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
Staff failed to follow established protocols for respiratory care when a resident's tracheostomy tube became dislodged. Instead of calling a rapid response or respiratory therapist as required, nursing staff attempted to reinsert the tube themselves without checking vital signs or airway patency, and without proper hand hygiene. The nurse involved did not have documented competency for this procedure, and the facility's policy was not followed, though the resident did not suffer harm.
A resident with a tracheostomy, who was at high risk for self-decannulation, had their trach tube reinserted by a nurse who was not trained or qualified to perform the procedure. Facility policy required a rapid response and reinsertion only by a respiratory therapist or qualified practitioner, but these steps were not followed. The nurse did not assess airway patency or vital signs before reinsertion, and documentation showed no evidence of required training or competency for this task. The resident did not experience harm from the incident.
A resident with a history of Acute Pulmonary Embolism and Hypertension was inaccurately assessed due to a discrepancy in discharge location documentation. The resident was admitted with an intake form indicating discharge from a nursing home, but the MDS assessment recorded a discharge from a hospital. This error was due to the MDS Coordinator relying on a hospital discharge summary, despite being informed otherwise by the DON.
A resident with a history of acute pulmonary embolism and hypertension was administered incorrect dosages of Eliquis and the wrong form of Metoprolol due to transcription errors at the facility. The staff used hospital discharge orders instead of the nursing home discharge summary, leading to the administration of Eliquis 10 mg instead of 5 mg and Metoprolol Tartrate instead of Metoprolol Succinate. The errors were discovered when the resident's daughter questioned the medication being given, resulting in the resident's discharge from the facility.
A resident with a history of Acute Pulmonary Embolism and Hypertension was administered an incorrect dosage of Apixaban (Eliquis) due to a transcription error. The staff transcribed the medication order from an outdated hospital discharge summary, leading to the resident receiving 10 mg instead of the prescribed 5 mg twice daily. The error was identified by the resident's daughter, and the medication order was subsequently corrected.
A medication cart on Unit 2 was found unlocked and accessible in a common area, with no staff in view. An RN confirmed the cart should have been locked, and an LPN admitted to leaving it unsecured.
A resident with a history of hypertension was prescribed Metoprolol Succinate (Toprol XL) but was incorrectly administered Metoprolol Tartrate (Lopressor) due to a documentation error in the MAR. The error was identified by the resident's daughter upon discharge, and the physician confirmed the intended prescription. The DON found that an LPN ordered the wrong medication from the pharmacy.
Failure to Follow Tracheostomy Decannulation Protocols
Penalty
Summary
Facility staff failed to provide necessary respiratory care to a resident following the decannulation of her tracheostomy tube, as required by the resident's comprehensive care plan and the facility's policy. The resident, who had a history of tracheostomy, acute and chronic respiratory failure, and was at high risk for self-decannulation, was found by staff with her trach tube either partially or completely out on multiple occasions. Despite clear physician orders and care plan interventions outlining the steps to take in the event of decannulation—including calling a rapid response team, assessing airway patency, and ensuring only qualified practitioners reinsert the trach tube—these protocols were not followed. On the day of the incident, staff observed the resident with her trach tube either halfway out or completely out, with no signs of respiratory distress. Instead of calling a rapid response or respiratory therapist as required, nursing staff attempted to reinsert or adjust the trach tube themselves. Interviews revealed that the nurses involved did not check the resident's vital signs or airway patency before reinserting the tube, and did not perform hand hygiene prior to the procedure. The facility's Director of Respiratory confirmed that nurses are not trained or authorized to reinsert trach tubes, and that the established protocol was not followed in this case. Documentation and staff interviews further indicated that the nurse who performed the reinsertion did not have documented competency or training to be considered a qualified practitioner for this procedure. The incident was reported by a speech therapist who witnessed the event and expressed concern about the lack of proper protocol adherence. Although the resident did not suffer harm as a result of this deficient practice, the failure to follow established respiratory care protocols and the resident's care plan constituted a deficiency.
Unqualified Nurse Reinserted Tracheostomy Tube After Decannulation
Penalty
Summary
Facility staff failed to demonstrate appropriate competencies and skills in providing safe nursing care for a resident with a tracheostomy. The resident, who had a history of self-decannulation and multiple respiratory diagnoses, was at high risk for airway complications. The care plan and facility policy required that, in the event of unplanned decannulation, a rapid response should be called and only a qualified practitioner, such as a respiratory therapist, should reinsert the tracheostomy tube. Despite these protocols, a registered nurse who was not trained or documented as a qualified practitioner reinserted the resident's tracheostomy tube after it was found dislodged. On the day of the incident, a speech therapist discovered the resident's tracheostomy tube had come out and notified nursing staff. Two nurses entered the room and one of them reinserted the tube without performing hand hygiene, checking vital signs, or assessing airway patency or oxygenation status. The resident showed signs of pain during the procedure. The nurse involved later confirmed that she did not follow the facility's protocol, did not call for a rapid response, and was not trained to reinsert a tracheostomy tube. Documentation and staff interviews confirmed that the nurse was not qualified to perform this procedure and that the required steps outlined in the resident's care plan and facility policy were not followed. The incident was reported by staff and confirmed through interviews and record review. The facility's Director of Respiratory and other leadership staff stated that only respiratory therapists or specifically trained staff are permitted to reinsert tracheostomy tubes, and that all nurses are instructed on the tube out procedure annually. However, there was no evidence that the nurse who performed the reinsertion had received the necessary training or competency validation. The resident did not suffer harm as a result of this incident.
