalty
Summary
A deficiency occurred when a nurse failed to provide appropriate care for a resident with a recently placed jejunostomy tube (j-tube) after it became dislodged. The resident, who had a history of stroke, global aphasia, dysphagia, and was fully dependent on tube feeding, was found without his j-tube in place. The nurse, who was an agency nurse unfamiliar with the specific type of tube, did not recognize the need for hospital treatment and instead inserted an indwelling urinary catheter tube into the j-tube site without a physician's order. This action was taken after consultation with the Wound Nurse, who advised replacing the tube with a similar-sized enteral tube or urinary catheter, but also instructed to call the provider for an order. The nurse did not obtain a physician's order before proceeding. The replacement tube became dislodged again within a short period, and the resident was subsequently sent to the hospital for reinsertion. Interviews revealed that the nurse was unaware the tube was a j-tube rather than a gastrostomy tube and stated she would have sent the resident to the hospital if she had known. The Wound Nurse and DON both confirmed that facility policy did not permit nurses to replace j-tubes in the facility, only gastrostomy tubes with a physician's order. The DON and Medical Director emphasized that j-tubes require surgical or radiological placement and that the site was not mature, increasing the risk of complications. The nurse did not complete documentation related to the incident, and the DON had to document the event after being notified. Additional interviews with staff and the responsible party confirmed that the tube was found on the floor, and the resident was bleeding from the site. The responsible party found the resident attempting to stop the bleeding and called for assistance. The resident was transferred to the hospital, where multiple attempts were made to replace the tube, ultimately requiring surgical intervention. The incident was identified as affecting one resident reviewed for feeding tubes, and the facility's failure to follow proper procedures for j-tube dislodgement led to the deficiency.
Removal Plan
- The Director of Nursing, Assistant Director of Nursing, and Unit Managers will provide education to Licensed Nurses on Enteral Feeding Tube(s) Policy, including what to do if a j-tube becomes dislodged, physician notification, not to attempt reinsertion of the j-tube, and sending the resident to the hospital for surgical reinsertion.
- The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence, vacation, agency staff or PRN staff will be re-educated prior to returning to duty by the DON or ADON.
- New hires and Agency Nurses will be educated by the Director of Nursing or Assistant Director of Nursing during the orientation process.
- The DON or ADON will review all new admissions in the Clinical Morning Meeting to determine if any admissions have a j-tube present and ensure all Licensed Nursing staff are made aware of the presence of a j-tube and the process for physician notification and treatment if a j-tube becomes dislodged.
- Licensed nurses will be made aware of residents that are admitted with a j-tube via the Admission Notification Form that is provided by the Admission Director for all pending admissions.
- Admission Notification Form will be delivered to the admitting nurse with the hospital discharge summary by the Admission Director prior to resident arrival.
Failure to Ensure Agency Nurse Competency in J-Tube Care
Penalty
Summary
The facility failed to ensure that agency nurses were properly trained and competent to care for residents with jejunostomy tubes (j-tubes). An agency LPN, who was hired without documented competency or specific training on j-tubes, was involved in an incident where a resident's j-tube became dislodged. The nurse did not recognize the need for hospital treatment and instead inserted a urinary catheter tube into the j-tube site, mistakenly assuming it was a gastrostomy tube. This action was performed without a physician's order and without the necessary radiographic or surgical guidance required for j-tube replacement. Record review confirmed that the nurse's employee file lacked evidence of j-tube competency or training, and the facility's orientation for agency nurses did not include specific instruction on j-tubes at the time of her employment. Interviews with the nurse revealed she did not recall receiving j-tube training during orientation at this facility, despite having prior experience elsewhere. The DON stated that the agency was responsible for verifying nurse competencies, and acknowledged that the facility's orientation did not cover j-tube care for agency nurses. The incident was identified during a review of three nurses for competency and three residents with feeding tubes. The nurse's improper handling of the dislodged j-tube created a high likelihood of serious harm, as confirmed by interviews with the nurse practitioner, medical director, staff, and the responsible party. The deficiency was limited to one resident with a j-tube, and no other residents with j-tubes were identified in the facility during the review period.
Removal Plan
- The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers will provide education to Licensed Nurses on Gastrostomy Tube Reinsertion Policy, including what to do if a j-tube becomes dislodged, physician notification, not to attempt reinsertion of the j-tube, risks, and sending the resident to the hospital for surgical reinsertion.
