Citations in Alabama
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Alabama.
Statistics for Alabama (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Alabama
- Implemented monthly printing of the Medication Administration Record (MAR) to ensure availability during internet outages, with responsibility assigned to the Director of Nursing, Assistant Director of Nursing, or Unit Manager (L - F0760 - AL) (L - F0580 - AL) .
- Conducted in-service training for all LPNs and RNs to ensure they know the location of the paper MAR and update it promptly with any new admissions or physician order changes (L - F0760 - AL) (L - F0580 - AL) .
- Educated all nursing and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR, including the importance of documenting medication administration at the time of administration (L - F0760 - AL) (L - F0580 - AL) .
- Established a monthly MAR printout schedule to ensure clarity and preparedness for potential internet downtimes (L - F0760 - AL) (L - F0580 - AL) .
- Conducted mock drills for nursing personnel to practice procedures during internet outages (L - F0760 - AL) (L - F0580 - AL) .
- Replaced the facility's router to improve internet reliability and reduce the likelihood of future outages (L - F0760 - AL) (L - F0580 - AL) .
- Held an ad-hoc Quality Assurance meeting to discuss the deficient practice and plan of correction, ensuring continuous improvement and oversight (L - F0760 - AL) (L - F0580 - AL) .
Medication Administration Failure During Internet Outage
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors during a forecasted snowstorm when the internet connection was lost, preventing access to the Electronic Health Record (EHR) and Electronic Medication Administration Record (eMAR). This resulted in the failure to administer critical medications, including insulin and other significant medications, to residents from the evening of one day until the following evening. The deficiency was identified as Immediate Jeopardy, indicating that the non-compliance was likely to cause serious harm or death. Resident Identifier #12, who had Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hyperglycemia, did not receive their prescribed insulin doses and blood glucose monitoring during this period. Similarly, Resident Identifier #15, with diagnoses including Type 2 Diabetes Mellitus and Hypertension, missed doses of insulin, blood pressure, and seizure medications. Resident Identifier #30, with conditions such as Type 2 Diabetes Mellitus and Chronic Heart Failure, also missed critical medications, including insulin and anticoagulants, and did not have their blood glucose monitored. Resident Identifier #308, who had epilepsy, did not receive their anticonvulsant medications, increasing the risk of seizure recurrence. Interviews with nursing staff revealed that the lack of access to the eMAR due to the internet outage was a significant barrier to medication administration. Some staff were unable to administer medications or monitor blood glucose levels because they did not have access to the necessary records. The facility's policy required medications to be administered in a timely manner and in accordance with prescriber orders, but the outage led to a failure in adhering to these protocols, affecting the care of the residents involved.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing educated all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR.
- In-service included the standard of practice to administer medication, monitor blood glucose, implement the prescribing physicians' orders, and the importance of documenting medication administration at the time of administration.
- In-service included calling the physician as well as notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how it led to neglect and the facility's Abuse Policy.
- A printed MAR will be ready and a copy will be kept at each nurses' station for use during downtime.
- RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both are responsible to print the paper MAR to be ready and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Neglect and Verbal Abuse During Internet Outage
Penalty
Summary
The facility failed to protect residents from neglect during a forecasted winter storm that caused an internet outage, preventing access to the Electronic Health Record (EHR) system. This outage occurred on January 21 and 22, 2025, and the facility did not have systems in place to ensure continuity of care. As a result, pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) were not available for the licensed nursing staff to use for resident care, treatment, and medication administration. Consequently, residents on the second and third floors did not receive their medications as ordered by the physician during this period. The nursing staff, including the nurse supervisor on duty, failed to ensure that residents received their medications and treatments as ordered. They also did not notify management staff or the residents' physicians of their inability to safely administer medications. This lack of communication and failure to implement a backup plan for medication administration during the internet outage led to a situation where residents did not receive necessary medications, including insulin and other significant medications, for more than 24 hours. Additionally, the facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The CNA, who was reportedly tired and frustrated from working a double shift, verbally abused the resident by using derogatory language. The resident reported feeling shocked and stunned by the CNA's behavior. The facility's investigation substantiated the allegation of verbal abuse, and the CNA was subsequently terminated.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff and provided the education with 1:1 in-service to specific staff.
