Citations in Indiana
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Indiana.
Statistics for Indiana (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Indiana
A resident with a hip fracture who was cognitively intact and required set-up assistance with meals was seated in the restorative dining room while another resident at the same table was already eating. Staff informed the resident they were looking for her lunch tray, but the tray was significantly delayed, leading the resident to repeatedly state she did not want to be a bother and could return to her room without eating. CNAs offered watermelon while she waited and helped her complete a lunch order form, yet the meal tray was not delivered for an extended period. Staff later acknowledged the resident waited an excessive amount of time, could not explain the delay, and the DON confirmed there was no policy addressing timely meal service, despite a resident rights policy requiring treatment with dignity and respect.
A cognitively intact resident reported not having a shower since before admission and stated she needed a shower badly, while records showed she repeatedly received only partial bed baths instead of scheduled showers. The shower schedule binder and the resident’s care plan indicated she was to receive showers twice weekly, but a QMA and an RN were unaware of when her showers were due, and the RN noted that shower days were not assigned in the electronic record. The DON stated showers are ordered twice weekly for all residents unless contraindicated, and the Executive Director acknowledged there was no facility policy on shower frequency, resulting in the resident’s bathing needs and preferences not being reasonably accommodated.
A resident with an intertrochanteric femur fracture and intact cognition was prevented from eating in the dining room and remained in bed for a meal because staff reported she lacked appropriate clothing. The resident expressed being very upset, stated she preferred to eat in the dining room, and questioned why she was confined to bed. Staff noted there were no pants in her closet; an LPN said the family had not brought enough clothes and only a hospital gown was available, while a CNA checked lost and found but did not seek further assistance. The Social Services Director later reported that donated clothing was available and that staff should have contacted her, but no one had done so. The resident was positioned upright in bed for lunch yet required frequent repositioning due to leaning to one side, and facility policy affirmed residents’ rights to choose daily activities and use dining rooms.
A resident with diabetes, Alzheimer’s, and epilepsy had a physician order for close monitoring of weight, oral intake, dental status, medication side effects, and for physician notification every shift due to malnutrition risk. Over a period of several weeks, the resident lost more than 3% of body weight and had multiple meals with 50% or less intake, including some with minimal or no intake, yet there was no documentation that the physician was notified or that alternatives or supplements were offered. The DON and an LPN confirmed that physician notifications are expected to be documented in progress notes and a communication book, but no such entries existed for this resident, demonstrating a failure to follow the physician’s orders for monitoring and notification.
Surveyors found that the kitchen stove hood and sprinklers above a frequently used griddle/stove had heavy greasy buildup, a furry substance covering the back panels and sprinklers, and stringy dark debris hanging over the food preparation area. The Dietary Manager reported that the griddle/stove was used regularly, had noticed the buildup, but had been told not to clean the hood to avoid voiding the warranty. Documentation showed the exhaust system was only scheduled for cleaning every 180 days, and the observed conditions did not comply with the facility’s sanitation policy requiring food service areas to be kept clean and sanitary, potentially affecting all residents who dine at the facility.
A resident with multiple chronic conditions and moderately impaired decision-making received another resident’s dementia medication due to a medication administration error witnessed by an LPN. After the error was reported, an NP instructed that the resident’s vital signs be monitored and that the resident be observed for anxiety and tremors every shift for 24 hours. However, there was no assessment, no progress note, and no vital signs documented in the EHR following the error, despite facility policy requiring assessment, monitoring, and documentation after medication errors.
A resident with traumatic brain injury, dementia, and bilateral upper extremity contractures had physician orders and a care plan for daytime use of bilateral palm protectors/hand orthoses, but surveyors repeatedly observed the resident without one or both splints in place. The MAR showed no refusals, and the resident was documented as severely impaired in decision making and needing assistance with self-care. Despite a facility policy assigning nurses responsibility for consistent use and monitoring of orthotic devices, staff did not ensure both hand splints were consistently applied as ordered.
A resident with dementia, agitation, and anxiety was admitted in a confused and combative state and quickly began wandering, entering other residents’ rooms, handling their belongings, and becoming physically aggressive with staff when redirected. His ordered psychotropic medication (including Risperidone) was not available on admission and was delayed until the second day, during which time he continued to roam hallways, refuse to stay in his room, and intrude into rooms of multiple residents, causing them discomfort and fear. Behavior notes and staff interviews described ongoing episodes of the resident striking staff, spitting on a nurse, lying on the floor at the nurse’s station, attempting to get into other residents’ beds, and being difficult to redirect. Residents reported feeling uncomfortable and scared when he entered their rooms, closed doors, lay on their beds, or spoke to them in a threatening manner. Despite persistent behaviors and complaints, continuous one-on-one supervision and effective monitoring were not implemented promptly, resulting in a failure to provide appropriate dementia care and services consistent with the facility’s own dementia care policy.
