Elevate Health And Rehabilitation

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its infection control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for two residents with chronic wounds. The Treatment Nurse did not wear the required personal protective equipment, specifically a gown, while providing wound care to both residents. Additionally, there were no signs indicating EBP on the residents' room doors, and the nurse was uncertain about the necessity of EBP orders for these residents, despite their chronic wound status as defined by facility policy. During wound care for the first resident, who had a stage 2 pressure ulcer to the coccyx, the Treatment Nurse entered the room without a gown, washed her hands, donned gloves, and removed a soiled dressing. Without changing gloves or performing hand hygiene, she continued with wound cleansing and dressing application. Hand hygiene was only performed at the end of the procedure after glove removal. The nurse later stated she was unsure if the resident required EBP and was unclear about the hand hygiene protocol between glove changes. For the second resident, who had wounds on both ankles from a prior motor vehicle accident, the Treatment Nurse again did not wear a gown and failed to perform hand hygiene between glove changes and between wound care steps. She removed and reapplied gloves without hand hygiene and completed wound care on both ankles before washing her hands at the end. The nurse expressed uncertainty regarding the need for EBP and the specific hand hygiene requirements during wound care. The Director of Nursing, who also served as the Infection Preventionist, confirmed that EBP was only applied to residents with chronic wounds and was unsure if the residents in question met the criteria, further contributing to the deficiency.

Penalty

Inspection fine: $17,345

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

Summary

Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, but does not provide further details regarding the specific actions, inactions, or events that led to the deficiency. No additional information about the residents involved or their medical conditions at the time of the incident is included in the report.

Penalty

Inspection fine: $17,345

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

Summary

Surveyors observed that the facility failed to properly date, label, and store food items in two nourishment room refrigerators. In the 100-hall nourishment room, two personal-sized food storage containers belonging to staff were found in the refrigerator door without any labels or use-by dates. These containers were not stored in the designated employee breakroom refrigerator as required. The Dietary Manager confirmed that these items were not present during her earlier check of the refrigerator that morning. In the 200-hall nourishment room, an open container of applesauce with approximately 25% of its contents missing was found in the snack cupboard instead of being refrigerated. The applesauce was used by nurses to administer medications to residents and was not dated or stored according to facility policy. The Dietary Manager stated that she had checked the nourishment room earlier that morning and did not see the opened applesauce container. The Administrator confirmed that both the staff food containers and the applesauce should have been properly dated, labeled, and stored in accordance with facility procedures.

Penalty

Inspection fine: $17,345

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

Summary

A deficiency occurred when a facility failed to remove a petroleum-based lotion from the room of a resident who was receiving continuous oxygen therapy via nasal cannula. The resident, who had diagnoses including congestive heart failure and chronic respiratory failure, had a physician's order and care plan for continuous oxygen at 2 liters per minute. During an in-room observation, a container of petroleum-based lotion was found on the resident's overbed table while the oxygen concentrator was running and delivering oxygen into the environment. The resident reported that her husband had brought the lotion and that she had used it previously on her arms, but not on her face or lips, and had not been informed by the facility that petroleum-based lotions should not be used while on oxygen. The assigned nurse confirmed that the resident should not use petroleum-based lotion while receiving oxygen due to fire risk and stated she was unaware the lotion was present in the room. The nurse removed the lotion after it was discovered. The DON also acknowledged that the resident should not have had petroleum-based lotion in her room and admitted to overlooking the lotion during a prior room check. The facility's failure to identify and remove the petroleum-based lotion from the resident's environment while she was receiving oxygen constituted the deficiency.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to notify the physician of a urologist appointment for a resident, which resulted in a delay in treatment for renal stones. The resident had been hospitalized for obstructing ureteral stones, UTI, and sepsis, and was discharged with instructions to follow up with urology for surgery and possible stent exchange. Despite attending a urology appointment, the facility did not inform the physician of the ordered CT scan and follow-up appointment, leading to prolonged treatment and ongoing hematuria. Another resident was affected by a similar communication breakdown. This resident, who had a history of diabetic foot ulcers and peripheral arterial disease, developed a new wound on the right heel. The Treatment Nurse Aide discovered the wound but did not notify the nurse or physician, resulting in a lack of treatment orders for the new wound. The podiatrist was also not informed of the new wound, which was only discovered during a follow-up visit. The deficiencies highlight a failure in communication and notification processes within the facility, affecting the timely and appropriate treatment of residents. The lack of notification to physicians and specialists about significant medical findings and appointments led to delays in necessary medical interventions, potentially impacting the residents' health outcomes.