- The in-services included the policy titled Policy on Computer or Internet Downtime and EHR, the standard of practice to administer medication, monitor blood glucose, the implementation of the prescribing physicians' orders, the importance of documenting medication administration at the time of administration.
- Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order.
- Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy.
- The in-service was completed for all nurses, PT staff, and administrative staff.
- The nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to specific staff.
- The in-service included that a printed MAR will be ready for each month.
- A copy of the paper MAR will be kept at each nurses' station for use during downtime.
- Education included that RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both of them are responsible to print the paper MAR to be ready for each month and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- A report was generated from the electronic medical records to see which residents could have been affected.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting which included the entire IDT team was conducted to discuss the deficient practice and plan of correction.
- The nurses that were responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
- The QA team discussed the needed in services/education for specific staff.
Failure to Notify Physician of Medication Administration Issues During Internet Outage
Penalty
Summary
The facility failed to ensure that the physician was notified when residents on the second and third floors did not receive their medications and treatments as ordered due to an internet outage. This outage occurred on January 21 and 22, 2025, and prevented access to the Electronic Health Record (EHR) system. As a result, nurses did not have access to pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) to administer medications during this period. The facility staff did not notify the Director of Nursing (DON), residents, or resident representatives about the residents not receiving their ordered medications and treatments. Interviews revealed that the Licensed Practical Nurse (LPN) who was a supervisor during the snowstorm was unsure if the residents received their medications and did not inform the DON or Administrator (ADM) about the system being down. The DON was not at the facility during the outage and was not informed about the issue until March 20, 2025. Similarly, the ADM was unaware that residents did not receive their medications until informed by the survey team. The Physician/Medical Director was also not informed about the facility's computer system being down and the residents not receiving their medications. The physician expressed that he would have liked to have been informed of this situation, as missing medications could lead to various health issues for the residents. The facility's non-compliance with the requirement to notify the physician and other relevant parties was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, leading to an Immediate Jeopardy citation.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing, Assistant Director of Nursing, or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current residents and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- In-services were conducted to educate all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR, standard practices for administering medication, monitoring blood glucose, implementing physician orders, and documenting medication administration.
- In-service included calling the physician and notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how the situation led to neglect and the facility's Abuse Policy.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that they are responsible for printing the paper MAR and placing it by each nurse's station.
- A monthly MAR printout schedule was created for clarity.
- The DON and ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of an outage, and nurses were educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director, and no adverse effects were identified.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Failure to Monitor Vital Signs in Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a system was in place to assess the vital signs of newly admitted residents at a frequency expected by the physician or CRNP. Specifically, a resident admitted after hospitalization for Atrial Fibrillation with Rapid Ventricular Response had orders for vital signs to be checked only once a month, contrary to the physician's expectation of daily assessments for new admissions. This oversight led to a situation where the resident's heart rate was significantly elevated, reaching 142 bpm, without timely intervention. The deficiency was further compounded by the lack of established parameters for when the physician should be notified of abnormal vital sign values. On one occasion, the resident's heart rate was recorded at 120 bpm, but no action was taken until the resident experienced chest pain and shortness of breath, prompting a request for hospital transfer. Interviews with facility staff, including the DON and CRNP, revealed a discrepancy between the expected and actual practices for monitoring vital signs in newly admitted residents. The facility's non-compliance with the requirements of participation was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, resulting in an Immediate Jeopardy citation. The deficiency was identified during the investigation of a complaint, highlighting the need for a systematic approach to vital sign monitoring and physician notification for newly admitted residents.
