Citations in Colorado F

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to provide appropriate care and monitoring for a resident with quadriplegia and an indwelling Foley catheter. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had a history of acute renal failure, dementia, and dysfunctional bladder. Over a 24-hour period, the resident's urine output was significantly decreased, with only 300 ml recorded, and then zero output documented for the following shift. This decrease in urinary output was not communicated to nursing staff or the physician, and no assessment was performed for possible urinary retention or catheter obstruction. Nursing staff did not conduct assessments or monitor the resident for impaired urinary elimination or changes in urine characteristics, such as color, odor, or clarity, which could indicate a problem with the resident's urinary status. The facility's baseline care plan lacked specific interventions for assessing catheter patency, placement, or complications related to quadriplegia, such as autonomic dysreflexia. Documentation showed that CNAs were responsible for recording urine output, but there was confusion and lack of knowledge among staff regarding what constituted low output and when to notify a nurse or physician. Additionally, a CNA with medication authority signed off on nursing orders, which was outside their scope of practice. The resident was eventually found unresponsive and in respiratory distress, with vital signs indicating a critical condition. Upon transfer to the hospital, the resident was found to have a distended bladder containing 2000 ml of bloody urine with pus, bilateral hydronephrosis, and was diagnosed with severe sepsis, acute respiratory failure, and myocardial infarction. Staff interviews revealed a lack of training and knowledge regarding the care of residents with indwelling catheters and those with special needs such as quadriplegia. The failure to monitor, assess, and communicate changes in the resident's urinary status directly led to the resident's hospitalization and critical illness.

Removal Plan

• Education for all nurses and CNAs on daily catheter care, as well as monitoring and reporting of urinary output, was completed by the DON or designee.
• Nurses were educated on how to perform bladder assessments for residents with indwelling catheters, with a special focus on residents unable to communicate or who are paralyzed.
• All residents with indwelling catheters were audited for their last catheter change date and ensured accurate physician's orders were obtained for the next catheter change.
• The electronic medication administration record (eMAR) was reviewed to ensure accurate orders were in place, including those for catheter care, urinary output monitoring, and catheter replacement.
• All residents with indwelling catheters were assessed by the DON for bladder fullness to ensure proper catheter drainage.
• An as needed catheter change physician's order was added for another identified resident affected by the deficient practice.
• A shift evaluation for residents with dwelling catheters was implemented, including assessments of bladder status, urine output, potential blockages, and urine characteristics, to be conducted by floor nurses and documented in the eMAR.
• Abnormal findings from the floor nurse will be reported to the director of nursing and the on-call physician.
• All new admissions, readmissions, and newly ordered indwelling Foley catheters will be audited by the DON or designee to ensure catheter insertions are completed in accordance with physician's orders.
• All new admissions with indwelling catheters will be audited by the DON or designee to confirm the presence of appropriate physician orders and nursing interventions for daily catheter care.
• The audit will be completed by the director of nursing or designee.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from physical abuse by another resident, resulting in a significant injury. On the date of the incident, a resident with a history of autistic disorder, dementia, and depression entered the facility from outside and was approached by another resident diagnosed with dementia and schizophrenia. The second resident pushed the first to the floor, causing the first resident to sustain a femur fracture that required surgical repair. The incident was observed by staff, and the injured resident reported pain and was subsequently transferred to the hospital for evaluation and treatment. Review of facility records and interviews revealed that both residents had documented behavioral histories, though neither had exhibited recent physical aggression or altercations according to their care plans and assessments. The resident who committed the abuse had severe cognitive impairment and was noted to have difficulty focusing and disorganized thinking, but no recent behaviors towards others were documented. The victim had moderate cognitive impairment and required supervision for mobility, using a cane or crutch for walking. At the time of the incident, staff were present in the area, but the altercation still occurred as the two residents passed each other near an exit doorway. Facility policy states that all residents have the right to be free from abuse, and the investigation substantiated that physical abuse occurred in this case. Staff interviews confirmed awareness of the incident and described standard practices for monitoring and redirecting residents with behavioral risks. However, the actions taken prior to the incident were insufficient to prevent the physical altercation and resulting injury.