- A quiz was created to validate staff understanding of the material that was taught. Any nurse that cannot answer the quiz questions appropriately will be retrained by the DON or ADON on the material.
- The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty.
- New hires and Agency Nurses will be educated by the DON or ADON during the orientation process using the Gastrostomy Tube Reinsertion Policy.
- The quiz will be given at the end of their training to validate understanding on what to do if a j-tube becomes dislodged, including physician notification, not to attempt reinsertion of the j-tube, risks, and sending the resident to the hospital for surgical reinsertion.
Failure to Address and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to act upon and communicate follow-up regarding concerns raised by the Resident Council over a six-month period. Resident Council meeting minutes consistently documented concerns about meal tickets not matching what was served, the taste of food, insufficient staff during mealtimes, and the unavailability of always available menu items. Although concern forms were reportedly filed and meeting minutes were signed by the Administrator, there was no documentation or evidence that these concerns were addressed or that any follow-up was communicated back to the Resident Council. Interviews with the Resident Council President and the Activity Director confirmed that concerns were regularly recorded and concern forms were completed, but no resolutions or responses were provided to the council. The Resident Council President expressed frustration over the lack of follow-up, stating that management did not address the council's concerns. The Activity Director indicated that she submitted concern forms and meeting minutes to the Administrator but did not see any follow-up or action taken. The Social Services Director reported not being involved in the process and had not seen any concern forms or attended meetings. The Administrator acknowledged that the Social Services Director was previously responsible for addressing Resident Council concerns, but after the previous Social Services Director left, the process lapsed. The Administrator admitted to not attending Resident Council meetings, not being involved in addressing concerns, and having no documentation to show that grievances were addressed. Despite signing the meeting minutes, the Administrator could not confirm awareness of the repeated concerns expressed by residents.
Failure to Follow Enhanced Barrier Precautions During High-Risk Resident Care
Penalty
Summary
The facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care activities for residents with indwelling devices. Specifically, two nurses were observed providing tracheostomy care, including suctioning, and administering tube feedings to residents without donning the required protective gown, despite wearing gloves and masks. Facility policy and posted signage clearly indicated that gowns and gloves were required for high-contact care activities involving residents with tracheostomies and gastrostomy tubes. Both nurses performed these procedures without a gown, and one nurse stated she was unaware of the requirement, while the other acknowledged the omission as an error. Observations confirmed that EBP signage and PPE supplies were present outside the residents' rooms, and interviews with the Infection Control Preventionist and Director of Nursing confirmed that staff had received education on EBP and PPE use. The residents involved had tracheostomies and gastrostomy tubes, placing them at higher risk for transmission of multi-drug-resistant organisms, which the EBP policy was designed to address. The failure to follow established infection control protocols was directly observed during care activities for these residents.
Insulin Administered Contrary to Physician Order Due to Nurse Distraction
Penalty
Summary
A deficiency occurred when a nurse administered 2 units of fast-acting sliding scale insulin to a resident with a blood sugar level of 103, despite a physician's order specifying that no insulin should be given for blood sugar levels below 150. The resident, who was nonverbal and unable to assess cognition, had a diagnosis of diabetes and was receiving insulin therapy. The nurse became distracted by multiple nurse aides while at the medication cart, which led to the administration of insulin in error. The nurse initially documented 0 units administered but later confirmed that 2 units had been given. The error was discovered when the resident's family questioned the need for insulin, prompting the nurse to realize the mistake. The nurse reported the incident to the Director of Nursing the same day. The Medical Director confirmed that the physician's orders for sliding scale insulin were not followed, and the Director of Nursing acknowledged that the nurse should not have administered insulin for a blood sugar reading less than 150. The resident did not experience any negative outcome from the medication error.
