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)
Latest Citations in Alabama
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
A resident with dementia and a history of falls did not consistently receive prescribed fall prevention interventions, as only one fall mat was placed and the bed was not kept in the lowest position over several days, despite staff awareness and care plan documentation.
Staff served pureed menu items using a #16 scoop (1/4 cup) instead of the required #8 scoop (1/2 cup), resulting in at least three residents on a pureed diet receiving inadequate portions at dinner. The error was discovered during trayline observation, and interviews confirmed that the incorrect scoop size was used before being corrected.
A resident did not receive the necessary behavioral health care and services required, as observed and documented by surveyors.
A resident with severe cognitive impairment and a history of wandering and aggression was able to enter another resident's room and place a pillow over their head, resulting in physical abuse. Staff were aware of the resident's behaviors and had a behavioral care plan in place, but interventions were insufficient to prevent the incident, and supervision was inadequate to protect other residents.
The facility did not keep an area free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors. Staff did not implement sufficient monitoring or protective measures to address environmental risks.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their care requirements.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including expired and improperly stored foods, dishwashing at inadequate temperatures without sanitizer, and cold foods held above safe temperatures on the tray line. These practices had the potential to affect all residents receiving meals, as staff did not consistently follow established policies for food safety and sanitation.
The facility did not ensure residents had ongoing access to their personal funds, as residents and staff reported that funds could only be withdrawn during weekday business office hours. Two residents stated they could not access their money on weekends, and staff interviews confirmed there was no established process for after-hours access. The Business Office Manager and Administrator acknowledged the lack of a system for weekend or after-hours withdrawals, resulting in residents being unable to manage their finances as needed.
A resident with severe cognitive impairment and a history of Alzheimer's disease was found with a gait belt fastened around their waist and wheelchair, constituting a physical restraint not documented in the care plan or MDS. Staff interviews confirmed that restraints and gait belts were not standard practice in the memory unit, and the device was placed by a hospice CNA.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement prescribed fall prevention interventions for a resident with dementia and a history of falls. According to the resident's care plan and incident reports, fall mats were to be placed on both sides of the bed and the bed was to be kept in the lowest position following a fall incident. However, during three out of four days of the survey, observations revealed that only one fall mat was present (on the left side of the bed) and the bed was not in a lowered position as required. These observations were consistent across multiple days and shifts. Interviews with nursing staff and CNAs confirmed that the interventions were known and documented in the resident's profile, and staff acknowledged the importance of following these interventions to prevent further falls. Despite this, the required safety measures were not consistently implemented for the resident, who had diagnoses including dementia with agitation and a history of transient attack. The deficiency was identified through direct observation, record review, and staff interviews, demonstrating a failure to ensure the environment was free from accident hazards and that adequate supervision and interventions were provided.
Incorrect Portion Sizes Served for Pureed Diets
Penalty
Summary
The facility failed to ensure that correct portion sizes of pureed food were served to residents on a pureed diet during dinner service. According to facility policy and menu documentation, pureed menu items such as Cheeseburger Soup, Carrots (substituted for Creamy Tomato & Onion Salad), and Fortified Mashed Potatoes were to be served using a #8 scoop (1/2 cup) for each portion. However, during observation, staff were found using blue-handled #16 scoops (1/4 cup) for these items. This resulted in residents receiving smaller portions than required by the menu and facility policy. Interviews with the Nutrition Department Director and Nutrition Manager confirmed that the incorrect scoop size was used for at least three of eleven residents on a pureed diet before the error was identified and corrected. The Nutrition Manager and Director both acknowledged that using a smaller scoop led to inadequate servings, which could affect the nutritional intake of residents. The staff involved were not aware of who placed the incorrect scoops in the food pans, and the error was only discovered after several trays had already been served.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and findings that the required behavioral health interventions and supports were not provided to residents as needed. The lack of appropriate behavioral health care and services was directly observed and documented by surveyors during the review.