East Carolina Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, North Carolina.
- Location
- 2575 W 5th Street, Greenville, North Carolina 27834
- CMS Provider Number
- 345377
- Inspections on file
- 22
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at East Carolina Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who was fully dependent on staff for transfers sustained a fractured humerus when a mechanical lift sling strap broke during a transfer, causing the resident to be lowered to the floor and strike her head and shoulder. Staff reported no visible defects in the sling prior to use, and the resident was hospitalized for evaluation and treatment before returning to the facility.
Two residents developed pressure sores that were not promptly reported to a physician, resulting in delayed treatment orders and incomplete documentation. Nursing staff initiated wound care without physician consultation, and facility protocols requiring physician notification for new pressure sores were not followed. The Wound Physician was only made aware of the wounds during routine rounds, rather than at the time of discovery.
Two residents experienced deficiencies in pressure ulcer care due to delayed reporting, lack of timely communication among nursing staff and the Wound Physician, and failure to promptly implement and document treatment orders. In one case, a pressure sore was not reported until it was unstageable, and diagnostic studies ordered for a non-healing wound were not completed in a timely manner. In another case, a sacral wound was not properly documented or treated for several days, and a change in wound care orders for a heel injury was not transcribed. Additionally, an air mattress was repeatedly set incorrectly for a resident's weight, compromising pressure relief.
A facility failed to involve a resident, who was cognitively intact and had multiple diagnoses, in the development of his person-centered care plan. Despite the expectation for a care planning meeting within 21 days of admission, neither the resident nor his representative were invited to participate. Interviews confirmed the absence of a scheduled meeting, highlighting a lapse in the facility's procedures.
The facility failed to complete a quarterly MDS assessment within 14 days following the ARD for a resident. The assessment remained in progress due to staffing challenges, as confirmed by MDS Nurses. The Administrator acknowledged that assessments should follow the RAI manual's schedule.
The facility inaccurately coded MDS assessments for three residents, leading to discrepancies in their medical records. One resident was incorrectly marked as receiving antipsychotic medication, another was not coded for hospice services despite being admitted to hospice, and a third was wrongly coded as having a pressure ulcer instead of a surgical wound. These errors were due to improper validation of assessment data by MDS nurses.
The facility failed to develop comprehensive care plans for three residents, including one with verbal behavioral symptoms, another prescribed antipsychotic medication, and a third with a surgical wound. Staff interviews revealed that expected care plans were not implemented, leading to deficiencies in addressing the residents' specific needs.
A nurse failed to properly store a bolus enteral feeding syringe after administering medication through a gastrostomy tube to a resident. The nurse did not separate the syringe parts to dry, instead placing the wet syringe back into a storage bag. The DON confirmed that the syringe should have been separated to prevent bacterial growth.
The facility failed to implement Enhanced Barrier Precautions (EBP) when a nurse, a wound nurse, and a wound physician did not wear gowns while providing care to two residents requiring EBP due to indwelling devices and wounds. The staff were unaware of the EBP requirements, despite being trained upon hire, and the facility did not use signage to indicate residents needing EBP.
The facility did not follow its infection control policy, failing to ensure staff received training on Enhanced Barrier Precautions (EBP). The Wound Care Nurse, employed since May 2024, was not trained on EBP and was unaware of its use. The DON could not confirm the nurse's training and could not locate the records, as the SDC responsible for training was no longer employed. The Administrator was unaware of the missing records.
A resident admitted with essential hypertension and dysphagia did not have a comprehensive care plan developed or implemented within the required timeframe. The MDS nurse confirmed the oversight, attributing it to the previous MDS nurse's departure around the time of admission. The DON and Administrator were unaware of the missing care plan, citing communication issues due to the resident's transfer and staff changes.
The facility failed to analyze and address the causes of a resident's multiple falls, leading to an impacted arm fracture, and did not ensure adequate supervision for a paraplegic resident during care, resulting in a fall and injury.
A facility failed to provide appropriate care for a resident with a feeding tube, leading to poor hygiene and a malfunctioning tube. Despite documentation indicating that care was provided, staff could not recall specifics, and an emergency room physician found the site to be unclean and leaking gastric contents.
The facility failed to follow physician orders and proper procedures for administering and documenting narcotic pain medications for three residents. An LPN repeatedly removed narcotics from the medication cart outside prescribed parameters and failed to document the administration, leading to discrepancies between the Controlled Drug Receipt/Record/Disposition form and the MAR.
