Citations in Arkansas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Arkansas.
Statistics for Arkansas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Arkansas
A resident with severe cognitive impairment and a history of threatening behavior repeatedly verbally threatened and ultimately physically assaulted their cognitively impaired roommate, resulting in injury. Despite staff awareness of ongoing threats and verbal aggression, effective interventions such as room changes or psychiatric evaluation were not consistently implemented, and documentation of monitoring was lacking. The facility failed to protect residents from abuse as required by policy.
A resident with severe cognitive impairment and total dependence on staff for transfers sustained a spiral femur fracture after being improperly transferred with a mechanical lift by only one staff member, despite care plan requirements for two-person assistance. Staff interviews revealed that single-person operation of the lift occurred during short staffing, and there was confusion about proper lift procedures, including whether to lock the wheels, leading to inconsistent practices and ultimately resident harm.
Surveyors found that expired food items, such as buttermilk and bread, were not promptly removed from storage, and opened bags of hamburger buns were left unsealed, exposing them to contamination. Ice scoop holders were dirty, and dietary staff failed to follow hand hygiene protocols, handling clean equipment and food items after touching dirty surfaces without washing their hands. These deficiencies were confirmed through staff interviews and direct observation.
A resident who was cognitively intact and admitted for anxiety disorder was discharged to another facility despite having filed an appeal against the involuntary discharge. Staff and the Medical Director reported no evidence of physical abuse or smoking policy violations by the resident. The Ombudsman and the resident's family confirmed the appeal was filed before the discharge, but the facility proceeded with the transfer in violation of policy requiring appeals to be resolved prior to discharge.
A cognitively impaired resident with a history of sexual behaviors engaged in a sexual act with a staff member, which was witnessed by another staff and reported to administration and law enforcement. Despite ongoing reports of the resident's inappropriate sexual behaviors, the facility did not implement adequate supervision or interventions, and the abuse policy lacked specific guidance on sexual abuse prevention. The resident's care plan and assessments failed to accurately document these behaviors or address the risk, contributing to the incident.
A resident with moderate to severe cognitive impairment and a history of inappropriate sexual behaviors did not have these behaviors identified or addressed in their care plan. Despite multiple incidents involving public sexual acts and sexual contact with staff and other residents, the care plan lacked goals, interventions, or assessments for consent, and there were no physician orders for safe sex education or competency evaluation. Staff were aware of the behaviors but did not implement formal interventions or update the care plan until after a significant incident occurred.
The facility did not complete a thorough facility assessment to determine appropriate staffing and resource needs for all shifts, nor did it develop a plan for staff recruitment and retention. The assessment team lacked input from direct care staff and residents, and staffing decisions were based on census and minimal requirements rather than resident acuity or needs. Leadership interviews confirmed the facility assessment was not used to guide staffing or operational planning.
Two residents did not receive necessary assistance with personal hygiene and nail care, despite being unable to perform these activities independently. One resident, with a recent amputation and diabetes, was not assisted with shaving as requested, resulting in significant facial hair growth. Another resident, with paralysis and chronic illness, had long, curled, and discolored toenails that were not addressed despite repeated reports to staff. Facility policies and staff interviews confirmed the expectation for such care, but it was not provided in these cases.
Staff failed to follow infection control protocols during wound care for a resident with a surgical wound, including not using barriers, reusing gauze, and improper glove changes. Additionally, two glucometers used for blood sugar checks on multiple residents were not disinfected according to manufacturer guidelines, as an LPN used alcohol pads instead of the required germicidal wipes.
A resident with severe cognitive impairment and limited mobility was observed using a wheelchair that remained visibly dirty over several days, with staff interviews confirming that cleaning was a night shift CNA responsibility. The facility lacked policies or in-service training for wheelchair cleaning, contributing to the failure to maintain necessary equipment in a clean and sanitary state.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse between residents, specifically involving a resident with severe cognitive impairment who repeatedly threatened and ultimately physically assaulted their roommate, who also had severe cognitive impairment and decreased physical mobility. The first incident involved verbal threats and aggressive language directed at the roommate, with staff intervention and short-term monitoring, but no room change or psychiatric consultation was initiated at that time. Staff and CNA interviews revealed that threatening behavior and verbal aggression from the resident continued over a period of weeks, with multiple reports made to nursing staff. Despite ongoing threats and escalating behaviors, the residents continued to share a room. Staff were aware of the repeated threats and verbal altercations, but interventions such as room changes or psychiatric evaluations were not consistently implemented. The facility's Director of Nursing and Administrator cited a lack of available beds and did not recall or act upon all reported incidents. Documentation of one-on-one monitoring after the second incident was not provided, and there was no evidence of consistent or effective measures to separate the residents or address the aggressive behaviors. The situation culminated in a physical assault, where the aggressive resident struck their roommate on the forehead with a remote control, resulting in visible injury and bleeding. Staff responded to the incident, provided treatment, and initiated neuro checks, but the failure to act on prior threats and to implement protective interventions contributed to the occurrence of abuse. The facility's policy required protection from abuse and management of aggressive behaviors, but these measures were not adequately followed, leading to the cited deficiency.