Failure to Obtain Ordered Urinalysis and Culture Due to Process Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to obtain an ordered urinalysis and culture and sensitivity for a resident who was experiencing symptoms of a urinary tract infection, including burning, urgency, and decreased urinary output. The resident, who had a history of chronic kidney disease and moderately impaired cognition, was admitted with frequent incontinence. On the day symptoms were noted, a physician ordered a urinalysis and culture and sensitivity, and an antibiotic was started. The nurse collected the urine sample and entered the order into the electronic medical record and the lab services website, but did not record it in the lab book, which is used by the lab service to identify samples for pickup. As a result, the urine sample remained in the facility refrigerator and was not picked up by the lab, and no test results were available for the period reviewed. The breakdown in the process was confirmed by staff interviews, which revealed that the required step of recording the order in the lab book was missed. The Director of Nursing and other staff acknowledged that the established process for obtaining laboratory tests was not followed in this instance.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with a jejunostomy tube, physician orders included tube feeding and multiple medications to be administered via the feeding tube. On a specific date, the Medication Administration Record (MAR) indicated that several medications were administered by a nurse during the morning medication pass. However, the nurse later stated that she did not actually administer these medications, despite having signed them off as given. Additionally, documentation related to the resident's change in condition and subsequent transfer to the hospital was incomplete, with significant portions of the SBAR form left unfilled, including vital signs, evaluations, and appearance sections. The nurse did not return to the facility to complete the required documentation despite multiple requests from the Director of Nursing (DON). For another resident with diabetes, there was a physician's order for sliding scale insulin, specifying no insulin should be given for blood sugar readings below 150. On a particular date, the MAR showed that zero units of insulin were administered when the resident's blood sugar was 103. However, the nurse later admitted to administering 2 units of insulin in error and stated that the documentation on the MAR was incorrect. The nurse attributed the error to being distracted by other staff and acknowledged that the record should have reflected the actual administration of insulin. Interviews with the DON confirmed awareness of the medication error and the incomplete documentation. The DON stated that nursing staff are expected to ensure documentation is complete and accurate, but in these cases, the records did not accurately reflect the care provided or the events that occurred.
Failure to Assess and Report Resident's Condition Post-Fall
Penalty
Summary
The facility failed to comprehensively assess a resident who experienced a fall, leading to a significant delay in identifying a serious injury. The resident, who had a recent total knee replacement, fell on the night of admission and exhibited signs of a potential fracture, including external rotation and shortening of the leg, severe pain, and inability to bear weight. Despite these symptoms, the nursing staff did not report these findings to the on-call provider, nor did they conduct a thorough assessment to determine the cause of the resident's pain and mobility issues. Throughout the resident's stay, multiple staff members, including nurses, nursing assistants, and therapists, observed the resident's pain and difficulty with mobility but failed to communicate these observations effectively. The resident's pain was often attributed to behavioral issues related to dementia, and assumptions were made that the pain was related to the recent knee surgery. The physical therapist and therapy assistant noted the resident's inability to bear weight and external rotation of the leg but did not report these findings to the nursing staff or medical provider. The lack of communication and failure to assess the resident's condition led to a delay in diagnosing a comminuted right intertrochanteric femur fracture. It was not until a family member expressed concern and a physician was called to evaluate the resident that the fracture was identified, and the resident was sent to the emergency room for treatment. This deficiency highlights a significant breakdown in the facility's processes for assessing and responding to changes in a resident's condition.
Inadequate Pain Management and Assessment
Penalty
Summary
The facility failed to provide thorough and ongoing pain assessments for a resident who was admitted after a total knee replacement and experienced a fall shortly after admission. The resident's pain levels were inadequately managed, with pain ratings ranging from 6 to 10 over several days. Despite the resident's increased pain and inability to bear weight, the facility staff did not effectively communicate these issues to the medical provider, nor did they reassess the resident's pain management regimen. The resident's electronic health record indicated orders for pain medications, but the administration of these medications did not consistently result in effective pain relief. Nursing staff and therapists observed the resident's high pain levels and difficulty with mobility, yet these observations were not adequately reported to the medical provider. The resident's pain was often attributed to behavioral issues related to dementia, leading to a lack of appropriate medical evaluation. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's pain and condition. Several staff members assumed the resident's pain was related to his recent surgery or dementia, and did not report significant changes in the resident's condition. Ultimately, the resident was found to have a comminuted right intertrochanteric femur fracture, which was not identified until the resident was evaluated at the hospital.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a vulnerable male resident from sexual abuse by another cognitively impaired male resident. The incident occurred when the family member of the victimized resident observed the perpetrator with his hand inside the victim's brief while the victim was lying in bed. The victim, who had severe cognitive impairment and was unable to give consent or protect himself, experienced increased agitation and restlessness following the incident, leading to an increase in his antidepressant medication. The perpetrator had a history of inappropriate sexual behavior, including disrobing in public and inappropriate touching of other residents. Despite this, the care plan for the perpetrator had not been updated since July 2024, and interventions to protect other residents were not effectively implemented. The perpetrator was able to propel himself in a wheelchair independently and was observed wandering the hallways, which ultimately led to the incident in the victim's room. Staff interviews revealed that the perpetrator frequently used sexually inappropriate language and exhibited sexually suggestive behavior. However, there was no indication that staff had taken adequate measures to prevent such incidents from occurring. The facility's failure to provide adequate supervision and intervention for the perpetrator's known behaviors directly contributed to the incident of sexual abuse.
