Autumn Care Of Saluda

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to accurately code the Minimum Data Set (MDS) assessment for a resident with a pressure ulcer. The resident was admitted with a documented pressure ulcer on the sacrum per the admission skin assessment, although the stage of the ulcer was not specified in that assessment. Subsequent nursing documentation, including a progress note, identified a reddened area on the bilateral inner/top buttocks covered with foam dressing, and the Medication Administration Record showed a physician’s order to cleanse the bilateral inner buttock area with normal saline and apply a foam border dressing, which was carried out. Another nurse’s progress note documented that the sacral dressing was changed the following day. Despite this documentation of a pressure-related skin condition present at admission, the admission MDS assessment indicated that the resident did not have an unhealed stage I pressure ulcer during the look-back period. In interviews, the MDS Coordinator stated that the admission MDS should have been coded to reflect a stage I pressure ulcer present on admission, and the DON stated that MDS assessments should be coded correctly and that she expected the admission MDS to show a stage I pressure ulcer present on admission. The Administrator also confirmed that the admission MDS should have been correctly coded to reflect a stage I pressure ulcer present on admission.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete required quarterly smoking risk assessments for a resident who smoked. The resident was admitted with diagnoses including mood disorder, nicotine dependence, and muscle weakness. The facility’s smoking policy required a smoking risk assessment on admission, quarterly, and upon changes in condition. The resident’s MDS assessments showed that he was cognitively intact, independent in most ADLs, and coded for tobacco use. Smoking risk assessments were documented on 06/05/25 with a score of 7, on 08/28/25 with a score of 8, and on 02/26/26 indicating the resident was not a current smoker. The resident’s care plan, updated on 04/10/26, identified him as a supervised smoker with interventions to explain the smoking policy as needed and monitor for unsafe smoking signs. The resident was observed smoking under supervision on 04/21/26 with no issues noted. The Social Worker stated she was responsible for quarterly smoking assessments and relied on computer notifications, confirming she last assessed the resident on 02/26/26 as a non-smoker. She reported that the resident’s smoking privileges were revoked in January 2026 due to escalating behavior toward other residents during smoking times and that the Administrator reinstated these privileges on 04/10/26. Although the Social Worker updated the care plan to include smoking at that time, she did not complete a new smoking risk assessment despite acknowledging she should have done so due to the change in smoking status. The DON and Administrator both confirmed that a new smoking risk assessment should have been completed when smoking privileges were reinstated, in accordance with the facility’s policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to effectively supervise a cognitively impaired resident who was assessed as being at risk for elopement and who exited the building unsupervised and without staff knowledge. The resident had diagnoses including dementia, bipolar disorder, panic disorder, and anxiety disorder, and an MDS documented severe cognitive impairment with a need for supervision for mobility and transfers. The resident’s care plan, initiated and updated prior to the incident, identified risk of elopement with behaviors such as standing by exit doors, verbalizing intent to walk out, and attempting to follow staff as they exited. Interventions on the care plan included 1:1 approach during elopement attempts, redirection from the front door area with offers of coffee, snacks, walks in the courtyard, or return to the room, and maintaining a calm environment. An elopement assessment completed prior to the incident documented that the resident was independent with ambulation and exhibited exit-seeking behaviors, including verbalizing a desire to go home or go on a trip, and not accepting the current residence. Despite this, the immediate intervention listed was to continue the current plan of care. On the morning of the elopement, the DON and Administrator reported that the resident had shown increased exit-seeking behavior, including asking about leaving and standing near common area doors that were locked with a keypad. This escalation was discussed in the morning interdisciplinary team meeting, and staff were informed they needed to increase observation and redirection of the resident due to the heightened behaviors. On the day of the incident, Nurse #1 reported that around 10:10 a.m. the resident was inquiring about leaving the facility; she told him he needed to talk to the physician and that it was almost time to go smoke. The resident then left the nurse’s station and went to his room, where he lay on his bed. NA #1 stated that at approximately 10:30 a.m. the resident was in his room sitting on his bed after she had redirected him with an offer of coffee when he asked how he could get home. NA #1 acknowledged she was aware of his exit-seeking behavior and the need to keep an eye on him but stated she had other residents to care for and could not continuously watch him. At 10:42 a.m., Nurse #1 saw the resident outside, midway down the facility driveway, approximately 150 feet from the building and about 50 feet from the road, and immediately brought him back inside. The facility’s investigation concluded that, on a day when multiple vendors and staff were entering and exiting through a side common area door, the resident was able to leave the building by following or being let out by a vendor or staff member through that door, resulting in an unsupervised exit despite his known elopement