A resident with dementia, agitation, and anxiety was admitted with hospital discharge orders for daily Risperidone and bedtime Trazodone, but these medications were not available or administered on the day of admission and were first given the following day. Nursing notes documented that shortly after arrival the resident was confused, combative, refused staff direction, entered a roommate’s area, moved items, made contact with the roommate, and later had to be moved due to screaming with a roommate and was found in another resident’s room while remaining combative. An LPN reported that the resident’s discharge medications, including scheduled Risperidone, were not available until the second day, and that an emergency behavior medication given in response to the behaviors had little to no effect, contrary to the facility’s pharmacy services policy requiring timely provision and administration of routine and emergency drugs.
Two residents with CHF, edema, and lymphedema did not receive ordered weekly weight monitoring as required by physician orders and care plans. For one resident, staff repeatedly documented temperatures instead of weekly weights in the MAR after an order was incorrectly entered in the EHR with a temperature task, and no weights appeared in the vitals section despite ongoing edema and diuretic use. For the other resident, whose plan of care and physician note called for weekly weights and who later had IV furosemide and fluid restriction for worsening edema and shortness of breath, there were no corresponding weight orders or documented weekly or daily weights in the EHR, even though a progress note stated the resident was placed on daily weights. Interviews with nursing, clinical support, and leadership staff confirmed that weight orders were either entered incorrectly or not entered at all, and that monitoring relied on incomplete EHR documentation rather than the actual physician orders.
Failure to Provide Timely and Dignified Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide dignified and timely meal service to one cognitively intact resident. During continuous observation, the resident was assisted to a table in the restorative dining room at 1:04 PM while another resident at the same table was already eating lunch. By 1:17 PM, a CNA informed the resident that staff were looking for her lunch tray. The resident, who had a diagnosis including a displaced intertrochanteric fracture of the left femur and required set-up assistance with meals per her care plan, stated she did not want to be a bother and offered to return to her room without eating. The CNA encouraged her to stay, but the meal tray still did not arrive. At 1:24 PM, another CNA offered the resident a cup of watermelon to eat while waiting for her meal tray, and the resident again expressed that she did not want to be a bother and could go back to her room. A third CNA then assisted the resident in filling out a lunch order on a menu form. The resident’s lunch tray was not delivered until 1:33 PM. Staff interviews confirmed that residents should be served promptly at mealtime and that the resident waited an excessive amount of time for her tray, with staff unable to explain what went wrong or provide updates while the tray was being sought on the hall tray cart or in the kitchen. The DON reported that the facility did not have a policy addressing timely meal service, and the existing Resident Rights Guidelines policy stated that residents have a right to be treated with dignity and respect.
Failure to Provide Scheduled Showers and Accommodate Resident Bathing Preferences
Penalty
Summary
Surveyors found that the facility failed to reasonably accommodate a cognitively intact resident’s bathing needs and preferences by not providing scheduled showers. The resident, who had a BIMS score of 15 on admission, reported on two separate interviews that she had not had a shower since before admission and stated she needed a shower badly. Record review of bathing notes from 3/5/26 to 3/10/26 showed the resident did not receive a shower on the scheduled shower day of 3/7/26 and instead only received partial bed baths on multiple consecutive days. The facility’s shower schedule binder listed the resident for showers twice weekly on specific days and shifts, and the resident’s care plan indicated she was to have showers twice a week per schedule, while the admission agreement stated residents had a right to receive services with reasonable accommodation of their needs and preferences. During interviews, both a QMA and an RN who assisted the resident indicated they did not know when the resident was due for a shower, and the RN noted that scheduled shower days had not been assigned in the electronic record. The DON stated that showers are ordered two days a week for every resident unless contraindicated, and the Executive Director reported the facility did not have a policy about shower frequency. This combination of staff unawareness of the resident’s shower schedule, lack of assignment in the electronic record, and absence of a facility policy resulted in the resident not receiving showers as planned and requested.