Removal Plan
- The facility failed to protect Resident #1's right to be protected from sexual abuse perpetrated by Resident #2. Resident #2 was redirected by his assigned certified nursing assistant once the nurse was made aware of the interaction. Resident #1 was assessed by the Director of Nursing with no signs of injury or emotional distress. Resident #1 was then moved to another room on the opposite side of the building. The Director of Nursing started continuous monitoring with Resident #2 while he was out of bed since Resident #2 cannot transfer independently. The continuous monitoring is one to one and is being performed by clinical and non-clinical staff members. This monitoring is ongoing. The Nursing Home Administrator notified the local police department, the Department of Health and Human Services and Adult Protective Services of the incident. Resident #1 was referred to psychiatric services and is pending Veteran Affair approval. Resident #2 was referred to psychiatric services and was seen in the facility. A root cause analysis was completed and it was determined that Resident #2 had poor impulse control and needed increased supervision while out of bed.
- The Director of Nursing, Unit Manager #1 and Unit Manager #2 interviewed all alert and oriented residents to ensure that no additional incidents had occurred in the facility. There were no additional incidents reported. The Director of Nursing, Unit Manager #1 and Unit Manager #2 assessed all cognitively impaired residents to ensure there were no signs of abuse. There were no negative findings on the physical assessments. The Interdisciplinary Team, consisting of the Director of Nursing, Unit Manager #1, Unit Manager #2, Nursing Home Administrator and the Minimum Data Set nurse reviewed resident care plans to identify any additional residents with similar behaviors. One additional resident was identified with like behaviors but had no documented behaviors. The additional resident was also placed on hourly visual observations that are conducted by the assigned nurse and certified nursing assistant.
- The Director of Nursing educated all staff on the North Carolina Abuse Policy and Procedure as well as Management of Sexual Behaviors Policy. The education reinforced documentation of behaviors, implementing immediate intervention to ensure the safety of other residents from inappropriate or unwanted sexual behaviors or conduct. The education also reviewed the development of individualized care plans and notification to the Director of Nursing and the Provider. All staff that were not educated face to face were educated via phone. Any staff member that the Director of Nursing was unable to reach will be required to sign the education prior to working their next scheduled shift. All newly hired staff will be educated by the Director of Nursing, upon hire, prior to working in resident care areas.
- The facility decided to monitor and take the plan of correction to the Quality Assurance Committee which consisted of the Director of Nursing, Nursing Home Administrator, Unit Managers, Wound Care Nurse, Minimum Data Set Nurse and the Social Worker. To monitor and maintain ongoing compliance, the Director of Nursing or designee will conduct 5 resident interviews weekly for 4 weeks, then 3 resident interviews weekly for 4 weeks, then 1 resident interview weekly for 4 weeks to ensure there are no allegations of inappropriate sexual touching. In addition, the Director of Nursing or designee will conduct 5 skin assessments on cognitively impaired residents weekly for 4 weeks, then 3 skin assessments on cognitively impaired residents weekly for 4 weeks, then 1 skin assessment on cognitively impaired residents weekly for 4 weeks to ensure there are no signs of inappropriate sexual touching. Audits will be reviewed by the Quality Assurance Performance Improvement Committee, which consist of the Director of Nursing, Nursing Home Administrator, Unit Managers, Wound Care Nurse, Minimum Data Set Nurse and the Social Worker monthly for 3 months.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a severely cognitively impaired resident, who was able to exit the building without the knowledge of the nursing staff. The incident occurred when the Weekend Receptionist unlocked the front door and allowed the resident to go outside unsupervised. The resident was outside for over an hour before being found by a nurse in the facility's parking lot, attempting to navigate her wheelchair up a curb. The resident had a history of non-traumatic brain dysfunction, unspecified dementia, and a history of falls, but was not coded for wandering and required supervision for activities of daily living. The resident's care plan included interventions for impaired cognitive function and a risk for falls, but did not include measures for preventing elopement, as she was not previously identified as an exit-seeking individual. The Weekend Receptionist, who was new to the facility, did not check with the nursing staff before allowing the resident to exit, assuming she could go outside by herself. The receptionist was called away from the desk, and upon returning, found the resident was no longer on the porch. The nursing staff was unaware of the resident's absence until she was found outside by Nurse #5. Interviews with staff revealed that the resident did not exhibit exit-seeking behaviors prior to the incident and was usually content staying in her room. The facility's failure to supervise the resident adequately and the receptionist's lack of awareness regarding the resident's cognitive status contributed to the deficiency. The resident was found safe and uninjured, but the situation posed a high likelihood of serious harm due to the proximity of a busy highway.
