Citations in District Of Columbia
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in District Of Columbia.
Statistics for District Of Columbia (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in District Of Columbia
Facility staff did not post the most recent survey results in an accessible location and failed to provide survey reports from the past three years, including certification surveys and complaint investigations, upon request. When a resident's representative asked for the latest survey results, only an outdated report was provided, and staff were unable to promptly locate the required documentation.
A resident with complex medical needs, including chronic respiratory failure and mobility limitations, was discharged without proper coordination of home care and oxygen therapy services. The social worker did not document arrangements for post-discharge care or confirm acceptance by a home care agency, and family members reported that promised services were not provided, leading to the resident using outdated equipment and experiencing falls at home.
A licensed nurse altered a resident's Trazodone medication order label without notifying the physician, resulting in the administration of a dosage not prescribed. The resident had multiple diagnoses, including dementia and depression, and was cognitively impaired. Facility staff could not identify who made the change, and the ADON stated that nurses could use their own judgment for non-narcotic medications, contrary to facility policy and accepted nursing standards.
Facility staff did not ensure that a resident received the correct prescribed dose of Trazodone for five days, as only 25 mg tablets were available when a 50 mg dose was ordered. Documentation indicated the 50 mg dose was given, but there was no confirmation that the correct amount was administered. The resident, with a history of depression and dementia, experienced lethargy and was sent to the ER, though no new findings were reported.
A resident with severe cognitive impairment and depression was prescribed Trazodone 50 mg at bedtime, but only 25 mg half-tablets were available for administration. Staff documented giving the full 50 mg dose on the MAR, but it could not be confirmed whether the correct amount was actually administered, as only half-tablets were present and staff could not verify the dosing process.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
Staff did not immediately inform a resident, their physician, and a family member about events such as injury, decline, or room changes that affected the resident, resulting in a deficiency for lack of timely notification.
A resident with dysphagia and other complex medical needs had inconsistent and incorrect information documented in speech-language pathology treatment notes and the care plan. The SLP's notes did not match the physician's diet order or the dietary records, and the care plan inaccurately described the resident's eating habits. Staff interviews confirmed the documentation errors and clarified the resident's actual dietary needs and preferences.
Two residents with complex medical needs were found to have inaccurate eating status documented in their comprehensive assessments. In both cases, CNA task sheets and staff interviews confirmed the residents' actual abilities and assistance needs, but the MDS assessments did not accurately reflect this information, with one resident incorrectly coded as not eating and another as requiring less assistance than was actually needed.
A resident with a history of dysphagia, adult failure to thrive, and dementia was observed requiring total staff assistance with eating and drinking, but the care plan lacked documented goals and interventions to address this need. Staff confirmed the resident's total dependence on assistance, yet the care plan did not reflect these requirements.
Failure to Make Survey Results and Reports Readily Accessible
Penalty
Summary
Facility staff failed to post the results of its most recent survey in a location that was readily accessible to residents, family members, and resident representatives. Observations revealed that only a sign indicating the survey book was available upon request was posted at the front security desk, rather than the actual survey results. When a resident's representative requested the most recent survey results, she was provided with an outdated report from 2022. Additionally, during a surveyor's visit, the front desk staff were unable to immediately locate the survey book and had to refer the surveyor to the Administrator. The Administrator confirmed that only the 2024 survey report was available at the front desk at that time. Further investigation showed that the facility did not have reports from the three preceding years, including certification surveys, complaint investigations, and any plan of correction in effect, available upon request for review by any individual. The Administrator acknowledged the absence of these reports during the surveyor's inquiry. The deficiency was identified through direct observation, staff interviews, and review of the available documentation, which confirmed that the facility did not meet the requirements for making survey results and related reports accessible to residents and the public.
Failure to Ensure Safe Discharge Planning and Coordination of Post-Discharge Services
Penalty
Summary
The facility failed to implement its discharge planning process to ensure a safe discharge for a resident with multiple complex medical needs, including chronic respiratory failure, morbid obesity, and sleep apnea. The resident required substantial to total assistance with mobility and activities of daily living, was incontinent, and was receiving physical therapy, occupational therapy, and oxygen therapy. Documentation indicated that the resident was to continue receiving therapy and home health services, as well as oxygen therapy, after discharge. However, the discharge was not properly coordinated, as the social worker did not have documented evidence of arranging home care services or confirming acceptance by a home care agency. Additionally, the social worker did not coordinate ongoing oxygen therapy services, stating she was unaware of the resident's need for oxygen, despite documentation to the contrary. Family members reported that they were unable to reach the social worker after discharge and that promised wrap-around services were not provided. They also stated that they had to use an old oxygen concentrator from two years prior, and that the resident experienced falls at home post-discharge. The home care agency representative confirmed that services were verbally denied to the social worker, but there was no documentation of this communication. The lack of documented coordination and follow-through resulted in the resident being discharged without the necessary support and services to ensure a safe transition home.
Nurse Altered Medication Order Without Physician Notification
Penalty
Summary
Facility nursing staff failed to ensure that a resident received care and services according to accepted standards of clinical nursing practice. Specifically, a licensed registered nurse altered a medication order label for a resident's Trazodone prescription without documented evidence that the physician was notified or made aware of the change. The original physician's order directed a specific dosage, which was later discontinued and replaced with a new order. However, the medication blister packet on the medication cart was found to have been manually altered by facility staff to reflect a different dosage, with the label changed from 0.5 tablet to 2 tablets at bedtime. There was no documentation in the resident's progress notes indicating that the physician was consulted regarding the available tablet strength or the alteration of the medication order label. The resident involved had multiple diagnoses, including Major Depressive Disorder, Adjustment Disorder, Unspecified Dementia, and Metabolic Encephalopathy, and was assessed as having severely impaired cognitive function and moderate depression. Interviews with facility staff revealed a lack of clarity regarding who was responsible for altering the medication label, and the Assistant Director of Nursing indicated that nurses were allowed to use their own judgment to adjust medication orders for non-narcotic medications. This action was not supported by facility policy or standards of nursing practice, which require that medication orders be administered only as prescribed and that any concerns or discrepancies be communicated to the prescribing physician.