Failure to Honor Resident Choice in Dining Location and Dressing Due to Clothing Shortage
Penalty
Summary
The facility failed to honor a cognitively intact resident’s right to choice in dining location and daily routine, including dressing. A resident with a diagnosis of displaced intertrochanteric fracture of the left femur, and a BIMS score of 13 indicating intact cognition, was observed one day fully dressed and seated in the restorative dining room awaiting lunch, and the next day positioned in bed with a lunch tray on an overbed table. During the second observation, the resident reported being very upset and stated that staff told her she could not get out of bed. She questioned whether she had a serious disease confining her to bed that she had not been informed about and stated she preferred to eat in the dining room but was not allowed to get out of bed. She also reported she was not in a comfortable position to eat and kept falling to her right side. Record review showed no clothing or personal items documented on the resident’s Inventory of Personal Items. An LPN stated the resident could not get out of bed because her family had not brought in enough clothes and that the facility had no clothing to offer other than a hospital gown. The Social Services Director reported that staff should contact family when clothing is lacking and that the facility maintained donated clothing of all sizes for such situations, but no staff had notified her of a shortage for this resident. A CNA reported that no pants were available in the resident’s closet on the morning in question, that she checked lost and found without success, and that she did not contact the Social Services Director for additional assistance. The CNA stated the resident was positioned upright in bed for lunch but required frequent repositioning due to leaning to the right. The facility’s Resident Rights Guidelines policy stated that residents have the right to enjoy full use of all campus areas, including dining rooms, and to exercise choice in daily activities.
Failure to Follow Physician Orders for Nutritional Monitoring and Notification
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for monitoring and responding to a resident’s nutritional risk. Resident 8, who had diagnoses including diabetes, Alzheimer’s disease, and epilepsy, had a physician order dated 1/13/26 stating the resident was at risk for malnutrition related to comorbidities. The order directed nursing to monitor weight and intakes as ordered, monitor dental status for adequate chewing ability, follow up with the dietitian as recommended, monitor medications for adverse effects such as nausea, vomiting, diarrhea, and decreased appetite, monitor for negative outcomes such as decreased oral intake or weight loss, and notify the physician every shift. Record review showed that Resident 8’s weight decreased from 175 lbs on 2/9/26 to 168.8 lbs on 3/4/26, a 3.54% loss in 23 days, with no documentation that the physician was notified of this weight loss. Progress notes for March 2026 contained no evidence of physician notification regarding the weight loss, and the physician communication book for 3/4/26 through 3/10/26 also lacked any entry about this issue. The DON stated that staff are expected to fax or call the provider about resident changes and document physician notification in a progress note, but confirmed there was no such documentation for this resident. A QMA reported that the resident ate in the restorative dining room so staff could assist and monitor intakes, and that changes in eating would be reported to a nurse. Review of intake records between 2/9/26 and 3/4/26 showed multiple meals at 50% or less intake, including several meals at 1–25% or zero, with no documentation that alternatives or supplements were offered. An LPN explained that staff receive alerts when weight changes require dietitian notification and that staff become concerned at specified weight-loss thresholds, but there was no documentation that the physician was notified as ordered. The facility’s Provider Notification Guidelines policy required documentation of attempts to notify the provider and their response in the electronic health record but did not address following specific physician orders.
Unsanitary Grease and Debris Buildup on Kitchen Stove Hood and Sprinklers
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions of the kitchen stove hood that had the potential to affect all 58 residents who dine in the facility. During a kitchen tour with the Dietary Manager (DM), the stove hood above a regularly used griddle/stove was observed to have a significant amount of built-up greasy debris on the back panels and sprinklers, with the back panels appearing to have a furry substance completely covering them and the sprinklers. There was also stringy, dark debris hanging from one of the sprinklers directly above the food preparation area. The service sticker on the hood showed it was last serviced on 11/26/25 with the next service scheduled for May 2026, and a work order confirmed the kitchen exhaust system was scheduled for cleaning every 180 days for two years. During the interview, the DM acknowledged noticing the buildup but stated she had been told not to clean the hood because it would void the warranty. The facility’s Sanitation policy required all food service areas to be kept clean, sanitary, and free from litter and rubbish, and the observed condition of the stove hood did not meet this standard. No specific residents were individually identified in the report; the deficiency was cited as having the potential to affect all residents who receive meals prepared in the kitchen.
