Citations in Maryland
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Maryland.
Statistics for Maryland (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Maryland
- Instituted continuous 24/7 visual monitoring of front entrance and inter-level exit doors by designated staff to prevent unauthorized resident elopement (J - F0689 - MD)
- Conducted staff education on the new door-security process changes to ensure all disciplines follow proper exit-control procedures (J - F0689 - MD)
- Initiated daily audits of front-entry and inter-unit door monitoring by the NHA or designee to verify sustained compliance (J - F0689 - MD)
- Established QAPI review of audit results for ongoing recommendations and corrective actions (J - F0689 - MD)
- Consulted a security company and obtained senior-technician assessment of door-security options to enhance alarm and notification systems (J - F0689 - MD)
Failure to Prevent Elopement of Cognitively Impaired Residents Due to Ineffective Monitoring and Alarm Systems
Penalty
Summary
The facility failed to maintain an effective system to prevent residents with cognitive impairments from leaving the premises without appropriate supervision. Two residents with known exit-seeking and elopement behaviors were able to leave secure areas of the facility undetected. One resident, who had a history of severe cognitive impairment and multiple prior elopement incidents, was able to exit the building after dinner and was found outside near the facility van. The WanderGuard system, which was intended to alert staff and prevent such incidents, did not trigger an alarm when the resident exited, and only recorded an event when the resident was escorted back inside. Staff documentation for this incident was also found to be mixed with records from a previous year, and no new elopement evaluation was completed after the incident. Another resident, also with severe cognitive impairment and a history of wandering, was found in the assisted living library after having previously eloped from the nursing home building. This resident had a WanderGuard bracelet in place, but the system failed to alarm when the resident passed through a monitored door. The alarm only activated when the resident was brought back through the door by staff. Interviews with facility leadership and maintenance staff revealed that the WanderGuard alarm system's audio alert was faint and not easily heard from a distance, and that the system was not integrated with staff phones, relying instead on pagers for notification. Observations confirmed that the physical environment outside the main entrance posed multiple hazards, including active roadways and parking areas. The facility's elopement evaluation process was found to be inadequate, as it was only used to determine the need for a WanderGuard and not updated after each incident. Staff interviews confirmed a lack of understanding regarding the need for post-incident evaluations. The combination of ineffective monitoring, unreliable alarm systems, and insufficient post-incident assessment contributed to the failure to provide adequate supervision and prevent accidents for residents at high risk of elopement.
Removal Plan
- A team member will be present monitoring the front entrance doors at nursing desk and the door exiting the healthcare center level of living and entering assisted level of living 24 hours a day, 7 days a week to ensure constant visual monitoring of individuals exiting the community until a mechanism is installed to create immediate notification to community staff for unauthorized exits.
- Install a mechanism to create immediate notification to community staff for unauthorized exits.
- Consult a security company to explore solutions to increase door security related to unauthorized exits and have a senior technician assess the situation.
- Educate current community staff of all disciplines on the immediate process change related to door security.
- Audit the front entry door monitoring and door between assisted living and nursing home daily by NHA or designee.
- Submit audit results for review and recommendation to the Quality Assurance Performance Improvement Committee.
Latest Citations in Maryland
A resident with severe cognitive and communication impairments reported to therapy staff that a GNA hurt their arm during care. Although the allegation was relayed to the DSW and Administrator, it was not reported to the state survey agency as required, because facility staff believed the incident was accidental. The facility maintained internal documentation but did not fulfill mandatory reporting obligations.
A resident with severe cognitive impairment and aphasia reported to therapy staff that a GNA hurt their arm during care. The facility did not report the allegation to the SSA, as staff believed the incident was accidental, and the investigation documentation was incomplete, lacking interviews with all relevant staff. The deficiency involved failure to follow policy for reporting and thoroughly investigating abuse allegations.
Facility staff failed to accurately code MDS assessments for several residents, resulting in omissions and errors related to significant weight loss, falls, pressure ulcers, wounds, and the administration of medications such as hypoglycemics, antibiotics, anticoagulants, and opioids. These discrepancies were confirmed by MDS coordinators after review of medical records and medication administration records.
Multiple wheelchairs were found to be unsanitary and in disrepair, including one used by a resident for an outside appointment that contained urine and fecal matter in the cushion. Several other wheelchairs had cracked, ripped, or missing armrests, with exposed foam and inadequate support. Housekeeping staff confirmed there was no prior cleaning or maintenance schedule for wheelchairs or their cushions.
The facility did not report allegations of abuse, neglect, or injuries of unknown origin to the regulatory agency within the required 2-hour timeframe for three residents. Incidents included a non-verbal resident with a laceration, a resident with a dislocated shoulder and complex medical needs, and an allegation of physical abuse by a GNA. In each case, delays in internal notification and external reporting were confirmed.
Facility staff did not hold or document required quarterly care plan meetings for a resident with dementia, despite completing quarterly MDS assessments. Only one care plan meeting was documented, and there was no record of meetings or summaries for other required quarters, as confirmed by the DON and noted by the resident's representative.
