Citations in Arizona
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Arizona.
Statistics for Arizona (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Arizona
Latest Citations in Arizona
Two residents with cognitive impairments were involved in a physical altercation, resulting in one sustaining a skin tear to the hand. The incident was reported by the injured resident to an LPN, who observed the injury and questioned both parties. Conflicting and delusional accounts were given, and the facility's investigation was unsubstantiated due to lack of witnesses, despite documentation of prior aggressive behavior by one resident.
A resident with severe cognitive impairment and a history of psychiatric disorders became physically aggressive, pulling another cognitively impaired resident to the ground in a common area. The incident was witnessed by staff, who separated the residents and assessed the victim for injuries. Facility records and care plans did not previously document aggressive behaviors for the aggressor, and the facility's investigation substantiated the occurrence of resident-to-resident abuse.
A resident with significant medical and cognitive conditions was allowed to smoke unsupervised, contrary to facility policy requiring staff supervision and control of smoking materials. The resident accessed the smoking patio alone, obtained smoking materials, and suffered severe burns when his blanket caught fire. Staff discovered the incident only after the resident was already injured, and the event resulted in the resident being sent to a burn center for treatment.
A resident with multiple medical conditions and intact cognition was found with a fractured finger of unknown origin. Although the incident was reported to authorities, the facility did not follow its abuse investigation policy, as required interviews with staff, family, visitors, and others were not conducted or documented, resulting in an incomplete investigation.
A resident with multiple medical conditions and intact cognition reported unexplained pain in a finger, which was found to be fractured. The facility reported the incident but did not conduct a thorough investigation as required by policy, failing to obtain written statements from staff, family, or others who may have had relevant information. Staff interviews confirmed that the expected investigative process was not followed, resulting in an incomplete investigation.
Two cognitively intact residents with behavioral histories were involved in a physical altercation on the patio, resulting in one resident losing a tooth after being struck by another. The incident was documented, and both police and APS were notified. Facility policies prohibiting abuse were reviewed, and the administrator confirmed the injury and refusal of treatment.
A resident with an indwelling catheter had urinary outputs documented in the medical record for days when the resident was not present in the facility, following a hospital transfer. Staff interviews revealed confusion about documentation procedures during resident absences, and the DON confirmed that such documentation should not have occurred, as facility policy requires accurate daily output records.
A resident with severe cognitive impairment and a history of wandering and agitation was identified as an elopement risk, yet was not placed on a secured unit or provided with sufficient supervision. Despite staff awareness of the resident's behaviors and repeated expressions of wanting to leave, the resident was able to exit the facility unsupervised and was later found at a nearby bus stop. The facility's policy required at-risk residents to be accompanied when leaving, but this was not followed, resulting in a failure to prevent the elopement.
A resident with a history of heart failure and other conditions experienced multiple episodes of low oxygen saturation, but staff did not administer oxygen, re-check levels, or notify the provider as required. The care plan did not address respiratory needs, and there was no evidence of an oxygen order or appropriate response to the resident's respiratory distress, despite facility policy and provider recommendations.
A resident with end stage renal disease and intact cognition repeatedly refused showers scheduled on dialysis days, expressing concerns about going to dialysis with wet hair and the risk of pneumonia. Despite communicating these preferences to staff, the resident's shower schedule was not adjusted, and documentation showed ongoing refusals without evidence that staff explored or accommodated her wishes, resulting in a failure to honor resident choice in personal hygiene care.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a skin tear injury. One resident, with a history of dementia, major depressive disorder, and traumatic brain injury, was identified as having potential for physical and verbal aggression. This resident was involved in an altercation with his roommate, who had moderate cognitive impairment and multiple psychiatric and medical diagnoses. The incident occurred when the aggressive resident struck his roommate on the left hand, causing a skin tear, as the latter was attempting to leave their shared room. Clinical documentation and staff interviews confirmed that the altercation resulted in a physical injury. The injured resident reported the incident to an LPN, who observed the wound and questioned both residents. Both provided conflicting accounts, with the aggressive resident referencing delusional beliefs and claiming the other resident had provoked him. The LPN and administrator both noted that the explanations given by the residents were inconsistent and, at times, nonsensical, but it was clear that a physical altercation had taken place, resulting in injury. The facility's investigation into the incident was ultimately unsubstantiated due to the lack of witnesses and conflicting statements from those involved. However, documentation revealed that the aggressive resident had a prior history of altercations and of taking belongings from others. Facility policies reviewed during the investigation emphasized the right of residents to be free from abuse and the facility's commitment to preventing such incidents, but the event demonstrated a failure to ensure this protection.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent one resident from physically abusing another resident. One resident with severe cognitive impairment and a history of psychiatric and behavioral diagnoses, including schizoaffective disorder and traumatic brain injury, exhibited physical and verbal aggression. On the day of the incident, this resident became aggressive with staff and attempted to hit them while trying to leave, ultimately requiring intervention by three staff members and the police. During this episode, the resident physically assaulted another resident by grabbing the individual's leg and pulling them to the ground. Prior to this event, the resident's care plan and assessments did not document any physical behaviors or incidents involving aggression toward other residents. The resident who was assaulted also had severe cognitive impairment and multiple psychiatric and medical diagnoses, including dementia with agitation and psychosis. At the time of the incident, this resident was attempting to ambulate in a common area when the aggressor pulled him down, resulting in a fall to his knees. Staff immediately separated the residents and assessed the assaulted resident for injuries, finding none. The facility's investigation substantiated that resident-to-resident abuse had occurred. Policy reviews confirmed that the facility was required to prevent all forms of abuse, including those perpetrated by other residents.