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse by another resident who also had severe cognitive impairment and a history of wandering and aggressive behaviors. On the date of the incident, a CNA observed one resident in another resident's room, placing a pillow over the resident's head while the resident was in bed. The CNA intervened by removing the resident and notifying the charge nurse immediately. Prior to the incident, the resident who committed the act was known to wander frequently, enter other residents' rooms, get into other residents' beds, and display aggressive behaviors such as hitting at staff. The behavioral care plan for the resident with wandering and aggressive behaviors included interventions such as encouraging activities, providing materials for independent activities, and using a calming voice during disruptive behaviors. However, these interventions did not address the resident's constant wandering and entry into other residents' rooms. Staff interviews confirmed that the resident was difficult to manage and that the behaviors were ongoing, with staff offering activities or food as redirection, but without effective supervision to prevent incidents. The facility's policy required identification of residents at risk for abusive or aggressive behavior and the development of appropriate intervention strategies to prevent occurrences. Despite this, the facility did not provide adequate supervision or interventions to prevent the resident with a known history of wandering and aggression from accessing other residents' rooms and perpetrating physical abuse. The facility's investigation substantiated that the incident occurred but did not classify it as abuse due to both residents' cognitive impairments.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations and staff interviews. Expired foods, including cucumbers, bell peppers, and buttermilk, were found in the walk-in refrigerator, with visible mold growth and use-by dates that had passed. Staff admitted to not properly rotating stock and sometimes adding new produce to older batches, resulting in expired items not being discarded. Additionally, several items in the walk-in freezer, such as beef hamburger patties, diced chicken, and cookie dough, were stored in open containers, contrary to policy requiring sealed and closed storage to prevent contamination. Dishwashing procedures were also found to be deficient. The dish machine logs showed that wash and rinse temperatures frequently fell below the required minimum of 120 degrees Fahrenheit, and on one occasion, the sanitizer solution was found to be empty during use. Staff responsible for operating the dish machine did not consistently check water temperature or sanitizer levels before washing dishes, and some washed and stored serving trays and dome lids without proper sanitization. The Dietary Manager and Registered Dietitian confirmed that staff were expected to follow manufacturer guidelines for dishwashing, but logs and interviews indicated this was not consistently done. Cold food holding practices on the tray line were inadequate, with temperatures of cold foods such as watermelon and grapes measured well above the required 41 degrees Fahrenheit. Staff reported that cold foods were kept in the refrigerator before service but were then brought out in large quantities, causing them to warm above safe temperatures during meal service. The Dietary Manager acknowledged that staff had not been checking food temperatures during tray line service to ensure compliance with policy. The facility census indicated that all 89 residents, on regular or controlled carbohydrate diets, were potentially affected by these deficiencies.
Failure to Provide Ongoing Access to Resident Personal Funds
Penalty
Summary
The facility failed to provide residents with ongoing access to their personal funds managed by the facility, as required by policy and regulation. Review of the facility's Resident Trust policy revealed it did not specify how or when residents could access their funds. Facility records showed that 62 residents had active trust accounts. Multiple interviews with residents confirmed that they were unable to withdraw funds on weekends or after business office hours, as the business office staff were only available Monday through Friday from 7:00 AM to 4:00 PM. Staff interviews further indicated uncertainty about the process for residents to access funds outside of these hours, with no clear alternative in place. The Business Office Manager (BOM) acknowledged that residents could only access their money during business office hours and that, while there had been discussions about leaving money at the nurse's desk or in the medication cart for after-hours access, this process had not been implemented. The BOM stated that residents were advised to withdraw money on Fridays if they anticipated needing it over the weekend, but there was no established process for those who did not plan ahead. The Administrator was under the impression that money was kept in the nurses' medication carts for distribution after hours, but was unaware that this was not actually occurring. As a result, residents did not have reliable access to their funds outside of regular business hours.
Failure to Prevent Unauthorized Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required for medical treatment. According to facility policy, residents who may require restraints must be evaluated for the least restrictive device, considering physical and medical issues and possible alternatives. In this case, a resident with Alzheimer's disease, severe cognitive impairment, and a high risk for falls was admitted and care planned for various interventions, but there was no documentation or care plan indicating the use of a restraint. The Minimum Data Set (MDS) also did not indicate restraint use. Despite this, the resident was observed by an occupational therapist and the Director of Care Coordination with a gait belt fastened around their waist and buckled behind their back while seated in a wheelchair. Facility documentation and an incident report confirmed this observation, and the gait belt was subsequently removed by the Maintenance Director. Interviews with staff revealed that restraints were not used in the memory unit, and gait belts were typically only used by therapy staff. A hospice CNA was identified as the individual who placed the gait belt on the resident.
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.
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