risk and recent increase in exit-seeking behavior. Interviews with the NP indicated that during prior visits the resident had always been observed sitting on his bed and had not shown exit-seeking behavior to her. However, staff interviews and documentation on the Kardex and elopement assessment confirmed that exit-seeking behaviors were known and that the resident was identified as at risk for elopement. The side common area doors used by vendors were locked with a keypad, and only certain management staff had the code, but on the day of the incident vendors and staff were going in and out through those doors, and the resident was able to leave undetected. The combination of known elopement risk, documented increased exit-seeking behavior that morning, reliance on intermittent observation rather than continuous supervision, and active vendor traffic through a secured exit led to the resident’s unsupervised departure from the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from the misappropriation of controlled narcotic pain medications, affecting three residents. Nurse #1 was involved in the misappropriation of medications, as evidenced by discrepancies in the controlled narcotic medication declining records. Nurse #1 signed off on the removal and wasting of medications without a second nurse's witness signature, which is against the facility's policy. This was observed in the records of three residents who were prescribed opioid medications for pain management. Resident #46, who had intact cognition, was prescribed hydrocodone-acetaminophen for hip pain. On a specific date, Nurse #1 signed for the removal of one tablet and claimed it was wasted without a witness, and later removed two more tablets, claiming both were administered. Similarly, Resident #1, with severely impaired cognition, was prescribed oxycodone-acetaminophen for chronic pain. Nurse #1 signed for the removal of two tablets on two occasions, claiming one was wasted each time, with one instance lacking a witness signature. Resident #18, with intact cognition and chronic pain, was prescribed oxycodone extended release. Nurse #1 signed for the removal of two tablets, claiming one was wasted with an unknown witness signature. The facility became aware of the alleged drug diversion when staff noticed double signatures and unknown witness signatures on the narcotic medication records. An investigation revealed that Nurse #1 admitted to signing as a witness without another nurse present and could not account for the wasted medications. The facility reported the incident to law enforcement and the state agency, and Nurse #1 faced criminal charges. The investigation confirmed that five narcotic medications were diverted, and the facility took steps to address the issue, including notifying relevant authorities and conducting audits.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly manage food storage and handling, as observed during a survey. In the walk-in refrigerator, cucumbers and green bell peppers were found with signs of spoilage, having been received on dates far exceeding the recommended storage period. The cucumbers were shriveled with white on the surface, and the bell peppers were shriveled with black on the surface. Additionally, in the kitchen refrigerator, a ham and cheese sandwich and a peanut butter and jelly sandwich were found without any date labels, indicating a lapse in the facility's protocol for dating food items. Furthermore, the canned goods rack contained an unopened can of catsup with a significant dent, which should have been placed in the damaged goods return area. Interviews with the Certified Dietary Manager (CDM) and the Administrator revealed that the vegetables should have been discarded after seven days, and the sandwiches should have been dated when made. The CDM acknowledged the oversight and indicated that the dented can of catsup was improperly returned to the shelf instead of being set aside for return. The Administrator confirmed that the expectation was for food to be stored and dated according to regulatory standards, and spoiled vegetables should be discarded.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician of a fall and a delay in a STAT x-ray order for a severely cognitively impaired resident on blood thinner. The resident experienced a fall while being transferred to the toilet using a sit-to-stand mechanical lift. The CNAs involved did not report the incident to a nurse or physician, and the resident was moved without a proper assessment. The resident later displayed signs of pain and decreased range of motion in her left hip, leading to a STAT x-ray order that was delayed without notifying the physician of the delay. The x-ray eventually revealed an acute fracture of the left hip, and the resident was transferred to the ER for further evaluation and treatment. The resident underwent surgery and was later discharged to hospice care, where she expired. The incident began when an agency CNA was lowering the resident to the toilet, and the resident's foot slipped, causing her to be lowered to the floor. The CNA did not report the incident to a nurse, believing it was not a fall. Another CNA assisted in moving the resident back to her chair without notifying a nurse for an assessment. The following day, the resident's decreased mobility and pain were noticed, and a STAT x-ray was ordered. However, the x-ray was delayed, and the physician was not informed of the delay. Interviews with the involved staff revealed a lack of communication and understanding of the facility's protocols for reporting falls and changes in condition. The CNAs did not recognize the incident as a fall and failed to notify the appropriate medical personnel. The delay in the STAT x-ray order was not communicated to the physician, resulting in a delay in the resident's diagnosis and treatment. The facility's failure to follow proper notification procedures contributed to the resident's prolonged pain and delayed medical intervention.