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide treatment and care in accordance with professional standards for two residents reviewed for wound care and weekly skin assessments. For one resident with a history of heart failure, multiple sclerosis, dementia, and diabetes, the facility did not complete weekly skin assessments as required by policy. This resident, who had a history of hemorrhoids and was receiving topical medication, was admitted to the hospital with a perianal abscess that required surgical intervention and IV antibiotics. Facility documentation did not show that skin assessments were performed from early to late October, and there was no documentation of the resident's hemorrhoids in the care plan. Another resident, who had quadriplegia, acute renal failure, dementia, and a dysfunctional bladder, was admitted with stage 3 pressure wounds and an indwelling Foley catheter. The facility did not enter or initiate physician's orders for wound care as outlined in the hospital discharge instructions. There was no documentation of wound care being provided or skin assessments being completed after the initial wound care note, despite the resident having significant skin breakdown upon hospital readmission. Interviews with facility staff, including the DON and wound care nurse, confirmed that required wound care orders were not entered or followed, and that skin assessments were not completed as per facility policy. The breakdown in communication and documentation led to a lack of appropriate wound care and monitoring for both residents, resulting in unaddressed and worsening skin conditions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident, admitted for postoperative left knee replacement rehabilitation and identified as a high fall risk due to her medical history and recent surgery, was left unattended in the bathroom and later in the shower. The facility's fall prevention policy required high-risk residents to have interventions such as supervision, routine toileting schedules, and line-of-sight monitoring. Despite these requirements, the resident experienced two unwitnessed falls: the first in the bathroom and the second in the shower after being left alone by a CNA who left to retrieve supplies. The resident's care plans and physical therapy notes indicated she required supervision or touching assistance with transfers, toileting, and bathing. Staff interviews confirmed that the resident was known to be a fall risk, wore a fall risk wristband, and had signage in her room. The CNA involved in the second fall admitted to leaving the resident alone in the shower, contrary to the care plan and facility policy, because she believed it was acceptable since the resident was scheduled for discharge that day. The CNA also acknowledged that she should have called for assistance rather than leaving the resident unsupervised. As a result of being left unattended, the resident attempted to get up on her own, fell, and sustained a left femur fracture that was deemed inoperable due to her comorbidities. The incident led to the resident being transferred to the hospital and subsequently discharged home with hospice care. The failure to consistently implement fall prevention interventions and provide adequate supervision directly resulted in a major injury for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect multiple residents from abuse, including sexual abuse and harassment, resulting in actual harm. One resident with moderate cognitive impairment and a history of traumatic brain injury and dementia was found in another resident's room, lying on top of a non-verbal, fully dependent resident with her pants and incontinence brief pulled down. The assailant's penis was found near the victim's mouth, and he admitted to attempting vaginal intercourse. The victim was unable to consent due to her cognitive status and was sent to the hospital for a sexual assault nurse exam. The facility's records did not indicate any prior behavioral concerns for the assailant, and staff interviews revealed a lack of understanding regarding new safety measures, such as colored door tags for at-risk residents. Another resident with a history of sexually inappropriate behavior toward female staff repeatedly made sexual advances and comments to two female residents, both of whom had cognitive or communication impairments. Despite these incidents, the facility failed to implement or document effective, ongoing interventions to prevent further harassment. The care plans for the involved residents were not consistently updated to reflect the incidents or to include new interventions, and there was no documentation of reassessment before discontinuing safety checks. Staff were not consistently informed or educated about the behaviors to monitor or the interventions required for the resident with a history of sexual inappropriateness. The facility's investigations substantiated that abuse and harassment occurred, but staff interviews and record reviews showed gaps in communication, education, and implementation of protective measures. Staff were unaware of the purpose of new safety tools, such as door tags and education binders, and there was inconsistent documentation and follow-through on safety interventions like one-to-one supervision and frequent rounding. These failures resulted in continued incidents of sexual harassment and abuse, causing distress and harm to the affected residents.

Removal Plan

• The director of nursing (DON), the social services director (SSD), and designee interview/assess residents with BIMS assessment scores of eight or above for potential abuse.
• For residents with a BIMS score below eight, the power of attorney (POA) or residents' representatives are contacted to identify any concerns regarding abuse.
• Resident #8 is issued an immediate discharge notice to prevent further abusive behaviors.
• Resident #4 is placed on a one-to-one caregiver until alternate placement can be found.
• One-to-one caregivers are provided resident specific education defining what they are watching for (sexually inappropriate comments, monitoring for any inappropriate responses in sexual nature, with history of sexual assault allegations).