A resident who required extensive two-person assistance for activities of daily living after hip surgery did not receive necessary turning, repositioning, or bowel and bladder care over several day shifts. Documentation showed that assigned GNAs did not perform these essential care tasks, and complaints included inadequate staffing and unanswered call bells.
Facility staff did not implement a consultant's recommendations for an appetite stimulant and protein supplement for a resident with anemia and thyrotoxicosis, and also failed to perform and document neurological assessments at required intervals after an unwitnessed fall for another resident, with inaccuracies in vital sign documentation as confirmed by the DON.
A resident with multiple medical conditions experienced a significant, unrecognized weight loss over a three-week period. Facility staff did not perform weekly weights as recommended, failed to promptly notify the physician or dietician of the weight loss, and delayed assessment and intervention, contrary to facility policy.
A resident with a leg amputation was not provided with their custom-made wheelchair during transport to a medical appointment, resulting in the use of other wheelchairs and repeated repositioning by staff. The facility lost the resident's specially fitted wheelchair on multiple occasions, and staff failed to follow up to ensure the resident had access to the necessary equipment, despite complaints from the resident's family and awareness among facility leadership.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency as required by its own policy and federal regulations. A resident with severe cognitive impairment, aphasia, and hemiplegia reported to therapy staff that a geriatric nursing assistant hurt their arm during care. The Director of Social Work (DSW) interviewed the resident, who described the incident as the table hitting their arm during care, but was unclear if it was intentional or accidental. The DSW also interviewed the assigned staff and other residents, found no additional concerns, and provided the information to the Administrator. However, the incident was not reported to the state survey agency because the DSW and Administrator believed it was accidental and not abuse. Multiple staff interviews confirmed that the resident initially alleged rough treatment by staff, but later changed their account, suggesting the injury may have been accidental. Despite this, the Director of Rehabilitation reported the allegation as required, but was unaware if it was escalated to the state. The Administrator later acknowledged that the resident's statement should have been considered an allegation of abuse and reported, but this was not done at the time. The facility maintained internal documentation of the incident but did not fulfill the mandatory reporting requirement.
Failure to Report and Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was properly reported to the state survey agency (SSA) and that the investigation documentation was thorough. The facility's policy required immediate investigation and reporting of any suspicion or report of abuse, neglect, or exploitation, including interviewing all involved persons and providing complete documentation. In this case, a resident with severe cognitive impairment, aphasia, and hemiplegia reported to a therapy staff member that a geriatric nursing assistant (GNA) hurt their arm during care. The Director of Social Work (DSW) interviewed the resident, who described an incident involving impact with a bedside table but was unclear if it was intentional or accidental. The DSW interviewed the assigned GNA and several other residents, finding no additional concerns, and submitted the information to the Administrator. However, the facility did not report the allegation to the SSA, as the DSW believed the incident was accidental. The Administrator confirmed that the decision not to report was based on the belief that not every negative statement constituted abuse. The facility maintained a "soft file" with statements from the DSW, the GNA, and documentation of interviews with other residents, but did not include statements from the therapy staff member who initially received the allegation or other potentially knowledgeable staff. Further interviews revealed that the Director of Rehabilitation (DOR), who first heard the allegation, was not asked for a statement until much later, and her account indicated the resident had repeatedly stated the staff was rough and hit their arm. The Director of Nursing (DON) stated that all abuse allegations should be reported and investigated. The Administrator later acknowledged that the allegation should have been reported and that the investigation did not include interviews with all relevant staff members. The documentation did not reflect a complete or thorough investigation as required by facility policy.
Inaccurate MDS Coding for Resident Assessments
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as evidenced by discrepancies between medical records and MDS documentation. For several residents, significant clinical events and treatments were not properly recorded in the MDS. One resident experienced a substantial weight loss and a fall, neither of which were accurately reflected in the corresponding MDS sections. Additionally, the administration of hypoglycemic medications and insulin was omitted from the MDS, while an opioid was incorrectly documented as administered when it was not present in the medication administration record. Another resident was admitted with bilateral heel wounds and received ongoing wound care and antibiotics, but the MDS failed to capture the presence of pressure ulcers, venous ulcers, and related treatments. The same resident's MDS also did not reflect the administration of multiple medications, including insulin, diuretics, opioids, antidepressants, antibiotics, and anticoagulants, despite clear documentation in the medical and treatment records. Similar omissions were found for other residents, where falls, pressure ulcers, and the use of specific medications such as antibiotics and anticoagulants were not accurately coded in the MDS, even though these events and treatments were documented elsewhere in the medical record. In one case, a resident's MDS assessment incorrectly indicated the presence of a pressure ulcer that had already healed, and failed to document the use of antiplatelet, hypoglycemic, and antipsychotic medications that were administered during the assessment period. Interviews with MDS coordinators confirmed the presence of these errors across multiple assessments, indicating a pattern of inaccurate MDS coding that did not align with the residents' actual clinical status and care provided.