Removal Plan

• The facility failed to notify the MD/NP and RP when Resident #1 fell and failed to notify the NP when there was a delay in a stat x-ray order. C.N.A. #1 and C.N.A #2 failed to notify a Nurse/MD or NP when Resident #1 fell and failed to notify before moving Resident #1 off the floor. C.N.A. #2 informed the NP that Resident #1 was having issues with her foot dragging. C.N.A #2 did not notify the NP of the fall. NP performed an assessment on Resident #1, no bruising or swelling was noted. NP ordered stat x-ray and changed scheduled Tylenol to three times daily for pain. Radiology contacted facility and notified the floor nurse that they would not be able to obtain the stat x-ray. Floor nurse did not notify NP of delay in stat x-ray. Director of Nursing and/or designee re-educated floor nurse on proper notification of MD for any delay in stat orders. X-ray results revealed acute fracture of left hip. Facility notified Nurse Practitioner and received orders to send resident to the hospital for evaluation and treatment.
• Director of Nursing and/or designee completed education with all licensed nurses and CNA's including agency staff on notification to MD/NP and RP of all incidents or falls and accidents.
• Director of Nursing and/or designee completed education with all licensed nurses including agency staff on notification to MD/NP on delay of stat x-rays orders. Interviews were conducted with communicative residents. These interviews were conducted to determine if any issues regarding care and services would be identified. No other issues were identified. Unit managers completed skin checks on all residents. Skin checks were completed to ensure there were no signs of injury from an unreported fall, no negative findings were noted. Director of Nursing checked for any other stat x-ray orders and there were none.
• The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses including agency staff on reporting of incidents and accidents and reporting protocols and change in condition to physician or nurse practitioner. New hires to the facility are educated with the onboarding procedures. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff including agency staff on reporting of accidents and incidents. The Director of Nursing and/or their designee educated all licensed nurses including agency nurses on stat orders and procedures. This education included notification to physician or NP on a delay of stat orders or other changes of condition for the residents.
• The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice for a period of 12 weeks. Director of Nursing and/or their designee will obtain copies of new and stat x-ray orders from NP. Director of Nursing and/or their designee will audit results daily for 12 weeks to ensure order for x-rays are completed as ordered. NP was notified of this process. Director of Nursing and/or their designee will audit change of condition and incident reports daily for 12 weeks to ensure physician notification of incidents/accidents and falls has been completed. Director of Nursing and/or designee will have daily huddles with licensed nurses and C.N.A.'s at beginning and end of shift to discuss any change in condition or incidents that may have occurred throughout the shift in order to ensure proper notifications have been made. This is to ensure that MD/NP have been notified of any incidents. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed for three months.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's right to be free from neglect when staff disregarded the resident's plan of care and transferred the resident without the use of a total mechanical lift and two-person assistance. During the first transfer, the resident was assisted to the floor. The following day, the Nurse Practitioner was asked to assess the resident due to her left foot dragging on the floor, and x-ray results revealed an acute fracture of the left hip. The resident underwent surgery to repair the left hip fracture and was later discharged to hospice care, where she expired shortly after. The incident began when a Nurse Aide transferred the resident independently using a sit-to-stand mechanical lift instead of the required total mechanical lift with two-person assistance. During the transfer from the toilet to the sit-to-stand mechanical lift, the resident's foot slipped, and the Nurse Aide had to lower the resident to the floor. Another Nurse Aide was called to assist, and they both helped the resident off the floor without using the proper mechanical lift. Transfers continued without using the total mechanical lift and assistance from two people. The following day, a Nurse Aide reported to the Nurse Practitioner that the resident's left foot was dragging on the floor when in a wheelchair but did not inform the Nurse Practitioner of the fall. The Nurse Practitioner assessed the resident and ordered immediate x-rays, which revealed an acute fracture of the left hip. The Director of Nursing was notified, and the resident was sent to the hospital for further evaluation and treatment. The resident underwent surgery and was later discharged to hospice care, where she expired shortly after.