The facility failed to document the administration of narcotic medication in the MAR for three residents. Multiple doses of narcotics were removed from the medication cart by various staff members, but there was no corresponding documentation on the MAR. The staff involved admitted to either forgetting to document or being bad at documentation. The DON confirmed the discrepancies.
The facility's Quality Assessment and Assurance Committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in supervision to prevent accidents, hospice services, and pharmacy services. Issues included not analyzing falls, improper management of narcotic medications, and poor communication with hospice services, leading to multiple incidents of harm to residents.
The facility failed to protect residents' rights to be free from potential diversion of narcotics, involving two residents. Discrepancies in the administration records for Dilaudid and Oxycodone, signed out by an LPN but not documented, raised concerns about potential misuse. Despite staff concerns, the DON and ADON did not suspect drug diversion, as the narcotics were accounted for on the medication cart. The facility's Medical Director and Pharmacist expressed concerns about the potential effects of undocumented administration of narcotics.
The facility failed to communicate and coordinate with hospice services regarding a resident who sustained a dislocated finger. Despite the resident's severe cognitive impairment and behavioral issues, the facility did not document or address the deformity, which was first noted by hospice staff. The lack of communication led to a delay in identifying and addressing the dislocation, resulting in inadequate care.
Mechanical Lift Sling Failure During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for transfers and had a history of stroke and chronic pain, was being transferred using a mechanical lift. During the transfer, one of the four straps on the lift sling broke at the seam where it joined the body of the sling. Both nurse aides assisting with the transfer reported that they had not noticed any issues with the sling prior to use and confirmed that the correct size sling was being used. As a result of the strap failure, the resident was lowered to the floor, hitting her head and left shoulder on the bed rail during the process. The resident was subsequently sent to the hospital for evaluation, where she was found to have sustained a left humerus fracture. Hospital records indicated that the resident was on anticoagulant medication and was already receiving multiple medications for chronic pain. Imaging confirmed the fracture, and the resident's arm was immobilized with a sling. She was discharged back to the facility in stable condition after assessment and treatment. Interviews with staff and a representative from the lift manufacturer revealed that the cause of the sling failure could not be definitively determined without examining the sling, but possibilities included normal wear from use and laundering or a manufacturing defect. The facility's Director of Nursing and Administrator confirmed that the sling was not old and that the resident's weight did not exceed the sling's capacity. Prior to the incident, there was no indication that the sling was in disrepair, and staff had not identified any visible defects.
Failure to Notify Physician of New Pressure Sores
Penalty
Summary
The facility failed to notify physicians in a timely manner when two residents developed pressure sores. In the first case, a resident with multiple comorbidities, including cellulitis, lymphedema, and chronic kidney disease, developed a sacral pressure sore that was first identified by the Wound Care Nurse. The nurse did not immediately notify the physician or enter treatment orders into the electronic record, instead applying skin prep and later Santyl without physician consultation. The physician was not notified until several days later during routine rounds, at which point a more comprehensive treatment plan was initiated. In the second case, another resident with a history of diabetes, hypertension, and stroke returned from a hospital stay and was found to have an open area on the sacrum and a deep tissue injury to the right heel. Documentation was incomplete regarding the sacral wound, and there was no evidence that the physician was notified at the time of discovery. The Wound Care Nurse began treatment for the heel injury but did not notify the physician about the pressure sores. A one-time dressing order was obtained for the sacral wound, but there was no further documentation of physician notification or ongoing treatment orders until the resident was seen by the Wound Physician several days later, at which point a stage 4 pressure sore was identified. Interviews with nursing staff and the DON revealed that facility protocols required nurses to notify physicians and obtain orders for new pressure sores, but these protocols were not followed. The Wound Care Nurse and other staff members did not consistently communicate the presence of new wounds to the physician, and documentation was lacking. The Wound Physician confirmed that she was not made aware of the wounds until her scheduled visits, and the DON acknowledged that nurses should have contacted the physician and obtained appropriate orders when new pressure sores were identified.
