Ashford Hall
Inspection history, citations, penalties and survey trends for this long-term care facility in Irving, Texas.
- Location
- 2021 Shoaf Dr, Irving, Texas 75061
- CMS Provider Number
- 455748
- Inspections on file
- 43
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Ashford Hall during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment, who had a documented history of verbal and physical aggression and an existing behavioral care plan, repeatedly engaged in aggressive acts toward three other cognitively impaired residents. In separate incidents, this resident pulled another resident’s hair in the dining room, scratched a resident’s face causing redness and agitation, and later grabbed a resident by the throat, pulled her hair, and verbally threatened to cut her throat. These episodes of resident-to-resident physical and verbal abuse occurred despite the facility’s abuse-prevention policy and the known behavioral history of the aggressor, and the DON acknowledged that failure to update and communicate care plan interventions after such acute incidents placed residents at risk.
A resident with dementia and severe cognitive impairment had a longstanding behavioral care plan listing general interventions for verbal and physical aggression, but the plan was not revised after three separate aggressive episodes toward three different residents, including hair pulling, scratching another resident’s face causing redness, and grabbing a resident by the throat while making verbal threats. Progress notes by nursing staff documented each incident and the immediate separation and assessment of the involved residents, who showed no documented injuries beyond transient redness and agitation. The care plans for the other involved residents did not reflect new behavioral concerns related to these events. The DON acknowledged that comprehensive care plans are supposed to be updated for acute incidents and that failure to update interventions poses a risk, yet the behavioral care plan for the aggressive resident contained no updates or new interventions following these repeated aggressive behaviors.
A resident with severe cognitive impairment and multiple neurologic and psychiatric diagnoses alleged through another resident that the Maintenance Director exposed himself to her. The allegation was reported up the chain from a CNA to the Social Worker and then to the Administrator, and the investigation was handed off to an Executive Assistant. Despite a written policy requiring immediate notification of the resident’s representative about abuse allegations and ongoing investigation status, the responsible party was not informed on the day the allegation was made and instead learned of it only after the resident called to report that police were present to question her. Staff interviews revealed that the Executive Assistant was new to the investigation process, the appropriate incident documentation template was not initiated, and nursing staff were not directed to notify the family, resulting in a failure to follow the facility’s abuse reporting and notification procedures.
Two residents were subjected to abuse by another resident with a history of aggression and psychiatric diagnoses. One resident had coffee thrown at him, resulting in temporary redness, while another was struck in the face with a closed fist. The aggressive resident repeatedly refused psychotropic medications and psychiatric services, and despite staff interventions and monitoring, the facility failed to prevent these incidents of abuse.
A facility failed to maintain accurate accountability of controlled narcotic drugs for a resident with severe cognitive impairment and cervical cancer. The narcotic count sheet for hydromorphone lacked required nursing staff signatures, and there was a discrepancy between the recorded and actual amounts. Interviews revealed that recent hires and insufficient training contributed to the oversight. The facility's policy requires signatures for administering medications to prevent errors and diversion.
A facility failed to conduct accurate and timely smoking assessments for a resident with nicotine dependence and dementia. The resident's assessments were not completed quarterly, and errors were found in the records, incorrectly identifying the resident as a non-smoker. The Activity Director, responsible for these assessments, acknowledged the mistakes, citing absence due to illness and misunderstanding of the EMR system. This deficiency could risk residents' safety due to lack of appropriate interventions.
The facility failed to provide Medicare Provider Non-Coverage letters to two residents, leaving them uninformed about their right to appeal coverage decisions. One resident had intact memory and multiple medical conditions, while the other had severe cognitive impairment. The deficiency was due to the absence of the former MDS Coordinator and lack of documentation or proof of notice delivery.
A resident with severe cognitive impairment and cervical cancer was found with a nephrostomy bag incorrectly placed on the bed, contrary to professional standards requiring it to be below the kidney. Staff interviews revealed inconsistent understanding and training regarding proper nephrostomy care, leading to a deficiency in maintaining professional standards and risking infection.
A resident's feeding tube was replaced due to malfunction, but the facility failed to confirm its placement by x-ray before use, leading to the administration of water, medications, and feedings. Despite the facility's policy requiring x-ray confirmation, staff relied on auscultation and residual checks, resulting in a deficiency. The resident had multiple medical conditions and was dependent on the feeding tube for nutrition.
A facility failed to ensure that nurses had the necessary competencies for g-tube replacement and verification, leading to a resident's g-tube being used without proper placement verification. An LVN replaced the g-tube without recent training, and other staff used it before x-ray confirmation, highlighting systemic training deficiencies.
A confidentiality breach occurred when a computer on a medication cart was left unlocked and unattended by an RN, displaying residents' medication information. This incident took place on a secured unit, allowing unauthorized access to sensitive information by staff, residents, and visitors. The facility's policy requires computers to be locked when unattended to protect electronic protected health information (e-PHI).