Removal Plan
- Nurse #5 assigned to Resident #7 notified the Unit Manager that Resident #7 needed a wander guard band because resident #7 was in the side parking lot of the building.
- Resident #7 was assisted back into the facility by Nursing Assistant #3 and assessed for injuries by Nurse #5.
- The wander guard was placed on Resident #7 by Nurse #5.
- The responsible party and provider were notified by Nurse #1.
- Resident #7's elopement assessment prior to the unauthorized departure was reviewed by the Director of Nursing and it was determined that the resident was not at risk for elopement at the time of the assessment.
- The Director of Nursing reviewed the progress notes between the date of the last elopement assessment and the date of the unauthorized departure to ensure there was no documentation of wandering behaviors.
- The root cause of the incident was discussed by the Interdisciplinary team and it was determined that Resident #7 displayed new onset of exit seeking behaviors not reported to nurse #5 by the receptionist.
- The Receptionist was re-educated by the DON to consult with the nurse before letting residents onto the porch and checking the wander guard book located at the reception desk.
- The Director of Nursing, Unit Manager #1, Unit Manager #2 and the Infection Control nurse completed a new Brief Interview for Mental Status assessment and an Elopement assessment on all residents in the facility that had not been assessed.
- The Director of Nursing reviewed all progress notes to ensure all residents with documented wandering behavior had a wander guard and care plan in place.
- The wander guard books were updated by the Director of Nursing, following the completion of the Elopement assessments.
- Staff education was started by the Director of Nursing on the Elopement Policy and Procedure and Immediately reporting exit seeking behaviors to the nurse and administration.
- Education included consulting the wander guard books which were placed at all three nurse stations and the reception desk.
- All newly hired staff will be educated by the Director of Nursing on the Elopement Policy and Procedure and Immediately reporting exit seeking behaviors to the nurse and administration before the end of their employee orientation.
- The Director of Nursing also validated there was a sign on the main entrance informing visitors and staff to talk with a nurse prior to assisting residents out of the facility.
- The facility decided to take the elopement incident and the plan of correction to the Quality Assurance Performance Improvement team.
- The Director of Nursing will review all progress notes to ensure all residents with wandering behaviors have a wander guard in place and that there are no other instances of other unsafe residents being outside of the facility without supervision.
- The Director of Nursing will interview 3 employees weekly to ensure all staff understand the elopement drill process.
- Elopement books will be reviewed weekly during resident review to ensure the books are up-to-date and all residents at risk for elopement are listed in the books.
- The audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Failure to Hold Tube Feeding Leads to Resident Hospitalization
Penalty
Summary
The facility failed to follow a physician's order to hold a tube feeding for a resident after an episode of vomiting, leading to severe health complications. The resident, who had a history of stroke, dysphagia, and was dependent on a feeding tube, experienced vomiting after a bolus tube feeding was administered. Despite a subsequent order from a Nurse Practitioner to hold the tube feeding due to intolerance, the order was not correctly entered into the electronic Medication Administration Record (MAR), resulting in the feeding continuing overnight. The resident was found the next morning with symptoms of respiratory distress, including coughing, struggling to breathe, and emesis of tube feeding from the nose and mouth. The resident's condition was critical, with low oxygen saturation and elevated heart rate, necessitating emergency medical intervention and hospitalization. The failure to hold the tube feeding as ordered and to maintain the resident's head of the bed elevated contributed to the resident's aspiration and subsequent hospitalization. Interviews with staff revealed that the order to hold the tube feeding was not communicated effectively, and the electronic MAR did not reflect the hold order, leading to the continuation of the feeding. The incident highlighted a breakdown in communication and procedural adherence, resulting in significant harm to the resident.