Failure to Ensure Timely Pressure Ulcer Care, Communication, and Equipment Settings
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. In one case, a resident with multiple comorbidities, including cellulitis, lymphedema, and chronic kidney disease, developed a sacral pressure sore that was not reported by nurse aides to a nurse until it was already unstageable. The wound was first identified by the Wound Care Nurse, who did not immediately notify the Wound Physician or enter treatment orders into the electronic record. As a result, there was a delay in initiating appropriate wound care, and the primary care nurses were unaware of the wound or any treatment orders during weekends. The Wound Physician was not consulted at the time of initial discovery, and the treatment plan was not implemented until several days later. Additionally, when the wound failed to heal, further diagnostic studies ordered by the Wound Physician, such as lab work and x-rays, were not completed in a timely manner due to a lack of communication and oversight, resulting in a prolonged period before the underlying infection and other complications were identified. In another instance, a second resident returned from hospitalization and was found to have an open area on the sacrum, but the initial assessment lacked detailed documentation. The Wound Care Nurse did not observe the sacral wound during her assessment, and there was a delay in obtaining and documenting treatment orders. A one-time dressing order was obtained, but no ongoing treatment plan was established or documented for several days. Communication lapses between nursing staff, the Wound Care Nurse, and the Wound Physician led to the wound not being properly addressed until it was identified as a Stage 4 pressure sore by the Wound Physician. Additionally, a change in the treatment plan for a heel wound was not transcribed into the electronic record, resulting in continued use of an outdated treatment. The facility also failed to ensure that the settings of a pressure-relieving air mattress were correctly adjusted for a resident's weight. The air mattress was observed to be set for a much higher weight than the resident's actual weight on multiple occasions, which could have compromised pressure relief. Staff interviews revealed a lack of clarity regarding responsibility for checking and maintaining correct mattress settings, and the Wound Care Nurse acknowledged that the setting was incorrect and should have been adjusted to match the resident's weight.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to invite a resident to participate in the development of his person-centered plan of care. This deficiency was identified for a resident who was admitted with diagnoses including non-traumatic brain dysfunction, renal insufficiency, diabetes, and hypertension. Despite being cognitively intact, the resident reported that he had never been invited to participate in the care planning process. The resident's care plan had a goal for discharge to the community, but there was no evidence that the resident or his representative had been involved in its development. Interviews with the resident's representative and the facility's social worker confirmed that no care plan meeting had been held within the expected timeframe of 21 days post-admission. The social worker acknowledged that the resident should have been included in a care plan meeting by a specific date but could not provide evidence of scheduling or invitations. The facility administrator also confirmed the expectation for timely care planning meetings, indicating a lapse in the facility's procedures for involving residents and their representatives in care planning.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days following the Assessment Reference Date (ARD) for one resident. Resident #48, who was admitted to the facility, had an MDS assessment with an ARD of 11/15/24 that remained in progress and was not completed timely. Interviews with MDS Nurses revealed that due to staffing challenges, they were behind in completing the assessment according to the Resident Assessment Instrument (RAI) manual requirements. The Administrator confirmed that MDS assessments should adhere to the RAI manual's schedule.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #50 was incorrectly coded as receiving antipsychotic medication, despite the Medication Administration Record (MAR) showing no such medication was administered in November 2024. This error was attributed to MDS nurses pulling answers from previous assessments without proper validation, as confirmed by interviews with MDS Nurse #1 and MDS Nurse #2. The administrator acknowledged that MDS assessments should reflect the resident's current status. Resident #173, who was admitted to hospice on November 26, 2024, was not coded for hospice services in her MDS assessment, despite her face sheet indicating hospice Medicaid as her payor source. MDS Nurse #1 confirmed the oversight, and the administrator reiterated the need for accurate coding. Additionally, Resident #58 was incorrectly coded as having a stage III pressure ulcer, although he only had a surgical wound from an abscess removal. The Wound Care Nurse and MDS Nurse #1 both confirmed the miscoding, and the administrator acknowledged the error, emphasizing the importance of accurate MDS coding.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #55, who was admitted with diagnoses including cerebral infarction and cognitive communication deficit, exhibited verbal behavioral symptoms. Despite being referred to psychiatric therapy multiple times, the care plan did not include measures to address these behaviors. The Social Worker acknowledged missing the inclusion of behavioral outbursts in the care plan update, and both the Social Worker and Administrator expected these behaviors to be documented in the care plan. Resident #62, diagnosed with conditions such as hypertension and dementia, was prescribed an antipsychotic medication. However, the care plan did not include information regarding the use of this medication. The Social Worker stated she would only include such information if side effects were exhibited, while the Director of Nursing and Administrator expected the medication to be part of the care plan. Additionally, Resident #58, who had a surgical wound from an abscess removal, did not have a care plan for wound care. The Wound Care Nurse and MDS Nurse were unaware of the absence of a wound care plan, and the Director of Nursing and Administrator confirmed that a care plan should have been implemented upon admission.
