Citations in Kansas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Kansas.
Statistics for Kansas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Kansas
The facility failed to obtain complete and properly executed informed consents for psychotropic medications for multiple residents. Several residents were receiving antidepressants, antianxiety agents, and antipsychotics, yet their psychotropic consent forms were either missing signatures or did not list the specific medications, dosages, routes, or administration frequencies. Staff reported that informed consent was required before starting or changing psychotropic drugs and that consents were to be provided to residents or their representatives, and facility policy required signed consents at initiation and with dosage increases, but the documentation for these residents did not include the necessary medication details.
A resident’s Medicare Part A coverage ended, and the resident remained for LTC on a private pay basis, but the facility could not produce evidence that the required SNF Advance Beneficiary Notice of Non-coverage (ABN) Form CMS-10055 was provided. Social service notes stated that the ABN was given and that a private pay quote was discussed, and an email to the resident’s representative referenced appeal rights and possible continued therapy, but the documentation did not specifically reference the SNF ABN or include estimated costs for continued therapy. The social worker later acknowledged she could not show that the ABN form had been provided, and no copy of the completed form was in the record, despite facility policy requiring appropriate Medicare discharge notification and appeal information when coverage ends.
A resident with hemiplegia and a documented left-hand contracture risk had physician orders and a care plan directing staff to place a rolled washcloth or splint in the hand on every day and night shift, with the MAR consistently indicating the device was in place and no refusals. However, surveyors repeatedly observed the resident with the left hand hanging in a loose fist, swollen, and without any device, while the prescribed hand splint was found across the room. Therapy staff confirmed the resident’s flaccid left arm and provision of a resting hand splint or rolled towel, and nursing and administrative staff acknowledged the device was supposed to be in the hand at all times and documented on the MAR, demonstrating a failure to follow ordered interventions to prevent contracture.
A resident with pneumonia and post-stroke hemiparesis, care planned and ordered for continuous 2L oxygen due to ineffective gas exchange, was observed in the dining area with a portable oxygen tank attached to the wheelchair but not receiving oxygen; the nasal cannula was hanging unused and the tank was empty. Staff, including an LPN and a CMA, acknowledged the resident was supposed to be on oxygen at all times, and facility policy required use of portable oxygen when off the main concentrator, but this was not followed.
A resident with Alzheimer’s disease, prior stroke, insomnia, and major depressive disorder was maintained on Quetiapine for “unspecified dementia with psychotic disturbances” without a CMS-approved indication and without behavioral monitoring. The MDS showed severe cognitive impairment but no documented behaviors, and the care plan referenced resisting care and yelling out but did not include a clear psychiatric indication for antipsychotic use. The resident was observed calm and behavior-free, while the EMR lacked behavior tracking tied to the antipsychotic. A consultant pharmacist recommended gradual dose reduction, which the provider declined, and staff acknowledged that antipsychotics are not indicated for dementia alone and that the resident’s representative refused medication changes, leaving the facility unable to document an appropriate rationale consistent with its own psychotropic medication policy.
Surveyors found that a resident was maintained on Quetiapine for an indication of unspecified dementia with psychotic disturbances without a clearly documented CMS-approved psychiatric indication. The MDS showed no documented behaviors during the assessment period, and the care plan referenced behaviors and use of Quetiapine but did not specify a psychiatric indication or include behavioral monitoring. The consultant pharmacist’s monthly reviews recommended gradual dose reduction, which the provider declined, but did not address the inappropriate dementia-related indication, and the facility could not produce documentation supporting an appropriate indication despite acknowledging that antipsychotics are not indicated for dementia alone.
A resident with paranoid schizophrenia, anxiety disorder, and cancer, who was care planned to be calmly redirected and reassured when escalating, became involved in a yelling incident with a dietary staff member during snack service. Camera footage and staff interviews confirmed that the staff member yelled and screamed at the resident in front of others, called the resident an expletive, and moved toward the resident until a CMA intervened and removed the resident from the situation. The resident reported she had only asked for more food, stated that being yelled at by staff was common, and said she did not feel safe when this occurred. The facility’s investigation acknowledged the staff member’s behavior as unacceptable but did not include written witness statements or documented psychosocial follow-up in the EMR, and social services staff either were unaware of the incident details or only performed undocumented, generalized verbal check-ins.