A resident with severe cognitive impairment was moved to a secured unit in a memory care facility without a physician's order, constituting involuntary seclusion. The resident's care plan noted behaviors of trying to leave, but there was no documented evidence of wandering or exit-seeking behaviors. The move was made due to a perceived risk of elopement, despite the resident's limited mobility. The facility's staff failed to obtain the necessary physician order prior to the move.
A medication cart in the secured unit was found unlocked and unattended, posing a risk for unauthorized access. RN E admitted to leaving the cart unlocked while assisting another nurse. The DON, new to the position, was unaware of the incident but confirmed that carts should always be locked when unattended, as per facility policy.
A resident with a history of cerebral infarction and end-stage renal disease was transferred to a hospital without a discharge notice or physician documentation indicating unmet needs at the facility. The resident exhibited aggressive behaviors and refused dialysis, leading to challenges in care. Despite these issues, the facility failed to follow proper discharge procedures, resulting in the resident not being readmitted after hospital treatment.
A resident with severe cognitive impairment and multiple health conditions had a wound on their left great toe that was not identified or treated by the facility staff. Despite the care plan requiring weekly skin assessments, the wound developed osteomyelitis and led to the amputation of the toe. Interviews with staff revealed a lack of awareness of the wound prior to the resident's hospital visit.
A resident with multiple medical conditions received wound care without privacy, as the ADON failed to close the door or curtain. This oversight occurred while several individuals passed by, despite the facility's policy on maintaining resident dignity and privacy.
A facility failed to ensure a resident receiving G-tube feeding was positioned correctly, risking aspiration. The resident was found lying flat while feeding, against care plan instructions. Staff interviews confirmed the need for upright positioning during feeding, as per facility policy.
A medication cart was left unlocked and unattended by an LVN in a hallway, contrary to facility policy requiring all drugs to be stored securely. The LVN admitted to being distracted and forgetting to lock the cart. Interviews with the ADON and DON confirmed that this action violated the facility's policy, which mandates that medication carts must be locked when not in use and when unattended.
A facility failed to maintain an effective infection control program when a CNA did not sanitize or wash her hands and failed to change gloves while providing incontinent care to a resident. The CNA handled supplies and performed perineal care without following proper hand hygiene protocols, as confirmed by interviews with facility staff. The facility's hand hygiene policy, which emphasizes preventing healthcare-associated infections, was not adhered to during this incident.
A facility failed to implement an effective discharge process for a resident with osteomyelitis and pressure ulcers, leading to an improper discharge. The resident was discharged home without the results of a pending appeal and without home health services. The social worker faced challenges in securing placement due to the resident's out-of-network insurance. The facility's discharge policy did not address the appeal process, contributing to the issue.
A resident identified as a fall risk experienced multiple unwitnessed falls due to the facility's failure to implement necessary interventions and provide adequate supervision. Despite a history of repeated falls and being on hospice care, staff did not consistently assess or document the resident's condition following falls, nor did they ensure the use of prescribed fall prevention measures. The facility's oversight failures placed residents at risk of harm.
The facility failed to provide adequate supervision and implement care plan interventions for fall-risk residents, leading to multiple incidents involving two residents. One resident, a 94-year-old male with dementia and mobility issues, sustained injuries from unwitnessed falls due to inconsistent implementation of safety measures. Another resident, a 76-year-old female with cognitive impairment, experienced a fall resulting in head trauma. The facility's failure to oversee care policies and ensure staff followed protocols contributed to these incidents.
A resident with multiple health issues, including a Stage IV sacral pressure ulcer, did not receive adequate wound care for 30 days, leading to hospitalization with sepsis and fluid overload. Facility records showed lapses in documentation and communication, with staff and physicians unaware of the resident's deteriorating condition.
A resident with multiple health issues developed severe pressure ulcers and was not added to the wound care physician's list, resulting in a lack of proper wound care for 30 days. This led to the resident being hospitalized with sepsis and fluid overload, eventually leading to her death.