Improper Mechanical Lift Use Resulting in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and fully dependent on staff for all activities of daily living, sustained a right distal third spiral femur fracture due to improper use of a mechanical lift during transfer. The resident had multiple diagnoses, including brain damage, weakened bones, and contractures, and required two-person assistance with a mechanical lift for all transfers, as documented in the care plan and Kardex. Despite these requirements, staff interviews and record reviews revealed that the mechanical lift was sometimes operated by a single staff member, particularly during periods of short staffing, contrary to facility policy and the resident's care plan. Multiple staff members, including CNAs and LPNs, admitted or reported witnessing the mechanical lift being used by only one person, with the second staff member sometimes merely standing at the doorway or not present at all. The incident leading to the resident's injury was not directly witnessed, but interviews indicated that the resident was found with a swollen knee, and subsequent x-rays confirmed a displaced femur fracture. The family was informed of the injury after they noticed the swelling, and there was confusion and lack of clear communication from staff regarding the cause of the injury. The facility's policy required two staff for mechanical lift transfers, and staff were aware of this requirement, but it was not consistently followed. Further review revealed inconsistencies in staff training and understanding of manufacturer guidelines for the mechanical lift, particularly regarding whether the wheels should be locked during transfers. Staff in-services had provided conflicting information, and some staff continued to lock the wheels despite manufacturer instructions to leave them unlocked. The facility's accident prevention policy emphasized a culture of safety and adherence to protocols, but the failure to ensure proper supervision and adherence to transfer procedures resulted in harm to the resident.
Deficient Food Storage, Expired Items, and Hand Hygiene in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and handling practices. Expired food items, including a half-gallon of buttermilk and three bags of bread, were found in storage past their expiration dates, despite the Dietary Manager's routine checks. Additionally, several opened bags of hamburger buns were left unsealed, exposing them to environmental contaminants and potential pests. Ice scoop holders attached to ice chests were found to be dirty, with residue at the bottom, and the scoops were resting directly on the unclean surfaces. Staff interviews confirmed that cleaning responsibilities for these items were not consistently followed. Dietary staff were also observed failing to adhere to proper hand hygiene protocols. One dietary aide turned off a faucet with bare hands and then handled clean glasses without washing hands. Another aide handled milk cartons, shakes, and condiments, then picked up cups and glasses by the rims without washing hands after touching potentially dirty objects. A third staff member touched a blender motor and then handled clean equipment without washing hands. These actions were in direct violation of the facility's hand washing policy, which requires hand hygiene after contact with dirty equipment or surfaces and before handling clean items.
Resident Discharged Despite Pending Appeal
Penalty
Summary
The facility failed to comply with regulations regarding the discharge of a resident who had filed an appeal against an involuntary discharge. The resident, who was cognitively intact and admitted with an anxiety disorder, was issued a 30-day discharge notice. Despite the resident filing an appeal on the same day the notice was given, the facility proceeded to discharge the resident to another facility the following day. The care plan for the resident did not indicate any anticipated discharge, and there was no documentation of smoking behavior or physical abuse by the resident. Multiple staff members, including CNAs and the Medical Director, reported no knowledge or evidence of the resident being physically abusive or violating smoking policies. Interviews with the resident, their family member, and the Ombudsman confirmed that the resident did not want to be discharged and had filed an appeal prior to being removed from the facility. The Ombudsman stated that the appeal was cancelled only after the resident had already been discharged. Facility policy and federal regulations prohibit the transfer or discharge of a resident while an appeal is pending, unless there is a documented risk to health or safety, which was not substantiated in this case. The Administrator acknowledged awareness of the pending appeal but chose to proceed with the discharge regardless.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Staff
Penalty
Summary
A cognitively impaired resident with a history of stroke, moderate dementia, and mood disorders was involved in a sexual act with a staff member, specifically a housekeeper, within the facility. The incident was witnessed by a CNA, who observed the resident performing oral sex on the housekeeper in the resident's bathroom. The event was reported to the facility administrator and local law enforcement, and the housekeeper was immediately terminated. The resident had a documented history of sexual behaviors with other residents and staff, as reported by multiple employees, but these behaviors were not consistently identified or addressed in the resident's Minimum Data Set (MDS) assessments or care plan documentation. Despite the resident's ongoing sexually inappropriate behaviors, the facility failed to implement adequate interventions or supervision to prevent such incidents. Staff interviews revealed that the resident was known for groping and attempting sexual contact with both staff and other residents, yet there were no specific measures in place to restrict unsupervised access to the resident by male staff or to ensure staff were not alone with the resident. The facility's abuse and neglect policy did not specifically address sexual abuse, nor did it provide clear guidance or training for staff on recognizing, preventing, or intervening in cases of sexual abuse involving residents. The facility's documentation and care planning did not accurately reflect the resident's sexual behaviors or risk for abuse, and there was a lack of physician orders or assessments regarding the resident's capacity to consent to sexual activity. Interviews with facility leadership and clinical staff indicated uncertainty about how to assess sexual consent capacity and how to manage residents with hypersexual behaviors. The failure to identify, document, and address the resident's risk for sexual abuse, combined with insufficient staff training and supervision, directly contributed to the occurrence of sexual activity between the resident and a staff member.
