Currituck Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Barco, North Carolina.
- Location
- 3907 Caratoke Highway, Barco, North Carolina 27917
- CMS Provider Number
- 345289
- Inspections on file
- 20
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Currituck Health & Rehab Center during CMS and state inspections, most recent first.
A resident with heart failure was admitted to hospice care, but staff failed to complete the required MDS Significant Change in Status Assessment (SCSA) following this change. The responsible MDS nurse acknowledged missing the assessment and could not explain the omission, and the administrator confirmed that the assessment should have been completed.
A resident with bipolar disorder and schizophrenia had a PASRR Level II determination requiring follow-up psychiatric services, but the MDS assessment was incorrectly coded to indicate the absence of serious mental illness. The MDS nurse acknowledged the error, and the administrator confirmed the assessment should have reflected the correct PASRR status.
A resident who was cognitively intact and independent with bed mobility had bilateral quarter bed rails installed without documented attempts at alternatives or an assessment for entrapment risk. Staff interviews confirmed that no alternatives were tried and no supporting assessments were available, despite the resident's independence and lack of recent falls.
A staff member took checks from a resident without consent, successfully cashed one for $1,000, and attempted to cash additional checks. The incident was discovered after the resident's responsible party was alerted by the bank and notified both the facility and law enforcement. The staff member was subsequently identified, arrested, and terminated. Facility staff were unaware the resident had checks in her possession, and the deficiency was cited for failing to protect the resident from misappropriation of property.
A resident with COPD and on continuous oxygen therapy was repeatedly found smoking in unsafe conditions, both inside and outside the facility, often near oxygen equipment. Despite being aware of the resident's non-compliance with the smoking policy, the facility failed to conduct timely reassessments or enforce effective interventions, allowing the resident to continue smoking unsupervised. The facility's attempts to manage the situation, such as confiscating smoking materials and using lockboxes, were ineffective, contributing to ongoing safety risks.
A resident with renal insufficiency developed a UTI with ESBL-producing E. coli, but the facility failed to notify the physician of the C&S results in a timely manner. This led to the resident being treated with an ineffective antibiotic, resulting in seizure-like symptoms and hospitalization for acute metabolic encephalopathy. The delay in communication and treatment highlighted procedural lapses in the facility's handling of lab results.
A resident with a history of aggressive behavior punched another resident, who was on blood thinners, causing bruising and swelling. Despite interventions in place, the facility failed to prevent the altercation, leading to the assaulted resident feeling unsafe and transferring to another facility.
A resident with renal insufficiency and CHF developed a UTI with ESBL-producing E. coli. The facility failed to act on lab results indicating resistance to the prescribed antibiotic, leading to ineffective treatment. The resident's condition worsened, resulting in hospitalization for acute metabolic encephalopathy. Staff interviews revealed lapses in communication and responsibility for reviewing lab results.
A medication error rate of 12.12% was identified in an LTC facility, involving two residents who did not receive prescribed medications during observed administration. A resident with chronic conditions did not receive Klor-Con, Fluticasone Propionate, and Polyethylene Glycol, while another resident with diverticulitis did not receive Polyethylene Glycol. The errors were attributed to a nurse's failure to offer the medications, with discrepancies noted in the Medication Administration Record.
The facility did not follow the approved menu for pureed diets, affecting 7 residents. Staff used incorrect scoop sizes for pureed chicken and omitted pureed bread, contrary to the menu specifications. The Interim Dietary Manager confirmed the error in portion sizes.
The facility failed to maintain accurate medical records and medication administration for several residents. A resident's seizure was not properly documented, leading to incomplete records. Another resident's MAR inaccurately reflected medication administration, as medications were not offered. Similarly, a third resident's MAR showed incorrect documentation of a laxative administration. These deficiencies highlight issues in documentation and communication among staff.
A facility failed to accurately document a resident's code status in the EMR, resulting in a discrepancy between a physician order for full code status and a signed DNR form. The resident, with severe cognitive impairment, had conflicting documentation due to a recent transition to a new EMR system. Staff interviews revealed inconsistencies in verifying and updating code status, contributing to the oversight.
A facility failed to provide a CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to a resident before discharge from Medicare Part A skilled services. The resident continued to stay in the facility after services ended, and although a Notice of Medicare Non-Coverage (NOMNC) was given by phone to the resident's power of attorney, the SNF ABN was not issued. The Social Worker, responsible for issuing these notices, could not explain the oversight, and the Administrator confirmed the SNF ABN should have been completed.
