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
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
Some of the Latest Corrective Actions taken by Facilities in Indiana
- Developed a sling replacement schedule per manufacturer instructions to help ensure slings were replaced before becoming unsafe (J - F0689 - IN)
- Added sling sizing guidance to resident care plans and CNA care guidance to support correct sling selection during mechanical lift transfers (J - F0689 - IN)
- Reeducated staff on identifying sling pad deterioration before use to prevent use of compromised slings (J - F0689 - IN)
Failure to Transcribe Hospital Diabetes Orders Resulting in Missed Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and enter a hospital’s discharge orders for a newly admitted resident with type 2 diabetes into the facility’s electronic health record. The resident was admitted for a short-term rehab stay with diagnoses including type 2 diabetes, acute upper respiratory infection, unspecified dementia, weakness, dehydration, and hydrocephalus. The hospital discharge orders dated 2-6-26 specified that the resident had type 2 diabetes and was to receive glargine (Lantus) 16 units subcutaneously twice daily, with blood glucose (BG) monitoring before meals or three times daily. These diabetes-related orders, including the diagnosis and insulin regimen, were not transcribed into the facility’s electronic health record at admission and were not entered until 2-12-26. Multiple facility staff, including the Director of Health Services (DHS), MDS staff, a Nurse Practitioner, and two nurses, reviewed the hospital discharge paperwork and entered orders into the electronic health record but failed to identify and transcribe the diabetes diagnosis and associated insulin and BG monitoring orders. The DHS later explained that the initial page of the hospital discharge summary did not specifically mention the diabetes diagnosis, which was located further into the document, and that staff did not locate this information during the initial review. The omission was discovered on 2-11-26 during an initial care planning meeting when a family member inquired about the resident’s BG levels, prompting a more thorough review of the hospital discharge documents. During the period when the diabetes diagnosis and insulin orders were not in place, the resident did not receive the ordered long-acting insulin for five days and had only one insulin injection documented since admission. The resident’s BG levels during this time were significantly elevated, with readings including 399, 451, 496, 316, 360, 356, 422, and 354. The resident, who was already severely cognitively impaired per the 5-day MDS assessment, experienced diminished cognitive levels and lethargy and was ultimately sent to the local hospital at the family’s request. Hospital records from that subsequent admission documented altered mental status possibly related to dehydration, infection, or diabetic ketoacidosis, and identified the resident’s diabetes as uncontrolled at that time.
Removal Plan
- notification of the physician and the responsible party of the identified issues
- obtaining updated physician orders
- implementing the orders
- educating the licensed nursing staff on the facility's policies related to transcribing physician orders and diagnoses from the discharging entity into the facility's electronic health record
- initiated an audit system to ensure residents had accurately transcribed admission orders and diagnoses correctly documented into the facility's electronic health record system
Failure to Prevent and Manage Progressive Sacral and Buttock Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and deterioration of a severe pressure ulcer in a resident who was admitted without documented pressure injuries to the buttocks or sacrum, despite being identified as at increased risk for skin breakdown. On admission, the resident had diagnoses including a displaced intertrochanteric fracture of the left femur, difficulty walking, morbid obesity, and bilateral hip osteoarthritis. The admission nursing evaluation documented normal skin color and temperature, with excoriations noted on the chest and bilateral iliac crest/groin areas, and a surgical dressing on the left thigh, but no pressure injuries were documented. A Braden Scale completed at admission identified the resident as at increased risk for pressure sores, with limited cognition, chairfast status, limited mobility, and friction and shear as potential problems. The care plan initiated the day after admission identified potential for skin impairment related to decreased mobility and included general interventions such as incontinence care, treatments as ordered, observation of skin during care, turning and repositioning, use of a pressure-reducing mattress and wheelchair cushion, weekly skin checks, and a wheelchair cushion, but no new or revised interventions were added when the care plan was revised several days later. Subsequent skin checks documented a stage 1 pressure injury to the medial buttocks that was considered present on admission, although the admission assessment had only described excoriation and did not stage a pressure injury. A skin check dated approximately nine days after admission described the buttocks as having a generalized stage 1 pressure ulcer/injury to the medial buttocks without undermining or tunneling, and a later skin check again documented a stage 1 pressure injury to the medial buttocks, still described as present on admission. The resident’s MDS indicated she was cognitively intact but totally dependent on staff for toileting, hygiene, showering, and transfers using a sit-to-stand device, and required substantial assistance for bed mobility and position changes. The DON later reported that the resident slipped from the bed on an early March date and that shearing was subsequently noticed, which was described as the resident’s skin tears. Despite the resident’s high risk status, dependence on staff for repositioning, and documented redness on the coccyx and buttocks, there is no indication in the record that the facility implemented additional or modified interventions beyond the original care plan to address the evolving skin issues. A wound note dated in early March documented that the resident, in addition to her post-surgical left proximal and distal wounds, had full-thickness skin tears to the right and left buttocks and sacrum. A physician’s order for non-pressure wounds of the coccyx and bilateral buttocks directed cleansing with normal saline, application of calcium alginate, and dressing as needed. A nurse’s note the same day indicated the resident was seen via telehealth by the wound nurse with the assistant DON, and the plan was for twice-daily dressing changes using Dakin’s solution, calcium alginate, and abdominal gauze. The following day, a wound note documented selective debridement of the right buttock and surgical excisional debridement of the sacrum. A subsequent alert note described the buttock/sacrum wound as tunneling with foul odor, requiring flushing with Dakin’s and normal saline, and application of Santyl, calcium alginate, and border gauze. Shortly thereafter, the resident was sent to the hospital for lethargy, altered mental status, and elevated temperature, and the hospital documented a diagnosis of sepsis likely due to an infected sacral wound. The surveyors determined that the facility failed to prevent the development and progression of a stage 4 pressure ulcer on the sacrum and full-thickness skin tears on the bilateral buttocks, and failed to ensure appropriate services were provided to these wounds, resulting in deterioration to a stage 4 pressure injury requiring surgical debridement and hospitalization for sepsis within three weeks of admission.