• One-to-one caregivers are educated on who to notify if any behaviors are identified/observed. The education is completed prior to the next scheduled shift.
• Nursing supervisors, the SSD and designee update Resident #4's behavior monitoring sheets to describe specific behaviors and staff response.
• Clinical resource reviews and updates Resident #4's Kardex, care plan and physician's orders.
• Resident #4 is evaluated by the primary care provider.
• Resident #4 receives psychology consultation orders, a medication adjustment to address sexual hyperactivity and a follow-up medication review is scheduled.
• Therapy sessions begin for Resident #4 to begin working with licensed mental health professionals.
• One-to-one supervision is in place for Resident #4. Updated education is initiated with all one-to-one caregivers.
• Education is provided to all staff on abuse, abuse prevention, behavior management, how to report new behaviors, how to locate information in the Kardex and care plan, and any one-to-one resident specific education prior to initiation of their next shift.
• All as needed (PRN) employees receive the education prior to the start of their next shift.
• Resident #4 is not seated near female resident(s) at activities or dining when at all possible.
• The interdisciplinary team (IDT) reviews and revises Resident #4's care plan to identify patterns in the resident's behaviors and implements interventions for Resident #4. The care plan revisions and interventions are communicated to front line staff caring for Resident #4. Interventions include Resident #4 is not to sit next to a female resident when at all possible.
• All residents with known behaviors are reviewed by the IDT team with updates as indicated to their care plans and Kardex.
• The facility updates the one-to-one education binder to detail residents' behavior pattern/risk; updates Resident #4's care plan; and, updates Resident #4's Kardex.
• The Abuse policies are reviewed/updated to include all sources of abuse, including resident-to-resident.
• The abuse investigation procedure and documentation process are reviewed and revised as needed. The NHA and the DON educate all staff on changes to the policies.
• The social SSD, the DON and the NHA re-educate all staff on facility abuse policies during the survey.
• In the event of any future resident-to-resident sexual abuse, the perpetrating resident is immediately placed on one-to-one supervision until the primary care physician, nursing, and psychology evaluations are completed. Outcomes of these evaluations result in continued one-to-one supervision or the initiation of discharge planning to a facility with a focus on behavior management. This is provided to the IDT team in the form of education.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide adequate supervision to prevent an elopement for a newly admitted resident with dementia, Alzheimer's disease, and a history of traumatic brain injury. Upon admission, the resident informed an LPN that he was not staying at the facility, but the LPN did not notify appropriate staff or implement immediate interventions to address the resident's expressed intent to leave. After the resident's family left, the resident followed them outside and was redirected back into the facility by the admissions coordinator, who then briefly supervised the resident in the lobby before leaving. When the admissions coordinator returned, the resident was missing. The facility's investigation revealed that the resident was admitted to an unsecured unit and no enhanced oversight or safety interventions were put in place, as staff believed the resident exhibited no behaviors indicating elopement risk and had no known history of elopement. However, the resident's statement about not staying and his attempt to follow his family outside were not acted upon according to facility policy and protocols. The admissions coordinator also failed to notify staff about the resident's attempt to leave and did not ensure continued supervision. The resident was later found by bystanders at a nearby gas station after having fallen, sustaining abrasions, a laceration, and a fracture to his right hand. Emergency medical services transported the resident to the hospital, and he did not return to the facility. Staff interviews indicated a lack of awareness and inconsistent application of the facility's elopement prevention protocols, including the use of wander guards and notification procedures for residents at risk of elopement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop, implement, and maintain an effective training program for its staff, as evidenced by the lack of required training for several certified nurse aides (CNAs). Record review showed that multiple CNAs did not have documentation of having received essential training in areas such as dementia care, behavioral health management, resident rights, infection control, quality assurance performance improvement (QAPI), and effective communication. Specifically, certain CNAs were missing training in one or more of these critical areas upon hire, and the facility was unable to provide evidence that these trainings had been completed. Interviews with the staff development coordinator (SDC) and the nursing home administrator (NHA) confirmed gaps in the staff education process. The SDC, who had only recently started at the facility, described providing education through monthly meetings, an education binder, and periodic skills fairs, but did not provide evidence of a comprehensive or consistently documented training program. The NHA, also new to the facility, acknowledged awareness of the deficiencies in staff education and indicated that efforts to improve tracking and compliance were underway, but at the time of the survey, the required training had not been documented for the affected CNAs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with dementia and right-sided hemiplegia was not protected from physical abuse by another resident with a history