Failure to Prevent Repeated Resident-to-Resident Abuse by a Behaviorally Symptomatic Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse by another resident with known behavioral symptoms. Resident #1, an elderly female with dementia, generalized anxiety disorder, and severe cognitive impairment (BIMS score of 0), had an active care plan identifying behavioral symptoms including verbal and physical aggression and calling 911. Her care plan included various behavioral interventions such as removal from group activities when behavior was unacceptable, moving her to a quiet environment when verbally abusive, avoiding power struggles, avoiding overstimulation, and assessing whether her behavior endangered herself or others. Despite these identified behavioral issues and interventions, Resident #1 engaged in multiple aggressive acts toward other residents. On 03/01/26, Resident #1 was involved in an incident with Resident #2, an elderly female with Alzheimer’s disease, severe cognitive impairment (BIMS score of 0), and a care plan that identified behavioral symptoms including physical aggression and sexually inappropriate behaviors. According to a progress note by RN A, a CNA/Medication Aide reported that Resident #2 was walking in front of Resident #1 in the dining room when Resident #1 suddenly stood up, ran toward Resident #2, and pulled her hair. RN A heard Resident #2 screaming loudly and believed the scream sounded like it was due to pain from having her hair pulled. Staff separated the residents, and a head-to-toe assessment revealed no injuries, bruises, or need for treatment, but the event constituted resident-to-resident physical aggression. On 03/05/26, Resident #1 engaged in another aggressive incident, this time with Resident #3, an elderly female with dementia, bipolar disorder, generalized anxiety disorder, severe cognitive impairment (BIMS score of 0), and a history of aggression noted in her care plan. LVN B reported observing Resident #1 yelling at Resident #3 and, before she could reach them, witnessing Resident #1 scratch Resident #3’s face with her fingernails. Resident #3 was noted to have red marks on her face without skin break, and she was angry and agitated for about forty minutes following the incident. On 03/10/26, Resident #1 again acted aggressively toward Resident #4, an elderly female with Alzheimer’s disease, epilepsy, mood disorder, and an admission MDS showing no mood or behavioral symptoms. LVN B reported that Resident #1, without provocation, grabbed Resident #4 by the throat, pulled her hair, and verbally threatened her, telling her to stop looking at her and threatening to cut her throat. Resident #4’s breathing was not restricted and no injuries were observed, but the incident involved physical and verbal aggression. These repeated episodes of resident-to-resident abuse occurred despite Resident #1’s known behavioral history and existing care plan, and the DON acknowledged that failing to update interventions in Resident #1’s care plan after such acute incidents would be a risk because the care plan is the means to communicate necessary interventions to all caregivers. The facility’s own policy titled “Abuse, Neglect, Exploitation and Misappropriation Prevention Program” stated that residents have the right to be free from abuse and included an objective to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone, including other residents. Nevertheless, Resident #1 was able to pull Resident #2’s hair, scratch Resident #3’s face, and grab Resident #4 by the throat and pull her hair while verbally threatening her. Staff interviews confirmed that these events occurred and that Resident #1’s behavior was described as random and unpredictable. The DON stated she had not been aware of at least one of the aggressive incidents at the time of interview and indicated that the comprehensive care plan is supposed to be updated for acute incidents. The combination of Resident #1’s known aggressive behaviors, the occurrence of multiple aggressive episodes toward other residents, and the lack of timely, effective care plan updates and interventions to prevent further abuse formed the basis of the deficiency under the facility’s obligation to protect residents from abuse by anyone, including other residents.
Failure to Revise Behavioral Care Plan After Repeated Resident Aggression
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with dementia and severe cognitive impairment who exhibited repeated aggressive behaviors toward other residents. Resident #1, an elderly female with diagnoses including dementia, generalized anxiety disorder, diabetes mellitus, and hyperlipidemia, had an admission MDS that did not reflect mood or behavioral symptoms other than often feeling lonely or isolated, and a BIMS score of zero indicating severe cognitive impairment. Her active care plan, with a behavioral symptoms problem initiated months earlier, listed interventions such as reminding her not to call 911, praising appropriate behavior, removing her from group activities when behavior was unacceptable, moving her to a quiet environment when verbally abusive, administering medications as ordered, assessing whether behavior endangered herself or others, avoiding power struggles and overstimulation, obtaining psychiatric consults, and offering preferred music when upset. However, this care plan contained no updates or revisions to address new or escalating aggression following three specific aggressive incidents on 03/01/26, 03/05/26, and 03/10/26. On 03/01/26, a progress note by RN A documented that Resident #1 suddenly stood up in the dining room, ran toward Resident #2, and pulled her hair while Resident #2 was walking in front of her. Staff separated the residents, and head-to-toe assessments revealed no injuries, though Resident #2 screamed loudly in what staff believed was pain from having her hair pulled. On 03/05/26, a progress note by LVN B recorded that Resident #1 was observed yelling at Resident #3; before LVN B could reach them, she witnessed Resident #1 scratch Resident #3’s face, resulting in redness without skin break. Resident #3 was angry and agitated for about forty minutes following the incident, and the redness remained for about 24 hours. On 03/10/26, a progress note by RN B described Resident #1, without provocation, grabbing Resident #4 by the throat, pulling her hair, and verbally threatening her with profane language. The residents were separated, and no injuries were documented for Resident #4. These three episodes of aggression toward different residents occurred despite an existing behavioral care plan, and there is no indication in the care plan that it was revised or expanded to address these specific behaviors or patterns. Additional record reviews and interviews confirmed that the care plans for the other involved residents did not identify new behavioral symptoms related to these incidents. Resident #2’s care plan listed behavioral symptoms including physical aggression and sexually inappropriate behaviors, with the last behavior dated months earlier, and did not reflect new issues arising from being the target of hair pulling. Resident #3’s care plan noted a history of aggression with the last incident dated 10/24/25, and Resident #4’s care plan identified wandering but no verbal or physical aggression or other behavioral symptoms. Observations on 03/24/26 showed Residents #2, #3, and #4 without obvious signs of abuse, neglect, bruises, or injuries, and family interviews for Residents #2 and #4 indicated no observed trauma or behavioral changes after the incidents. The DON, interviewed on 03/24/26, stated that the comprehensive care plan is updated by herself and assistant directors of nursing for acute incidents and acknowledged that failing to update interventions in Resident #1’s care plan would be a risk because the care plan is a way to communicate the plan of care to anyone providing care. Despite this, the documentation showed no revisions to Resident #1’s behavioral care plan after the three aggressive episodes, constituting the cited failure to develop and implement a comprehensive person-centered care plan consistent with resident rights and identified needs.