The facility failed to accurately code the MDS assessments for three residents, leading to deficiencies in documenting smoking status, medication use, and pain management. A resident with COPD was inaccurately coded as a non-smoker, another resident was incorrectly documented as receiving anticoagulants instead of antiplatelets, and a third resident's opioid use was not reflected in the MDS. These errors were acknowledged by the facility's staff and attributed to a lack of diligence by the previous MDS nurse.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in smoking and antipsychotic medication management. A resident with COPD was not initially care planned for smoking despite documented incidents, and another resident receiving Risperidone lacked a care plan focus on antipsychotic use. The MDS nurse's abrupt departure contributed to these oversights.
A resident was discharged from a facility without ensuring a caregiver, medications, or home health services were in place. Despite being bedbound and requiring extensive assistance, the facility assumed family support would suffice. The resident's spouse was incapacitated, and the listed home health agency did not serve the resident's area. The resident was left without necessary support, highlighting a failure in discharge planning.
A resident discharged to the community did not receive a complete discharge summary. The summary lacked contact information for medical equipment providers, details on necessary assistive devices, and follow-up appointments with a PCP. Interviews confirmed these deficiencies, with the interdisciplinary team responsible for the incomplete documentation.
A Pharmacy Consultant failed to identify that a resident was prescribed an ineffective antibiotic for a UTI. The resident, with renal insufficiency and CHF, received levofloxacin despite C&S results showing resistance. The Pharmacy Consultant did not have access to the C&S report during the review, leading to the oversight. Interviews revealed that the C&S results and prescribed antibiotic should have been compared to ensure effectiveness.
A facility failed to follow infection control protocols when staff did not use required PPE for residents on contact isolation and enhanced barrier precautions. A nurse aide entered a resident's room without a gown and gloves, while a nurse and another aide provided care to another resident without gowns. Both incidents occurred despite available PPE and prior staff training.
Failure to Complete MDS SCSA After Hospice Enrollment
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice care. The resident, who had a diagnosis of heart failure, was enrolled in the hospice program at the facility, as documented on a Long-Term Care Status Form. Despite this significant change in condition, there was no evidence in the medical record that an MDS SCSA was completed. During interviews, the MDS nurse confirmed responsibility for completing the assessment and acknowledged that it was missed, without being able to provide a reason for the oversight. The facility administrator also confirmed that an SCSA should have been completed when the resident began receiving hospice services.
Inaccurate PASRR Coding on MDS Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) for one resident with diagnoses of bipolar disorder and schizophrenia. The resident's PASRR Level II determination indicated that nursing home placement was appropriate and required follow-up psychiatric services by a psychiatrist, with no expiration date on the determination. However, the resident's annual MDS assessment was incorrectly coded to indicate that the resident was not considered by the state Level II PASRR process to have a serious mental illness or related condition. The MDS nurse responsible for coding acknowledged that the resident's PASRR status was Level II and admitted to not coding the annual MDS assessment accurately. The administrator also confirmed that the MDS assessment should have been coded accurately.
Failure to Attempt Alternatives and Assess Entrapment Risk Before Bed Rail Use
Penalty
Summary
The facility failed to attempt alternatives prior to the installation and use of bed rails and did not assess for risk of entrapment when completing assessments for one resident. The resident was admitted with a diagnosis of hypertension and was cognitively intact, independent with bed mobility and transfers, and had no recent falls or behavioral issues. Despite these factors, bilateral quarter bed rails were ordered and installed to promote bed mobility, with the stated goal of preventing decline in bed mobility. Documentation revealed that the resident had a physician's order for the bed rails and had given verbal consent after being informed of potential risks and benefits. However, there was no evidence in the assessment or care plan that any alternatives to bed rail use had been attempted or considered prior to installation. Additionally, the assessment did not include an evaluation for risk of entrapment associated with the use of bed rails. Interviews with facility staff, including the DON, Maintenance Director, Therapy Director, and Administrator, confirmed that no alternatives had been tried and that there was no documentation of such attempts. Staff also could not provide records of a therapy or nursing assessment supporting the need for bed rails or documenting failed alternatives. The Maintenance Director reported conducting safety inspections and checking for entrapment risk during installation, but this was not documented in the resident's assessment.