Removal Plan

• The facility failed to transfer resident #1 in a safe manner which resulted in a left hip fracture. Resident #1 was supposed to be transferred using a total lift and was transferred by C.N.A #1 with a sit to stand when the fall occurred. C.N.A. # 1 requested help from C.N.A. # 2. Both C.N.A.'s transferred the resident from the floor to her chair without the use of the proper lift.
• X-ray was obtained which revealed fracture of left hip, facility notified Nurse Practitioner and orders were obtained to transfer resident to the hospital for further evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated. The Director of Nursing conducted an interview with C.N.A. #2 which confirmed that resident was on the floor in the shower room, and she assisted C.N.A #1 in returning resident to chair. CNA #1 is no longer permitted to work at the facility, CNA #2 has been terminated.
• The Director of Nursing and/or designee completed interviews with communicative residents regarding care and services provided to identify any other injury of unknown origin. No other issues were identified. Unit managers completed skin check on all residents to ensure there were no signs or symptoms of injury noted, no negative findings were noted. Current lift status was obtained from the therapy department. Unit managers cross-referenced the lift status to the Kardex and Care Plans.
• The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses on safe transfers, reporting of incidents and accidents and reporting protocols. Agency staff will be educated prior to the first shift working on proper lifts, facility policies, and reporting all incidents and changes in condition. New hires to the facility are educated with the onboarding procedures. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on lift competencies and transfers and proper use of the lift, with return demonstration by the licensed staff and C.N.A.'s, reporting of accidents and incidents, following the Kardex for proper transfers and change in condition. The Director of Nursing and/or their designee educated all facility staff on abuse and neglect, definition of abuse/neglect and facility policy for reporting. Staff educated that facility has no tolerance for abuse/neglect and will result in immediate termination. Director of Nursing and/or their designee educated agency staff on abuse/neglect policy, reporting and consequences of abuse/neglect. New staff will be educated upon hire by the Director of Nursing and/or their designee.
• The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice.
• To monitor ongoing compliance the Director of Nursing and/or their designee will complete observations of five (5) residents per week to ensure residents requiring assist utilizing lifts are receiving the proper transfer. Unit Mangers will select 5 residents weekly that currently use a lift and compare therapy lift status to the current care plan and Kardex to ensure accuracy.
• Administrator and/or their designee will audit five (5) random staff members weekly to ensure that they understand the definition abuse/neglect and the reporting requirements for abuse/neglect.
• The Social Services Director and/or their designee will interview 5 alert residents and 5 responsible parties per week to ensure that no abuse/neglect is occurring.
• Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assess a resident by a nurse after a fall and prior to getting her off the floor. On the day of the incident, a nurse aide transferred the resident from her bed to a sit-to-stand lift and then to the shower room. During a transfer in the shower room, the resident's foot slipped, and the nurse aide had to lower the resident to the floor. The nurse aide called for assistance from another nurse aide, but neither of them notified a nurse about the fall. Consequently, an assessment for injury was not completed by a nurse before the resident was moved back to her wheelchair. The following day, the nurse practitioner placed a STAT order for a left hip x-ray due to the resident's decreased range of motion and pain. However, there was a delay in executing the STAT x-ray order, and the facility did not inform the nurse practitioner about the delay. The x-ray results, which revealed a fracture of the resident's left hip, were not available until the next day. The delay in obtaining the x-ray results led to a delay in sending the resident to the hospital for further evaluation and treatment. Interviews with the involved staff revealed that they did not consider the incident as a fall and therefore did not follow the proper protocol of notifying a nurse and having the resident assessed before moving her. The nurse aides involved admitted to not reporting the incident to the nurse or the nurse practitioner, which contributed to the delay in care. The facility's failure to ensure timely assessment and execution of the STAT x-ray order resulted in delayed care for the resident, who suffered a hip fracture.