Failure to Assess and Monitor Resident After Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care, including assessment and monitoring, after a medication error involving Resident B. An LPN reported witnessing an RN administer one of Resident E’s morning medications to Resident B; this was later identified by the NP as rivastigmine 3 mg, a medication used to treat dementia. The NP stated that when the error was reported, she instructed the LPN to monitor Resident B’s vital signs and observe for anxiety and tremors every shift for 24 hours. The facility’s Medication Error policy required the nurse to assess and examine the resident’s condition, monitor and document the resident’s condition and response to interventions, and document actions taken in the medical record when a medication error occurs. Despite these requirements and the NP’s specific instructions, the Regional Nurse Consultant reported that there was no assessment, no progress note, and no vital signs documented in the EHR for Resident B following administration of Resident E’s medication. The floor nurse was identified as responsible for ensuring this was completed. Resident B’s clinical record indicated multiple diagnoses, including diabetes, chronic kidney disease, osteoporosis, hypertension, congestive heart failure, depression, anxiety disorder, intellectual disability, and a history of cerebral infarction, and an MDS assessment showed moderately impaired daily decision-making. The lack of documented assessment, monitoring, and vital signs after the medication error constituted the failure to provide care and services in accordance with physician orders, resident needs, and facility policy.
Failure to Consistently Apply Physician-Ordered Hand Splints for Contractures
Penalty
Summary
The facility failed to implement physician-ordered bilateral palm protectors/hand orthoses for a resident with bilateral hand contractures. On multiple observations over several days, the resident was seen without any splints in place on either hand, and later with a splint only on the left hand while the right-hand splint was on the bedside table or not in use. The resident’s care plan documented an alteration in functional performance requiring assistance with self-care and included an intervention for bilateral palm protectors per order. An Occupational Therapy assessment identified impaired ROM in both upper extremities due to contractures, and the quarterly MDS documented severe impairment in daily decision making and impaired ROM in both upper extremities. A physician’s order directed that the resident was to have bilateral palm protectors or hand orthoses during the daytime, removed at night and for bathing, with no documentation on the MAR of any refusals to wear the devices. Despite this, surveyors repeatedly observed the resident without one or both splints in place. During interview, the Regional Nurse Consultant stated that floor nurses were responsible for ensuring the resident had bilateral splints in place. The facility’s assistive device and splint policy stated that nurses were responsible to monitor for consistent use of such devices, including orthotic equipment and splints, to maintain or improve function, dignity, and quality of life.
Failure to Adequately Monitor and Manage Dementia-Related Wandering and Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and treat a resident’s dementia-related wandering and behavioral symptoms in accordance with its dementia care policy. Resident C was admitted with diagnoses including dementia with agitation and anxiety and was documented on admission as confused and combative. Within minutes of arrival, he refused to wait for a physical therapy evaluation, would not follow staff direction, moved into his roommate’s area, handled the roommate’s belongings, and made physical contact with the roommate. Verbal redirection was unsuccessful, and he became physical, striking staff. Later that evening, he and his roommate were screaming at each other, leading staff to temporarily move him to another room. During this period, he continued to leave his room, wander into other residents’ rooms, and remain physically combative with staff. The facility did not have Resident C’s discharge medications, including his scheduled Risperidone, available upon admission, and emergency medication obtained that night had little to no effect. His medications were not available until his second day at the facility. During this time, multiple female residents voiced that they wanted him kept away from them. Behavior notes documented that he was confused, ambulating in the hallways, refusing to stay in his bed despite repeated attempts, and wandering without purpose. He rummaged through his roommate’s belongings and irritated his roommate. Staff interviews confirmed that he repeatedly entered other residents’ rooms, was difficult to redirect, and was combative when staff attempted to intervene. One CNA reported that it was chaotic when he was not provided one-on-one supervision and that he wandered into other residents’ rooms, including climbing into bed with another resident as reported in shift report. Multiple residents described specific incidents of Resident C entering