Failure to Prevent Misappropriation of Resident Property by Staff
Penalty
Summary
A staff member, identified as Nurse Aide #1 and employed through an agency, took checks belonging to a resident without the resident's knowledge. One of the checks was cashed for $1,000, and additional checks were presented for cashing. The incident came to light when the resident's Responsible Party, who also held Power of Attorney, was notified by the bank about the suspicious activity. The Responsible Party then informed the facility and law enforcement, leading to an investigation. The resident had approximately five checks with her at the facility, and the bank ultimately refunded the lost funds after the account was closed. Interviews with facility staff revealed that the Business Office Manager was unaware that the resident had checks in her possession, and it was noted that residents are discouraged from keeping cash, checks, or credit cards on their person. Law enforcement confirmed that Nurse Aide #1 was arrested and charged in connection with the fraudulent checks. The facility's internal investigation substantiated the misappropriation, and the nurse aide's employment was terminated. The deficiency was identified as a failure to protect the resident's right to be free from misappropriation of property.
Failure to Supervise Resident Smoking with Oxygen
Penalty
Summary
The facility failed to provide necessary supervision and enforce its smoking policy, leading to multiple incidents involving a resident who was found smoking in unsafe conditions. The resident, who was initially assessed as a non-smoker upon admission, was observed smoking on several occasions both inside and outside the facility, often in the presence of supplemental oxygen devices. Despite being aware of the resident's smoking behavior, the facility did not conduct timely reassessments or implement effective interventions to address the resident's non-compliance with safe smoking practices. The resident, diagnosed with chronic obstructive pulmonary disease (COPD) and prescribed continuous oxygen therapy, was found smoking in non-designated areas and with oxygen equipment nearby, posing a significant fire hazard. The facility's staff, including nurses and nursing assistants, were aware of the resident's repeated violations of the smoking policy but failed to take appropriate actions, such as completing new smoking assessments or updating the resident's care plan to reflect the risks associated with their smoking behavior. Additionally, the facility's smoking policy, which required residents to sign a Safe Smoking Contract and prohibited the storage of smoking materials in resident rooms, was not enforced effectively. Throughout the period of observation, the resident continued to smoke unsupervised, despite multiple incidents and warnings. The facility's attempts to manage the situation, such as confiscating smoking materials and using lockboxes, were ineffective as the resident retained access to their smoking materials. The lack of consistent supervision and enforcement of the smoking policy contributed to the ongoing safety risk posed by the resident's smoking behavior in the presence of oxygen equipment.
Failure to Notify Physician of UTI Results Leads to Resident Hospitalization
Penalty
Summary
The facility failed to notify the physician when a resident experienced a change of condition due to a urinary tract infection (UTI) with extended-spectrum beta-lactamase (ESBL) producing Escherichia coli. The resident's urine culture and sensitivity (C&S) results, which indicated the presence of ESBL, were not communicated to the physician in a timely manner. This oversight led to the resident being treated with an ineffective antibiotic, levofloxacin, which the bacteria was resistant to, delaying appropriate treatment. The resident, who had been admitted with renal insufficiency, began showing signs of agitation and combativeness, prompting the Assistant Director of Nursing (ADON) to order laboratory tests. The preliminary urinalysis results were reviewed by the physician, who advised waiting for the C&S report before initiating treatment. However, the C&S results were not communicated to the physician until a week later, after the ADON returned from being out of town. By this time, the resident's condition had worsened, leading to seizure-like symptoms and hospital admission for acute metabolic encephalopathy caused by the untreated UTI. Interviews with staff revealed a breakdown in communication and procedure adherence, as the charge nurses were expected to report lab results to the physician during their shift, but this was not consistently done. The Director of Nurses acknowledged that the results should have been reported sooner, and the physician expressed expectations for timely notification and appropriate antibiotic selection based on C&S results. The delay in treatment resulted in the resident experiencing further complications, including altered mental status and bradycardia, before being stabilized with the correct antibiotic treatment in the hospital.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a moderately cognitively impaired resident punched a severely cognitively impaired resident in the face. The assaulted resident, who was on a daily blood thinner, sustained bruising and swelling to the left side of his face. The incident left the resident feeling scared and unwilling to be near the aggressor. The two residents were immediately separated, with the aggressor moved to another room by himself. The assaulted resident requested to be sent to the emergency room for evaluation and did not return to the facility, eventually transferring to a different facility. The assaulted resident had a history of hemiplegia and hemiparesis following a stroke, vascular dementia, psychotic disturbance, and anxiety. His care plan included interventions to avoid activities that could result in injury due to his blood-thinning medication. The aggressor had a history of physical aggressive behavior, with interventions in place such as one-to-one observation and room changes to prevent altercations. Despite these measures, the incident occurred, highlighting a failure in the facility's ability to prevent resident-to-resident abuse. Staff interviews and written statements revealed that the incident was reported to the nurse on duty, who followed protocol by notifying the necessary parties and separating the residents. However, the facility's failure to adequately monitor and manage the aggressor's behavior, despite his known history, contributed to the occurrence of the altercation. The facility's inability to prevent the incident resulted in emotional and physical harm to the assaulted resident, who did not return to the facility after the hospital evaluation.