Surveyors observed a dietary staff member plating meals while wearing the same pair of gloves to handle multiple food items, including ready-to-eat bread, and then touching her face and glasses before continuing to plate food without changing gloves or washing hands. The staff member reported she had been trained to serve in this manner and usually changed gloves several times during the process. These practices did not follow the facility’s hand hygiene policy, which requires handwashing in designated sinks, appropriate glove use when handling ready-to-eat food, and handwashing before distributing meals.
The facility used an admission packet containing an Arbitration Provision that did not inform residents or their representatives of their right to rescind the agreement within 30 days or that signing it was not a condition of admission. All residents had signed arbitration agreements, and staff reported that the provision in the packet was the only written information provided, with explanations given verbally at admission. Administrative staff and an administrative nurse indicated that the provision had been created by a previous company and possibly altered by current leadership, and they were not aware of the specific regulatory language required to be included in the arbitration agreement.
The facility used an admission packet arbitration provision for all 22 residents that did not inform residents or their representatives of their right to participate in selecting a neutral arbitrator or a mutually convenient venue. Administrative staff reported that the arbitration provision in the admission packet was the only written information provided and that they verbally explained it at admission, but they were not aware of the specific language required to be included. The arbitration language had been created under a previous company and may have been altered by the current board and administrator, yet it still lacked the required provisions, resulting in a deficiency related to the arbitration process.
Failure to Obtain Complete Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their representatives were fully informed about specific psychotropic medications, including their names, dosages, routes, and frequencies, as required for informed consent. For one resident with orders for mirtazapine for depression, fluoxetine for depression, and alprazolam for anxiety, the psychotropic medication consent form was dated several months after the medication orders and did not list any of the prescribed psychotropic medications or their details. Another resident with orders for mirtazapine for insomnia and fluoxetine for a mood disorder had a signed psychotropic consent form that also lacked the names of the medications, their dosages, routes, or administration frequencies. A third resident had multiple psychotropic orders, including sertraline for depression, quetiapine in two different strengths for major depressive disorder and behavioral disturbances, mirtazapine for depression, and lorazepam for anxiety. The scanned psychotropic consent for this resident was unsigned and similarly did not specify any of the psychotropic medications, their dosages, routes, or frequencies. Staff interviews confirmed that informed consent was expected before starting or changing psychotropic medications and that consents were to be provided to residents and/or their legal representatives. The facility’s own policy required a signed informed consent on initiation and with any dosage increase of psychoactive medications to ensure potential adverse effects were reviewed, but the documentation reviewed for these residents did not meet those requirements.
Failure to Provide Required SNF ABN and Cost Information When Medicare Coverage Ended
Penalty
Summary
The deficiency involves the facility’s failure to provide the required Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) Form CMS-10055 to a Medicare Part A beneficiary when his covered stay ended and he remained in the facility. The resident census was 61, with 15 residents sampled and three reviewed for beneficiary notifications. For one resident, documentation showed that his Medicare Part A last covered day was 01/28/26, after which he remained in the facility for long-term care on a private pay basis. Facility records, including the medical record and business office documentation, did not contain evidence that the SNF ABN Form CMS-10055 was provided. A social service note dated 01/30/26 stated that the social worker provided the SNF ABN and that the resident would remain private pay for approximately 30–60 days until an apartment was available, and that a private pay quote was given to the resident’s representative. Another social service note, created on 02/09/26 with an effective date of 01/30/26, documented that the resident requested staff review the SNF ABN with his representative, who was not present and whose arrival time was unknown. Email communication from the facility to the resident’s representative on 01/27/26 indicated there was a form the resident would need to sign that reviewed his appeal rights and his right to appeal if he believed Medicare should cover the long-term care stay, and that the appeal could take up to four months while therapy continued, with room, board, and therapy to be billed if the appeal was unfavorable. However, this email chain did not mention the SNF ABN or provide an estimated cost to continue therapy services. During an interview on 02/10/26, the social worker stated the ABN should be provided prior to discharge and reported that she had provided the form, but that the resident did not sign or return it because he wanted to review it with his representative. She confirmed she was unable to show that the resident was provided with the ABN Form CMS-10055 because she did not have a copy. The facility’s policy dated 12/01/17 required appropriate notification of discharge from Medicare services, including appeal rights, when Medicare coverage ends, but the appropriate notification of discharge from Medicare services was not provided in this case.