Removal Plan

• The facility failed to have resident assessed by a nurse after the fall and prior to getting her off the floor. The facility failed to report the fall and improper transfer when CNA #2 reported the resident having issues with her foot dragging. Nurse Practitioner was notified by C.N.A. #2 that resident could not move her left foot. Nurse Practitioner performed an assessment on resident, no bruising or swelling was noted. Nurse Practitioner ordered stat x-ray and changed Tylenol order to three times daily for pain. Radiology contacted facility and notified the floor nurse that they would not be able to obtain the stat x-ray. Floor nurse did not notify NP of delay in stat x-ray. Director of Nursing and/or designee re-educated floor nurse on proper notification to MD for any delay in stat orders. X-ray results revealed acute fracture of left hip. Facility notified Nurse Practitioner and received orders to send resident to the hospital for evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated. Director of Nursing conducted an interview with C.N.A. #2 which revealed the incident and a conclusion on how the fracture occurred. C.N.A. #2 confirmed that resident was on the floor in the shower room and C.N.A #2 assisted C.N.A #1 in returning resident to chair. C.N.A #1 cannot return to the facility, CNA #2 has been terminated from the facility.
• Director of Nursing and/or designee completed interviews with communicative residents regarding care and services provided to identify any unreported incidents or other injury of unknown origin. No other issues were identified by residents. Head to toe skin assessments were completed on all residents by Unit Managers. This was done to ensure there were no signs or symptoms of injuries related to incidents not being reported. No negative findings were noted from residents. The Director of Nursing checked for any other stat x-ray orders and there were none.
• The Director of Nursing and/or their designee completed education of 100% C.N.A.'s and licensed nurses which included, safe transfers, reporting of incidents and accidents, and reporting protocols and change in condition. This includes having a licensed nurse assess a resident after all falls and/or incidents. Agency staff will be educated prior to first shift working on proper lifts, facility policies, and reporting all incidents and change in condition. New hires to the facility are educated with the onboarding procedures. The Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on reporting of incidents and accidents and the definition of a fall. Agency staff were educated prior to taking an assignment. The Director of Nursing and/or their designee completed 100% education of all licensed nurses on stat orders. This education included notification to MD/NP if stat order has been delayed. Agency nurses are educated on STAT orders prior to first shift working.
• The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice. Director of Nursing and/or their designee will obtain copies of new and stat x-ray orders daily from NP. Director of Nursing and/or their designee will audit results daily to ensure orders for x-rays are completed as ordered. NP was notified of this process. Director of Nursing and/or their designee will randomly audit five (5) staff members weekly to monitor knowledge of reporting of incidents, falls and what is considered a fall. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to safely transfer a resident from the toilet to the shower chair, resulting in the resident falling to the floor. A nurse aide used a sit-to-stand mechanical lift instead of the total mechanical lift as indicated in the resident's care plan, which required two-person assistance. During the transfer, the resident's foot slipped, and the nurse aide had to lower the resident to the floor. Another nurse aide assisted in manually lifting the resident off the floor without using a mechanical lift, and the incident was not reported to a nurse for assessment. The resident, who had severe cognitive impairment and required total dependence on staff for mobility, was later found to have an acute fracture of the left hip. The injury was discovered after a nurse aide noticed the resident's foot dragging while in a wheelchair and reported it to the nurse practitioner. The resident was sent for an x-ray, which confirmed the fracture, and was subsequently transferred to the hospital for surgery. The resident was later discharged to hospice care and expired. Interviews with staff revealed that the nurse aide who performed the transfer had not received proper orientation or education on resident transfers or lift equipment from the facility. Additionally, the nurse aides involved did not follow the care plan or report the incident, leading to a delay in the resident receiving appropriate medical attention. The facility's failure to ensure proper use of mechanical lifts and adequate supervision during transfers directly contributed to the resident's injury and subsequent decline in health.