Removal Plan
- The facility failed to ensure a system was in place to ensure newly admitted residents' vital signs were assessed at a frequency expected by the physician/CRNP.
- Resident specific vital sign parameters were established including when the physician should be notified of abnormal values.
- The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
- The Medical Director was contacted by the DON on his expectations on vital sign monitoring.
- An updated New Admit/Readmit Checklist was implemented to ensure vital sign frequency and parameters are established at the time of admission.
- The vital sign monitoring policy was updated by the RDHS to require at least daily vital signs for all newly admitted or readmitted residents for 2 weeks.
- The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
- The Medical Director was contacted by the DON on his expectations on vital sign frequency.
- Vital sign parameter thresholds and frequency were updated for all newly admitted or readmitted residents over the last 30 days, vital sign orders by the RDHS and DON.
- The Daily Clinical Meeting form was revised by RDHS to include review of vital signs outside physician ordered parameters with follow up documentation.
- The DON and Staff Development Coordinator provided education for licensed staff on the updated VS Monitoring Policy, monitoring residents' vital signs at least daily for 2 weeks following an admission or re-admission and vital signs thresholds that require physician notification, and process to document vitals, notification, and physician recommendations.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident identified as RI #497. On January 4, 2025, the resident experienced an elevated heart rate of 142 beats per minute at 1:24 PM, which was not communicated to the physician. Later that day, at 9:22 PM, the resident's heart rate remained elevated at 120 beats per minute, yet again, the physician was not informed. This lack of communication resulted in no additional treatment or interventions being implemented, leading to a delay in necessary medical care. The resident, who had a history of Chronic Obstructive Pulmonary Disease and Atrial Fibrillation, continued to experience elevated heart rates and eventually complained of chest pain and difficulty breathing. Despite these symptoms, the resident was not transferred to the hospital until the early hours of January 5, 2025. Upon arrival at the hospital, the resident was admitted to the Intensive Care Unit for treatment of Atrial Fibrillation with Rapid Ventricular Response. Interviews with facility staff revealed that there was a failure to follow the facility's policy on notifying physicians of changes in a resident's condition. The Registered Nurse and Licensed Practical Nurse involved did not notify the physician or follow up on instructions given by the Certified Nurse Practitioner. This oversight was identified as a deficiency under Resident Rights, specifically regarding the notification of changes in a resident's condition.
Removal Plan
- The Director of Nursing (DON) provided 1:1 in-service with the licensed nurse who failed to notify the physician on physician notification when resident experiences change in condition and notification parameters on vital signs.
- All residents in house most recent vital signs were reviewed by the DON, Regional Director of Health Services and Regional Assessment Coordinator for any change of condition as well as vital signs outside parameters that were set forth by the Medical Director.
- Any resident with a change of condition or vital signs outside the parameters, the provider was notified by DON, Unit Manager or Charge nurse for any additional orders or treatment.
- All licensed nurses, which are 31 in total, were educated on notification to the provider for change in condition, to include vital signs outside the parameters given by the DON and Staff Development Coordinator. Any licensed nurse who did not receive the in-service will not be allowed to work until the in-service has been provided. There is 1 LPN pending (on medical leave) and the DON is responsible to ensure they are educated before working.
Latest Citations in Alabama
During an internet outage, the facility failed to notify the physician and relevant parties when residents on the second and third floors did not receive their medications and treatments as ordered. The outage prevented access to the EHR system, and staff did not have pre-printed documentation forms to administer medications. The DON and ADM were not informed of the issue until much later, and the Physician/Medical Director was not notified at all, leading to an Immediate Jeopardy citation.
The facility failed to ensure that nurses adhered to professional standards of practice and facility policies regarding medication administration and CBG monitoring. Several nurses did not administer medications or perform CBG checks as ordered, nor did they notify the appropriate personnel about the missed medications and checks. This affected a significant number of residents, with many not receiving their medications as ordered during the specified period. The facility's policy on Computer or Internet Downtime and EHR Access was not followed, contributing to the deficiency.