Inaccurate Resident Assessment Due to Discharge Location Error
Penalty
Summary
The facility's staff failed to ensure an accurate assessment for one of the sampled residents, leading to a discrepancy in the resident's documented discharge location. The resident, who had a history of Acute Pulmonary Embolism and Hypertension, was admitted to the facility with an admission intake form indicating discharge from an out-of-state nursing home. However, the Entry Minimum Data Set (MDS) assessment inaccurately documented the resident as being discharged from a short-term general hospital. This error occurred because the MDS Coordinator coded the resident's discharge based on a hospital discharge summary provided by the nursing staff, despite being informed by the Director of Nursing that the resident had been discharged from a nursing home.
Medication Administration Errors for a Resident
Penalty
Summary
The facility failed to administer medications according to the prescribed orders for a resident with a history of acute pulmonary embolism and hypertension. Upon admission, the resident was supposed to receive Eliquis 5 mg twice daily and Metoprolol Succinate Extended Release 50 mg at bedtime. However, due to a transcription error, the resident received Eliquis 10 mg twice daily for four occasions and Metoprolol Tartrate instead of the prescribed Metoprolol Succinate. The error occurred because the staff transcribed the hospital discharge orders instead of the nursing home discharge summary, which led to the incorrect administration of medications. The resident's daughter provided the facility with the correct medication list from the previous nursing home, but the staff failed to use this information accurately. The attending physician was not informed of the discrepancy in the Metoprolol prescription, and the error was only discovered when the resident's daughter questioned the dosage being administered. Interviews with staff revealed a lack of communication and verification of the correct medication orders. The Director of Nursing acknowledged the transcription error and the failure to administer the correct form of Metoprolol. The resident's daughter decided to discharge her mother from the facility due to these medication errors, highlighting the impact of the facility's failure to adhere to the prescribed medication regimen.
Medication Dosage Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, resulting in the administration of an incorrect dosage of Apixaban (Eliquis). The resident, who had a history of Acute Pulmonary Embolism and Hypertension, was admitted to the facility with a prescription for Eliquis 5 mg twice daily. However, due to a transcription error, the resident received Eliquis 10 mg twice daily for four occasions. This error occurred because staff transcribed the medication order from an outdated hospital discharge summary instead of the most recent nursing home discharge summary. The error was discovered when the resident's daughter noticed the incorrect dosage being administered and brought it to the staff's attention. The attending physician was notified, and the medication order was corrected. The resident was assessed and monitored for any adverse effects, and no negative outcomes were reported. The primary care physician acknowledged the oversight, stating that the discharge summary from the discharging nursing home was not seen in the resident's record at the time of admission.
Medication Cart Security Breach
Penalty
Summary
The facility staff failed to ensure a medication cart was locked and secure from residents, visitors, and other personnel. This deficiency was observed on Unit 2, where an unlocked medication cart was parked in a common area with its drawers facing forward, making it visible and accessible to anyone passing by. At the time of the observation, there were no staff members in view of the medication cart, and residents and staff were gathered in a nearby dining area. During interviews, an RN acknowledged that the cart should have been locked, and an LPN admitted to leaving the cart unlocked, stating she should have locked it before leaving.
Medication Administration Error Due to Incorrect Formulary
Penalty
Summary
The facility failed to ensure that a resident's Medication Administration Record (MAR) included the correct formulary for a medication used to treat elevated blood pressure. A resident with a history of Acute Pulmonary Embolism and Hypertension was admitted to the facility and was supposed to receive Metoprolol Succinate (Toprol XL) Extended Release 50 mg at bedtime. However, the MAR incorrectly documented an order for Metoprolol Tartrate (Lopressor) 50 mg, which was administered on five occasions. The error was discovered when the resident's daughter, who is also the Power of Attorney, noticed the discrepancy upon the resident's discharge. The physician confirmed that Metoprolol Succinate was the intended prescription and was not informed of the administration of Metoprolol Tartrate. The Director of Nursing identified that the error occurred when an LPN mistakenly ordered the incorrect medication from the pharmacy.
Explore Popular Searches
