Citations in Alaska
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Alaska.
Statistics for Alaska (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Alaska
A resident with vascular dementia and asthma, who had moderate cognitive impairment, was allowed to self-administer a Budesonide/Formoterol Fumarate inhaler without proper assessment or documentation of their ability to do so safely. The resident was observed using incorrect technique and exceeding the prescribed dosage, and staff did not ensure mouth rinsing after use. Assessments indicated the resident was unable to correctly identify, understand, or administer their medications, yet no documentation supported their clinical clearance for self-administration.
Two residents were allowed to self-administer medications, including a topical cream and an inhaler, without their care plans being updated to reflect this practice. Staff confirmed that the residents were self-administering, but care plans did not include any information or guidance on medication self-administration, and proper technique was not always followed.
A resident with a history of PTSD, agitation, and self-harm ideation was allowed access to pointed scissors during a group activity, resulting in the resident grabbing the scissors, threatening self-harm, and requiring police intervention to resolve the situation. Staff were unable to de-escalate the incident or prevent the resident from accessing the hazardous equipment, despite the resident's known behavioral risks.
A resident with severe pain and multiple serious diagnoses experienced an eight-hour delay in receiving Morphine due to medication supply shortages, communication errors with the contracted pharmacy, and procedural barriers for accessing controlled substances. The resident reported significant pain and distress during this period, as nurses were unable to obtain the necessary medication in a timely manner.
A resident with complex medical needs, including myasthenia gravis and chronic pain, experienced significant delays in receiving prescribed Morphine and Pyridostigmine due to medication shortages and late administration by nursing staff. These delays led to unmanaged pain and respiratory distress, with documentation inconsistencies noted in the medication administration records.
Medication carts in two cottages were repeatedly left unlocked and unattended by LNs, including times when narcotic drawers were open and the main lock was not engaged. The carts were left unsupervised in community spaces, and staff acknowledged that carts should only be unlocked when within eyesight, but this protocol was not consistently followed. The DON confirmed that facility policy requires medication carts to be locked when not in sight of authorized staff.
Physicians did not consistently conduct in-person assessments of residents at least every 60 days, with several residents experiencing extended gaps between visits. The facility lacked a reliable system for tracking and following up on missed appointments, and staff interviews confirmed that reminders were inconsistently communicated, leading to missed visits.
The Medical Director did not ensure physician compliance with required resident visits, resulting in multiple residents experiencing significant gaps between physician visits, some exceeding a year. The MD relied on staff to track visits and did not address the issue in QAPI meetings, leading to a lack of oversight and coordination of medical care.
The facility did not document that residents or their representatives received education on the benefits and potential side effects of Influenza and Pneumococcal vaccines before consent or declination. Although staff and public health partners may have provided education, there was no evidence of this in the medical records for several residents who received or declined immunizations.
The facility did not document that residents or their representatives were educated about the benefits and side effects of the COVID-19 vaccine before vaccination was offered or administered. For four residents, there was no evidence in the medical record that this required education occurred, despite facility policy requiring such documentation.
Failure to Ensure Clinically Appropriate Self-Administration of Inhaler
Penalty
Summary
The facility failed to ensure that self-administration of medication was clinically appropriate for a resident with vascular dementia and asthma. The resident, who had a moderate cognitive impairment as indicated by a BIMS score of 12, was observed self-administering a Budesonide/Formoterol Fumarate inhaler. During the observation, the resident took three puffs in quick succession without holding their breath between puffs, contrary to the prescribed two puffs and proper inhaler technique. The LPN present did not ensure the resident rinsed their mouth after administration, as recommended for this medication. Review of the resident's assessments revealed that the most recent Medication Self-Administration Safety Screen indicated the resident was unable to correctly read medication labels, state the purpose, timing, or dosage of medications, or administer inhalant medications according to proper procedure. An additional assessment scored the resident low on cognitive skills, requiring one-step prompting and encouragement, and showed the resident was unable to identify or understand possible side effects of their medications. There was no documentation that the resident had been observed using the inhaler correctly, nor was there a list of medications the resident was clinically cleared to self-administer.
Failure to Revise Care Plans for Medication Self-Administration
Penalty
Summary
The facility failed to revise the comprehensive care plans to include medication self-administration for two residents who were observed self-administering their medications. For one resident with chronic kidney disease, anemia, and cerebrovascular disease, records showed that the resident was permitted to apply a topical medication independently due to the private nature of the application site. However, there was no documentation in the care plan addressing the resident's ability or plan to self-administer this medication. The nurse confirmed that the resident applied the medication independently but did not indicate that an assessment or care plan update had been completed. For another resident with vascular dementia and asthma, the resident was observed self-administering an inhaler medication, taking more puffs than prescribed and not following proper inhaler technique. The nurse acknowledged that the resident self-administered the inhaler but did not ensure the resident followed the correct procedure or updated the care plan to reflect self-administration. Review of both residents' care plans revealed no inclusion of medication self-administration, despite staff statements and observations confirming that self-administration was occurring.