During a snowstorm, a facility lost internet access, preventing staff from accessing the eMAR and leading to significant medication errors. Residents with conditions such as diabetes and epilepsy missed critical medications, including insulin and anticonvulsants. Interviews revealed that staff were unable to administer medications or monitor blood glucose due to the lack of access to records.
During a forecasted winter storm, a facility experienced an internet outage that prevented access to the EHR system, leading to neglect as residents did not receive medications as ordered. The nursing staff failed to implement a backup plan or notify management of the issue. Additionally, a CNA verbally abused a resident, which was substantiated by the facility's investigation, resulting in the CNA's termination.
The facility failed to follow its food safety and sanitation policies, affecting all residents receiving meals. Observations revealed unlabeled and undated food items in storage, a dirty ice machine, and improper hand hygiene practices in the dish room. The Food Service Director acknowledged these lapses, which could lead to foodborne illnesses and cross-contamination.
The facility's QAPI committee failed to adequately review and analyze an abuse allegation involving a resident who was verbally abused by a CNA. The incident was not reported to the State Agency within the required timeframe, and the committee did not conduct a thorough investigation or root cause analysis. Contributing factors, such as the CNA's fatigue after a double shift, were not identified, and no action plan was developed to address these issues.
A facility failed to report an allegation of verbal abuse within the required two-hour timeframe. A resident reported being verbally abused by a CNA, and the incident was reported to the Administrator at 11:20 AM. However, the Facility Reported Incident was not submitted to the State Agency until after 3:00 PM, exceeding the two-hour reporting requirement.
A facility failed to thoroughly investigate and address a verbal abuse incident involving a resident and a CNA. The CNA, frustrated from working double shifts, verbally abused the resident. The investigation lacked clarity, did not identify contributing factors, and failed to involve other residents or staff. Additionally, the Social Services Director and Mental Health Nurse were not notified, leaving the resident without necessary support.
A facility failed to implement a care-planned preventive measure for a resident with potential for impaired skin integrity. The resident's oxygen tubing was observed without padding behind the ears on multiple occasions, despite the care plan's directive. An LPN confirmed the absence of padding and its importance in preventing skin breakdown.
A resident was verbally abused by a CNA, but the facility failed to provide necessary social services and mental health evaluation as per policy. The SSD was unaware of the incident and did not assess the resident, while the DON failed to ensure communication and documentation. The Administrator was aware but the mental health evaluation was not conducted.
Failure to Notify Physician of Medication Administration Issues During Internet Outage
Penalty
Summary
The facility failed to ensure that the physician was notified when residents on the second and third floors did not receive their medications and treatments as ordered due to an internet outage. This outage occurred on January 21 and 22, 2025, and prevented access to the Electronic Health Record (EHR) system. As a result, nurses did not have access to pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) to administer medications during this period. The facility staff did not notify the Director of Nursing (DON), residents, or resident representatives about the residents not receiving their ordered medications and treatments. Interviews revealed that the Licensed Practical Nurse (LPN) who was a supervisor during the snowstorm was unsure if the residents received their medications and did not inform the DON or Administrator (ADM) about the system being down. The DON was not at the facility during the outage and was not informed about the issue until March 20, 2025. Similarly, the ADM was unaware that residents did not receive their medications until informed by the survey team. The Physician/Medical Director was also not informed about the facility's computer system being down and the residents not receiving their medications. The physician expressed that he would have liked to have been informed of this situation, as missing medications could lead to various health issues for the residents. The facility's non-compliance with the requirement to notify the physician and other relevant parties was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, leading to an Immediate Jeopardy citation.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing, Assistant Director of Nursing, or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current residents and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- In-services were conducted to educate all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR, standard practices for administering medication, monitoring blood glucose, implementing physician orders, and documenting medication administration.