Removal Plan

• The facility failed to transfer resident #1 in a safe manner which resulted in a left hip fracture. Resident #1 was supposed to be transferred using a total lift and was transferred by C.N.A #1 with a sit to stand when the fall occurred. C.N.A. # 1 requested help from C.N.A. # 2. Both C.N.A.'s transferred the resident from the floor to her chair without the use of the proper lift. X-ray was obtained which revealed fracture of left hip, facility notified Nurse Practitioner and orders were obtained to transfer resident to the hospital for further evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated. Director of Nursing conducted an interview with C.N.A. #2 which confirmed that resident was on the floor in the shower room and she assisted C.N.A #1 in returning resident to chair. CNA #1 is no longer permitted to work at facility, CNA #2 has been terminated.
• Director of Nursing and/or designee completed interviews with communicative residents regarding care and services provided to identify any other injury of unknown origin. No other issues were identified. Unit managers completed skin check on all residents to ensure there were no signs or symptoms of injury noted, no negative findings were noted. Current lift status was obtained from therapy department. Unit managers cross referenced the lift status to the Kardex and Care Plans.
• The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses on safe transfers, reporting of incidents and accidents, reporting protocols, and what constitutes a fall, which is a change of plane. Director of Nursing and/or their designee educated agency staff on proper lifts, facility policies, reporting all incidents and accidents, change in condition and what constitutes a fall, which is a change of plane. New hires to the facility are educated with the onboarding procedures by the Director of Nursing and/or their designee. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on lift competencies and transfers. Education also included proper use of the lift, with return demonstration by the licensed staff and C.N.A.'s. Staff were educated on how to report accidents and incidents, how to understand the Kardex for proper transfers, and how to report change of condition with residents. Director of Nursing and/or designee educated Agency staff prior to taking an assignment on the units and completed return demonstration to ensure understanding and compliance with education.
• The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice. To monitor ongoing compliance the Director of Nursing and/or their designee will complete observations of five (5) residents per week to ensure residents utilizing a lift are receiving the proper transfer. Unit Mangers will select 5 residents weekly that currently use a lift and compare therapy lift status to the current care plan and Kardex to ensure accuracy. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed. Corrective action will be completed. The facility alleged a IJ removal date.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all nursing staff, including agency staff, received proper orientation and competency verification before providing care to residents. Specifically, Nurse Aide (NA) #1 transferred a resident using a sit-to-stand mechanical lift, contrary to the resident's care plan, which required a total mechanical lift with two-person assistance. This improper transfer resulted in the resident's foot slipping, causing the resident to be lowered to the floor and subsequently lifted manually by NA #1 and NA #2 without using the appropriate mechanical lift. The resident later suffered an acute fracture of the left hip, underwent surgery, and was eventually discharged to hospice care, where they expired shortly after. The incident highlights a significant lapse in ensuring that staff were adequately trained and aware of the resident's specific care requirements as outlined in their care plan and Kardex system. The competency checklist for NA #1 from the agency indicated previous training and experience in patient transfers but lacked specific information on using mechanical lifts. NA #1 admitted to not receiving orientation or education on resident transfers or lift equipment from the facility and was unaware of how to access resident care plans or the Kardex system. NA #2, who assisted NA #1, also did not provide proper guidance on the required transfer method for the resident. The Director of Nursing (DON) and the Scheduler failed to verify NA #1's competency in using mechanical lifts before allowing her to provide care, relying instead on a general skills checklist from the staffing agency. Interviews with various staff members, including the DON, Scheduler, and other nurses, revealed a lack of consistent orientation and competency verification for agency staff. The DON acknowledged that agency staff were given only basic resident care information and were expected to seek guidance from nursing staff if needed. The Administrator admitted that the incident was avoidable if the staff had followed the care plan, indicating a systemic issue in ensuring that all staff, including agency staff, were adequately trained and aware of the specific care needs of residents. This deficiency in staff training and competency verification directly led to the resident's fall and subsequent injury.

Removal Plan

• Director of Nursing and/or their designee completed education with facility licensed nurses and C.N.A.'s on lift competency with return demonstration. Licensed agency nurses and C.N.A.'s were educated on proper lift competency with return demonstration. Education was also provided on where licensed nurses and C.N.A.'s can locate current lift status.
• Director of Nursing and/or their designee educated all licensed nurses and C.N.A.'s, including agency staff on location of resident care guides.
• All new facility licensed nurses and C.N.A.'s will receive education from the unit managers on the location of the resident care guides during their orientation. Unit Managers were notified of this responsibility.
• All licensed nurses and C.N.A.'s from an agency are required to come in prior to their first shift to receive lift training and review facility policies. This training is completed by the Director of Nursing and/or their designee. The nursing scheduler is responsible for scheduling agency staff for this orientation. The nursing scheduler notified the agencies of this requirement. Each agency staff is now required to read through facility policies and procedures related to resident care which are located at each nurse's station in the Agency Orientation book. They are to acknowledge understanding of these policies by signing the Policy Acknowledgement Sheet. Agency staff are required to complete lift competency prior to working, this is completed by the Director of Nursing and/or their designee. The facility is requiring the agency to provide the skills checklist of each agency staff member for review prior to working. The Director of Nursing and/or their designee will review the skills check list to ensure that they have the skills to meet the needs of our residents.
• The Director of Nursing and/or their designee completed lift competencies with return demonstration for all licensed nurses and C.N.A.'s and agency staff.
• New hires will be educated Director of Nursing and/or designee on facility policies and lift competencies upon hire.
• The facility made the decision to have an ad hoc QAPI (Quality Assurance and Process Improvement) committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice for a period of 12 weeks.
• The Director of Nursing and/or their designee will audit five (5) agency staff, licensed staff and C.N.A.'s, to the location of the care guides for the residents.
• The Director of Nursing and/or their designee will audit five (5) facility and agency C.N.A.'s weekly for 12 weeks observing lift transfers. Any negative observations will be corrected immediately.
• Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and or their designee for review and/or revision as needed for three (3) months.