Failure to Notify Resident Representative of Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its own written abuse investigation and reporting policy by not immediately notifying a resident’s responsible party of an allegation of sexual abuse. The facility’s policy, revised July 2017, required the Administrator to keep the resident and representative informed of the progress and status of any abuse investigation and to report all alleged violations of abuse, neglect, exploitation, or mistreatment to the resident’s representative. An allegation was made that the Maintenance Director had exposed himself to a resident, and this information was relayed through another resident to a CNA, then to the Social Worker, and then to the Administrator. Despite this, the resident’s responsible party was not notified on the day the allegation was reported. The resident involved was an elderly female with diagnoses including unspecified dementia, Alzheimer’s disease, chronic pain, depression, and sequelae of cerebral infarction. Her MDS showed a BIMS score of 3, indicating severe cognitive deficits, and documented that her preferred language was Spanish and that she required an interpreter for communication with healthcare staff. She required partial or moderate assistance with several ADLs, including toileting, bathing, dressing, transfers, and walking short distances, and had a history of refusing incontinence care and showers. Her care plans also noted mild depression and a preference for in-room, self-led activities, including Spanish-language media. According to interviews and record review, the allegation that the Maintenance Director exposed himself to the resident originated when the resident reportedly told another resident, who then informed a CNA. The CNA reported it to the Social Worker, who reported it to the Administrator. The Administrator, who is married to the Maintenance Director, left the facility after learning of the allegation and handed the investigation over to the Executive Assistant. The Executive Assistant acknowledged that she did not notify the resident’s responsible party on the day the allegation was made and stated that she was new to the investigation process. Nursing staff who learned of the allegation later that day attempted to assess the resident, but the resident refused assessment and denied that anything had happened; the nurse was not instructed to notify the family and did not know whether they had been notified. The resident’s responsible party later reported that she first learned of the allegation when the resident called her and said that the police were at the facility trying to speak with her about the allegation, and that the resident did not want to talk to them. The responsible party stated that facility staff routinely called her for relatively minor issues, such as the resident refusing showers, but no one contacted her about the abuse allegation. The Executive Assistant later confirmed that she met with the responsible party after the police involvement but had not contacted her on the day the allegation was reported. The Administrator also acknowledged that, in the usual process, the family would be notified immediately as part of completing the incident documentation, but that this did not occur because the appropriate incident template was not opened and the nursing portion of the investigation was not followed through. As a result, the facility did not implement its own abuse and neglect prevention policy regarding timely notification of the resident’s representative.
Failure to Prevent Resident-to-Resident Abuse Due to Ongoing Aggressive Behaviors
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving aggressive behavior by one resident towards others. In the first incident, a male resident with a history of physically and verbally aggressive behaviors, moderate cognitive impairment, and multiple psychiatric diagnoses, threw coffee at another male resident, resulting in redness to the face and chest. The nursing assessment completed the same day found no injury or changes in the skin assessment from baseline. The aggressive resident had a documented pattern of agitation and aggression, with care plan interventions in place, but continued to exhibit behaviors such as hitting, throwing objects, and verbal outbursts. In the second incident, the same aggressive resident struck another male resident on the left side of the face/jaw with a closed fist during an activity. The resident who was struck had a history of traumatic subdural hemorrhage, dementia, and unsteadiness on his feet, and was noted to be rarely or never understood. The nurse assessed no injuries following the incident. The aggressive resident had a care plan that included interventions for behavioral symptoms, but he consistently refused his prescribed psychotropic medications and psychiatric services, and his aggressive behaviors persisted despite staff attempts at redirection, monitoring, and environmental modifications. Staff interviews and record reviews revealed that the aggressive resident had a long-standing pattern of combative and disruptive behaviors, including multiple episodes of aggression towards both staff and other residents. Despite frequent monitoring, care plan updates, and attempts to accommodate his preferences and needs, the facility was unable to prevent further incidents of resident-to-resident abuse. The aggressive resident's refusal of medication and psychiatric intervention, combined with his independence and quick actions, contributed to the facility's inability to ensure the safety and protection of other residents from abuse.
Inadequate Narcotic Accountability and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in maintaining accurate accountability of controlled narcotic drugs for a resident with severe cognitive impairment and a primary diagnosis of cervical cancer. The narcotic count sheet for hydromorphone, a Schedule II controlled substance, lacked required nursing staff signatures from a specific period, and there was a discrepancy between the recorded remaining amount and the actual amount in the bottle. This inconsistency was identified during an observation and interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). Interviews with nursing staff revealed that the lack of signatures was due to recent hires and insufficient training. The DON, who had been at the facility for two weeks, acknowledged the oversight in training and management. The facility's Controlled Substances policy requires signatures for administering medications and reconciling controlled substances to prevent loss or diversion. The absence of signatures and discrepancies in narcotic counts could lead to medication errors, including potential overdoses or diversion of narcotic medications.