Removal Plan

• The facility failed to notify the Medical Director of the appointment with the Urologist, order for CT scan, and follow-up appointment to schedule surgery for treatment.
• The facility has updated the clinical morning meeting process, upcoming appointment schedule and provided education.
• The Regional Director of Clinical Services reviewed the current facility residents to ensure the Medical Director was made aware of upcoming appointments.
• Upcoming appointments for the next 30 days were placed on the electronic health record dashboard making them accessible to medical director and nurse practitioner.
• All current facility and agency licensed nurses and medical records clerk were in-serviced on facility policy on Notification of Change and new process.
• When a resident is admitted to the facility, the discharge summary is to be reviewed by the admitting nurse to determine if any appointments need to be made after discharge.
• The licensed nurse will then enter the order for the referral or appointment into electronic health record.
• The licensed nurse will notify the medical director of the need for an order on the discharge summary, on admission/re-admissions or consultations.
• The licensed nurse will then place a copy of the order in the medical record box located at each nursing station.
• Medical records will check each box every morning before the morning meeting and bring the copy of the order for the appointment or consultation to the morning meeting for review.
• The order will then be verified and entered/updated into the electronic health record system.
• A copy of the order will then be given to the transporter by the medical record staff member for the appointment to be placed on the calendar.
• A copy of the order will then be placed into the MD box for notification.
• Appointments will be entered onto the EHR dashboard during the daily meeting for MD to review.
• All appointments will be reviewed daily during the clinical morning meeting for accuracy and follow-up.
• The previous day's appointments will be reviewed during the daily clinical meeting to make sure that any correspondence has been reviewed and followed up on.
• Newly hired facility and agency licensed nurses not receiving education will receive education prior to first worked shift by the Director of Nursing, Assistant Director of Nursing, Unit Manager, or Administrator.
• The daily schedule will be monitored to ensure education is completed prior to the first shift worked.
• Education will be completed by the DON, ADON, UM, or Administrator and monitoring of completion will be tracked by the active employee report.
• The Administrator and DON are ultimately responsible for the implementation and completion of this removal plan.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to follow up on a urologist's order for a CT scan and subsequent treatment for a resident with ureteral stones and a stent. The resident, who had a history of obstructing ureteral stones, hydronephrosis, UTIs, and sepsis, was discharged from the hospital with instructions to have a follow-up appointment with urology within 1-2 weeks for surgery and possible stent exchange. Despite these instructions, the facility did not ensure the CT scan was scheduled or completed, nor did they arrange the necessary follow-up appointment. The resident continued to experience hematuria and was treated with antibiotics for suspected UTIs, although urinalysis results showed no growth. The facility's failure to act on the urologist's recommendations left the resident susceptible to ongoing kidney obstruction and potential permanent damage. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's medical needs, with several staff members unaware of the resident's urology appointment or the orders that resulted from it. The deficiency was further compounded by the facility's inadequate system for tracking and processing medical orders and appointments. The transport scheduler and nursing staff did not effectively communicate or document the resident's medical needs, leading to delays in necessary medical interventions. This lack of coordination and oversight resulted in the resident not receiving timely and appropriate care for their condition.

Removal Plan

• A urology referral for Resident #53 was faxed by the facility medical record clerk and appointment received and scheduled.
• The Director of Nursing (DON) received and processed a physician order for a CT scan and provided a copy of the order to the medical records clerk who then requested and received an appointment for Resident #53.
• The DON and Assistant Director of Nursing (ADON) completed an audit of all current facility residents with urology referrals to ensure orders and follow-up appointments were received and processed.
• Audit included a review of resident's most recent discharge summaries and current active orders to identify and validate that urology orders and follow-up appointments were received and processed as indicated.
• Additional residents identified with urology referrals were all validated to have orders and/or follow-up appointment received and processed as indicated.
• The Administrator, Director of Nursing (DON), President of Operations (VPO), President of Clinical and Quality (VPCQ), Regional Director of Clinical Services (RDCS), Unit Manager, Minimum Data Set (MDS) Nurse, and Medical Director conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting to review the facility process for receiving, reviewing and processing urology consultation reports, referrals and orders and to determine root cause of the deficient practice.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to provide appropriate treatment and care for a resident with diabetic foot ulcers, leading to a significant deficiency. The Treatment Nurse Aide (NA) incorrectly applied a Coban 2 two-layer compression system to the resident's feet instead of the ordered regular Coban wrap. This error resulted in the resident experiencing purple discoloration of the toes on the right foot and dusky gray skin discoloration under the left foot dressing, indicating potential circulation issues. The resident's medical history included non-pressure chronic ulcers and diabetes mellitus type 2, with specific wound care orders that were not followed. The Treatment NA, who was responsible for the wound care, mistakenly used the Coban 2 two-layer compression system, believing it was the correct product due to its labeling. The NA did not check the snugness of the wraps or the circulation to the resident's feet after application, which led to the observed discoloration. The NA later reported the error to the Assistant Director of Nursing (ADON) and requested a check on the dressings, but the ADON did not personally verify the situation, relying instead on another nurse's assessment. Interviews with the facility's staff, including the Podiatrist and Medical Director, confirmed that the use of the compression system was inappropriate for the resident's condition and could have led to serious complications if left unaddressed. The facility's failure to adhere to the physician's orders and the lack of proper oversight and verification of wound care practices contributed to the deficiency, highlighting a significant lapse in the facility's wound care management.