Removal Plan
- The Nurse Practitioner ordered a diagnostic imaging for the Kidneys, Ureters and Bladder, a complete blood count, basic metabolic panel, Zofran 4 mg every 6 hours as needed for nausea and to hold tube feedings.
- The Assistant Director of Nursing reviewed the electronic medical record and determined that the tube feeding order was never placed on hold and Resident #98 received enteral tube feeding.
- Root cause was discussed by the Interdisciplinary team and it was determined that an additional order to hold the tube feeding was entered into the Electronic Medical Record but the actual tube feeding order was not placed on hold.
- The Assistant Director of Nursing reviewed the electronic medical records for all other residents that had received enteral feeding to ensure the tube feeding orders were correct and there were no missed hold orders and that each resident had an order to maintain the head of the bed at 30-40 degrees during feeding and for 30 minutes after, if tolerated.
- The Assistant Director of Nursing provided education to the nurses on appropriately placing an order on hold instead of entering an additional hold order.
- The nurse who failed to enter the order correctly received one on one education on appropriately placing an order on hold instead of entering an additional hold order by the Assistant Director of Nursing.
- Unit Managers, the Wound Care Nurse and the Minimum Data Nurse were educated during the Interdisciplinary Team meeting by the Assistant Director of Nursing.
- The Assistant Director of Nursing contacted all nurses and certified nursing assistants and provided education on ensuring residents with enteral tube feeding are kept at a 30-40-degree angle when in bed. 100% education was completed via telephone.
- The Director of Nursing or designee will review all new orders to ensure any orders to hold tube feedings, medications or treatments were applied to the actual tube feeding, medication or treatment order instead of only entering an additional hold order.
- Weekend orders will be reviewed during the Clinical Morning Meeting.
- The facility determined the need to take the plan of correction to the Quality Assurance Performance Improvement Committee.
- A meeting was held with the Medical Director and the Quality Assurance Performance Improvement committee to review the plan of correction and the monitoring plan.
- The facility conducts concierge rounds for all residents. Residents with enteral feeding are assigned the Minimum Data Set nurse.
- The concierge document includes resident bed positioning and are discussed in the administrative meeting.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to accurately document the administration of a narcotic pain medication, Hydrocodone-Acetaminophen, for a resident. A physician's order indicated that the resident was to receive one tablet every six hours as needed for pain. However, upon reviewing the controlled substance declining count sheet, it was found that the medication was signed off as administered on several dates, but there was no corresponding documentation in the Medication Administration Record (MAR) for those dates. Attempts to contact the nurses responsible for signing out the medication on the declining inventory count sheet were unsuccessful. Nurse #8, who signed out the medication on one occasion, was unreachable as the contact number was invalid, and it was later revealed that this nurse went on leave and never returned. Nurse #19, who signed out the medication on multiple occasions, was an agency nurse who no longer worked at the facility and did not respond to contact attempts. Nurse #6, who signed out the medication on two occasions, was suspended indefinitely and also did not respond to contact attempts. The Director of Nursing (DON) acknowledged the issue during an interview, stating that upon discovering the missing Hydrocodone-Acetaminophen tablets, a full investigation was initiated. It was found that the MARs were not accurate, leading to the initiation of a corrective action plan. The facility identified missing declining narcotic count sheets and a lack of a system to reconcile narcotic documents, which contributed to the deficiency.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the presence of a black greenish substance with a foul sewage odor around the base of commodes in multiple resident rooms. Observations revealed that this substance was present in rooms across three hallways, affecting a significant number of commodes. Interviews with housekeeping and maintenance staff indicated a lack of communication and responsibility regarding the issue. Housekeeper #1 acknowledged the problem but did not report it, assuming maintenance was already aware. The Maintenance Assistant and Director were also interviewed, with the Assistant dismissing the issue due to the absence of leaks, while the Director admitted ignorance about the substance and acknowledged the need for repairs. Additionally, the facility failed to address broken or missing bathroom door threshold strips in several resident rooms, posing potential safety hazards. The Maintenance Director could not provide documentation of completed or pending work orders, indicating a lack of oversight and follow-up on maintenance issues. The Housekeeping Supervisor was unaware of the black substance and lacked a cleaning schedule or documentation to verify daily cleaning checks. The Administrator, upon a follow-up tour, confirmed the presence of the substance and missing thresholds, expecting these issues to have been addressed.