Failure to Respond to UTI Lab Results Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide necessary care and services for a resident who experienced a urinary tract infection (UTI) with extended-spectrum beta-lactamase (ESBL) producing Escherichia coli. The resident, who had renal insufficiency and congestive heart failure, showed signs of a change in condition, including increased agitation and combativeness. Despite a urinalysis (UA) and culture and sensitivity (C&S) test being ordered, the facility did not effectively follow up on the results. The C&S results, which indicated resistance to the prescribed antibiotic levofloxacin, were not communicated to the physician in a timely manner, leading to the administration of an ineffective antibiotic. The resident's condition worsened, resulting in seizure-like symptoms and hospitalization for acute metabolic encephalopathy due to the untreated UTI. The facility's failure to promptly review and act on the C&S results delayed the effective treatment of the infection. The Assistant Director of Nursing (ADON) and other nursing staff did not ensure that the physician was informed of the resistant bacteria, and the physician's order for levofloxacin was not questioned despite the resistance noted in the C&S report. Interviews with staff revealed a lack of communication and responsibility in checking laboratory results. The Director of Nurses (DON) acknowledged that the expected procedures for reviewing and reporting lab results were not followed, as charge nurses relied on nurse managers to review results the next day. This oversight contributed to the resident receiving an ineffective antibiotic, which allowed the UTI to progress and cause further complications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 12.12%, exceeding the acceptable threshold of less than 5%. This was identified during medication administration observations involving two residents. Resident #18, who has diagnoses including chronic obstructive pulmonary disease and congestive heart failure, did not receive several prescribed medications during the observed medication pass. Nurse #3 failed to offer or administer Klor-Con Extended Release, Fluticasone Propionate nasal spray, and Polyethylene Glycol 3350 powder to Resident #18, despite these medications being recorded as administered in the Medication Administration Record (MAR). Resident #18 confirmed not receiving these medications and expressed that she had not been offered Klor-Con since December 2023. Nurse #3 admitted to not offering the medications, citing anticipated refusal by Resident #18 as the reason. However, another nurse, Nurse #6, reported being able to administer all medications to Resident #18 without issues. The Pharmacy Consultant and Medical Director acknowledged the omission of Klor-Con as a medication error but not a significant one, given the resident's normal potassium levels and the nature of the diuretic prescribed. The Director of Nursing (DON) and the Administrator both emphasized that medications should be offered and administered as ordered, and any refusals should be documented accurately. Similarly, Resident #71, who is severely cognitively impaired and diagnosed with diverticulitis, did not receive the prescribed Polyethylene Glycol 3350 powder during the observed medication pass. Nurse #3 did not offer this medication, mistakenly believing it had been discontinued, yet it was recorded as administered in the MAR. Resident #71 confirmed not receiving the medication, which is intended to address constipation. The DON and Administrator reiterated that the medication should have been administered as ordered unless refused by the resident.
Failure to Follow Approved Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the approved menu for residents on a pureed diet, affecting 7 residents. During a dinner meal observation, it was noted that the staff used incorrect scoop sizes for serving pureed chicken and omitted pureed bread entirely. The menu specified that residents should receive one #10 scoop of pureed chicken and two #20 scoops of pureed bread. However, a staff member used a blue scoop, which was later identified as a #16 scoop, for the chicken and did not serve any bread, assuming the breading on the chicken patties sufficed. The Interim Dietary Manager confirmed the discrepancy in portion sizes and acknowledged that the correct portions were not served.