Resident Sustains Severe Burns Due to Lack of Supervision During Smoking
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including hemiplegia, peripheral vascular disease, dementia, and cognitive communication disorder, was allowed to smoke unsupervised, resulting in life-threatening injuries. The resident had a care plan in place identifying the potential for injury related to smoking, with interventions such as maintaining smoking materials at the nurses' station and monitoring compliance with the facility's smoking policy. The resident was assessed as cognitively intact and had a recent smoking assessment indicating the need for supervision and use of a smoking apron. Despite these interventions, the resident accessed the smoking patio alone, outside of designated supervised smoke break times, and was able to obtain smoking materials. Staff interviews confirmed that the facility's policy required staff to hold all smoking paraphernalia and supervise residents during scheduled smoke breaks. However, on the day of the incident, the resident was found on the patio without staff supervision, and his blanket caught fire, resulting in burns to his face and neck. The incident was discovered by a staff member passing by, who called for help and attempted to extinguish the fire. The facility's smoking policy explicitly stated that residents were not allowed to keep smoking materials on their person and that all smoking was to be supervised at specific times. The failure to adhere to these protocols led to the resident sustaining third-degree burns and requiring emergency medical attention. Staff interviews and documentation confirmed that the resident was not being supervised at the time of the incident, and the most recent smoking assessment was not provided upon request.
Failure to Adhere to Abuse Investigation Policy After Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its abuse policy following an incident involving an injury of unknown origin for one resident. The resident, who had multiple diagnoses including type 2 diabetes, PTSD, and depression, was found to have a red, swollen, and painful pinky finger, which was later confirmed by x-ray to be a nondisplaced fracture. The resident was cognitively intact and did not recall any fall or incident that could have caused the injury. The facility reported the incident to the appropriate authorities and documented the event, but the internal investigation was unsubstantiated due to the resident's underlying bone conditions. Despite the reporting, the facility's investigation did not include interviews with staff, family, visitors, other departments, or other residents, as required by the facility's abuse policy. Interviews with facility staff, including the RN, CNA, DON, ADON, and Administrator, revealed that the expected process for investigating injuries of unknown origin included interviewing all relevant parties and obtaining written, signed statements. However, in this case, these steps were not followed, and the investigation documentation lacked evidence of comprehensive interviews. The facility's policy clearly stated that all allegations of abuse, including injuries of unknown origin, must be thoroughly investigated with interviews of all potential witnesses and involved parties, and that these interviews should be documented in writing. The failure to conduct and document these interviews represented a deviation from the established policy and resulted in an incomplete investigation of the incident.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an injury of unknown origin for one of three sampled residents. The resident, who had a history of multiple medical conditions including type 2 diabetes, depression, and osteopenia, reported pain in the left pinky finger, which was found to be red, swollen, and fractured upon x-ray. The resident was cognitively intact and did not recall any fall or incident that could have caused the injury. The facility reported the incident to the appropriate authorities and documented the resident's statement, but the investigation was deemed unsubstantiated based on the x-ray findings and the resident's lack of recollection. Despite the facility's policy requiring a thorough investigation—including interviews with the person reporting the incident, witnesses, the resident or representative, staff members in contact with the resident, the resident's roommate, family members, and visitors—there was no evidence that such comprehensive interviews were conducted. The investigation documentation lacked statements from staff, family, visitors, other departments, or other residents who may have had relevant information about the incident. Interviews with facility staff, including the DON, ADON, and Administrator, confirmed that the expected process would involve obtaining written, signed, and dated statements from all potentially involved parties, but this was not done in this case. The deficiency was further highlighted by staff interviews, which revealed an understanding of the required investigative process, yet the actual investigation for this incident did not follow those protocols. The Administrator acknowledged that interviews were not conducted because the resident denied issues with staff, but also stated that interviews are required during such investigations. The facility's failure to follow its own policy and thoroughly investigate the injury of unknown origin resulted in an incomplete investigation for the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent one resident from physically abusing another resident, resulting in physical harm. Resident #2, who was cognitively intact and had a history of behavioral issues including outbursts of anger and exposing himself, was involved in an altercation with Resident #4 on the facility patio. During this incident, Resident #2 knocked out Resident #4's tooth, while Resident #4 struck Resident #2 with a stick. The altercation was documented in progress notes, and both the police and Adult Protective Services were notified immediately after the event. Resident #4, also cognitively intact and with a history of behavioral problems such as making false accusations and interfering with facility protocols, lost newly cemented dental bridges as a result of the altercation. Interviews confirmed that Resident #4 had been involved in previous altercations at the facility. The facility's policies on abuse and resident rights, which prohibit physical abuse and guarantee freedom from abuse and neglect, were reviewed as part of the investigation. The administrator confirmed the loss of the tooth and noted that the resident refused treatment.