Improper Storage of Enteral Feeding Syringe
Penalty
Summary
The facility failed to properly store a bolus enteral feeding syringe used for medication administration through a gastrostomy tube for a resident. During an observation, Nurse #3 was seen administering medication to the resident using a 2-part piston and barrel syringe. After use, the nurse rinsed the syringe with water but did not separate the piston from the barrel to dry. Instead, she reassembled the wet syringe and placed it into a plastic storage bag. In an interview, Nurse #3 admitted to storing the syringe without separating the parts, which is against proper protocol. The Director of Nursing confirmed that the syringe should have been separated to prevent bacterial growth during storage.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which is designed to reduce the transmission of multidrug-resistant organisms through the use of gloves and gowns during high-contact resident care activities. This deficiency was observed when Nurse #3, the Wound Nurse, and the Wound Physician did not wear gowns while providing care to two residents, Resident #21 and Resident #58, who required EBP due to their medical conditions involving indwelling devices and wounds, respectively. During a medication administration observation, Nurse #3 entered Resident #21's room to administer medications via a gastrostomy tube without donning a gown, despite the resident being care planned for EBP due to the feeding tube. Nurse #3 was unaware of the requirement to wear a gown for residents with indwelling devices. The Wound Physician confirmed that EBP should have been followed to prevent the transmission of multidrug-resistant organisms. The Director of Nursing (DON) and the Administrator acknowledged that Nurse #3 should have worn a gown, and staff were trained on EBP upon hire. In another instance, the Wound Care Physician and Wound Care Nurse entered Resident #58's room to provide wound care without wearing gowns, despite the resident being on EBP for chronic wound care. Both the Wound Care Physician and the Wound Care Nurse were unaware of the EBP requirement, with the Wound Care Nurse stating she had not been trained on EBP. The DON and the Administrator confirmed that gowns should have been worn during wound care, and staff were educated on EBP upon hire, although the facility did not use EBP signage to indicate which residents required these precautions.
Failure to Train Staff on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy and procedure by not ensuring that staff received training on Enhanced Barrier Precautions (EBP). The Wound Care Nurse, who had been employed since May 2024, reported not receiving any training on EBP and was unaware of its use within the facility. During an interview, the Director of Nursing (DON) admitted to not knowing whether the Wound Care Nurse had been educated on EBP and was unable to locate the training records, as the Staff Development Coordinator (SDC), who was responsible for the education, was no longer employed at the facility. The Administrator also confirmed that staff were supposed to be trained on EBP upon hiring, but was unaware that the DON did not have access to the training records.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted with diagnoses of essential hypertension and dysphagia. Upon review of the resident's medical record, it was found that no comprehensive care plans had been developed or implemented. The MDS nurse confirmed that the resident, who had been in the facility for about six weeks, should have had a care plan completed within the first 21 days after admission. The MDS nurse attributed the oversight to the departure of the previous MDS nurse around the time of the resident's admission. The Director of Nursing (DON) stated that the MDS nurse was responsible for developing care plans, and nurses could add to them if they notified the MDS nurse. The DON was unaware of the missing care plan and believed it was a communication issue due to the resident's transfer from assisted living to long-term care coinciding with the MDS nurse's departure. The Administrator also was not aware of the missing care plan and attributed it to the timing of the MDS nurse's departure on the day of the resident's admission to long-term care.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to adequately analyze and address the causative factors of Resident #2's falls, leading to multiple incidents and an impacted arm fracture. Resident #2, who had severe cognitive impairment and a history of falls, experienced several falls between January and February 2024. Despite these incidents, there was no documented evaluation by therapy staff or a thorough review of the resident's medications, which included Risperdal and Minipress, both of which could contribute to orthostatic hypotension and falls. The facility's investigation into these falls was insufficient, as it did not result in effective interventions to prevent further falls or address the potential medication side effects contributing to the resident's condition. Resident #2's medical records revealed a series of falls, including an unwitnessed fall on January 11, 2024, where the resident reported that God had told her to walk. Subsequent falls occurred on January 21, January 26, and February 2, 2024, with the latter resulting in hospitalization for recurrent falls, orthostatic hypotension, and bradycardia. Despite these incidents, the facility's interventions remained largely unchanged, focusing on ensuring proper footwear, bed positioning, and nursing rounds without addressing the underlying issues. The resident's medications were not adequately reviewed in relation to her falls, and the Psychiatric Nurse Practitioner and Consultant Pharmacist were not fully aware of the frequency and potential medication-related causes of the falls. Additionally, the facility failed to ensure adequate supervision and safety measures for Resident #1, a paraplegic resident, during care. On February 21, 2024, Resident #1 fell out of bed while being bathed by a Nursing Assistant (NA #1), resulting in a superficial forehead laceration. The incident occurred despite the use of short upper side rails, which were later changed to half rails to aid in bed mobility and positioning. The Director of Nursing (DON) attributed the fall to improper body mechanics and positioning by the nursing assistant, and an in-service training on falls prevention was conducted for the staff. However, the facility's documentation and investigation into the incident were inadequate, as the DON did not document interviews with staff or conduct a thorough review of the events leading to the fall.