Failure to Address and Care Plan Resident Sexual Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed a resident's sexual behaviors, resulting in the absence of goals, interventions, or plans for safe sexual activity, assessment of competency for consent, redirection from other residents, and protection from unethical staff. Despite multiple documented incidents of inappropriate sexual behaviors, including public sexual acts and sexual contact with both staff and other residents, the care plan did not reflect these behaviors or provide specific interventions to address them. The care plan only noted the resident as sexually active and included general statements about respecting privacy during sexual activity with consenting partners, without addressing the resident's cognitive impairment or the need for consent assessment. The resident in question had a history of stroke, hemiplegia, moderate dementia, major depressive disorder, mood disorder, and anxiety disorder, with consistently low BIMS scores indicating severe to moderate cognitive impairment. Multiple MDS assessments failed to identify any sexual behaviors, despite staff and witness reports of ongoing inappropriate sexual conduct. Staff interviews and documentation revealed that the resident engaged in repeated sexual behaviors, including grabbing and touching staff and other residents, and was involved in an incident of oral sex with an employee. However, there were no physician orders for safe sex education, STD screening, or competency evaluation for sexual consent. Interviews with staff, including the DON, Administrator, and APRNs, confirmed that the resident's sexual behaviors were known and discussed, but no formal interventions or care plan updates were made to address these behaviors until after a significant incident occurred. Staff relied on informal redirection and discussions with the resident's representative, but there was no policy or procedure in place to manage such behaviors, nor were there documented interventions to prevent further incidents or protect the resident and others from harm.
Failure to Conduct Comprehensive Facility Assessment for Staffing and Resource Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not specify staffing requirements for day, evening, night, or weekend shifts based on the needs of the resident population. There was no documented plan for staff recruitment or retention, and the assessment team did not include direct care staff or resident representatives. The assessment relied on census numbers and minimal state requirements rather than a detailed analysis of resident acuity or specific care needs. Additionally, the assessment was not referenced by staff responsible for scheduling or staffing decisions. Interviews with facility leadership revealed a lack of understanding and utilization of the facility assessment in staffing and operational planning. The ADON and DON indicated that staffing decisions were based on corporate direction and minimal state formulas, without reference to the facility's own assessment. The Administrator also did not use the assessment to determine staffing needs, instead relying on general federal requirements. The facility's policy required a detailed review of resident acuity and available resources, but this was not reflected in the actual assessment or in practice.
Failure to Provide Personal Hygiene and Nail Care Assistance
Penalty
Summary
The facility failed to provide necessary personal care and assistance with activities of daily living for two residents who were unable to perform these tasks independently. One resident, admitted with multiple diagnoses including a recent amputation, diabetes, and vascular disease, was documented as requiring moderate assistance with personal hygiene. Despite being cognitively intact and expressing a clear preference to remain clean-shaven, the resident reported only receiving a shave once in the facility's barber shop, for which they had to pay. Over several days of observation, the resident continued to have a significant growth of facial hair, and staff interviews confirmed that CNAs were responsible for assisting with shaving but had not consistently provided this care as requested by the resident. Another resident, admitted with a history of stroke, paralysis, and chronic illnesses, was identified as having a self-care deficit and required assistance with nail care. Although records indicated that the resident's nails were checked regularly, direct observation revealed that the resident's toenails were long, curled, discolored, and jagged. The resident confirmed that the condition of their toenails was bothersome and had been reported to nursing staff multiple times. Interviews with CNAs and nursing staff revealed that there was an established process for nail care, particularly for residents with diabetes or other complicating conditions, but the process was not followed in this case. The resident was not listed for podiatry care, despite the need for professional attention to their toenails. Facility policies required that residents unable to perform activities of daily living independently receive necessary services to maintain grooming and hygiene, and that foot care be provided in accordance with professional standards. Staff interviews confirmed awareness of these policies and the procedures for providing or escalating care needs. However, the failure to provide timely and appropriate assistance with shaving and toenail care for these two residents resulted in unmet personal care needs, as directly observed and reported during the survey.