Inaccurate Smoking Assessments for Resident
Penalty
Summary
The facility failed to ensure complete and accurate smoking assessments for Resident #26, who was one of two residents reviewed for smoking assessments. The deficiency was identified through observation, interview, and record review. Resident #26's smoking assessments were not conducted quarterly as required, and the assessments that were completed contained inaccuracies. This failure could potentially place residents who smoke at risk due to inaccurate information, leading to a lack of appropriate safety interventions. Resident #26, a male resident with a history of nicotine dependence, dementia, and epilepsy, was admitted to the facility with a care plan indicating he was a smoker at risk for injury. The care plan included goals and interventions to assist and supervise him during smoking activities. However, discrepancies were found in his smoking risk assessments. The assessment completed on 03/13/24 indicated he was a safe smoker, but subsequent assessments on 06/14/24 and 01/22/25 incorrectly noted him as a non-smoker, with no information about his smoking capability or behaviors. Interviews with the Activity Director revealed that she was responsible for conducting smoking assessments and arranging smoke breaks. She admitted to errors in Resident #26's assessments, attributing them to her absence due to illness and a lack of understanding of the electronic medical record system. The facility's policy required smoking assessments to be conducted quarterly and upon significant changes, but these were not consistently followed, leading to the deficiency.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide Medicare Provider Non-Coverage letters (CMS 10123 or CMS 10055) to two residents, which included information about their right to appeal. This deficiency was identified through interviews and record reviews, revealing that the facility did not ensure the delivery and receipt of these important notices. The absence of these notifications could potentially leave residents uninformed about their rights regarding Medicare coverage and their ability to appeal decisions. Resident #71, a female with a BIMS score indicating intact memory, was admitted to the facility and discharged from skilled services without receiving the required notice. Her medical conditions included unspecified cirrhosis of the liver, chronic respiratory failure with hypercapnia, and end-stage renal disease. Similarly, Resident #95, a male with a severely impaired cognitive status, was also discharged from skilled services without receiving the necessary notification. His diagnoses included hypertensive urgency, unspecified encephalopathy, and dementia. Interviews with facility staff revealed that the former MDS Coordinator, responsible for completing the NOMNCs, had left the facility, and the Admission Coordinator could not locate the completed forms or proof of their delivery. The facility's failure to provide these notices was confirmed by the absence of documentation and evidence of delivery, as required by Medicare guidelines. This oversight highlights a significant lapse in ensuring residents are informed of changes in their Medicare coverage and their rights to appeal.
Improper Nephrostomy Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate nephrostomy care for a resident, leading to a deficiency in maintaining professional standards of practice. Resident #350, a female with severe cognitive impairment and a primary diagnosis of cervical cancer, was observed with a nephrostomy bag placed incorrectly on the bed near her shoulder, rather than below the kidney as required. This improper placement was noted during an observation and interview, where the resident confirmed the presence of a nephrostomy tube. The facility's policy and professional standards dictate that the nephrostomy bag should be positioned below the kidney to ensure proper drainage and prevent infection. Interviews with facility staff revealed a lack of consistent understanding and training regarding the correct positioning of nephrostomy bags. LVN A was unsure of the consequences of incorrect bag placement, while CNA G had been misinformed to keep the bag above the kidney. RN F and the DON both acknowledged the importance of keeping the bag below the kidney to prevent infection and ensure proper drainage. The facility's policy, last revised in October 2010, also emphasized the need for the drainage bag to be below the kidney level. The Administrator confirmed the necessity of proper bag placement for effective urine flow, highlighting a gap in staff training and adherence to established care protocols.
Failure to Confirm Feeding Tube Placement Before Use
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received appropriate treatment and services. Specifically, the facility did not confirm the placement of a newly inserted feeding tube by x-ray before administering water, medications, and bolus feedings. This oversight involved a resident with multiple medical conditions, including acute respiratory failure, critical illness myopathy, and dementia, who was dependent on a feeding tube for nutrition. The resident's feeding tube was replaced by an LVN due to leakage and malfunction. Although the LVN obtained a verbal order from the physician to replace the tube and requested an x-ray to confirm placement, the x-ray was not completed before the tube was used. The LVN and other staff members, including an RN, proceeded to use the feeding tube based on auscultation and residual checks, despite the facility's policy requiring x-ray confirmation of tube placement before use. Interviews with facility staff revealed a lack of clear communication and understanding of the policy regarding feeding tube placement verification. The DON and ADON were not aware of the tube replacement until after it occurred, and there was confusion among staff about whether it was permissible to use the tube before x-ray confirmation. The physician indicated that while x-ray confirmation was not always necessary for mature stomas, the facility's policy required it, and the failure to adhere to this policy led to the deficiency.