Failure to Provide Appropriate Care for Feeding Tube
Penalty
Summary
The facility failed to provide appropriate care for a resident with a feeding tube, leading to a deficiency. Resident #1, who had oropharyngeal dysphagia and a percutaneous gastrostomy tube, was readmitted to the facility after a hospital stay. Upon return, there was no documentation describing the condition of the gastrostomy tube site. Multiple nurses and a medication aide documented that they performed the required cleaning and dressing changes, but none could recall the specifics of the site or the dressing. Additionally, there was a day when the cleaning was not documented at all. The situation escalated when the medication aide noticed an issue with the gastrostomy tube and informed Nurse #2, who then sent Resident #1 to the emergency room. The emergency room physician found that the dressing on the gastrostomy tube was dated 12 days prior and was very unclean, with gastric contents leaking from the site and a ruptured balloon. The physician expressed concerns about the poor hygiene care of the gastrostomy tube site. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that they believed the staff had completed the required care as documented. However, they did not believe the emergency room physician's description of the gastrostomy tube site. The DON and ADON stated that supplies for dressing changes were readily available and that there was good communication among the staff regarding wound care needs.
Failure to Adhere to Physician Orders and Document Narcotic Administration
Penalty
Summary
The facility failed to adhere to physician orders and proper procedures for administering and documenting narcotic pain medications for three residents. For Resident #6, Nurse #5 repeatedly removed Oxycodone with Acetaminophen from the medication cart outside the prescribed parameters and failed to document the administration on the Medication Administration Record (MAR). Despite the resident's severe cognitive impairment, the Director of Nursing (DON) confirmed that the resident was knowledgeable about his pain medication. However, the DON and Nurse #5 did not follow the physician's orders or document the administration properly, leading to discrepancies between the Controlled Drug Receipt/Record/Disposition form and the MAR. For Resident #7, Nurse #5 removed Hydromorphone (Dilaudid) tablets from the medication cart and failed to document the administration on the MAR. Additionally, a tablet was reported lost on the floor without a corresponding signature from another nurse, violating the facility's procedures for handling controlled substances. Resident #7, who was cognitively intact, stated she would not have taken more than the prescribed dose of Dilaudid, indicating a potential over-administration by Nurse #5. Resident #8 also experienced similar issues, with Nurse #5 removing Oxycodone HCL tablets from the medication cart without a physician's order and failing to document the administration on the MAR. The DON confirmed that the Controlled Drug Receipt/Record/Disposition form should match the MAR and that nurses should follow physician orders. The facility pharmacist and Medical Director both emphasized the need for proper documentation and adherence to physician orders, highlighting the facility's failure to monitor and reconcile controlled medications effectively.
Failure to Document Administration of Narcotic Medication
Penalty
Summary
The facility failed to document the administration of narcotic medication in the medication administration record (MAR) for three residents. For Resident #6, multiple doses of Oxycodone with Acetaminophen were removed from the medication cart by various nurses, but there was no corresponding documentation on the MAR. The nurses involved admitted to either forgetting to document or being bad at documentation. The Director of Nursing (DON) confirmed that the Controlled Drug Receipt/Record/Disposition form should match the MAR for accuracy of documentation. For Resident #7, doses of Hydromorphon were removed from the medication cart by a nurse, but there was no corresponding documentation on the MAR. Additionally, there was a dose documented on the MAR without a corresponding entry on the Controlled Drug Receipt/Record/Disposition form. The nurse involved did not respond to interview requests, and the DON confirmed the discrepancy. For Resident #8, multiple doses of Oxycodone HCL were removed from the medication cart by various staff members, but there was no corresponding documentation on the MAR. The staff members involved admitted to either forgetting to document or making human errors. The DON confirmed that the Controlled Drug Receipt/Record/Disposition form should match the MAR for accuracy of documentation.
