Citations in Kentucky
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Kentucky.
Statistics for Kentucky (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Kentucky
A failure to safeguard and account for controlled substances led to the diversion of narcotic pain medications by an LPN, resulting in three residents with chronic pain conditions not receiving their prescribed doses. These residents experienced unmanaged pain, with no documented pain assessments or provider notifications, and staff failed to follow facility policies for medication administration and pain management.
A facility failed to ensure proper control and documentation of controlled substances when an LPN administered medications to several residents but did not sign the controlled medication records at the time of administration, instead completing the documentation later in front of a surveyor. The residents involved had various medical conditions and were prescribed controlled medications such as gabapentin, pregabalin, morphine, oxycodone, and lorazepam. Facility policy required real-time documentation and shift-to-shift reconciliation, but these procedures were not followed, as confirmed by staff interviews and record reviews.
A resident with severe disabilities and requiring 1:1 supervision was placed in isolation for a contagious illness. During this time, staff positioned the resident's bed to block the doorway, preventing the resident from exiting the room while in a wheelchair. Staff interviews confirmed the bed was intentionally placed to restrict movement, contrary to the care plan, resulting in involuntary seclusion.
A resident with severe cognitive impairment and behavioral issues reported being hit by a CNA, but the facility delayed reporting the abuse allegation to OIG, citing the resident's history of making unsubstantiated claims. Staff and leadership were inconsistent in following the policy requiring immediate reporting, resulting in the report being submitted two days after the allegation was made.
A resident with cerebral palsy was admitted with an abdominal bruise, but the facility did not conduct a full internal investigation into the injury of unknown origin. Facility staff paused interviews and investigative steps, believing that CPS involvement required them to stop their own investigation, despite CPS stating otherwise. As a result, necessary interviews and documentation were not completed, and the incident was not discussed in the QAPI meeting.
A resident with autism and cerebral palsy continued to receive a discontinued antipsychotic medication at school due to the facility's failure to properly communicate the medication change to both the school and pharmacy. The required written notifications and forms were not completed or sent, resulting in the school administering the medication for several days after it had been discontinued. The error was discovered only after the resident was hospitalized for a change in mental status.
Two residents with moderate cognitive impairment were observed engaging in sexual activity on multiple occasions without documented assessment of their capacity to consent. The facility's policy did not address procedures for determining capacity to consent to sexual relationships or coordination with the QAPI program, and staff interviews revealed confusion and lack of awareness regarding required assessments.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple chronic conditions was given Zofran for nausea by a KMA after an LPN mistakenly believed it was a standing order, despite no such order existing. The medication was administered without prior physician authorization, and the Medical Director was not notified or consulted before the order was entered. Facility leadership confirmed that staff are expected to follow protocols requiring physician orders for all medications not on the standing order list.
Failure to Safeguard Controlled Substances Results in Unmanaged Pain
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for residents requiring such services by not safeguarding and accounting for controlled substances, which led to the diversion of narcotic medications by a staff member. This resulted in ordered pain medications not being available for administration, causing unmanaged pain and discomfort for three residents. A comparison of medication counts and controlled substance record sheets revealed discrepancies, and an investigation found that scheduled narcotic pain medications were not administered as ordered. One resident with chronic pain syndrome, osteomyelitis, and peripheral vascular disease reported almost constant pain with high intensity and did not receive scheduled doses of oxycodone. The resident stated he was in severe pain for two days due to missed doses. Another resident with liver cancer and chronic pain, who was also receiving hospice services, missed a dose of morphine and reported severe pain, stating he cried because the pain was so bad. A third resident with pain, major depressive disorder, and personality disorder missed a dose of oxycodone-acetaminophen and reported increased pain, with staff unable to provide the medication due to its unavailability. Documentation in the medical records was incomplete, with no pain assessments or evidence that staff assessed or addressed the residents' pain or notified providers about missed medications. Interviews with staff confirmed that residents' complaints of pain were not properly documented or communicated to providers, and the controlled substance counts were inaccurate. The facility's failure to follow its own policies for controlled substance management and pain assessment led to residents experiencing unmanaged pain due to missed doses of prescribed narcotic medications.
Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper control, accountability, reconciliation, and safeguarding of controlled substances in accordance with professional standards of practice and its own policy. Licensed nurses were required to count all controlled medications at every change of shift, with reconciliation performed jointly by outgoing and incoming nurses, and documentation required at the time of administration. However, observations and record reviews revealed that an LPN did not accurately complete and reconcile controlled medication record sheets for four sampled residents. The LPN administered controlled medications but failed to document the administration on the Individual Patient Controlled Substance Administration Record (IPCSAR) at the time the medications were given. Instead, the LPN completed the documentation later, in front of a surveyor, and recorded the time as after the actual administration. The residents involved had various medical conditions, including cerebral infarction, paranoid schizophrenia, contractures, Parkinson's disease, osteoarthritis, anxiety disorder, chronic pain, COPD, and dementia. Each resident had physician orders for controlled medications such as gabapentin, pregabalin, morphine sulfate, oxycodone, and lorazepam. Medication Administration Reports (MARs) indicated that the medications were given as scheduled, but the corresponding controlled substance records were not signed at the time of administration. In some cases, the LPN provided explanations for the lack of timely documentation, such as not having a pen, and stated an intention to complete the records after finishing medication administration. Interviews with other nursing staff and the Director of Nursing confirmed that the facility's policy required controlled medications to be signed out at the time of administration and that staff had been educated on this process. The Director of Nursing acknowledged ongoing issues with nursing documentation and stated that all staff, including agency nurses, were expected to follow established procedures for controlled medication counts and documentation. The administrator also confirmed the expectation that nurses follow all facility policies for controlled substances, including logging and documentation at the time medications are given.
Resident Subjected to Involuntary Seclusion Due to Bed Placement
Penalty
Summary
A deficiency occurred when a resident with severe intellectual disabilities, spastic quadriplegic cerebral palsy, tracheostomy, and gastrostomy status was subjected to involuntary seclusion. The resident, who required 1:1 supervision when up in his wheelchair due to lack of self-mobility and safety awareness, was placed in isolation for rhinovirus and was not to be left unattended in his room. On the day of the incident, staff positioned the resident's bed in such a way that it blocked the resident from exiting his room freely while he was in his wheelchair. Multiple staff interviews confirmed that the bed was intentionally placed to prevent the resident from leaving the room, with some staff believing this was an acceptable practice during isolation precautions. The resident was visible from the window, but did not have the ability to leave the room independently due to the bed's placement. The care plan specifically required direct supervision and prohibited leaving the resident unattended when up in his wheelchair, but this was not followed. The incident was observed by a nurse manager during rounds, who found the resident blocked in his room and subsequently moved the bed. Staff involved in the incident acknowledged the bed was positioned to restrict the resident's movement, and there was a lack of clarity among some staff regarding the appropriateness of this action. The event was documented and reported, and the facility's investigation confirmed that the resident was involuntarily secluded by staff action.
Failure to Timely Report Allegation of Abuse Due to Staff Judgment on Resident Credibility
Penalty
Summary
The facility failed to ensure that all allegations of abuse and injuries of unknown origin were reported to the State Survey Agency (SSA) within the required two-hour timeframe. Specifically, a resident with severe cognitive impairment and a history of Lesch Nyhan Syndrome, which includes symptoms of uncontrollable self-injury and behavioral issues, reported to staff that a Certified Nursing Assistant (CNA) had been hitting him at night. Although the facility's policy required immediate reporting of such allegations, the initial report to the Office of Inspector General (OIG) was not submitted until two days after the allegation was made. Interviews with facility staff revealed that while staff were trained to report allegations of abuse to leadership immediately, there was confusion and inconsistency among leadership regarding the necessity and timing of reporting, especially when the resident was known to make frequent and sometimes unsubstantiated claims. The QAPI Manager initiated an internal investigation but did not initially plan to report the allegation due to the resident's history of making false accusations. The decision to report was only made after consultation with the Chief Quality and Compliance Officer, who emphasized the importance of reporting regardless of the resident's diagnosis. Further interviews with the DON and Administrator indicated a reliance on the QAPI Manager to determine reportability and a lack of clarity about the required reporting timeframes. The Administrator stated that if a resident was not considered a reliable reporter and there was no corroborating evidence, the incident might not be reported. Ultimately, the delay in reporting the allegation was attributed to the staff's judgment about the credibility of the resident's report, rather than adherence to the facility's policy and federal requirements.
Failure to Investigate Injury of Unknown Origin Due to Misinterpretation of CPS Involvement
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an injury of unknown origin for a resident with cerebral palsy who was admitted with an abdominal bruise. The facility's policy required the QAPI Manager or designee to initiate an investigation for any allegation of abuse, neglect, or misappropriation, and to take immediate action to ensure resident safety. However, there was no documented evidence in the resident's medical record or in the facility's Final Report/5 Day Follow Up that a full internal investigation was initiated regarding the abdominal bruise. The facility paused interviews and other investigative steps, citing their interpretation of state law and guidance from their experience as a childcare agency, believing that interviewing during an active Child Protective Services (CPS) investigation would be considered obstructive. Despite this, the CPS Case Manager clarified that CPS never advised the facility to halt its internal investigation and that most facilities begin their own investigations immediately. Facility leadership, including the QAPI Manager, DON, and Administrator, confirmed that their practice was to stop interviews and internal investigation processes when CPS was involved, based on their understanding of regulatory requirements. As a result, necessary interviews and investigative actions were not completed, and the incident was not discussed in the QAPI meeting. The lack of a thorough internal investigation meant the facility did not fully determine the cause of the injury or whether staff had followed policies and procedures.