Failure to Implement Ordered Hand Splint/Positioning Device to Prevent Contracture
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered care and services to prevent reduction in range of motion and contracture development for a resident with left-sided weakness and a left-hand contracture risk. The resident had a history of hemiplegia and hemiparesis following a stroke affecting the left nondominant side, and the admission MDS documented a contracture of the left hand with intact cognition. The care plan and physician’s orders directed staff to place a clean, dry, rolled washcloth between the resident’s fingers and palm and ensure good hygiene on every day and night shift. The MAR from late September through early February documented that the rolled washcloth was in place every day and night with no refusals, and progress notes did not document any refusals or missed treatments. Despite this documentation, surveyor observations on multiple occasions showed the resident without any device in the left hand to address contracture risk. The resident was observed in a wheelchair with the left hand hanging down in a loose fist and swollen, and later in bed with the left hand dangling, swollen, and without a rolled cloth or device. The resident reported that therapy had given her a hand device described as a pool noodle with a strap to prevent her hand from contracting and stated she should have been wearing it at the time, but it was observed across the room on her dresser. A therapy consultant reported that an evaluation had been completed for a left-hand contracture, that the resident’s left arm was completely flaccid, and that a simple resting hand splint or rolled towel had been provided for use. Nursing staff and an administrative nurse confirmed that a towel or splint was supposed to be in the resident’s hand at all times and that nurses were responsible for placement and documentation on the MAR. The facility’s restorative nursing policy stated that goals for elders receiving restorative services include preventing contractures.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered continuous oxygen therapy to a resident with significant medical needs. The resident had diagnoses including pneumonia, anxiety, and hemiplegia/hemiparesis following a stroke, and her admission MDS documented intact cognition with receipt of oxygen. Her Care Area Assessment noted impaired physical functioning related to a past stroke with left-sided weakness and a need for staff assistance with all care. The resident’s care plan documented she was to be on oxygen related to ineffective gas exchange, with an order for two liters of oxygen continuously. Physician’s orders directed staff to monitor oxygen saturation and provide oxygen at two liters every day and night shift. During observation, the resident was seated in the dining room in a wheelchair with a portable oxygen tank attached to the back of the wheelchair and a bag containing nasal cannula tubing. The nasal cannula prongs were hanging freely and were not in use, and the resident was not receiving oxygen despite the continuous oxygen order. When a licensed nurse placed the nasal cannula on the resident and attempted to turn on the oxygen, the portable tank was found to be empty, and the nurse then returned the resident to her room to place her on oxygen via a concentrator. Subsequent interviews with a CMA and another licensed nurse confirmed their understanding that the resident required oxygen all the time, and an administrative nurse stated she expected nurses to follow the oxygen orders. The facility’s oxygen therapy policy stated that residents would use oxygen from a portable source when off the main concentrator, but this was not implemented for the resident at the time of observation.
Inappropriate Antipsychotic Use Without CMS-Approved Indication
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident remained free from chemical restraint through the inappropriate use of an antipsychotic medication without a CMS-approved indication. The resident had diagnoses including Alzheimer’s disease, cerebral infarction, insomnia, and major depressive disorder, with a BIMS score indicating severe cognitive impairment but no documented behaviors on the MDS during the assessment period. The care plan, initiated months earlier, described behaviors of resisting care and yelling out related to depression, anxiety, and dementia, and noted the use of Quetiapine (Seroquel) for these behaviors, but it did not include a psychiatric indication for the antipsychotic. The physician’s order renewed Quetiapine 12.5 mg daily for “unspecified dementia with psychotic disturbances,” and the resident had been admitted on this medication and diagnosis. Record review showed no behavioral monitoring related to the antipsychotic use, despite the resident’s psychotropic CAA identifying antipsychotic use and risk for adverse effects. Consultant pharmacist documentation over several months included a recommendation for gradual dose reduction of Quetiapine, which the provider declined, citing risk of decompensation, but the recommendations did not address the lack of an appropriate CMS indication for use in dementia. The facility was unable to provide a documented rationale for continued Quetiapine use without an appropriate CMS indication when requested. Observations showed the resident calm, engaged in group activity, and without behaviors at the time of surveyor observation. Interviews with facility staff confirmed that antipsychotics are not indicated for dementia alone and that dementia was the listed indication, with staff acknowledging that the resident’s representative refused changes to the medication or its indication. The facility’s own policy required psychotropic drugs to be used with specific diagnoses and to be closely monitored, but this was not supported by the documentation for this resident’s antipsychotic therapy.