Failure to Prevent Resident Access to Hazardous Equipment During Activity
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for a resident with a history of PTSD, depression, agitation, and prior self-harm ideation. The resident, who had been recently admitted with diagnoses including Parkinson's disease with dyskinesia and PTSD, had documented behavioral issues such as agitation, paranoia, aggression toward staff, and delusional thinking. The care plan for this resident included monitoring for danger to self or others, identifying triggers, and using de-escalation techniques, but did not specifically address the risk associated with access to sharp objects during group activities. During a group baking activity, the resident requested removal of a hospital wrist band. The DON retrieved pointed desk scissors to remove the band and approached the resident. The resident grabbed the scissors from the DON, threatened self-harm, and pressed the open blades against their chest. Staff attempted to de-escalate the situation by asking for the scissors to be returned and removing other residents from the area, but were unsuccessful in calming the resident or retrieving the scissors. The incident escalated, requiring activation of a code grey, and the involvement of hospital security, police, and EMS. The event lasted over an hour, during which the resident continued to make threats of self-harm and resisted staff interventions. The police ultimately intervened to remove the scissors, and the resident was transported to the emergency department for evaluation and placed on suicide precautions. The facility's actions did not prevent the resident from accessing unsafe equipment, despite the resident's known behavioral risks and history of harm to self and others, resulting in a situation that placed the resident and others at risk.
Failure to Provide Timely Pain Medication Due to Medication Supply and Communication Issues
Penalty
Summary
The facility failed to provide routine and as-needed Morphine for a resident with severe pain, resulting in the resident experiencing unrelieved pain for over eight hours. The resident, who had diagnoses including myasthenia gravis with acute exacerbation, diffuse large B-cell lymphoma, chronic respiratory failure, and heart failure, was on hospice care for pain management. The hospice agency did not supply medications, so the facility was responsible for providing all necessary drugs. The resident reported that it was a frequent occurrence for their cottage to run out of medications, requiring nurses to search other cottages for needed drugs. The deficiency occurred after a change in facility ownership, during which the previous owner removed all medication stock, leaving only two weeks of scheduled medications for continuity of care. The new owner contracted with an off-site pharmacy, PharMerica, and used E-kits for emergency medication needs. However, the process for accessing medications from the E-kits required authorization from PharMerica, which involved obtaining a pull code and, for controlled substances like Morphine, a hard copy prescription with a physician's wet signature. On the day of the incident, a fax error prevented timely ordering of additional Morphine, and when the need arose, PharMerica would not authorize access to the E-kit without the required documentation, causing a significant delay. As a result, the resident received a scheduled dose of Morphine at 2:00 AM but was unable to receive an additional requested dose for severe pain until 1:30 PM, waiting over eight hours. During this time, the resident reported pain levels of 5 out of 10 when still and 8 out of 10 when moving, and was also attempting to pass a kidney stone, which increased their discomfort. The delay in medication administration was attributed to late ordering by nurses, communication errors with the pharmacy, and procedural requirements for controlled substances.
Failure to Prevent Significant Medication Errors Resulting in Pain and Distress
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors, resulting in pain and respiratory distress due to delayed and inconsistent medication administration. The resident, who had diagnoses including myasthenia gravis with acute exacerbation, diffuse large B-cell lymphoma, chronic respiratory failure, and heart failure, was also on hospice for pain control. The facility was responsible for providing all medications, as the hospice agency did not supply them. The resident reported frequent occurrences of medication shortages, requiring licensed nurses to search other cottages for medications, which led to delays in receiving prescribed doses. On one occasion, the resident received a scheduled dose of Morphine at 2:00 AM but did not experience adequate pain relief and requested an additional dose at 5:00 AM. The nurses were unable to provide the medication due to lack of supply and only administered the next dose at 1:30 PM, resulting in an 8.5-hour wait. The resident described significant pain during this period, with pain levels increasing when moving. Review of the electronic Medication Administration Record (eMAR) showed that scheduled doses of Morphine and Pyridostigmine (a time-sensitive medication for myasthenia gravis) were repeatedly administered late, sometimes by several hours, and documentation was inconsistent or missing regarding these delays and medication shortages. The resident also reported that delays in receiving Pyridostigmine affected muscle function and breathing, with several doses documented as being given late and outside the prescribed four-hour intervals. The facility's policy required medications to be administered within prescribed time frames and proper documentation, but these standards were not met. Nurse notes did not consistently reflect the late administration or lack of medication on hand, contributing to the deficiency.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts in two cottages, Kenai and Aniak, were repeatedly left unlocked and unattended by licensed nurses. In Kenai Cottage, the medication cart was found with open and unlocked drawers, including the narcotic drawer, while the nurse was not present in the area. The nurse was seen leaving the cart unlocked multiple times, including during lunch breaks and while attending to residents in other rooms. On several occasions, the main lock of the cart was not engaged, and the cart was left unsupervised in community spaces. The nurse acknowledged that the cart should only be left unlocked when within eyesight, but failed to consistently follow this protocol. In Aniak Cottage, similar observations were made where the medication cart was left unlocked and unattended in the hallway, with no staff present in the vicinity. When questioned, the nurse confirmed that the cart should be locked when not in use and proceeded to lock it after being prompted. The Director of Nursing confirmed that medication carts are to be locked when not in sight of authorized staff, as per facility policy. The facility's policy review indicated that only specific staff should have access to the medication carts and that they must be secured when not supervised.