Failure to Ensure Correct Dose of Antidepressant Administered
Penalty
Summary
Facility staff failed to ensure that a resident received the correct dose of Trazodone, an antidepressant medication, as ordered by the physician. The resident, who had multiple diagnoses including Major Depressive Disorder, Dementia, and Metabolic Encephalopathy, had a physician's order for Trazodone 50 mg at bedtime, which was later changed to 0.5 tablet (25 mg) and then back to 50 mg. During a medication cart observation, it was found that only 25 mg tablets (half-tablets) were available, and there was no clear documentation or assurance that the correct 50 mg dose was being administered as ordered for five consecutive days. Review of the Medication Administration Record (MAR) indicated that staff documented administration of the 50 mg dose, but the Assistant Director of Nursing could not confirm whether two 25 mg tablets were given to make up the correct dose. The resident experienced an episode of lethargy and was sent to the emergency room for altered mental status, though no new findings were reported and the resident returned to the facility. The facility's policy required medications to be administered according to prescriber's orders and for staff to verify the right dose, but this was not ensured in this case.
Inaccurate Medication Administration Documentation for Antidepressant
Penalty
Summary
Facility staff inaccurately documented the administration of Trazodone 50 mg to a resident with multiple diagnoses, including major depressive disorder, dementia, and metabolic encephalopathy. The resident's physician order specified Trazodone HCl 50 mg, one tablet by mouth at bedtime for depression. The Medication Administration Record (MAR) indicated that staff documented the administration of the full 50 mg dose on several consecutive days. However, observation of the medication cart revealed that only 25 mg half-tablets of Trazodone were available for the resident, with the blister pack labeled for administration of 0.5 tablet (25 mg) at bedtime. There was no evidence that the resident received the full 50 mg dose as ordered, and staff could not confirm whether two half-tablets were given to equal the prescribed dose. The Assistant Director of Nursing acknowledged the discrepancy and was unable to verify the actual administration of the correct dosage.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Promptly Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the failure to provide prompt notification to all required parties when significant events impacting the resident occurred, as required by regulation.
Inaccurate Documentation in Speech-Language Pathology Notes and Care Plan
Penalty
Summary
The facility failed to ensure that a resident's speech-language pathology treatment notes and care plan contained accurate information. The resident, who had multiple diagnoses including dysphagia, gastrostomy, gastroesophageal reflux disease, and hemiplegia, had a physician order for a regular diet with honey-thick liquids. However, a review of the speech-language pathologist's treatment notes over a period of several weeks documented inconsistent and incorrect information, such as indicating the resident was on a mechanical soft diet with nectar thick liquids and at times listing thin liquids, which did not match the physician's order or the dietary meal ticket. The speech-language pathologist acknowledged during an interview that the documentation was incorrect and that the resident was actually on a regular diet with honey-thick liquids, as confirmed by the dietician. Additionally, the resident's care plan inaccurately described the resident as a messy eater who refused to eat or resisted feeding, with interventions focused on providing privacy due to messiness. Interviews with the assigned LPN and CNA revealed that the resident preferred to eat alone in his room and was able to feed himself independently, contradicting the care plan's statements. The RN/Unit Manager also confirmed that the care plan was incorrect, stating the resident was not a messy eater and simply preferred privacy during meals.
Inaccurate Comprehensive Assessments for Eating Status
Penalty
Summary
The facility failed to ensure that comprehensive assessments contained accurate information for two of six sampled residents. For one resident with multiple diagnoses including dysphagia, gastrostomy, and hemiplegia, physician orders specified a regular texture diet with honey-thick liquids. Certified nursing assistant (CNA) task sheets consistently documented that the resident required set-up or clean-up assistance with eating, and interviews with staff confirmed the resident was able to feed himself. However, Minimum Data Set (MDS) assessments incorrectly coded the resident as 'not applicable' for eating, indicating the resident was not eating at all. The MDS Coordinator acknowledged this was an error and that the resident was able to feed himself at the time of the assessments. For another resident with diagnoses including dysphagia, adult failure to thrive, and dementia, CNA task sheets documented that the resident required partial to total assistance with eating. Observations and staff interviews confirmed that the resident required total assistance for all activities of daily living, including eating, and was unable to feed herself. Despite this, quarterly MDS assessments inaccurately documented the resident as only requiring set-up or clean-up assistance with eating. Both the LPN/MDS Coordinator and the RN/MDS Director confirmed that the eating status documented in the assessments was not accurate and did not reflect the resident's actual needs.
Failure to Develop Care Plan for Total Assistance with Eating
Penalty
Summary
A deficiency was identified when the facility failed to develop a care plan addressing a resident's need for total staff assistance with eating and drinking. The resident, who was admitted with multiple diagnoses including a history of dysphagia, adult failure to thrive, and dementia, was observed sitting in a Geri-chair and being assisted by a CNA to drink water. Review of the resident's care plan revealed no documented goals or interventions related to the need for total assistance with eating and drinking. Staff interviews confirmed that the resident was totally dependent on staff for these activities, yet the care plan did not reflect this requirement.
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