Inaccurate Weight Monitoring in LTC Facility
Penalty
Summary
The facility failed to obtain and record accurate weights for four residents, leading to significant discrepancies in their weight records. Resident #83, who had severe cognitive impairment and a diagnosis of cirrhosis of the liver, experienced significant weight fluctuations that were not accurately recorded or verified. Despite having orders to monitor weight weekly, there were multiple instances where weights were not recorded, and significant changes were not reweighed as per facility policy. Interviews with staff revealed that the nursing assistants were responsible for obtaining weights, but there was a lack of consistency and communication regarding significant weight changes. Resident #63, admitted with diabetes, did not have a weight recorded upon admission, contrary to physician orders. Subsequent weights showed an increase, but the initial baseline was missing, complicating the assessment of the resident's nutritional status. The unit manager admitted to not checking if admission weights were obtained, highlighting a gap in the facility's adherence to its weight policy. Resident #91, with a history of pulmonary embolism and diabetes, also had discrepancies in weight records, with significant fluctuations that were not addressed. The lack of accurate weights made it difficult for the nurse practitioner to adjust medications appropriately. Similarly, Resident #29, with congestive heart failure, had missing daily weights despite orders, affecting the monitoring of their condition. The facility's failure to consistently obtain and verify weights as ordered compromised the ability to monitor and manage the residents' health conditions effectively.
Failure to Obtain Monthly CBCs for Resident on Immunosuppressive Therapy
Penalty
Summary
The facility failed to obtain a monthly complete blood cell count (CBC) for a resident receiving immunosuppressive drug therapy, as ordered by the physician. The resident, who was admitted with diagnoses including rheumatoid arthritis and heart failure, had a physician's order dated 11/27/23 for monthly CBCs. A CBC was collected on 11/30/23, but from 12/31/23 through 07/08/24, there was no documentation or results of the required monthly CBC tests in the resident's electronic medical record. The Nurse Practitioner, who began working at the facility in January 2024, was unaware of the order for monthly CBCs and relied on lab results from the resident's Rheumatologist, which were accessible through the hospital's electronic medical record system. The issue arose because the Unit Manager, who entered the initial order for monthly CBCs, did not complete the necessary requisition form to notify the lab vendor to draw the labs. The facility had recently transitioned to a new electronic medical record system, which included a new process for ordering labs. This process required entering the order into the electronic medical record and then directly into the vendor's website, bypassing the previous method of using a handwritten requisition form. The Director of Nursing confirmed that the new process was in place and that nurses had been educated on it, but was unaware of the specific order for the resident's monthly CBCs.