Failure to Ensure Timely In-Person Physician Visits
Penalty
Summary
The facility failed to ensure that physicians consistently conducted in-person assessments of residents at least once every 60 days, as required. Record review revealed multiple instances where residents experienced significant gaps between physician visits, ranging from 71 to 368 days. These lapses were documented for several residents, with some not being seen by a physician for over three months, and one resident not seen for over a year. The facility's own Physician Visits Non-compliance Flowsheets confirmed these extended intervals between required visits. Interviews with the Long-Term Care Manager and the Medical Director indicated that the facility lacked a reliable system for tracking and following up on missed physician appointments. Nurses maintained logs, but reminders to physicians were inconsistently communicated, and the process was further hindered when physicians were unavailable due to vacations or busy schedules. The Medical Director acknowledged reliance on staff for reminders and admitted to missing visits, especially during periods of absence or high workload. The facility's policy required timely physician visits and prompt rescheduling of missed appointments, but these procedures were not effectively implemented.
Failure of Medical Director to Oversee Physician Visit Compliance
Penalty
Summary
The facility failed to ensure that the Medical Director (MD) fulfilled her responsibilities for oversight and coordination of medical care, specifically regarding physician compliance with required resident visits. Review of facility documentation and policies confirmed that the MD was responsible for implementing resident care policies and coordinating medical care, including organizing and coordinating physician services. However, multiple instances were identified where residents did not receive physician visits within the required intervals, with gaps ranging from 71 to 368 days between visits, exceeding the policy requirement of at least one physician visit every 60 days after the first 90 days post-admission. Interviews revealed that the MD relied on staff to track physician visits and did not have a system in place to ensure compliance. The MD acknowledged a lack of oversight and expressed that the responsibility could not rest solely on her. Additionally, the Regional Quality Manager confirmed that the MD did not proactively address issues related to physician visit compliance in QAPI meetings and was unaware of the extent of noncompliance until informed during the survey. These actions and inactions resulted in a failure to provide adequate oversight and coordination of medical care as required by facility policy.
Lack of Documentation for Vaccine Education Prior to Consent or Declination
Penalty
Summary
The facility failed to ensure that documentation was present in the medical records showing that residents or their representatives were educated about the benefits and potential side effects of Influenza and Pneumococcal immunizations prior to obtaining consent or declination for vaccine administration. Record review revealed that several residents received these immunizations, and one resident declined, but there was no documentation in the electronic health records indicating that education was provided before the vaccines were offered. The facility's vaccination policy stated that education would be provided to all residents and their legal representatives regarding vaccination risks and benefits, but this was not reflected in the records reviewed. Interviews with facility staff confirmed that while education may have been provided verbally, it was not documented in the residents' records. The Long-Term Care Manager indicated that the State of Alaska Public Health provided education at the time of vaccination, but relied on the vaccination record as evidence of education, which did not specifically document the educational content or its delivery. The Clinical Director also acknowledged that staff were providing education but not documenting it. This lack of documentation affected all residents reviewed and had the potential to affect all residents in the facility.
Lack of Documentation of COVID-19 Vaccine Education
Penalty
Summary
The facility failed to ensure that documentation was present in the medical records to show that residents or their representatives were educated about the benefits and potential side effects of the COVID-19 vaccine prior to either consenting to or declining vaccination. Specifically, for four out of five residents reviewed, there was no evidence in the electronic health record that education was provided before the vaccine was offered or administered. This included residents who received the vaccine as well as one resident whose representative declined the vaccine on their behalf. Interviews with facility staff revealed that while education may have been provided verbally by staff or by the State of Alaska Public Health prior to vaccination, this education was not documented in the residents' records. The facility's own policy required that education regarding vaccination risks and benefits be provided to all residents and their legal representatives, but there was no documentation to confirm this occurred for the affected residents.
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