Inadequate G-Tube Competency and Training
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to replace a g-tube and to follow g-tube verification of placement procedures. This deficiency was identified in the case of a resident who had a g-tube replaced by an LVN without having completed a competency validation course. The LVN had not received recent training or competency check-offs for g-tube replacement, relying instead on outdated training from another facility. The LVN replaced the g-tube based on a physician's verbal order but without the necessary verification of placement through an x-ray before use. Additionally, the facility did not provide adequate training for other nursing staff, including an RN and another LVN, regarding the safe use of a g-tube for feeding and medication administration. These staff members used the g-tube before its placement was verified via x-ray, relying on residual checks instead. The RN involved had not been checked off for competency in g-tube management and was new to the facility, indicating a lack of proper orientation and training. Interviews with facility staff, including the DON and ADON, revealed a lack of awareness and adherence to facility policies regarding g-tube management. The DON acknowledged the potential risks of using a g-tube without verified placement and expressed concern over the lack of communication and training among the nursing staff. The facility did not have documentation of training or competencies for g-tube management, highlighting systemic issues in ensuring staff are adequately trained and competent in critical nursing procedures.
Confidentiality Breach Due to Unattended Computer
Penalty
Summary
The facility failed to protect the confidentiality of residents' personal and medical records, as observed during a survey. Specifically, a computer on a medication cart was left unlocked and unattended by RN E, displaying residents' medication information. This incident occurred on the secured unit, with the computer facing the hallway, allowing unauthorized access to sensitive information by other staff, residents, and visitors passing by. RN E acknowledged the oversight, admitting that he left the computer unlocked while assisting another nurse. The Director of Nursing (DON), who had been in the position for only four days, was unaware of the incident until informed. The facility's policy on safeguarding electronic protected health information (e-PHI) mandates that computers be locked when unattended to prevent unauthorized access. The policy emphasizes the importance of maintaining the confidentiality, integrity, and availability of e-PHI. The incident highlights a lapse in adherence to this policy, as the computer was not secured, potentially compromising residents' privacy and dignity.
Resident Moved to Secured Unit Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident in the locked memory care unit was free from involuntary seclusion. The resident, a female with severe cognitive impairment and multiple diagnoses including unspecified dementia with behavioral disturbance and schizoaffective disorder, was moved to a secured unit without a physician's order. The resident's care plan indicated behaviors of trying to leave the facility, but there was no documented evidence of wandering or exit-seeking behaviors prior to the move. The resident's move to the secured unit occurred on 11/21/24, but the physician order for the secured unit was not placed until 01/12/25. Interviews with facility staff revealed that the move was made due to a perceived risk of elopement, although the resident was not ambulatory and unable to propel herself in her wheelchair. The resident's primary care physician stated that he did not recall giving an order for the move and was not aware of any wandering or elopement attempts. The facility's social worker and ADON were involved in the process, with the social worker responsible for notifying the family and documenting the move, and the ADON placing the order in the system after reconciling physician orders. However, there was a lack of communication and documentation regarding the necessity and authorization for the resident's move to the secured unit, leading to the deficiency of involuntary seclusion.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were stored securely in a locked compartment, as observed with one of the four medication carts reviewed. Specifically, the Secured Unit medication cart was found unlocked and unattended near a resident's room. RN E, who was responsible for the cart, admitted to leaving it unlocked while assisting another nurse, which could have allowed unauthorized access to medications by residents, staff, or visitors. During interviews, RN E acknowledged the oversight and the potential risk it posed. The Director of Nursing (DON), who had been in the position for only four days, was unaware of the incident but confirmed that medication carts should always be locked when unattended. The facility's policy, revised in April 2007, clearly states that medication carts must be locked at all times when not in use or out of the nurse's view, to prevent unauthorized access.
Improper Discharge of Resident Without Adequate Documentation
Penalty
Summary
The facility failed to adhere to proper discharge protocols for a resident, leading to a deficiency in care. The resident, a female with a history of cerebral infarction, end-stage renal disease, and mood disorder, was transferred to a hospital without being provided a discharge notice. The facility did not document any physician's indication that the resident's needs could not be met at the facility, which is a requirement for discharge. This lack of documentation and communication resulted in the resident not being readmitted to the facility after hospital treatment. The resident exhibited aggressive behaviors, including refusal of dialysis and medication, yelling, and threatening staff, which were documented in her care plan. Despite these challenges, the facility's policy required that a discharge notice be given, and a physician's documentation was necessary to justify the discharge. The facility's failure to provide these documents and follow the proper procedure for discharge placed the resident at risk of unnecessary transfer and unmet needs. Interviews with facility staff, including the Social Worker and Administrator, revealed that the resident was non-compliant with care and exhibited behaviors that were challenging for the staff to manage. The Administrator admitted to instructing the hospital not to return the resident, indicating a lack of adherence to the facility's policy on resident discharge. The facility's policy clearly states that residents sent to acute care settings are expected to return unless a formal discharge process is followed, which was not done in this case.