Deficiencies in Medical Record Documentation and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to deficiencies in documentation and medication administration. For Resident #6, the facility did not document the assessment and orders related to a change in condition when the resident experienced a seizure. Despite multiple nurses being involved in the incident, none documented the necessary information, including vital signs or interventions, on the Situation, Background, Appearance, and Review (SBAR) Communication Form or the progress notes. Additionally, there was a discrepancy in the Medication Administration Record (MAR) regarding the administration of IV antibiotics, which was incorrectly documented as refused by the resident. Resident #18's medical records also contained inaccuracies. The MAR indicated that certain medications were administered or refused, but observations and interviews revealed that these medications were not offered to the resident. Nurse #3 admitted to not offering the medications and incorrectly documenting their administration, citing the resident's usual refusal as the reason for her actions. This inconsistency in documentation was acknowledged by both the nurse and the Director of Nursing (DON), who emphasized the importance of accurate record-keeping. Similarly, Resident #71's records showed discrepancies in medication administration. The MAR recorded the administration of a laxative, but observations indicated that the medication was not offered. Nurse #3 mistakenly believed the medication had been discontinued and documented its administration inaccurately. Interviews with the resident and the DON confirmed the error, highlighting the need for accurate documentation and proper communication regarding medication orders.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to accurately document the code status of a resident in the electronic medical record (EMR), leading to a discrepancy between a physician order and a signed Do Not Resuscitate (DNR) form. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, had a physician order for full code status dated 3/19/24. However, the EMR contained a DNR form dated 03/20/24, signed by both the resident and the physician. The care plan, revised on 6/26/24, indicated the resident had chosen DNR status, yet the quarterly Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired. Interviews with various staff members, including nurses, the Assistant Director of Nursing (ADON), the Social Worker (SW), and the Director of Nursing (DON), highlighted inconsistencies in verifying and documenting code status. The facility had recently transitioned to a new EMR system, which did not automatically update code status to match physician orders, unlike the previous system. This transition contributed to the oversight, as some nurses were unaware of the need to update DNR status in multiple areas of the EMR. The SW mentioned an audit conducted on 5/16/24 to verify residents' code statuses, but Resident #63 was not included in this audit. The Medical Director emphasized the importance of ensuring accurate and reconciled information regarding code status in the system.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to a resident prior to discharge from Medicare Part A skilled services. Resident #30 was readmitted to the facility and received Medicare Part A services, which ended on April 24, 2024, while the resident remained in the facility. Although a Notice of Medicare Non-Coverage (NOMNC) was given by phone to the resident's power of attorney on April 22, 2024, there was no record of an SNF ABN being provided. The facility's Social Worker, responsible for issuing the NOMNC, stated that she typically issued the SNF ABN form alongside the NOMNC when a resident stayed in the facility after Medicare Part A services ended, but could not explain why it was not done in this case. The Administrator confirmed that the SNF ABN should have been completed for residents with remaining days who choose to stay for long-term care.
Inaccurate MDS Coding for Smoking and Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in documenting smoking status, medication use, and pain management. Resident #31, who was admitted with chronic obstructive pulmonary disease (COPD), was inaccurately coded as a non-smoker on the MDS, despite nursing documentation and the resident's own admission of smoking since his arrival at the facility. The Director of Nursing and the Administrator acknowledged that the MDS should have accurately reflected the resident's smoking status. Resident #3, admitted with a stroke diagnosis, was prescribed Aspirin, an antiplatelet, but the MDS inaccurately documented the use of anticoagulants instead. The Regional MDS Consultant confirmed the error, noting the facility was training a new MDS nurse. Similarly, Resident #54, who was receiving oxycodone for pain management, was not coded for opioid use on the MDS, despite receiving the medication as ordered. The Regional MDS Consultant attributed this oversight to the previous MDS nurse's lack of diligence before leaving the position abruptly.
Deficiencies in Care Planning for Smoking and Antipsychotic Use
Penalty
Summary
The facility failed to develop and implement comprehensive individualized person-centered care plans for two residents, leading to deficiencies in the areas of smoking and antipsychotic medication management. Resident #31, who was admitted with chronic obstructive pulmonary disease (COPD), was initially assessed as a non-smoker. However, documentation revealed that the resident had been smoking since admission, including an incident where he removed his oxygen to smoke. Despite this, the resident's care plan did not initially address smoking behaviors, and the facility's transition from Point Click Care to Matrix systems resulted in a lack of documentation for the care plan. The care plan was only revised months later to include smoking-related goals and interventions. Resident #65, diagnosed with Alzheimer's and dementia with behavioral disturbances, was prescribed Risperidone, an antipsychotic medication, upon readmission. However, the resident's care plan did not include a focus on the use of psychotropic medications, despite the resident receiving the medication regularly. Interviews with facility staff revealed that the MDS nurse was responsible for updating care plans, but the care plan for Resident #65 was not updated to reflect the use of antipsychotics. The MDS nurse had vacated the position abruptly, and the facility was unable to provide a reason for the oversight.