Misappropriation of Narcotic Pain Medication in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotic pain medication, specifically Hydrocodone-Acetaminophen oral tablets. This deficiency was identified for two residents who were reviewed for medication misappropriation. Resident #20, who was severely cognitively impaired, had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for pain. However, a shipment of 30 tablets received on 05/03/24 was unaccounted for, with no record of administration or declining count sheet. The issue was discovered during a transition to a new electronic medical record system, and the missing medication was never found. Similarly, Resident #61, who was on hospice care and also cognitively impaired, had a physician's order for the same medication. A shipment of 30 tablets was received on 04/05/24, but only 10 doses were documented as administered, and the declining inventory sheet was missing. Further investigation revealed that additional tablets were ordered and received, but again, the documentation was incomplete, and the medication was unaccounted for. The facility's investigation pointed to discrepancies in the handling and documentation of narcotic medications, with Nurse #6 being a central figure in both cases. Despite attempts to contact her, Nurse #6 did not respond, and she was suspended indefinitely. The facility's failure to maintain accurate records and secure narcotic medications led to the misappropriation of these controlled substances, compromising the residents' rights and safety.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to maintain a system of records for the receipt and disposition of controlled drugs, specifically Hydrocodone-Acetaminophen 5-325 mg, for two residents. For Resident #20, there was no declining count sheet for 30 tablets received on multiple occasions, and attempts to contact the nurses responsible for receiving these medications were unsuccessful. The Medication Administration Record (MAR) showed that 18 of the 30 tablets were administered without proper documentation, and the facility's investigation revealed missing declining count sheets, indicating a lack of reconciliation for narcotic documents. Similarly, for Resident #61, the facility was unable to locate the declining inventory sheets for Hydrocodone-Acetaminophen tablets received on two separate occasions. The MAR indicated that 15 of the 45 doses were administered, but the absence of declining count sheets made it impossible to reconcile the medication records. The Director of Nursing confirmed that the missing sheets were discovered during audits initiated due to discrepancies found with Resident #20's medication records. Interviews with staff, including the Pharmacy Manager, Consultant Pharmacist, and Director of Nursing, highlighted the absence of a system to reconcile narcotic documents and the failure to maintain accurate records of controlled substances. The Consultant Pharmacist admitted to not reviewing declining count sheets regularly, and the Director of Nursing acknowledged the lack of a system to track and reconcile narcotic medications, which led to the discrepancies and missing documentation.
Failure to Maintain Safe Environment Due to Broken Equipment and Lack of Signage
Penalty
Summary
The facility failed to maintain a safe environment in the 700-hall by using a floor scrubber with a broken squeegee attachment, which left large puddles of water on the floor. This issue was observed during a tour on 07/08/24, where no wet floor signs were posted despite the presence of staff. Interviews with the Unit Manager and the Director of Nursing confirmed the presence of water puddles and the absence of wet floor signs, acknowledging the situation as a potential fall hazard. The Maintenance Director and Housekeeping Supervisor both noted that the scrubber was worn out and needed replacement, but budget constraints prevented this. Further interviews revealed that the Floor Technician was aware of the malfunctioning squeegee, and Housekeeper #1, who mopped the 700-hall, did not place wet floor signs as she believed the floor was dry. The Administrator acknowledged the oversight of not posting wet floor signs on the observed wet floors, which posed a fall risk. The deficiency was due to the failure to address the broken equipment and the lack of proper signage to warn of the wet floors, leading to unsafe conditions in the facility.
Failure to Date Insulin Pens
Penalty
Summary
The facility failed to record an opened date on two insulin pens, specifically Lantus and Novolog, which have a shortened expiration date of 28 days after opening. This deficiency was identified during an observation of the 200/300 hall medication cart, where the insulin pens were found without the required opened dates. Nurse #7, who was present during the observation, stated she was unaware that the insulin pens were not dated and confirmed she did not administer them to residents that day. She also mentioned that she was not typically assigned to that medication cart and acknowledged that it was the responsibility of the nurse who initially opened the insulin pen to label it with an opened date. The Director of Nursing confirmed that insulin pens should be labeled with opened dates when initially opened.
Resident Dignity Compromised by Medication Aide's Inappropriate Action
Penalty
Summary
The facility failed to maintain a resident's dignity when a Medication Aide flicked a severely cognitively impaired resident's forehead with her finger during care. The resident, who was admitted with a diagnosis of dementia, was known to have severely impaired cognition and exhibited physical behavioral symptoms directed toward others several times a week. On the day of the incident, the resident had a large bowel movement and was found smearing feces around her room, which was not typical behavior for her. During the incident, two Nurse Aides were cleaning the resident when the Medication Aide entered the room with towels. Witnesses, including the two Nurse Aides, reported that the Medication Aide flicked the resident on the forehead and made a comment about the resident's behavior. The resident responded verbally, indicating surprise and discomfort, although she later stated that the flick did not hurt her and she was not afraid. The Medication Aide claimed the action was a joke and denied any intent to harm, stating that the flicking motion was to remove feces from her gloves. The facility conducted an investigation following the incident, with interviews from the involved staff and the resident. The Medication Aide admitted to the action during an interview with the Administrator, although she later denied it to the Director of Nursing. The Administrator emphasized that such actions are inappropriate and should not occur, regardless of intent. The incident was documented as a failure to uphold the resident's right to dignity and respect.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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