of behavioral disturbances, including agitation and aggression. The incident took place in a common area, where the first resident told the second resident to "shut up" after the latter was loudly talking to himself. In response, the second resident stood up and pushed the first resident, causing her to fall and sustain a left wrist fracture. Multiple staff members witnessed or heard the altercation, confirming the sequence of events. The resident who committed the abuse had a documented history of behavioral issues, including yelling at the television and other residents, and had previously exhibited escalating agitation and threatening behavior. His care plans included interventions for managing agitation and physical behaviors, but did not specify actions for guiding other residents away from him when he became agitated or physically aggressive. Staff interviews indicated that the resident was known to be triggered by being told to "shut up," and that staff had previously redirected him or advised other residents not to use such language toward him. Despite the known behavioral risks and triggers associated with the second resident, the facility failed to implement sufficient measures to prevent the altercation. The care plan lacked specific interventions to protect other residents from potential physical aggression, and staff did not intervene before the incident occurred. As a result, the first resident was not safeguarded from abuse and suffered a significant injury.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that staff followed appropriate transfer techniques and provided adequate supervision and assistive devices to prevent accidents, resulting in a resident sustaining rib fractures after a fall during an improper transfer. The resident, who had a history of falls and required substantial/maximal assistance for transfers, was being assisted by a CNA from bed to wheelchair. During the transfer, the CNA positioned herself at the side of the resident due to limited space, rather than in front as per facility training and policy. The resident was wearing slip-on shoes with no backs, and as she pivoted, her shoe became lodged on a wheelchair wheel, causing her to lose balance and fall forward to the floor. The CNA was unable to prevent the fall due to her position and the obstruction caused by the wheelchair and room layout. The incident report and staff interviews confirmed that the CNA did not follow the facility's in-service training, which instructed staff to stand in front of the resident, use a gait belt properly, and ensure the resident wore appropriate footwear during transfers. The care plan for the resident required a one-person transfer with a gait belt but did not specify the need for proper footwear. The CNA admitted to using a side-assist technique and acknowledged she should have been in front of the resident. Other CNAs interviewed stated that standing in front of the resident was the safest method and allowed them to better protect the resident from falls. The facility's policies and training materials emphasized the importance of proper positioning and use of gait belts during transfers to minimize fall risk. Following the fall, the resident was assessed and found to have a hematoma and bruising on her face and head. She was later transferred to the hospital, where imaging revealed acute, mildly displaced fractures of the left anterior third rib and a non-displaced fracture of the left anterior fourth rib, in addition to facial bruising. The resident was cognitively intact and had no impairments in range of motion but required significant assistance for transfers due to weakness and other medical conditions. The failure to adhere to established transfer protocols and ensure the use of appropriate footwear directly contributed to the resident's fall and subsequent injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide treatment and care in accordance with professional standards of practice for two residents. For one resident with a recent left below-the-knee amputation, the facility did not provide timely, consistent, and effective monitoring or appropriate documentation of the surgical incision. Although the initial skin assessment documented the incision as well approximated, subsequent wound care assessments failed to address the amputation site. When the resident and physician identified signs of infection, antibiotics were ordered, but there was a delay of two days before these medications were entered into the electronic medical record and administered. Throughout this period, nursing documentation did not consistently reflect monitoring of the incision for signs of worsening infection, despite the resident being on antibiotics. The resident ultimately required hospitalization for an infected amputation site, where she underwent further surgical intervention and did not return to the facility. Additionally, the facility failed to obtain timely wound care orders for another resident admitted with a skin tear to the left lower leg. Upon admission, the nursing note documented a single wound, but did not address a larger skin tear observed later. The admitting nurse did not change the dressing, citing the absence of wound care orders, and the wound care nurse delayed entering the necessary orders into the electronic medical record. As a result, the resident did not receive appropriate wound care or documentation for two days after admission, and the wound care provided was not properly documented. Staff interviews confirmed lapses in communication and documentation. The wound care nurse stated she was not notified of changes to the amputation site and did not follow wounds unless issues were reported. The director of nursing and other nursing staff described expectations for wound monitoring and documentation that were not met in these cases. The deficiencies were directly related to failures in timely assessment, documentation, and implementation of physician orders for wound care and infection management.