Failure to Identify and Treat Wound Leads to Amputation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for a resident reviewed for quality of care. The facility did not identify and treat a wound on the resident's left great toe before the resident was sent to a local hospital, where the wound was found to have developed osteomyelitis. This led to the amputation of the resident's left great toe. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was admitted to the facility with multiple diagnoses, including cerebrovascular disease, end-stage renal disease, essential hypertension, and type 2 diabetes mellitus. Despite the resident's care plan indicating the need for weekly skin assessments and monitoring for changes, the facility's records showed that the resident's skin was documented as clear and free of problems. However, upon hospital admission, the resident was found to have a chronic necrotic ulcer on the left great toe, which was not previously identified by the facility staff. Interviews with facility staff, including CNAs and nurses, revealed that none of them recalled noticing any skin integrity issues or wounds on the resident's left foot prior to the hospital visit. The facility's wound care nurse and the IDON were also unaware of any issues with the resident's left great toe before the amputation. The resident himself stated that he had informed the facility staff about the wound on his toe, but could not remember specific details. The lack of proper identification and treatment of the wound by the facility staff led to a delay in necessary care, resulting in the resident's toe amputation.
Privacy Violation During Wound Care
Penalty
Summary
The facility failed to protect the personal privacy rights of a resident during medical treatment. Specifically, during wound care for a resident with multiple medical conditions, including encephalopathy, pressure ulcer, type 2 diabetes mellitus, peripheral vascular disease, and end-stage renal disease, the Assistant Director of Nursing (ADON) did not ensure privacy. The resident, who had a moderate cognitive impairment and required substantial assistance with activities of daily living, received wound care without the door or curtain being closed. This lack of privacy occurred while several staff members, residents, and visitors passed by the open door. The ADON acknowledged the oversight, stating that she normally would have closed the door or pulled the curtain to provide privacy. The resident expressed indifference to the door being open, as long as his foot was checked as needed. However, the facility's policy on dignity, which emphasizes treating residents with respect and maintaining their privacy during care, was not followed. The incident was reported to the Interim Director of Nursing (IDON) and the Administrator, who both confirmed the expectation of privacy during care.
Improper Positioning During G-Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding through a G-tube was positioned correctly to prevent complications such as aspiration. On the date of observation, the resident was found lying flat sideways in bed while the G-tube feeding was running, contrary to the care plan and physician's orders which required the head of the bed to be elevated. This improper positioning was observed by a Licensed Vocational Nurse (LVN) who was not informed of the correct positioning requirements for the resident. Interviews with facility staff, including another LVN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that residents with G-tubes should be in an upright position during feeding to prevent aspiration. The staff acknowledged that the resident frequently repositioned himself, necessitating more frequent checks to ensure proper positioning. The facility's policy also required residents to be positioned in a semi-Fowler's or higher position during feeding, which was not adhered to in this instance.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, LVN B was found to have left a medication cart unlocked and unattended in the hallway of Station 100. LVN B walked away from the cart to attend to a resident without securing it, leaving it unattended for two minutes. When questioned, LVN B admitted to being distracted and forgetting to lock the cart but refused to discuss the potential consequences of this action. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's policy mandates that medication carts must be locked when not in use and when unattended. Both the ADON and DON expressed that leaving medications unsecured could allow unauthorized access, potentially leading to harm if medications were ingested by residents not prescribed those medications. The facility's policy on medication labeling and storage, as well as the security of medication carts, clearly states that all medications must be stored in locked compartments and that medication carts must be locked when out of the nurse's view.
Infection Control Lapse During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during the provision of incontinent care for Resident #1. CNA A did not sanitize or wash her hands and failed to change gloves appropriately while providing care. Specifically, CNA A donned double gloves without sanitizing her hands, handled various supplies, and performed perineal care without changing gloves or sanitizing her hands between tasks. This lapse in protocol was observed during an incident where CNA A provided care to a resident who was always incontinent of bowel and urine and required total assistance with personal hygiene due to physical and cognitive impairments. Interviews with facility staff, including CNA A, LVN C, the ADON, and the DON, confirmed that the facility's expectations and policies regarding hand hygiene and glove use were not followed. CNA A acknowledged the failure to change gloves and sanitize hands, recognizing the risk of infection to residents. The facility's policy on hand hygiene, which emphasizes its importance in preventing healthcare-associated infections, was not adhered to during the incident. The policy outlines specific instances when hand hygiene is required, including before and after resident contact and after glove removal, which were not observed in this case.