Infection Control Deficiencies in Wound Care and Glucometer Cleaning
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care and blood glucose monitoring. During wound care for a resident with a surgical wound and wound vacuum on the left foot, the LPN did not follow established infection control protocols. Supplies were placed directly on an un-sanitized over-bed table without a barrier, and no protective barrier was placed under the resident's foot, resulting in purulent drainage contaminating the bed linen. The LPN reused gauze pads to clean the wound, did not change gloves between removing the old dressing and cleaning the wound, and used scissors that had been placed on an un-sanitized surface to cut wound care materials. After the procedure, items such as the skin prep spray and scissors were handled with ungloved hands and placed on the treatment cart without immediate sanitization. Additionally, the facility failed to ensure that glucometers were cleansed according to the manufacturer's guidelines between resident uses. An LPN was observed performing fingerstick blood sugar checks on multiple residents using two glucometers, but did not properly disinfect the devices between uses. Instead of using a registered disinfectant or germicidal wipe as required by the manufacturer, the LPN used alcohol pads to clean the glucometers and only did so after multiple uses. The LPN stated that she had been instructed by management to use alcohol wipes, although the DON was unaware of this change and confirmed that germicidal wipes were the expected method. Facility policy for wound care required establishing a clean field, using barriers to protect linens, performing hand hygiene, changing gloves appropriately, and sanitizing reusable items before returning them to the treatment cart. The policy for glucometer cleaning aligned with the manufacturer's guidelines, which specified the use of a registered disinfectant or bleach solution. These protocols were not followed during the observed incidents, resulting in deficiencies in infection prevention and control.
Failure to Maintain Resident Wheelchair in Clean and Sanitary Condition
Penalty
Summary
The facility failed to ensure that necessary equipment, specifically a resident’s wheelchair, was maintained in a clean and sanitary condition. Over multiple days of observation, the wheelchair assigned to a resident with severe cognitive impairment and limited mobility was found to have visible dirt, white and brown flakes, and crumbs caked on the seat cushion and frame. The resident, who had diagnoses including hypertensive heart disease, vascular dementia, and acute kidney failure, reported that the wheelchair had been dirty for a long time. Staff interviews confirmed that it was the responsibility of night shift CNAs to check and clean wheelchairs, but the resident’s wheelchair remained unclean over several days. Further review revealed that the facility did not have any policies or in-service training related to environmental or wheelchair cleaning. Multiple staff members, including CNAs, LPNs, and the DON, acknowledged that cleaning wheelchairs was part of the night shift CNAs’ duties, but the lack of a formal policy or training contributed to the ongoing issue. The deficiency was identified through direct observation, resident and staff interviews, and review of facility records.
Some of the Latest Corrective Actions taken by Facilities in Arkansas
- Provided comprehensive in-service training for all staff on abuse-reporting procedures to the Administrator, DON, and Office of Long-Term Care (L - F0610 - AR)
- Appointed the DON as Abuse and Neglect Coordinator to monitor, investigate, and report all allegations (L - F0610 - AR)
- Implemented a monitoring tool for ongoing documentation and reporting of abuse allegations (L - F0610 - AR)
Failure to Investigate and Report Alleged Abuse and Protect Residents
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations of abuse involving a resident who required assistance with transfers and had intact cognition. In both cases, there was no evidence that a resident statement, accused staff statement, assessment of the resident, bedside staff interviews, or a police report were completed. The facility also did not document a body audit or a nurse assessment in the medical record following the allegations. The incidents were not reported to the appropriate authorities or the State Agency/Office of Long Term Care (OLTC) as required by facility policy and state regulations. When the first allegation was made that a staff member was rough with the resident, the staff member was simply reassigned to another hallway and allowed to continue working with other residents. The incident was reported to the Assistant Director of Nursing (ADON), but no formal investigation or documentation was completed at that time. The ADON did not conduct a body audit or assessment and did not know if the allegation was investigated further. The Certified Nursing Assistant (CNA) Supervisor also failed to report a separate incident involving another staff member and did not complete any write-up or formal report, only moving the accused staff member to a different hall. The Administrator later provided a minimal two-page investigation that lacked essential elements such as resident and staff interviews, body audits, and proper documentation. The Administrator admitted that the incident was not reported to mandatory authorities and that the documentation provided was the entirety of the investigation. The facility did not have an abuse coordinator at the time, and the highest-ranking person present was responsible for investigations. The Director of Nursing (DON) confirmed that the accused staff should have been separated from residents and that the incident should have been reported and investigated immediately.
Removal Plan
- Provide in-service training for all staff on reporting abuse and neglect to the Administrator, the DON, and Office of Long-Term Care.
- Report all incidents properly.
- Ensure resident safety.