Unsafe Discharge Planning for Resident
Penalty
Summary
The facility failed to provide a safe discharge planning process for a resident who was discharged to an independent living apartment. The resident, who was bedbound and required extensive assistance with activities of daily living (ADLs), was discharged without ensuring a caregiver was available, without a means to obtain necessary medications, and without securing a home health provider for continuity of care. The resident's discharge summary did not include essential information such as contact details for the medical equipment company or a scheduled primary care physician (PCP) appointment. The resident's family member had informed the facility that the resident's spouse, who was the primary caregiver, had suffered a stroke and was in another skilled nursing facility, leaving no one to care for the resident at home. Despite this, the facility proceeded with the discharge, assuming that the resident's family would assist at home. However, the resident was left alone during the day without a caregiver, and the home health agency listed on the discharge summary did not have the resident in their system, nor did they provide services in the resident's area. The facility's social worker and director of rehabilitation believed the resident's discharge was safe, citing the resident's ability to propel herself in a wheelchair and perform some ADLs independently. However, the resident was found at home without medications, a wheelchair, or home health services, and was unable to perform necessary tasks such as toileting and meal preparation. The facility's physician was unaware of the discharge issues and stated that concerns raised by the family should have been addressed, including ensuring the resident had medications and a wheelchair at home.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for a resident who was discharged to the community. The resident, who was cognitively intact, required extensive assistance with activities of daily living and had a medical history that included a urinary tract infection with antibiotic-resistant bacteria, sepsis, a chronic immune system disease, and a history of deep vein thrombosis. The discharge summary was incomplete, lacking contact information for the medical equipment provider, details about necessary assistive devices, and information on scheduled follow-up appointments with a primary care physician. Additionally, it did not include instructions on how to obtain medications needed at home. Interviews with the resident's family member and the social worker confirmed the deficiencies in the discharge summary. The family member noted the absence of information regarding follow-up doctor's appointments, and the social worker acknowledged the missing details about the wheelchair provider and incorrect contact information for the home health provider. The interdisciplinary team was responsible for completing the discharge summary, but it failed to include essential information for the resident's transition to home care.
Pharmacy Consultant Fails to Identify Ineffective Antibiotic Prescription
Penalty
Summary
The Pharmacy Consultant failed to identify an irregularity in the drug regimen review for a resident who was prescribed and received an ineffective antibiotic for a urinary tract infection (UTI). The resident, who had renal insufficiency and congestive heart failure, was found to have a UTI caused by Escherichia coli (E. coli) that was resistant to the antibiotic levofloxacin. Despite this, the resident was prescribed and administered levofloxacin for several days. The Pharmacy Consultant did not identify any irregularities during the medication review because the culture and sensitivity (C&S) results were not available in the electronic medical record at the time of the review. Interviews with facility staff, including the Pharmacy Consultant and the Director of Nurses (DON), revealed that the C&S results and the prescribed antibiotic should have been compared to ensure effectiveness. The Pharmacy Consultant stated that he did not have access to the C&S report during his review, as it was not uploaded to the electronic medical record until after his review. The resident's physician expected the facility to review the C&S results and inform him if the prescribed antibiotic was ineffective, to prevent complications from an untreated UTI.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to adhere to infection control measures as observed in two separate incidents involving residents on contact isolation and enhanced barrier precautions. In the first incident, a nurse aide entered the room of a resident on contact precautions without wearing the required personal protective equipment (PPE), specifically a gown and gloves, while delivering a meal tray. The nurse aide moved the resident's personal items without wearing gloves, despite the facility's policy requiring PPE for contact precautions to prevent the transmission of infectious agents. The nurse aide later acknowledged the mistake, attributing it to confusion between contact precautions and enhanced barrier precautions. In the second incident, a nurse and a nurse aide provided care to a resident on enhanced barrier precautions without wearing gowns, as required by the facility's policy. The care activities included handling a urinary catheter, providing gastrostomy tube care, and changing a wound dressing. Both staff members admitted to not wearing gowns during these procedures, with one citing a lack of PPE in the room as the reason. The facility's policy mandates the use of gowns and gloves for high-contact activities to prevent the transmission of multi-drug resistant organisms. Interviews with the infection preventionist and the director of nursing confirmed that the staff involved had received training on the appropriate use of PPE for both contact precautions and enhanced barrier precautions. The facility had adequate PPE supplies, and it was the responsibility of the nursing staff to ensure PPE was restocked as needed. Despite this, the staff failed to comply with the infection control protocols, leading to the observed deficiencies.
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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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