Failure to Ensure Appropriate CMS-Approved Indication for Antipsychotic Therapy
Penalty
Summary
Surveyors identified a deficiency in the facility’s drug regimen review process related to the use of an antipsychotic medication for a resident with dementia. The resident’s EMR listed diagnoses of Alzheimer’s disease, cerebral infarction, insomnia, and major depressive disorder, with a BIMS score indicating severe cognitive impairment. The MDS showed the resident was independent in activities of daily living and did not exhibit behaviors during the assessment period, though it documented antipsychotic use. The CAA noted antipsychotic use and risk for adverse effects from Seroquel. The care plan, initiated earlier, described behaviors of resisting care and yelling out related to depression, anxiety, and dementia, and stated that Quetiapine (Seroquel) was used for these behaviors, but it lacked a clear psychiatric indication for the medication. The EMR contained a renewed order for Quetiapine 12.5 mg daily with an indication of unspecified dementia with psychotic disturbances, and there was no behavioral monitoring documented related to the antipsychotic use. Review of the consultant pharmacist’s monthly recommendations from May through February showed that the pharmacist recommended a gradual dose reduction of Quetiapine to the lowest effective dose, which the medical provider declined, citing risk of decompensation. The pharmacist’s recommendations did not address the use of the antipsychotic with the indication of dementia, and the facility could not provide documentation supporting a CMS-approved indication for the continued use of Quetiapine despite a request for such rationale. Observations showed the resident calm and engaged in group activity without behaviors. Interviews revealed that the consultant pharmacist stated the resident was admitted on the antipsychotic and that the representative refused changes or discontinuation, and that the medication was believed to be needed for dementia-related hallucinations and delusions. A nurse and an administrative nurse both stated that antipsychotics were not indicated for dementia alone and required a psychiatric diagnosis, and that the resident had been admitted with the medication and dementia diagnosis. This sequence of actions and inactions demonstrated a failure to ensure the consultant pharmacist addressed the lack of an appropriate CMS indication for the antipsychotic during the monthly drug regimen review, contrary to the facility’s drug regimen review policy.
Verbal Abuse of Resident by Dietary Staff During Snack Service
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a staff member. The resident had diagnoses including paranoid schizophrenia, anxiety disorder, shortness of breath, and malignant neoplasm of the breast, with a BIMS score indicating intact cognition. Care plan interventions directed staff to allow the resident to voice needs and concerns, avoid arguing with delusions, redirect the resident to a quiet area if escalating, offer reassurance, and interact in ways that built rapport and monitored for precursors to socially inappropriate behaviors. Despite these interventions, during a snack pass the resident became involved in a yelling and screaming incident with a dietary staff member in the dining room. According to the facility’s investigation and staff interviews, the dietary staff member was seen and heard on camera yelling and screaming at the resident in front of other residents, shouting profanities and using vulgar and offensive references. A CMA reported hearing the dietary staff member call the resident an expletive and described the staff member attempting to get in the resident’s face, prompting the CMA to step between them and remove the resident from the hostile environment. The CMA stated the resident was not getting into anyone’s face or going after staff and that the resident had only asked for more food when the dietary staff member yelled at her. Administrative staff confirmed that camera audio captured the dietary staff member calling the resident an expletive and that staff had to intervene. The resident later stated she remembered the incident, recalled that she was only asking for more food when she was yelled at, and reported that being yelled at by staff was nothing new or out of the ordinary, stating she was yelled at all the time and did not feel safe when this occurred. The facility’s investigation documented that the resident admitted she shouted back at the staff member and that staff intervened and helped calm her down and support her. The investigation noted that the staff member’s behavior, as seen on camera, was not accepted by the facility. The facility’s abuse prevention policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included verbal abuse. The surveyors determined that the facility failed to ensure the resident remained free from verbal abuse, and this failure placed the resident in immediate jeopardy. The investigation and record review also showed gaps in follow-up related to the incident. The facility’s investigation did not include any staff witness statements, despite identification of a direct witness. The resident’s EMR lacked evidence of any follow-up psychosocial assessments or documented staff interviews with the resident related to the incident. One social services staff member stated she was not aware of the details of the incident and had not completed any psychosocial follow-up. Another social services staff member reported speaking with the resident the next day and performing generalized verbal check-ins but did not document these interactions and did not conduct or record a formal psychosocial assessment related to the event. Administrative staff stated there was no additional staff education completed after the incident because the involved staff member was terminated and other staff had prior ANE training.
Removal Plan
- Conduct interviews with each resident to identify if any residents were having adverse outcomes due to staff yelling and shouting profanities and/or any other incidents that may have gone unreported.
- Educate all staff that shouting profanities, calling residents vulgar names, or acting in any other excessive, obtuse, obscene, or nonsensical way would not be permitted at the facility.