- Interview residents regarding abuse and conduct body audits for residents unable to verbalize abuse.
- Appoint the DON to monitor, investigate, and report allegations of abuse.
- Implement a monitoring tool for documenting and reporting allegations of abuse.
- Appoint the DON as the Abuse and Neglect Coordinator.
- Ensure all staff complete training on reporting of abuse before returning to work.
Administrative Failures Result in Multiple Immediate Jeopardy Deficiencies
Penalty
Summary
The facility's administration failed to implement and enforce policies necessary for the effective management and operation of the facility, resulting in multiple deficiencies. There was no full-time RN working eight consecutive hours per day, and the facility lacked a Director of Nursing (DON) for an extended period. The responsibilities of the DON, including care planning, fall assessments, and MDS completion, were not being fulfilled, as confirmed by staff interviews. The Assistant Director of Nursing (ADON) was unable to assume these duties due to other responsibilities, and the Med Records Nurse had been working as a bedside nurse for six months, leaving medical records unattended. Employee files for former DONs showed no signed job descriptions, and there was no evidence of staff orientation or training programs as required by facility policy. The facility also failed to ensure that LPNs managing peripherally inserted central catheters (PICC) were properly certified or trained. The Administrator admitted to not tracking which LPNs were IV certified and confirmed there was no IV training provided in the facility. Bed rails were installed on most beds without proper assessments, consent, or documentation. The Housekeeping/Maintenance Supervisor, responsible for installing and maintaining bed rails, had not read manufacturer guidelines and did not keep logs or forms related to bed rail safety. Staff interviews revealed a lack of knowledge about bed rail assessments and documentation, and the process for determining bed rail use was informal and based on resident preference rather than clinical assessment. Residents who experienced falls did not receive fall assessments or updated care plans, and interventions to prevent further falls were not identified or implemented. A newly admitted resident was not assessed for mobility function, and necessary interventions and equipment to maintain independence were not provided. The facility was unable to provide a policy for Activities of Daily Living/Mobility when requested. These failures in administration and oversight led to Immediate Jeopardy findings for multiple federal regulations, with the potential to cause serious harm to all residents in the facility.
Removal Plan
- In-service/meeting given via phone by regional director to governing body members (Manager, medical director) and in person to administrator.
- Administrator in-serviced management staff (DON, COM, SS, HR, MOS) regarding the following: Responsibility of the Governing Body (facility oversight, operations and policy/procedure), Survey findings and Plan of Removal to correct: Fall Clinical Protocol, Registered Nurse requirement, Competent staff, Mobility, Bed rail usage and Supervision to prevent accidents, Plan moving forward to improve findings.
- In-service provided to Administrator by Regional Director.
- In-service provided to nursing staff regarding policy and procedure of bed rails, assessing, consent to use and physician order required.
- Consent forms for residents with bed rails obtained.
- Bed rail assessments for residents with bed rails completed.
- Assessments and consents obtained for six residents identified as having bed rails with no assessments/consents.
- Monitoring sheets completed by Administrator and Director of Nursing (DON), by Housekeeping Supervisor and by Administrator and DON, for bed rail assessment and consents.
- File containing manufacturer guidelines for bed rails provided.
- Housekeeping Supervisor in-serviced by the Administrator regarding bedrails, maintenance, ensuring bedrails are compatible with the bed frame, and has reviewed and will refer to guidelines if needed.
- Staff in-serviced on bed rails and enhanced barrier precautions.
- Staff who were not physically present to receive the in-services were in-serviced by telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.
Failure to Maintain Full-Time DON and RN Coverage Resulting in Lapses in Resident Care
Penalty
Summary
The facility failed to ensure the employment of a full-time Director of Nursing (DON) and did not provide registered nurse (RN) coverage for at least 8 consecutive hours per day, as required. Review of employee files and timecard reports revealed that the facility was without 8 consecutive hours of RN coverage on 53 out of 65 days, and there were periods when the DON position was vacant or filled by staff who did not fulfill the required duties. The lack of RN oversight and management led to significant lapses in care planning, assessment, and intervention for multiple residents. Several residents were directly affected by these deficiencies. One resident with severe cognitive impairment and a history of falls suffered two major falls with injuries, including fractures to both arms, without appropriate updates or escalation of interventions in their care plan. Another resident with a peripherally inserted central catheter (PICC) line did not receive RN assessment or care of the line for 18 days, and intravenous medications were administered by LPNs, some of whom were not verified as IV certified. Additional residents were admitted without timely completion of Minimum Data Set (MDS) assessments or comprehensive care plans, resulting in a lack of documented interventions for their care needs for extended periods. Interviews with staff confirmed that in the absence of an RN or DON, LPNs and CNAs were left to make assessments and update care plans, often without proper oversight or knowledge of the requirements. The Assistant Director of Nursing (ADON) did not assume DON responsibilities and was unaware that MDS assessments and care plans had not been completed. The facility's own documentation and staff statements indicated a lack of clear processes for ensuring RN coverage, verifying LPN IV certification, and maintaining compliance with federal and state regulations regarding nursing services.