Inaccurate Documentation of Urinary Output for Absent Resident
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for one resident regarding urinary output. The resident, who had multiple diagnoses including muscle weakness, mobility issues, and both acute and chronic respiratory failure, was admitted with an indwelling catheter and an order for routine catheter care. Despite being transferred to the hospital and not present in the facility, the resident's Treatment Administration Record (TAR) showed documented catheter outputs for days when the resident was not in the facility. Interviews with staff revealed uncertainty about documentation procedures when a resident is out of the facility. The LPN was unsure if outputs should be recorded during a resident's absence, while the CNA stated that output documentation is only done when the resident is present. The DON confirmed that documentation of outputs should not occur when a resident is not in the facility and verified that incorrect entries were made in the resident's record. Facility policy requires maintaining an accurate record of daily output, which was not followed in this instance.
Failure to Provide Adequate Supervision for Resident at Risk of Elopement
Penalty
Summary
A resident with a history of cerebral infarction, encephalopathy, stimulant abuse, and schizophrenia was admitted to the facility with severely impaired cognition, as indicated by a BIMS score of 3. The resident was identified as an elopement risk and exhibited behaviors such as wandering, agitation, rejection of care, and attempts to leave the facility. Multiple clinical notes documented frequent wandering, unsteadiness, agitation, and verbal expressions of wanting to leave. The care plan and wander risk assessments recognized the resident's risk for elopement, but despite these documented risks, the resident was not placed on a secured unit prior to the incident. Staff interviews revealed that the resident was known to be a 'runner' and was closely watched by staff, but there were lapses in supervision. On the day of the incident, the resident was highly agitated and expressed a desire to leave. The resident's wheelchair was later found outside the facility's front doors, and a search determined that the resident had eloped and was found at a nearby bus stop. The receptionist, responsible for monitoring the front door, did not observe the resident leaving, and the facility's policy required that at-risk residents be accompanied by staff or a responsible party when leaving the grounds. Despite staff awareness of the resident's behaviors and risk factors, the resident was able to exit the facility unsupervised. The facility did not implement additional interventions, such as transferring the resident to a secured unit, prior to the elopement, even though staff had discussed this option. The deficiency resulted from the failure to provide adequate supervision and to follow established policies for residents at risk of elopement.
Failure to Provide Appropriate Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a history of diabetes mellitus, hypertension, and heart failure with preserved ejection fraction. The resident was admitted with recommendations from medical providers for supplemental oxygen to maintain oxygen saturation above ninety-two percent. However, the care plan did not address oxygen use or respiratory needs, and there was no evidence of an order for oxygen therapy. Multiple documented oxygen saturation readings were at or below ninety-two percent, with some as low as eighty percent, all recorded while the resident was on room air. There was no documentation that staff re-checked oxygen saturation after low readings, applied oxygen, or notified the provider of these findings. Interviews with staff and review of facility policies confirmed that staff were expected to notify providers and obtain orders in the event of low oxygen saturation or respiratory distress. Despite this, there was no evidence that the provider was contacted or that oxygen was administered as a nursing or emergency measure. The resident's family also reported observing episodes of respiratory distress and felt that staff did not respond appropriately. Facility policies required communication of changes in condition and administration of oxygen as ordered or as an emergency measure, but these procedures were not followed in this case.
Failure to Honor Resident's Shower Preferences on Dialysis Days
Penalty
Summary
The facility failed to honor a resident's preferences regarding personal hygiene care, specifically related to shower scheduling. The resident, who had diagnoses including metabolic encephalopathy, urinary tract infection, and end stage renal disease, was cognitively intact and received dialysis three times a week on Mondays, Wednesdays, and Fridays. Documentation showed that the resident frequently refused showers on Wednesdays, which coincided with her dialysis days, and expressed concerns about going to dialysis with wet hair and the risk of developing pneumonia. Despite the resident communicating her preferences to multiple staff members, her shower schedule was not adjusted to accommodate her wishes. Review of the care plan indicated interventions to support resident choice and provide opportunities for decision-making during care. However, records from February to early May showed repeated refusals of showers on dialysis days, with staff documenting refusals but not consistently exploring or addressing the underlying reasons. Progress notes and psychiatric notes confirmed that the resident occasionally refused showers, but there was no evidence that staff had asked the resident about her reasons for refusal or attempted to modify the schedule based on her expressed preferences. Interviews with staff, including a CNA, LPN, and the DON, revealed that while staff were aware of the resident's refusals and her concerns about showering before dialysis, there was no indication that her preferences were formally considered or that her shower schedule was changed. The facility's policy required involving residents in decision-making related to ADLs, but in this case, the resident's choice regarding shower timing was not honored, leading to the deficiency.
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