Repeated Deficiencies in Supervision, Hospice, and Pharmacy Services
Penalty
Summary
The facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions following multiple surveys, resulting in repeated deficiencies in supervision to prevent accidents, hospice services, and pharmacy services. Specifically, the facility did not analyze a resident's falls to determine causative factors and implement interventions to reduce the risk of further falls. Additionally, the facility failed to ensure a paraplegic resident did not roll out of bed during care. These issues were observed in multiple surveys, including a failure to repair a loose siderail, ensure a fall mat was in place, and provide supervision to a resident assessed as a supervised smoker. The facility also failed to manage narcotic pain medications properly, including removing medications from the cart without physician orders, not following procedures for disposal of wasted narcotic medication, and lacking effective safeguards to control and reconcile controlled medications. Furthermore, the facility did not communicate and coordinate with hospice services effectively, resulting in a resident sustaining a dislocated finger without proper identification and intervention. These deficiencies were observed across several surveys, indicating a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.
Failure to Protect Residents from Potential Narcotic Diversion
Penalty
Summary
The facility failed to protect residents' rights to be free from potential diversion of narcotics, specifically involving two residents. Resident #7, who was cognitively intact, had an order for Dilaudid 2 mg tablets to be administered every 6 hours as needed for pain. However, documentation revealed discrepancies in the administration of the medication, with multiple doses signed out by Nurse #5 but not recorded on the Medication Administration Record. Resident #7 confirmed she would not have taken the medication in such a short time frame, and the facility's Medical Director expressed concerns about the potential effects of such administration. Nurse #5 admitted to poor documentation practices and did not seek physician approval for administering the medication outside the prescribed parameters. Resident #6, who had severely impaired cognition, had an order for Oxycodone with Acetaminophen 5-325 mg tablets to be administered every 4 hours as needed for severe pain. Similar to Resident #7, there were discrepancies in the administration records, with multiple doses signed out by Nurse #5 but not documented on the Medication Administration Record. Interviews with other staff members revealed concerns about the number of doses removed and the lack of documentation. Despite these concerns, the facility's DON and ADON did not suspect drug diversion, as the narcotics were accounted for on the medication cart. Nurse #5 admitted to administering the medication without proper documentation and without seeking physician approval for deviations from the prescribed order. The facility's failure to monitor and document the administration of narcotic medications accurately led to potential diversion and misuse of residents' medications. The discrepancies in the Controlled Drug Receipt/Record/Disposition forms and the Medication Administration Records for both residents raised concerns about the facility's adherence to its abuse prevention program policies and procedures. The facility's Medical Director and Pharmacist both expressed concerns about the potential effects of the undocumented administration of narcotics, highlighting the need for proper monitoring and documentation to ensure residents' safety and well-being.
Failure to Communicate and Coordinate Care for Hospice Resident
Penalty
Summary
The facility failed to communicate and coordinate with hospice services regarding a resident who sustained a dislocated finger. Resident #3, who had a history of stroke, hemiplegia, hemiparesis, dysphagia, and advanced dementia, was admitted to the facility as a hospice resident. The resident's care plan noted behavioral issues, and a significant change Minimum Data Set assessment indicated severe cognitive impairment. Despite these conditions, the facility did not document or address the deformity of the resident's left index finger, which was first noted by hospice staff on 2/27/24. Hospice Nurse #1, who routinely visited the resident twice per week, observed an open wound and a deformity in the resident's left index finger on 3/28/24. The Director of Nursing (DON) was unaware of the deformity, as there had been no documentation by facility staff. Hospice Nurse #2, who had cared for the resident during Nurse #1's absence, reported no deformity when she last saw the resident on 2/27/24. The facility physician, who was also the medical director, was not informed of the deformity until an x-ray was performed on 3/30/24, revealing a dislocated finger with possible septic arthritis. The facility administrator was also unaware of the dislocation until the x-ray results were obtained. The lack of communication between hospice staff and facility staff led to a delay in identifying and addressing the resident's dislocated finger. The hospice physician decided that no further treatment was necessary, and the facility continued with dressing changes as per the hospice orders. The deficiency highlights a significant lapse in communication and coordination between the facility and hospice services, resulting in inadequate care for the resident.
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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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