Removal Plan
- Hire Interim Registered Nurse/Director of Nursing. Provide Registered Nurse weekend coverage and replace Director of Nurses in event of a call in. Update schedule to reflect Registered Nurse Coverage. Ensure Registered nurse coverage is 8 consecutive hours daily.
- In-service Administrator by Regional Director on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week.
- Remove Resident #33 peripherally inserted central catheter (PICC) Line. Review and update care plan as needed.
- In-service bedside LPN 1:1 by administrator about scope of practice regarding PICC line and site care.
- In-service all LPNs/RNs by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care.
- In-service all staff by administrator and/or director of nursing in person or by phone on ESP and infection control.
Failure to Ensure Competent Nursing Staff for IV Therapy and PICC Line Management
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies to care for every resident in a manner that maximized their well-being. Specifically, the facility did not ensure that LPNs with IV certification were the only staff accessing and managing a resident's PICC line, including administering IV antibiotics, performing IV flushes, and assessing the line's condition. Documentation revealed that multiple LPNs, some without documented IV certification, administered IV medications and performed assessments that were outside their scope of practice according to state regulations. The facility's own policies required consultation of state laws regarding scope of practice, but there was no evidence that the facility verified or tracked IV certification for LPNs, nor did it provide IV training to its staff. A review of the facility's staffing assessment and policies showed a lack of clear guidelines for RN coverage and no self-assessed staffing standards. The facility's job descriptions and interviews with staff indicated that LPNs were expected to perform assessments and interventions that should have been conducted by an RN, particularly for residents with complex needs such as those with a PICC line. The Arkansas Board of Nursing regulations specify that LPNs must work under the direction of an RN for tasks requiring substantial specialized judgment and skill, such as IV therapy and PICC line management. However, the facility did not ensure RN oversight or presence for these tasks, and staff interviews confirmed that LPNs were performing assessments and interventions independently. The deficiency was identified after a review of records for several residents, including one who was admitted with a PICC line for IV antibiotics and wound care. There were multiple days when no RN assessment or care of the line was documented, and IV antibiotics were administered by LPNs without verification of their IV certification. The facility's failure to ensure appropriate staffing, competency verification, and adherence to scope of practice requirements resulted in non-compliance with federal and state regulations, creating a situation that was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents.
Removal Plan
- Hire Interim Registered Nurse/Director of Nursing. Provide Registered Nurse weekend coverage and replace Director of Nurses in event of a call in. Update schedule to reflect Registered Nurse Coverage. Ensure Registered nurse coverage is 8 consecutive hours daily.
- In-service Administrator by Regional Director on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week.
- Remove Resident #33 peripherally inserted central catheter (PICC) Line. Review and update care plan as needed.
- In-service bedside LPN 1:1 by administrator about scope of practice regarding PICC line and site care.
- In-service all LPNs/RNs by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care.
- Provide in-services by the Administrator and/or Director of nursing to licensed nursing staff regarding: Care plans-Baseline, comprehensive, and closet care plans completed timely; MDS Timeliness; RN Assessments and interventions; Fall Documentation; Enhanced Barrier Precautions (EBP)/INFECTION CONTROL.
- Regional Director to provide in-service via phone to Administrator regarding LPN Administration of IV medication. Administrator to in-service DON and Human Resource Coordinator on tracking IV certifications of LPNs in event of another PICC line admission.
Failure to Assess, Obtain Consent, and Ensure Safe Installation of Bed Rails
Penalty
Summary
The facility failed to ensure that proper assessments, informed consents, and compatibility checks were completed prior to the installation and use of bed rails for two residents. Observations revealed that bed rails were in use on both sides of the beds for these residents, but there was no documentation of bed rail assessments, informed consent from the residents or their representatives, or evidence that the bed rails were compatible with the beds according to manufacturer guidelines. Staff interviews confirmed a lack of understanding and inconsistent practices regarding bed rail assessments, installation, and documentation, with some staff unaware of the requirements or the process for determining bed rail use. For one resident with a history of falls, dementia, and chronic ischemic heart disease, bed rails were observed in the up position on multiple occasions. However, neither the care plan nor the closet care plan indicated the use of bed rails, and staff were unsure if the resident was supposed to have them. The spouse of this resident reported never being informed about the bed rails or asked for consent. Maintenance staff responsible for installing bed rails admitted to not measuring beds for compatibility, not reading manufacturer guidelines, and not keeping records of maintenance or safety checks, despite acknowledging that loose bed rails could be unsafe. For another resident with multiple diagnoses including dementia and insomnia, bed rails were also observed in use, but the care plan and MDS did not reflect this. Staff interviews indicated that bed rails were already installed upon admission and that housekeeping, not nursing, installed them. The resident's family confirmed they were not informed about the bed rails, the risks involved, or asked for consent. There was also evidence of gaps between the mattress and bed rails, raising concerns about entrapment, and no documentation was found to support the safe and appropriate use of bed rails for either resident.