their rooms uninvited. One resident reported that he came into her room, shut the door, removed her wheelchair foot pedals from the bed, asked where to put them, and ultimately placed them in the trash before leaving. On another occasion, he lay on her bed until staff redirected him. Another resident stated that he entered her room, closed the door, sat on the empty bed, turned back the covers, made inappropriate hand signs, and told her to “shut up,” which left her feeling scared and uncomfortable. Behavior notes further documented that he continued to enter other residents’ rooms, strike staff during redirection attempts, spit on a nurse, lay on the floor at the nurse’s station, and exhibit exit-seeking behavior. Staff, including the Social Services Director and Administrator, acknowledged that he wandered everywhere, went into other residents’ rooms, and was aggressive with staff, and that he was not placed on one-on-one supervision until several days after admission, despite ongoing behaviors and resident complaints. These actions and inactions demonstrate the facility’s failure to provide appropriate monitoring and dementia care services to address his wandering and behavioral symptoms as required by its own dementia care policy. Additional documentation showed that Resident C wandered the facility for entire shifts, entered multiple residents’ rooms, upset residents, and at one point sat on another resident’s bed, removed his pants and socks, and attempted to lie down while the room’s occupant became angry and told him to leave. Staff required multiple attempts to redirect him from these rooms. Residents reported feeling uncomfortable and, in at least one case, scared by his presence and behavior in their rooms. The Social Services Director stated that the facility had believed he was not ambulatory and was surprised by his ability to walk everywhere upon admission, and also noted that he was more confused when off his original hospital medications. Despite the facility’s dementia care policy requiring assessment, individualized care planning, person-centered non-pharmacological approaches, environmental modifications, and ongoing monitoring of interventions for effectiveness, the record and interviews show that Resident C’s wandering and intrusive behaviors into other residents’ rooms persisted over several days without timely implementation of effective monitoring and supervision. The Administrator confirmed that Resident C wandered into other residents’ rooms and was aggressive with staff, and that other residents were upset because they were not used to residents entering their rooms. Staff accounts and behavior notes consistently described ongoing wandering, room entries, combative behavior, and difficulty with redirection over multiple days following admission. The delay in obtaining his scheduled psychotropic medications, the lack of immediate and sustained one-on-one supervision despite repeated incidents, and the continued reports from residents and staff about his intrusive and aggressive behaviors collectively demonstrate the facility’s failure to provide appropriate treatment and services for a resident with dementia-related wandering and behavioral symptoms, as required by its dementia care policy and regulatory standards.
Failure to Provide Ordered Psychotropic Medications at Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident’s ordered psychotropic medications were available and administered as scheduled upon admission. The resident, who had diagnoses including dementia with agitation and anxiety, was discharged from the hospital with orders for Risperidone 0.5 mg tablets (three tablets once daily, next dose due at 4:00 p.m.) and Trazodone 50 mg at bedtime (next dose due at bedtime). Review of the February medication administration record showed that neither the 4:00 p.m. dose of Risperidone nor the bedtime dose of Trazodone were given on the day of admission, and both medications were first administered the following day. The nurse admission note documented that shortly after arrival the resident was confused, combative, refused to wait for physical therapy, refused staff direction, entered the roommate’s area, moved items, and made contact with the roommate, with verbal redirection failing and the resident striking staff. A later nursing note the same evening documented that the resident had to be temporarily moved to another room because he and his roommate were screaming at each other, and that the resident was found in another resident’s room and remained combative with redirection. In an interview, the LPN on duty at admission stated that the resident’s discharge medications, including the scheduled Risperidone, were not available for administration when the resident arrived and were not available until the resident’s second day in the facility. The LPN reported that an emergency behavior medication was administered with little to no effect while the resident was having behaviors and was difficult to redirect. The facility’s Pharmacy Services policy stated that the facility would provide pharmaceutical services and procedures to assure accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet each resident’s needs.