Removal Plan

• The licensed nurse unit manager removed the incorrect dressing from Resident #31's right foot ulcer.
• A registered nurse assessed the dressing on Resident #31's left foot ulcer to ensure it was not impeding circulation.
• The licensed nurse applied the correct dressing per physician's order.
• The DON assessed Resident #31 for pain and completed a full skin assessment.
• The nurse practitioner assessed the resident and was notified of the incorrect wound dressing.
• Resident #31's family was notified of incorrect treatment.
• The DON and ADON completed an audit of all facility residents with all pressure and non-pressure wound care orders to ensure the correct physician ordered treatment was in place.
• The RDCR reviewed resident's care plans to ensure appropriate care plans were in place for all facility residents with non-pressure and pressure wounds.
• The ADON removed the two-layer compression system from the treatment carts and supply room.
• An Ad Hoc QAPI meeting was conducted to review the facility Wound Treatment Management Policy and to determine root cause of the deficient practice.
• Education was provided on differentiating the two types of wraps and removed the Coban2 from the treatment carts and supply room.
• The DON and ADON completed education to facility and agency Licensed Nurses on the facility Wound Treatment Management Policy and Medication Orders Policy.
• Education included the facility's wound care protocol and the expectation of each Licensed Nurse for following physician's orders when administering wound care.
• Education included the 5 p's circulation acronym when observing residents for circulatory compromise related to wound treatment dressing.
• Education included how to differentiate two layer compression system from coban when administering wound treatments.
• Education included the risks of applying the incorrect dressing.
• Facility and agency Licensed Nurses and newly hired facility and agency licensed nurses not receiving education will not be allowed to work until completed.
• Education will be included during orientation for newly hired facility and agency Licensed Nurse.
• The facility will not assign unlicensed assistive personnel (UAP) to provide wound treatments.
• A licensed nurse who has received education will be assigned to administer wound care treatments.
• The ADON or DON will ensure a licensed nurse is assigned to provide wound treatments.
• The Administrator and Director of Nursing will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to obtain a physician's order for a resident who returned from the hospital on continuous oxygen and did not ensure oxygen was delivered at the prescribed rate for another resident. Resident #3, who had chronic respiratory failure with hypoxia and congestive heart failure, returned from the hospital without a physician's order for continuous oxygen. Observations showed Resident #3 using oxygen at 2 liters per minute, but the electronic medical record lacked a physician's order for this treatment. Interviews with staff revealed that the oversight occurred because the oxygen order was not updated after the resident's hospital visit. Resident #70, diagnosed with congestive heart failure and asthma, had a physician's order for oxygen at 2 liters per minute. However, observations indicated that the oxygen concentrator was set at 1 liter per minute, contrary to the physician's order. The resident was not in distress during the observations, but the discrepancy in the oxygen flow rate was noted. Staff interviews confirmed that the oxygen setting was not checked against the physician's order, leading to the incorrect flow rate being administered. The Director of Nursing and other staff members acknowledged the necessity of having a physician's order for oxygen therapy, including the prescribed flow rate. The failure to ensure proper documentation and adherence to physician orders for oxygen therapy was identified as a deficiency in the facility's respiratory care practices.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to secure medications properly, as evidenced by a medication aide leaving a medication cup with a pill at a resident's bedside. The resident, who was cognitively impaired and unable to self-administer medication, was found with the medication cup and a cup of water on his bedside table. The medication aide admitted to not checking the medication cup after administering the resident's morning medications, which led to the medication being left unattended. Interviews with the nurse, Director of Nursing (DON), and the Administrator confirmed that medications should not be left at the bedside and that the medication aide should have ensured the resident took all his medications before leaving the room. Additionally, the facility failed to discard expired medications on two of the four medication carts reviewed. On one cart, a bottle of Ferrous Gluconate and an opened insulin pen were found to be expired, while on another cart, bottles of Bisacodyl and Nitroglycerin tablets were also expired. Interviews with the nurse, DON, and Administrator confirmed that expired medications should be removed from the medication carts and discarded, but this had not been done, leading to the presence of expired medications in the facility.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to label opened foods with a use-by date in both the reach-in and walk-in refrigerators, as observed during a survey. In the reach-in refrigerator, items such as a sandwich in a plastic bag, four dessert cups, and a cup of fruit cocktail were found without any date labels. Similarly, in the walk-in refrigerator, items including lettuce wrapped in plastic, an open package of shredded cheese, a container of unknown ingredients, a container of pinto beans, two pieces of watermelon wrapped in plastic, and a container of barley were also found without date labels. An interview with the Interim Dietary Manager revealed that open foods should be labeled with a use-by date seven days after opening, but she was unaware of why the labeling had not been done. The Administrator acknowledged awareness of the kitchen concerns and mentioned working closely with the Dietary Manager to make improvements.