Removal Plan
- Provide in-service to Administrator by Regional Director regarding bed rails and assessing, getting signed consent and order prior to use.
- Administrator to provide in-service to nursing staff in person and via phone regarding policy and procedure of bed rails, assessing, consent to use and physician order requirement.
- Review records to be completed by nurse manager to identify other residents with bed rails.
- Identified residents will be assessed by nurse and consent obtained.
- Administrator and DON will monitor care areas weekly to ensure bed rails are assessed and consent obtained and in the record.
- Care plan and MDS will be updated by LPN Nurse consultant.
- IDT team will work with environmental services supervisor to ensure bed frame and bed rails are compatible for the provided bed per manufacturers guidelines and recommendations.
- Provide in-service by administrator to environmental service supervisor regarding bed rails, bed maintenance and ensuring bedrails and bedframe are compatible to prevent entrapment zones.
Failure to Update Fall Interventions and Care Plans After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls received proper assessments and interventions to prevent further accidents. The resident, who had severe cognitive impairment and required substantial assistance for mobility, experienced multiple falls within a short period. Despite documented incidents, including unwitnessed falls resulting in significant injuries such as fractures to both arms, the facility did not update the resident's care plan or implement new interventions after each event. The care plan remained unchanged even after the resident returned from the hospital with a cast, which the resident repeatedly removed, leading to additional falls and injuries. Staff interviews revealed that after each fall, assessments and incident reports were completed, but immediate interventions were not consistently documented or added to the care plan. The process for updating care plans and communicating new interventions to staff was not followed, particularly in the absence of a Director of Nursing (DON). The Assistant Director of Nursing (ADON) acknowledged that fall assessments and care plan updates were not being completed due to the lack of a DON, and that there was confusion among staff regarding their responsibilities in monitoring and preventing falls. The facility's policy required staff to identify and implement pertinent interventions after each fall, but this was not adhered to. The lack of timely and appropriate interventions, failure to update care plans, and insufficient staff training and oversight contributed to repeated falls and serious injuries for the resident. These actions and omissions resulted in non-compliance with federal requirements for quality of care and accident prevention.
Removal Plan
- Fall assessments and interventions reviewed and updated as needed for Residents #15 and #25 by facility nurse.
- In-service by administrator, regional director and nurse consultant for Nursing staff (RN, LPN, CNA) present and via phone for those not in facility regarding the following: Assessing, monitoring and intervening in falls to prevent injury and/or reduce falls; Proper interventions for falls; Care plans related to falls; Notification of PCP, DON, family and administrator.
- DON/Administrator in-serviced by regional director in regards to monitoring of incident and accident (I&A), fall records and daily nurse documentation to identify and address any concerns immediately.
Failure to Secure Exit Doors Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that exit doors were secured and functioning properly, resulting in a resident with severe cognitive impairment and a known history of elopement being able to exit the building without staff knowledge. The resident, who had diagnoses including alcohol-induced persisting dementia, major depressive disorder, anxiety disorder, and altered mental status, was identified as an elopement risk and had a care plan reflecting this risk. Despite this, the resident was able to leave the facility through the front entrance door after a nurse had entered, and staff only became aware of the elopement when the resident was not found in their usual locations during rounds. Staff interviews and record reviews revealed that the front door's locking mechanism was unreliable, particularly during high winds, which could prevent the door from latching and cause alarms to malfunction. Maintenance staff and nursing personnel acknowledged that the issue with the door not latching due to wind was a known problem, and a note had been posted at the door to remind staff to ensure it was closed during high winds. Additionally, staff reported that the alarms at the front and side doors were not working at the time of the incident, and the door could be opened after a short delay even when it was supposed to be locked. The resident was eventually found by law enforcement in a field behind the facility and returned safely. The incident was documented, and staff interviews confirmed that the resident was more confused when off the secure unit. The facility's failure to maintain secure exit doors and ensure proper functioning of door alarms directly contributed to the resident's ability to elope, despite the resident's documented risk and history of similar behaviors.
Removal Plan
- Place resident in secured unit for safety and monitor by staff and nurse manager/designee.
- Re-inservice all staff on abuse prevention program and facility elopement policy.
- Assess all residents for elopement risk using elopement and wandering assessment, review care plans, and update care plans for residents at risk for elopement.
- Update elopement binder with resident pictures and demographics and inservice staff on use of elopement binder.