Improper Discharge Due to Ineffective Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge process for a resident, leading to an improper discharge. The resident, a cognitively intact male with osteomyelitis and pressure ulcers, was admitted to the facility with plans to discharge to the community. However, the care plan did not address discharge planning. The resident was given a notice of Medicare non-coverage, although he did not have Medicare, and was informed that skilled services would end. Despite an appeal being completed, the resident was discharged home without the results of the appeal and without home health services. Interviews revealed that the social worker attempted to find a nursing home and set up durable medical equipment (DME) for the resident, but faced issues due to the resident's insurance being out of network. The resident's family was offered the option to pay for respite care, which they declined. The administrator stated that the resident was discharged after staying a week past the last coverage date, as the facility could not secure placement due to insurance issues. The facility's policy on discharge and transfer did not discuss the appeal process, contributing to the improper discharge.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide resident-centered care and services according to the residents' preferences, goals, and professional standards of practice, which resulted in unmet physical, mental, and psychosocial needs for two residents. Specifically, a resident identified as a fall risk experienced multiple unwitnessed falls, including incidents in the dining room and from a wheelchair. Despite being identified as a fall risk, the facility did not implement necessary interventions such as frequent observation and supervision when the resident was out of bed. The resident had a history of repeated falls and was admitted to hospice care with diagnoses including dementia, anxiety, and unsteadiness on feet. The facility's staff, including LVNs and CNAs, failed to assess, evaluate, and document necessary care following the resident's falls. On several occasions, the resident fell without immediate staff intervention or proper assessment of injuries, such as vital signs and range of motion checks. Video surveillance revealed that staff were not in a position to prevent or respond promptly to the falls, and interventions like Dycem mats were not consistently used. The resident's care plan included interventions to prevent falls, but these were not effectively implemented or monitored. Additionally, the facility did not ensure protection from harm during abuse or neglect investigations. The resident experienced a significant head injury from a fall, which was not promptly addressed by the facility's staff. Communication with the resident's primary care physician and hospice services was delayed, and necessary medical evaluations, such as a skull x-ray, were not immediately ordered. The facility's failure to oversee and implement resident care policies placed residents at risk of serious injury or harm.
Inadequate Supervision and Care Plan Implementation for Fall-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of assistive devices for residents identified as fall risks, leading to multiple incidents involving two residents. One resident, a 94-year-old male with a history of repeated falls, dementia, and other mobility issues, sustained several injuries, including skin tears and head trauma from unwitnessed falls. Despite being identified as a fall risk, the resident's care plan interventions, such as keeping the bed in the lowest position and using a Dycem mat in the wheelchair, were not consistently implemented. Video surveillance revealed that the resident was often left unsupervised or inadequately supervised, contributing to the falls. Another resident, a 76-year-old female with severe cognitive impairment and a history of repeated falls, also experienced an unwitnessed fall resulting in head trauma and a laceration. The facility's failure to oversee the implementation of resident care policies was evident when staff did not assess, evaluate, or document the necessary follow-up after the falls. For instance, a Licensed Vocational Nurse (LVN) did not assess vital signs or initiate an investigation after the incidents, contrary to the facility's policies. The facility's deficient practices placed residents at significant risk of serious injury or harm. The lack of adequate supervision and failure to implement effective care plan interventions for residents identified as fall risks were critical factors leading to these incidents. The facility's inability to ensure that staff followed established protocols for assessing and responding to falls further exacerbated the situation, highlighting a pattern of non-compliance with safety standards.
Neglect in Wound Care Management
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, specifically in the context of wound care management. The resident, an elderly female with a history of hypertension, chronic respiratory failure, dysphagia, and end-stage renal disease, had a Stage IV sacral pressure ulcer, a skin tear on the right knee, and a pressure ulcer on the left foot. Despite these conditions, the facility did not provide adequate wound care monitored by a physician for 30 days. This neglect led to the resident being sent to the hospital with symptoms of lethargy, disorientation, anorexia, and hypotension, where she was admitted to the ICU as septic with fluid overload and shortness of breath. The facility's records revealed multiple lapses in wound care documentation and management. The resident's electronic medical records showed a history of pressure ulcers and skin tears, but there were significant gaps in weekly documented skin checks from early February to early March. Physician orders for wound care were not administered as required, and the resident's condition deteriorated without appropriate medical intervention. Interviews with facility staff, including the ADON and the contracted wound care physician, highlighted issues in communication and documentation, with the wound care physician not being aware of the resident's condition due to her not being included in the rounding list. The resident's primary care physician was also unaware of her wounds, and the responsible party reported that the resident had been in excruciating pain for a month without adequate care. The facility's ADON acknowledged the documentation issues and stated that efforts were being made to improve communication and documentation practices. However, these deficiencies in wound care management and communication placed the resident at significant risk and resulted in actual harm, as evidenced by her critical condition upon hospital admission.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care according to professional standards to prevent and manage pressure ulcers. The resident, who had a history of hypertension, chronic respiratory failure, dysphagia, and end-stage renal disease, developed a Stage IV sacral pressure ulcer, a skin tear on the right knee, and a pressure ulcer on the left foot. Despite having wound care orders in place, the facility did not add the resident to the wound care physician's list, resulting in a lack of physician-monitored wound care for 30 days. This lapse in care led to the resident being sent to the hospital with symptoms of lethargy, disorientation, anorexia, and hypotension, where she was diagnosed with sepsis and fluid overload and subsequently admitted to the ICU. The resident continued to decline and was eventually discharged to hospice care, where she expired shortly after. Interviews with facility staff revealed that the wound care orders were not properly followed, and the resident was not referred to the wound care physician as required. The facility's ADONs and other staff members acknowledged the oversight and the failure to ensure the resident received timely and appropriate wound care. The facility's failure to provide adequate wound care and monitoring placed the resident at significant risk and contributed to her decline in health.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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