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to maintain an accurate Treatment Administration Record (TAR) for a resident when a Treatment Nurse Aide (NA) used another nurse's login credentials to sign off treatments. The issue arose because the Treatment NA was unable to log into the electronic medical record system due to a mistake in creating her login credentials. As a result, she used Nurse #3's login information to access the system and sign off treatments for the resident over a period of 3-4 weeks. This action was taken without the knowledge or approval of the Director of Nursing (DON) or the Administrator. The Treatment NA claimed that Nurse #3 had given her the login information to help her out, but Nurse #3 denied providing her credentials and stated she was not aware of the situation. Nurse #3 expressed concern that it appeared as though she had performed treatments she did not complete. The DON and the Administrator were unaware of the Treatment NA's actions and stated that it was inappropriate for her to use another nurse's login information, as it falsely indicated that a nurse had completed the treatments instead of an NA.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to implement its infection control policy, as evidenced by multiple instances of improper hand hygiene and personal protective equipment (PPE) use by the Treatment Nurse Aide (NA) and Nurse #1. The Treatment NA did not perform hand hygiene and wore the same pair of gloves while conducting wound care for two wounds and incontinence care for a resident. Additionally, the Treatment NA failed to wear a gown while providing wound care for a resident who required Enhanced Barrier Precautions (EBP) and did not change gloves or perform hand hygiene while providing several treatments and wound care for another resident. The Treatment NA touched the resident, several surfaces in the room, and obtained supplies from the treatment cart while wearing soiled gloves. The Treatment NA was observed performing wound care on a resident with diabetic foot ulcers without adhering to proper infection control practices. She did not perform hand hygiene before collecting supplies, entering the resident's room, or donning gloves. The Treatment NA wore the same gloves while removing and applying dressings to both of the resident's feet and while providing incontinence care. She also failed to change gloves or perform hand hygiene after providing incontinence care and before applying cream to the resident's buttocks. Furthermore, the Treatment NA did not wear a gown while performing wound care on a resident who required EBP, and there was no EBP signage or PPE available outside the resident's room. Nurse #1 also failed to perform hand hygiene after removing soiled dressings and before donning new gloves to cleanse a wound for another resident. Despite being educated on hand hygiene practices, Nurse #1 did not perform hand hygiene after removing gloves during wound care, as she believed it was unnecessary if the gloves were not visibly soiled. The facility's infection preventionist and Director of Nursing confirmed that the staff should have followed the infection control policy and performed hand hygiene whenever gloves were removed during wound care.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to protect the private health information of a resident by leaving confidential medical information unattended in a publicly accessible area. During an observation, a wound care cart was left unattended in a hallway with the Treatment Administration Records (TAR) of a resident visible on the computer screen. The screen displayed the resident's name, picture, and private health information, including current medications, which could be accessed by anyone passing by. The incident occurred when the Treatment Nurse Aide, who was responsible for the wound care cart, was distracted by a call light in the hallway and left the cart without activating the privacy protection screen. The nurse aide acknowledged the oversight and confirmed that she had completed HIPAA training provided by the facility. Interviews with the Director of Nursing and the Administrator revealed that the facility had expectations and training in place for staff to protect residents' personal health information, but these were not followed in this instance.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to follow physician orders for wound care for a resident with multiple co-morbidities, including chronic respiratory failure, end-stage renal disease, epilepsy, diabetes mellitus, and congestive heart failure. The resident had three unhealed stage IV pressure ulcers and required specific wound care treatments as per physician orders. However, during an observation, it was noted that the treatment nursing assistant did not follow the prescribed wound care orders. Instead of using the specified calcium alginate and foam dressing, the nursing assistant used collagen powder and medi-honey, which were not in accordance with the orders. The discrepancy in wound care was attributed to the treatment nursing assistant feeling overwhelmed and nervous during the procedure, leading to incorrect application of wound care products. Additionally, there was a failure in updating the computer system with the most recent wound care orders from the nurse practitioner, resulting in the use of outdated orders. Interviews with the wound care nurse practitioner, the Director of Nursing, the Medical Director, and the Administrator confirmed the expectation that staff should follow the prescribed wound care orders, highlighting a lapse in communication and adherence to protocols within the facility.