- Complete body audit, incident, accident and elopement form when resident is found and returned to building, including documentation of last seen, when resident was found, and notification of family and doctor.
- Recheck all doors by maintenance for working locking mechanisms.
- Contact door company to check all doors for proper working condition.
Failure to Prevent Elopement Due to Inadequate Supervision and Unsecured Exit Codes
Penalty
Summary
The facility failed to adequately monitor and supervise a severely cognitively impaired resident, resulting in the resident exiting the facility without staff knowledge. The resident, who had a history of traumatic brain injury and a BIMS score indicating severe cognitive impairment, was able to access and use an exit door code that had been provided to certain residents by staff. This allowed the resident to leave the facility unsupervised and travel approximately 250 feet away, where they were found by a community member. At the time of the incident, the resident was observed in the lobby near the front door and subsequently exited the building using the code. Staff were unaware of the resident's departure until notified by an individual who saw the resident outside her home. The resident was outside for approximately 30 minutes in hot weather conditions before being returned to the facility by staff. Interviews with staff indicated that residents not considered at risk for elopement had access to the exit code, and the resident in question was not previously identified as having exit-seeking behaviors. The facility's elopement policy required identification and monitoring of residents at risk for unsafe wandering, but the failure to secure exit codes and supervise the resident led to the elopement event. Documentation and interviews confirmed that the resident was not injured during the incident, but the lack of adequate supervision and unsecured exit codes constituted non-compliance with requirements to prevent accidents and ensure resident safety.
Removal Plan
- Resident #46 was placed on the secured unit following their return to the facility.
- Elopement assessments were completed for all residents including Resident #46. The care plan for each resident identified at high risk of elopement was reviewed and updated as necessary.
- The administrator/designee initiated an in-service for staff on elopement and/or wandering. All staff have/will be in-serviced prior to working their next shift. The in-service was completed.
- Exit door codes were changed, and continue to be changed monthly or as needed.
- Staff was ordered to monitor behaviors and triggers for Resident #46.
- Window stoppers were placed on the windows of the secured unit to prevent residents from opening the windows and removing screens to leave the facility.
Failure to Assess and Support Resident Mobility and Independence
Penalty
Summary
The facility failed to assess and address the mobility needs of a resident with multiple complex medical diagnoses, including respiratory failure, diabetes mellitus, atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and Raynaud's syndrome. Upon admission, the resident was documented as requiring assistance for most activities of daily living (ADLs) and was using a wheelchair for mobility. However, the initial evaluation was not a comprehensive assessment, and a required admission MDS was not completed by the deadline. The resident did not have a comprehensive, individualized care plan in place until well after admission, and the only care plan available was a generic, undated document with limited information. Observations and interviews revealed that the resident became totally dependent on staff for mobility and ADLs, resulting in a significant decline in functional status and psychosocial well-being. The resident reported feeling imprisoned, totally dependent, and expressed distress over the loss of independence. The resident was unable to maneuver the manual wheelchair due to multiple finger amputations and blackened fingertips, and staff did not provide or assess for appropriate adaptive equipment to promote independence. The resident's own mobility aids from home were not supplemented or replaced by the facility, and staff did not inquire about or provide interventions to support the resident's independence until prompted by surveyors. Staff interviews confirmed that care planning responsibilities were neglected due to the absence of a Director of Nursing, and no one had assumed those duties. The resident's psychosocial harm was compounded by missed opportunities to participate in activities due to lack of assistance and appropriate equipment. The facility also failed to communicate with the resident and their representative regarding available tools and interventions to improve mobility and independence, only reaching out after surveyor involvement. The lack of assessment, individualized care planning, and provision of necessary equipment led to a preventable decline in the resident's mobility and psychosocial health.
Removal Plan
- Provide in-service to Administrator by Nurse Consultant regarding preventing decline in residents' level of activities of daily living (ADL) functions, including providing necessary equipment appropriate for resident and facility.
- Administrator to provide in-service to DON regarding preventing decline in resident ADL functions, including providing necessary equipment and assessing for appropriate interventions to prevent declines.
- Administrator and Nurse Consultant to in-service nursing staff to identify and respond appropriately to a resident's decline in ADL functions, including assessing, monitoring and providing interventions. Nurses will be responsible for assessing and providing appropriate interventions.
- Contact Resident #184 family to bring specialized equipment (special belt for foot movement and trapeze bar) from home that is being requested by resident to facility so it can be used to assist with his independent transfer and repositioning.
- Administrator and DON to monitor care areas routinely to ensure equipment is in place.
- Notify Primary Care Physician of Resident #184 of mental health concerns and request further direction/orders. Contact family to bring personal items from home, notify Physician for any new orders and contact pharmacy for medication consult.
- Complete care plan and MDS for Resident #184.
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