Failure to Communicate Discontinued Medication Order Led to Continued Administration
Penalty
Summary
The facility failed to ensure that a resident's discontinued medication order was properly communicated to both the resident's school and the contracted pharmacy, resulting in the administration of a discontinued medication. The process breakdown began when a physician discontinued the resident's Aripiprazole order, but the required school forms and notifications were not completed or sent. The Resident Education Nurse Coordinator verbally communicated the discontinuation to the school but did not follow the established process of completing and faxing or emailing the appropriate forms. As a result, the school and pharmacy were not formally notified of the medication change. The resident, who had diagnoses including autism and spastic quadriplegic cerebral palsy, was admitted with behavioral challenges such as refusals of care and physical behaviors. The resident's Aripiprazole order was initially communicated to the school and pharmacy, and the medication was delivered to the school after the order had already been discontinued. Due to the lack of formal written notification, the school nurse continued to administer Aripiprazole to the resident for eight days after the discontinuation, only becoming aware of the error following the resident's hospitalization for a change in mental status. Interviews with facility staff and the contracted pharmacy confirmed that the pharmacy and school did not receive timely or proper notification of the medication discontinuation. The facility's policy required daily order reviews and written communication of medication changes, but this process was not followed. The deficiency was identified through a root cause analysis, which found that the medication-order double-check process failed and that communication lapses led to the continued administration of a discontinued medication.
Failure to Establish and Implement Protocol for Assessing Capacity to Consent to Sexual Contact
Penalty
Summary
The facility failed to develop and implement policies and procedures establishing a protocol for determining residents' capacity to consent to sexual contact. Specifically, the facility's abuse investigation policy did not address how, when, and by whom determinations of capacity to consent would be made, nor where such documentation would be recorded. Additionally, the policy lacked the required component for coordinating situations of abuse with the Quality Assurance Performance Improvement (QAPI) program. These deficiencies were identified after staff observed two residents engaging in sexual behavior on multiple occasions, with no evidence that the facility had assessed their capacity to consent prior to the survey. One resident was admitted with diagnoses including vascular dementia, delusional disorder, bipolar disorder, Alzheimer's disease, and Lewy Body dementia, and had a BIMS score indicating moderately impaired cognition. This resident was under state guardianship, and there was confusion among staff and guardians regarding whether a capacity to consent assessment had been completed. The psychiatric nurse practitioner had not performed such an assessment prior to the observed incidents, and documentation of any evaluation was absent until after the survey began. The second resident involved also had moderately impaired cognition and multiple physical comorbidities. Nursing notes documented that both residents expressed a desire to engage in sexual activity and claimed to understand the consequences, but there was no documented assessment of their ability to consent. Interviews with staff, including the DON, social services director, and medical director, revealed a lack of awareness and established process for evaluating capacity to consent to sexual relationships. The administrator was unaware that the abuse policy required procedures for such assessments and coordination with the QAPI program.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Medication Administered Without Valid Physician Order
Penalty
Summary
A deficiency occurred when a resident with dementia, diabetes, and congestive heart failure was administered a Zofran tablet for nausea without a valid physician's order. The resident, who was severely cognitively impaired, requested something for nausea. A Kentucky Medication Aide (KMA) checked the electronic health record and found no order for Zofran, then informed an LPN, who incorrectly stated that Zofran was available as a standing order. However, review of the facility's standing orders confirmed that Zofran was not included. Despite this, the KMA administered Zofran to the resident after the LPN entered an order under the Medical Director's name, but without prior authorization or notification to the Medical Director. Interviews revealed that the Medical Director was not contacted about the new medication and was unaware of the order, expressing that she would have needed more information before approving Zofran for the resident. The LPN later acknowledged the mistake, stating she should have obtained a proper order before administration. The Director of Nursing and the Administrator both confirmed that staff are expected to know the standing orders and obtain physician orders for all medications not on the list, emphasizing the importance of following these protocols for resident safety. The facility was unable to generate a Pyxis report to verify the medication dispensing process.
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