Failure to Implement and Document Ordered Weekly Weights for Residents with CHF and Edema
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights for two residents with CHF, edema, and lymphedema. For one resident, multiple observations over several days showed the resident asleep in a recliner with legs elevated, wearing pants that had been cut from the hem to the calf and appeared wet, with bilateral lower leg edema noted each time. The resident’s care plans, addressing CHF, edema, diuretic use, and nutritional risk, directed staff to obtain and document weights as ordered. A physician’s order dated 12/19/25 specified weekly weights on Tuesday mornings. However, review of the MAR showed that staff documented weekly temperatures instead of weights, and the vitals section of the EHR contained no documentation of the ordered weekly weights. Interviews revealed that the QMA/Scheduler responsible for obtaining weights acknowledged that temperatures were documented instead of weights and that she was responsible for ensuring weights were completed and re-weights obtained for significant changes. An LPN confirmed that the physician’s order was for weekly weights but that temperatures were entered and documented, indicating the order had been entered incorrectly into the EHR. The Clinical Support Nurse explained that the order had been placed in the EHR with a task incorrectly set to “temperature” rather than “weight,” and that the IDT reviewed only the compiled weight report, not the underlying orders, when monitoring residents. The Executive Director stated that a nurse should have caught the entry error when completing the task, and the NP indicated that weights were difficult to monitor because they were not always documented in the same EHR location and that she relied on nurses to notify her of changes. For the second resident, observations documented the presence of a midline IV in the right upper arm and bilateral lower extremity edema, with the resident reporting weight gain from swelling and uncertainty about how often he was weighed. An empty IV bag labeled Furosemide 80 mg IV was observed, and later the midline had been removed while edema persisted. The resident’s diagnoses included CHF, edema, and lymphedema, and a care plan directed that his weight be obtained and documented per order. A physician visit note dated 1/28/26 included a plan to monitor weekly weights, but no weekly weight documentation or corresponding physician order was found in the EHR. A change in condition note on 2/20/26 documented increased edema and shortness of breath and new orders for IV Furosemide and fluid restriction, but did not include weight monitoring. A progress note on 2/25/26 stated that the DON contacted the MD, confirmed IV Lasix 80 mg, and indicated the resident was placed on daily weights, yet no daily weight documentation or physician order for daily weights was found in the EHR. In a later text message, the MD clarified the resident was supposed to be on weekly weights, and the DON acknowledged she had not placed an order for weekly weights in the EHR, contrary to the facility’s policy requiring physician orders to be followed and reviewed.
Some of the Latest Corrective Actions taken by Facilities in Indiana
- Trained staff on specific clinical processes including enteral nutrition guidelines, lab/radiology services, change-of-condition notification, admission evaluations, blood glucose point-of-care testing, physician orders, clinical morning meeting, and admission audits (J - F0684 - IN)
- Implemented reviews of all new admissions to help ensure admission orders and related care processes were carried out (J - F0684 - IN)
- Implemented audits for newly admitted residents to monitor compliance with admission-related requirements (J - F0684 - IN)
Failure to Implement Admission Orders for Medications, Tube Feeding, and Hydration
Penalty
Summary
The deficiency involves the facility’s failure to transcribe and implement physician-ordered medications, nutrition, and hydration for a newly admitted resident. The resident was admitted from a rehabilitation hospital with diagnoses including hemiplegia following a stroke, type 2 diabetes mellitus, gastrostomy, and dysphagia, and was comatose with feeding via a tube. An interdisciplinary team conference note from the sending rehabilitation hospital, provided at the time of admission, listed multiple critical medications and continuous tube feeding with Vital 1.2 at 65 mL/hr and a 25 mL/hr water flush. Despite this, there were no admission orders in the resident’s record from the date of admission until two days later. Physician orders for the resident’s medications and tube feeding flushes were not written until two days after admission, and the Medication Administration Record (MAR) showed that some medications (glargine insulin, levetiracetam, metformin) were first administered only on that date, with others (aspirin, hydrochlorothiazide, Jardiance, lisinopril) not started until the following day. The MAR documented initiation of Jevity 1.2 tube feeding and water flushes even later, and there was no documentation of any tube feeding, water flushes, or other fluids or nutritional feedings from admission until that time. Care plans addressing altered nutritional status and tube feeding needs were also not initiated until two days after admission, with no care plans in place prior to that date. A nursing progress note later documented that when a nurse entered the resident’s room to administer medications, the resident was found sweaty, with an oxygen saturation of 85% on room air, no obtainable blood pressure, and a blood glucose monitor reading “HI,” indicating a level beyond the device’s measurable range. Emergency services were called, and hospital records showed the resident had a blood glucose of 954 mg/dL, hypernatremia, extreme volume depletion, and acute kidney injury, and was admitted to a higher-acuity unit for hyperosmolar hyperglycemic state. An RN interview confirmed that, upon auditing the admission orders the Monday after the weekend admission, she discovered that medication, tube feeding, and hydration orders had not been initiated and that there was no documentation of these being provided during the initial days after admission, despite facility policy requiring timely admission evaluation, medication reconciliation, hydration, and 72-hour admission progress notes with vital signs and assessments.
Removal Plan
- Facility staff was in-serviced regarding enteral general nutrition guidelines, laboratory and radiological services, notification of change of conditions, admission evaluations, blood glucose point of care testing, physician orders, clinical morning meeting and admission audits.
- A house-wide clinical assessment of all residents was completed.
- All new resident admissions were reviewed.
- Audits were implemented regarding newly admitted residents.
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