- In-service included calling the physician and notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how the situation led to neglect and the facility's Abuse Policy.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that they are responsible for printing the paper MAR and placing it by each nurse's station.
- A monthly MAR printout schedule was created for clarity.
- The DON and ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of an outage, and nurses were educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director, and no adverse effects were identified.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Failure to Administer Medications and Perform CBG Monitoring
Penalty
Summary
The facility failed to ensure that several nurses adhered to professional standards of practice and facility policies regarding medication administration and capillary blood glucose (CBG) monitoring. Specifically, LPN #14 and RN #15 did not administer medications or perform CBG checks as ordered by the physician during their shift. They also failed to notify the residents' physician, Director of Nursing (DON), or the Administrator about the missed medications and CBG checks. This non-compliance was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, leading to an Immediate Jeopardy citation. Additionally, RN #20 and RN #16 administered medications using pre-packaged medications without verifying the physician's order and did not document the administration of medications at the time of administration or when the Electronic Health Record (EHR) system was restored. LPN #18 also failed to administer and document medication administration per standards of practice and facility policy. This affected a significant number of residents on the Second and Third Floors, with a total of 48 out of 52 residents not receiving their medications as ordered during the specified period. The facility's policy on Computer or Internet Downtime and EHR Access was not followed, as staff did not initiate downtime procedures or use paper documentation for resident care activities during the internet outage. The failure to administer medications and perform CBG checks as ordered, along with the lack of proper documentation and notification, contributed to the deficiency. The facility's non-compliance with these requirements was identified during the investigation of a complaint, leading to the citation of Immediate Jeopardy.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing, Assistant Director of Nursing, or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current residents and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- In-services were conducted to educate all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR.
- In-services included the standard of practice to administer medication, monitor blood glucose, implement the prescribing physicians' orders, and the importance of documenting medication administration at the time of administration.
- In-service included calling the physician as well as notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how the failure led to neglect and the facility's Abuse Policy.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both are responsible for printing the paper MAR to be ready and will be placed by each nurse's station.
- A monthly MAR printout schedule was created for clarity.
- The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of an outage and nurses were educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Medication Administration Failure During Internet Outage
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors during a forecasted snowstorm when the internet connection was lost, preventing access to the Electronic Health Record (EHR) and Electronic Medication Administration Record (eMAR). This resulted in the failure to administer critical medications, including insulin and other significant medications, to residents from the evening of one day until the following evening. The deficiency was identified as Immediate Jeopardy, indicating that the non-compliance was likely to cause serious harm or death. Resident Identifier #12, who had Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hyperglycemia, did not receive their prescribed insulin doses and blood glucose monitoring during this period. Similarly, Resident Identifier #15, with diagnoses including Type 2 Diabetes Mellitus and Hypertension, missed doses of insulin, blood pressure, and seizure medications. Resident Identifier #30, with conditions such as Type 2 Diabetes Mellitus and Chronic Heart Failure, also missed critical medications, including insulin and anticoagulants, and did not have their blood glucose monitored. Resident Identifier #308, who had epilepsy, did not receive their anticonvulsant medications, increasing the risk of seizure recurrence. Interviews with nursing staff revealed that the lack of access to the eMAR due to the internet outage was a significant barrier to medication administration. Some staff were unable to administer medications or monitor blood glucose levels because they did not have access to the necessary records. The facility's policy required medications to be administered in a timely manner and in accordance with prescriber orders, but the outage led to a failure in adhering to these protocols, affecting the care of the residents involved.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing educated all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR.
- In-service included the standard of practice to administer medication, monitor blood glucose, implement the prescribing physicians' orders, and the importance of documenting medication administration at the time of administration.
- In-service included calling the physician as well as notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how it led to neglect and the facility's Abuse Policy.
- A printed MAR will be ready and a copy will be kept at each nurses' station for use during downtime.
- RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both are responsible to print the paper MAR to be ready and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Neglect and Verbal Abuse During Internet Outage
Penalty
Summary
The facility failed to protect residents from neglect during a forecasted winter storm that caused an internet outage, preventing access to the Electronic Health Record (EHR) system. This outage occurred on January 21 and 22, 2025, and the facility did not have systems in place to ensure continuity of care. As a result, pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) were not available for the licensed nursing staff to use for resident care, treatment, and medication administration. Consequently, residents on the second and third floors did not receive their medications as ordered by the physician during this period. The nursing staff, including the nurse supervisor on duty, failed to ensure that residents received their medications and treatments as ordered. They also did not notify management staff or the residents' physicians of their inability to safely administer medications. This lack of communication and failure to implement a backup plan for medication administration during the internet outage led to a situation where residents did not receive necessary medications, including insulin and other significant medications, for more than 24 hours. Additionally, the facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The CNA, who was reportedly tired and frustrated from working a double shift, verbally abused the resident by using derogatory language. The resident reported feeling shocked and stunned by the CNA's behavior. The facility's investigation substantiated the allegation of verbal abuse, and the CNA was subsequently terminated.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff and provided the education with 1:1 in-service to specific staff.
- The in-services included the policy titled Policy on Computer or Internet Downtime and EHR, the standard of practice to administer medication, monitor blood glucose, the implementation of the prescribing physicians' orders, the importance of documenting medication administration at the time of administration.
- Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order.
- Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy.
- The in-service was completed for all nurses, PT staff, and administrative staff.
- The nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to specific staff.
- The in-service included that a printed MAR will be ready for each month.
- A copy of the paper MAR will be kept at each nurses' station for use during downtime.
- Education included that RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both of them are responsible to print the paper MAR to be ready for each month and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- A report was generated from the electronic medical records to see which residents could have been affected.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting which included the entire IDT team was conducted to discuss the deficient practice and plan of correction.
- The nurses that were responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
- The QA team discussed the needed in services/education for specific staff.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its own policies regarding food safety and sanitation, which had the potential to affect all 53 residents receiving meals from the kitchen. During an inspection, it was observed that food items in the freezer and cooler, such as a large bag of okra, chicken fingers, and corned beef, were not labeled or dated as required by the facility's DATING AND LABELING POLICY. The Food Service Director (FSD) confirmed that these items should have been labeled with the date opened, use-by date, and the initials of the person who stored them. The lack of proper labeling and dating could lead to foodborne illnesses, as stated by the FSD. Additionally, the facility's ICE MACHINE SANITATION POLICY was not followed, as a black substance was found on the ice guard and lid inside the ice machine. The FSD acknowledged that the ice machine was dirty and had not been serviced, which could result in bacteria or infectious diseases contaminating the ice served to residents. The FSD admitted responsibility for ensuring the cleanliness of the ice machine, which was supposed to be cleaned monthly. The HAND WASHING POLICY was also violated, as observed in the dishware washing area. Dietary Aide (DA) #23 was seen working on both the dirty and clean sides of the dish room without changing gloves or apron, leading to potential cross-contamination. DA #24 also failed to change his apron when moving from the dirty to the clean side. Both aides admitted to not following proper procedures, with DA #23 citing inexperience and DA #24 mentioning being too busy. The FSD confirmed that such practices could lead to cross-contamination, posing a risk to resident health.
Inadequate QAPI Review of Abuse Allegation
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee adequately reviewed and analyzed an allegation of abuse to determine causes and implement corrective actions to prevent recurrence. Specifically, the committee did not identify concerns with the reporting and investigation of an abuse allegation involving a resident who was verbally abused by a CNA. The incident was not reported to the State Agency within the required two-hour timeframe, and the QAPI committee did not conduct a thorough investigation or root cause analysis. The QAPI committee also failed to identify contributing factors to the verbal abuse, such as the CNA's fatigue and frustration after working a double shift. The facility's policies on abuse and QAPI were not effectively followed, as the committee did not develop an action plan to address the late reporting or the lack of a comprehensive investigation. The facility administrator acknowledged that a root cause analysis was not performed and was unaware that a written action plan was necessary.