- Complete Abuse, Neglect, and Exploitation training with staff, with an emphasis on their duty to report.
Improper Glove Use and Hand Hygiene During Meal Service
Penalty
Summary
Surveyors identified a deficiency in food preparation and service sanitation when observing the noon meal service for a census of 22 residents from the facility’s main kitchen. During the meal, a dietary staff member wearing gloves plated food by removing the lid from a roasting pan and using utensils to serve meat, potatoes, and spinach, then used the same gloved hand to pick up a roll and continued plating. While still wearing the same gloves, she touched her face and glasses and then resumed the plating process without removing the gloves or washing her hands. In a subsequent interview, the dietary staff member stated she had been trained to serve in that manner and typically changed her gloves about three times during the process. The facility’s written hand hygiene policy for food handlers requires that hands always be washed in designated handwashing sinks, that gloves be worn when serving residents on transmission-based precautions or when touching ready-to-eat food, and that staff perform handwashing prior to distributing meals.
Arbitration Agreement Lacked Required Rescission and Non-Condition of Admission Language
Penalty
Summary
The facility failed to ensure its arbitration agreement informed residents or their representatives of their right to rescind the agreement within 30 days of signing and that signing the agreement was not a condition of admission. With a census of 22 residents, all 22 had signed arbitration agreements, and there were no residents in active arbitration. Review of the admission packet showed that Exhibit E, titled Arbitration Provision, did not contain language notifying residents or representatives of the 30-day rescission right or that the arbitration agreement was optional and not required for admission. During interviews, an administrative staff member stated that the Arbitration Provision in the admission packet was the only information provided about the agreement and that she verbally explained it to new admissions when they signed, but there was no indication that the required language was included in writing. Another administrative nurse reported that the previous company had written the Arbitration Provision and that the current board and administrator might have modified it, and she was not aware of the specific language required to be included. A separate administrative staff member also stated they followed whatever the admission agreement said about the Arbitration Provision and acknowledged not being aware of the required elements of the provision. These findings demonstrate that the facility’s written arbitration documents, as provided to all residents at admission, lacked the federally required notifications regarding the right to rescind within 30 days and the non-mandatory nature of signing the arbitration agreement for admission, and that key administrative personnel were unaware of these specific regulatory requirements.
Deficient Arbitration Agreement Lacking Neutral Arbitrator and Venue Provisions
Penalty
Summary
The facility failed to ensure its arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue convenient to both parties. At the time of survey, the facility had a census of 22 residents, all of whom had signed the arbitration agreement, and there were no residents in active arbitration. Record review of the admission packet, specifically Exhibit E Arbitration Provision, showed it did not notify residents or their representatives of their right to participate in selecting a neutral arbitrator or a mutually convenient venue. During interviews, an administrative staff member stated that the Arbitration Provision in the admission packet was the only information provided about the agreement and that she verbally explained it to new admissions when they signed it. Another administrative nurse reported that the previous company that operated the facility had written the Arbitration Provision and that the current board and administrator might have modified it, and she was not aware of the specific language required in the provision. A further administrative staff member stated the facility followed whatever was written in the admission agreement regarding arbitration and acknowledged not being aware of the required elements for the Arbitration Provision. These combined actions and inactions—using an admission arbitration form that lacked required language about neutral arbitrator and venue selection, having all residents sign this form, and administrative staff’s lack of awareness of the required arbitration language—led to the identified deficiency.