Removal Plan
- staff education/in-services on daily wound monitoring
- assess all residents for identifying skin impairments
- review all resident care plans regarding skin issues
- ensure pressure injury prevention interventions are in place for at-risk residents
- wound team to complete a risk management assessment of physician notification, obtaining new orders, transcribing new orders, contacting families regarding new orders, updating care plans with new interventions, and providing therapy referrals as needed
Improper Sling Selection and Use Leads to Fatal Mechanical Lift Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff used a correctly sized, properly labeled, and intact mechanical lift sling when transferring a resident, and to have an effective process for sling sizing and condition assessment. A resident with hemiplegia affecting the left side and a left above-knee amputation required transfers with a Hoyer (mechanical) lift and assistance of two staff. The resident’s MDS documented a height of 78 inches (6 feet 6 inches) and weight of 252 pounds. The resident’s care plan and physician orders specified use of a Hoyer lift with two staff for transfers but did not identify the size of sling to be used. There was no documentation of an interdisciplinary assessment to determine appropriate sling size prior to using the lift, and no physician orders specifying sling size. During a transfer from bed to chair, an LPN and a CNA used a blue sling with four straps and color‑coded rings. The CNA reported that the sling straps were inspected before use and did not appear worn, though she described the sling as old. The straps were attached to the lift bar using the last black ring on each strap to accommodate the resident’s size. While the resident was suspended in the lift and being moved backward, the black ring on the left bottom (leg) strap broke in the middle, causing the resident to fall from the sling, strike his head on a bed frame, and land on the floor. The resident briefly lost consciousness, then became lethargic and complained of pain in the head, back, and hips. Vital signs were obtained and the NP was notified, who ordered transfer to the hospital. Hospital CT scans later showed multiple fractures of the lower back, pelvis, and neck, and the resident died at the hospital. Subsequent observation of the sling in the Administrator’s office showed a blue sling with pilling along the edges, a torn black ring on the left bottom strap, and a worn, torn label with no legible writing. There were no visible tags identifying sling size or directions for use. Facility documentation for the sling model indicated that a large universal sling was generally intended for patients 225–325 pounds and 5 feet 5 inches to 6 feet 1 inch tall, and that sling size and fit could vary based on weight and girth, with physician consultation recommended for sling selection. Staff interviews revealed that, prior to the incident, all slings in use were the same size, residents did not have specific sling sizes assigned, and staff did not know who was responsible for monitoring slings for age or defects. The Rehabilitation Director stated that rehab evaluated residents for need of mechanical lifts but did not determine sling size, and that staff were expected to follow sling label directions, even though the sling involved had an illegible tag. External guidance from the FDA and a sling manufacturer emphasized the need to select sling size based on patient measurements and manufacturer recommendations, and to remove slings from service if tags were missing, faded, or illegible, or if deterioration was present. The facility’s own policy required availability of varying sling sizes, correct resident measurement per manufacturer instructions, and removal of damaged or unsafe slings from service, which was not carried out in this case.
Removal Plan
- Removed all lift pads from service
- Assessed residents utilizing lifts for proper fit according to manufacturer's guidelines
- Replaced all slings with properly sized slings
- Added sling sizing to care plans and care guidance for CNAs
- Developed a replacement schedule for slings according to manufacturer's instructions
- Reeducated staff on how to identify deterioration of sling pads before use
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