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Agency within the required two-hour timeframe. On January 30, 2025, a Licensed Physical Therapy Assistant (LPTA) became aware of an incident at 10:50 AM where a resident claimed to have been verbally abused by a Certified Nursing Assistant (CNA), who allegedly called the resident a 'stupid mother fucker.' The LPTA reported this allegation to her supervisor and the Administrator (ADM) at approximately 11:20 AM. However, the Facility Reported Incident (FRI) was not submitted to the State Agency until 3:04 PM, exceeding the two-hour reporting requirement outlined in the facility's Abuse Policy. The deficiency affected one resident who was part of a sample of three residents reviewed for abuse. During interviews, both the LPTA and the ADM acknowledged the requirement to report such allegations immediately, but the ADM confirmed that the report was delayed. The facility's policy, updated in August 2022, clearly states that all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made known. This delay in reporting constitutes a failure to adhere to the established protocol for handling allegations of abuse.
Failure to Investigate and Address Verbal Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation and take appropriate corrective actions following an incident of verbal abuse involving a resident identified as RI #15. On the date of the incident, Certified Nursing Assistant (CNA) #10 verbally abused RI #15, expressing frustration and fatigue from working double shifts. The facility's investigation did not identify potential contributing factors to the verbal abuse, such as staff burnout or inadequate training on handling stress, which prevented the development and implementation of measures to prevent recurrence. The investigative file contained handwritten statements that were unclear and lacked proper identification of the individuals who provided them. The facility did not conduct interviews with other residents or staff to determine if there were additional instances of unreported abuse involving CNA #10. Furthermore, there was no evidence of a root cause analysis being conducted to address the incident, and the facility did not have a process in place to monitor or support staff working extended hours to prevent burnout and frustration. Additionally, the facility failed to ensure that the Social Services Director (SSD) and Mental Health Nurse were notified and involved in assessing and supporting RI #15 following the incident. The SSD was unaware of the abuse until the survey, and no mental health evaluation was conducted for RI #15. This lack of communication and follow-up could have resulted in emotional distress for the resident, as noted by the Director of Nursing (DON).
Failure to Implement Preventive Measures for Skin Integrity
Penalty
Summary
The facility failed to implement a care-planned preventive measure to prevent skin breakdown for a resident identified as having a potential for impaired skin integrity. The resident, who was admitted to the facility with a care plan indicating the need for padding around oxygen tubing when in use, was observed on multiple occasions without padding on the tubing behind their ears. This was noted during observations on two consecutive days, where the resident's oxygen was set at two liters per minute via a nasal cannula/concentrator, yet the tubing remained unpadded. An interview with an LPN confirmed the absence of padding and acknowledged the importance of padding to prevent skin breakdown.
Failure to Provide Social Services After Verbal Abuse Incident
Penalty
Summary
The facility failed to provide appropriate social services to a resident, identified as RI #15, following an incident of verbal abuse by a Certified Nurse Assistant (CNA). The incident occurred when the CNA allegedly called the resident a derogatory name. Despite the facility's policy requiring the Social Services Director (SSD) to monitor the resident's reactions and statements following such incidents, the SSD was unaware of the abuse and had not assessed the resident. The SSD, who had been in the position since early January 2025, stated that she was not informed of the incident or the need for a mental health evaluation for the resident. The Director of Nursing (DON) acknowledged that the policy required notifying the SSD to evaluate the resident, but this was not documented or communicated. The Administrator was aware of the incident and had planned for a mental health evaluation, but it had not been conducted. The lack of communication and follow-up resulted in the resident not receiving the necessary monitoring and counseling, potentially causing emotional distress.