Some of the Latest Corrective Actions taken by Facilities in Kansas
- Educated all staff that shouting profanities, calling residents vulgar names, or acting in any other excessive, obtuse, obscene, or nonsensical way would not be permitted at the facility (J - F0600 - KS)
- Completed Abuse, Neglect, and Exploitation training with staff with an emphasis on their duty to report (J - F0600 - KS)
Verbal Abuse of Resident by Dietary Staff During Snack Service
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a staff member. The resident had diagnoses including paranoid schizophrenia, anxiety disorder, shortness of breath, and malignant neoplasm of the breast, with a BIMS score indicating intact cognition. Care plan interventions directed staff to allow the resident to voice needs and concerns, avoid arguing with delusions, redirect the resident to a quiet area if escalating, offer reassurance, and interact in ways that built rapport and monitored for precursors to socially inappropriate behaviors. Despite these interventions, during a snack pass the resident became involved in a yelling and screaming incident with a dietary staff member in the dining room. According to the facility’s investigation and staff interviews, the dietary staff member was seen and heard on camera yelling and screaming at the resident in front of other residents, shouting profanities and using vulgar and offensive references. A CMA reported hearing the dietary staff member call the resident an expletive and described the staff member attempting to get in the resident’s face, prompting the CMA to step between them and remove the resident from the hostile environment. The CMA stated the resident was not getting into anyone’s face or going after staff and that the resident had only asked for more food when the dietary staff member yelled at her. Administrative staff confirmed that camera audio captured the dietary staff member calling the resident an expletive and that staff had to intervene. The resident later stated she remembered the incident, recalled that she was only asking for more food when she was yelled at, and reported that being yelled at by staff was nothing new or out of the ordinary, stating she was yelled at all the time and did not feel safe when this occurred. The facility’s investigation documented that the resident admitted she shouted back at the staff member and that staff intervened and helped calm her down and support her. The investigation noted that the staff member’s behavior, as seen on camera, was not accepted by the facility. The facility’s abuse prevention policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included verbal abuse. The surveyors determined that the facility failed to ensure the resident remained free from verbal abuse, and this failure placed the resident in immediate jeopardy. The investigation and record review also showed gaps in follow-up related to the incident. The facility’s investigation did not include any staff witness statements, despite identification of a direct witness. The resident’s EMR lacked evidence of any follow-up psychosocial assessments or documented staff interviews with the resident related to the incident. One social services staff member stated she was not aware of the details of the incident and had not completed any psychosocial follow-up. Another social services staff member reported speaking with the resident the next day and performing generalized verbal check-ins but did not document these interactions and did not conduct or record a formal psychosocial assessment related to the event. Administrative staff stated there was no additional staff education completed after the incident because the involved staff member was terminated and other staff had prior ANE training.
Removal Plan
- Conduct interviews with each resident to identify if any residents were having adverse outcomes due to staff yelling and shouting profanities and/or any other incidents that may have gone unreported.
- Educate all staff that shouting profanities, calling residents vulgar names, or acting in any other excessive, obtuse, obscene, or nonsensical way would not be permitted at the facility.
- Complete Abuse, Neglect, and Exploitation training with staff, with an emphasis on their duty to report.
Failure to Initiate Timely CPR for a Full Code Resident on Hospice
Penalty
Summary
The deficiency involves the facility’s failure to provide timely CPR to a resident who had clearly documented Full Code status. The resident was admitted with multiple diagnoses including atherosclerotic heart disease, generalized anxiety disorder, atrial fibrillation, and chronic kidney disease, and had intact cognition per a recent MDS. The resident’s care plan, EMR profile sheet, physician orders, and a recent physician progress note all documented the resident as Full Code, and the care plan directed staff to ensure the resident’s wishes regarding advanced directives were honored and reviewed at least quarterly and with any change in condition. On the day of the incident, the resident was on hospice services and had been declining since around midnight, with hospice and family present much of the day. Shortly before the event, the resident exhibited Cheyne-Stokes respirations and cool skin, and received a dose of morphine from a hospice nurse. At approximately 5:10 p.m., a family member informed a nurse that the resident may have passed. The nurse assessed the resident and documented no audible heart sounds or respirations, but did not check the resident’s code status at that time and did not initiate CPR, despite the resident’s documented Full Code status. Over the next 45–66 minutes, multiple staff interactions occurred without CPR being started. The nurse contacted a consultant nurse, and hospice was notified and en route. Administrative and consultant nurses later questioned and confirmed the resident’s code status as Full Code in the EMR. Only after being prompted by the hospice nurse and another nurse, and after confirmation of Full Code status by administrative staff, did the involved nurses return to the room and initiate CPR, at approximately 6:10–6:16 p.m. EMS arrived shortly thereafter and pronounced the resident deceased. The lapse between the initial notification of the resident’s presumed death and the initiation of CPR constituted the failure to provide basic life support to a Full Code resident, which surveyors determined placed the resident and all Full Code residents in immediate jeopardy.
Removal Plan
- Suspended the two nurses involved (LN I and LN G) pending investigation (LN G later terminated).
- Completed training for all licensed staff on the advanced directive policy and how to identify a resident's code status in the EMR (signature sheets on file).
- Required all licensed staff to complete the training before working.
- Conducted interviews of nurses by the DON or designee regarding procedures when a resident is found unresponsive and how to identify code status.
- Scheduled mock reviews/audits of checking resident code status (audits on file).
- Reported patterns or trends to the Quality Assurance committee for recommendations and follow-up.
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