Penalty

Inspection fine: $139,932

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

Summary

The facility failed to ensure accurate and timely completion of smoking assessments for residents, leading to discrepancies in the supervision and management of smoking activities. Resident #65, who was admitted with chronic respiratory failure and muscle weakness, was assessed as a supervised smoker due to incidents of having vapes in his room. However, a smoking assessment completed on 4/15/24 inaccurately indicated that he was an independent smoker who did not require supervision. This inconsistency was not reflected in the care plan or the smoking list provided to staff, leading to confusion about the level of supervision required for Resident #65. Similarly, Resident #57, who was admitted with dementia and nicotine dependence, had a smoking assessment completed on 3/31/23 indicating the need for supervision while smoking. Despite this, no additional smoking assessments were conducted since that date, and the quarterly MDS assessments did not include information about tobacco use. Interviews with staff revealed a lack of awareness regarding Resident #57's smoking habits, contributing to the oversight in conducting regular smoking assessments. The Director of Nursing acknowledged that smoking assessments should be completed upon admission, quarterly, and as needed for changes in smoking status. However, the facility failed to adhere to this protocol, resulting in inaccurate care plans and supervision levels for residents who smoke. The lack of updated assessments and communication among staff members contributed to the deficiencies identified in the facility's smoking management practices.

Penalty

Inspection fine: $17,069

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

Summary

The facility failed to prevent a significant medication error when Nurse #1 administered medications to Resident #1 that were prescribed for Resident #2. The medications included Risperidone, Furosemide, Lisinopril, and Amlodipine, which were not ordered for Resident #1. This error led to Resident #1 experiencing elevated heart rate and hypotension, resulting in her being sent to the emergency department. Resident #1 was admitted to the hospital for observation due to the effects of the antihypertensive medications she received in error. The error occurred during the morning medication pass when Nurse #1 mistakenly gave Resident #2's medications to Resident #1 due to distractions and confusion at the medication cart. The incident report documented that Nurse #1 was administering medications when both Resident #1 and Resident #2 approached her at the same time demanding their medications. Nurse #1 inadvertently gave Resident #2's medications to Resident #1, leading to the significant medication error. Nurse #1 realized the error while documenting the medications in the medication administration record, prompting her to notify the Unit Manager, Director of Nursing, and Administrator. The on-call physician was contacted, and Resident #1 was promptly sent to the hospital for evaluation due to the severity of the error. The Medical Director highlighted that the error was significant as the medications were not ordered for Resident #1, and the hypotension she experienced was a direct result of receiving antihypertensive medications not intended for her. Interviews with Nurse #1, Resident #1, Unit Manager, and Medical Director provided insights into the events leading to the medication error. Nurse #1 admitted to the mistake, attributing it to confusion and distractions at the medication cart. Resident #1 recalled feeling unwell after taking the medications and being sent to the hospital for observation. The Unit Manager acknowledged the distractions at the medication cart and the sequence of events that led to the error.

Penalty

Inspection fine: $17,069

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

Summary

The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions following multiple surveys, leading to repeated deficiencies in preventing significant medication errors. During a complaint investigation survey, a nurse administered medications prescribed for another resident, resulting in the affected resident being sent to the emergency department due to elevated heart rate and hypotension. The resident experienced chest pain and weakness, and was admitted to the hospital for observation due to the prolonged effect of antihypertensives and hypotension. This incident was part of a pattern of medication errors, including missed doses of Copaxone and unadministered pain medications during previous surveys. Interviews with the Administrator revealed that despite holding monthly QA meetings and reviewing performance improvement plans, the facility struggled with high staff turnover, particularly among nurses and medication aides, and continued reliance on agency staffing. Additionally, the facility faced challenges with a younger resident population exhibiting increased behaviors. These factors contributed to the facility's inability to sustain an effective QAA program and prevent significant medication errors, as evidenced by repeated deficiencies during federal surveys.