Failure to Maintain Sanitary and Safe Wheelchairs
Penalty
Summary
The facility failed to maintain wheelchairs in a sanitary, comfortable, and well-maintained condition, as evidenced by observations and interviews during a complaint survey. One resident attended a medical appointment in a wheelchair with a cushion that was found to contain urine and fecal matter, emitting a strong odor that had been a source of complaints for months. Upon inspection, the gel pad and pillow cover were visibly soiled, and the family, as well as medical staff at the appointment, were disturbed by the condition. Housekeeping staff confirmed that prior to this incident, there was no established schedule for cleaning or maintaining wheelchairs or their cushions, and the wheelchair in question appeared to have never been cleaned. Further observations revealed multiple wheelchairs across two nursing units in disrepair, including cracked and ripped vinyl on armrests, missing armrests, and exposed foam. Several residents were observed using these damaged wheelchairs, which lacked proper padding and support. The Nursing Home Administrator was made aware of these issues by both staff and family members, confirming the lack of a maintenance process for wheelchairs prior to the incident.
Failure to Timely Report Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe for three residents. In one case, a non-verbal, cognitively impaired resident was found with a laceration to the right thumb, but the incident was not documented or reported by the LPN on duty, and facility administration only became aware the following day. The self-report to OHCQ was sent more than 24 hours after the injury was discovered. In another instance, a resident with multiple complex medical conditions, including tracheostomy, G-tube, diabetes, hemiplegia, and ventilator dependence, was found to have a dislocated shoulder. The injury was confirmed, but the report to OHCQ was not made until the following day, exceeding the 2-hour reporting requirement. A third incident involved an allegation of physical abuse by a GNA, reported by a resident's spouse. The DON was not notified until the next morning, and the initial report to OHCQ was sent several hours after the required timeframe. Documentation from staff revealed inconsistencies in awareness and reporting of the alleged abuse. In all three cases, the DON confirmed the findings of late reporting during interviews, although the DON was not employed at the facility at the time of the incidents.
Failure to Hold and Document Required Quarterly Care Plan Meetings
Penalty
Summary
Facility staff failed to conduct quarterly care plan meetings for a resident diagnosed with dementia, as required following comprehensive and quarterly MDS assessments. The medical record review showed that while quarterly MDS assessments were completed, there was only documentation of a care plan meeting in April and a scheduled meeting in September, with no evidence of meetings in January and July. Additionally, there was no documentation summarizing or detailing what was discussed during the April and September care plan meetings. The resident's representative expressed concerns about the facility's lack of communication. The Director of Nursing confirmed that the required quarterly care plan meetings were not held for the resident in January and July, and that documentation of the content of the meetings that did occur was missing from the medical record.
Failure to Provide Required ADL Assistance and Repositioning
Penalty
Summary
A deficiency was identified when a resident, admitted for rehabilitation following surgery for a periprosthetic hip fracture and requiring extensive assistance with two-person support for transfers, bed mobility, dressing, toileting, and general hygiene, did not receive necessary care on multiple day shifts. Documentation review revealed that the assigned geriatric nursing assistant (GNA) failed to perform required turning, repositioning, and bowel and bladder care for the resident over three consecutive days. Additionally, complaints were made regarding inadequate staffing, lack of resident changing, turning, repositioning, and unanswered call bells. These findings were based on direct review of the resident's medical record and GNA documentation.
Failure to Follow Consultant Recommendations and Neuro Check Protocols
Penalty
Summary
Facility staff failed to provide care in accordance with consultant recommendations for a resident admitted with anemia and thyrotoxicosis. The resident was evaluated by a consultant who recommended starting an appetite stimulant and a prosource protein supplement due to poor appetite and low albumin levels. Despite these recommendations, the staff did not initiate either intervention before the resident was discharged from the facility. The Director of Nursing confirmed that these recommendations were not addressed. Additionally, staff did not properly perform and document neurological assessments following an unwitnessed fall for another resident. According to facility policy, neuro checks should be completed at specific intervals after such an event. However, the medical record showed that neuro checks were not performed or documented at the required times, and some entries included inaccurate or reused vital signs. The Director of Nursing confirmed that neuro checks were completed at incorrect intervals and with inaccuracies.
Failure to Recognize and Respond to Significant Resident Weight Loss
Penalty
Summary
Facility staff failed to recognize and respond to significant weight loss in a resident admitted for comprehensive rehabilitation with multiple diagnoses, including cerebral infarction, hypertension, type 2 diabetes with hyperglycemia, and a sacral wound. Upon admission, the resident's weight was documented as 128 lbs, a notable decrease from the ideal body weight of 154 lbs. Despite a dietician's recommendation for weekly weights and monitoring due to malnutrition risk, weekly weights were not performed after admission. The next recorded weight, taken three weeks later, showed a further drop to 102.2 lbs, representing a 20% loss. There was no evidence that the physician, dietician, or family were notified of this significant weight loss as required by facility policy. Additionally, the dietician did not assess the resident until 11 days after the documented weight loss, and the resident was not discussed in weekly risk meetings until 13 days after the weight loss was identified. The facility's policy required immediate notification of the dietician in writing for significant weight changes, but this was not followed. Interviews with the physician confirmed the expectation for prompt notification in such cases, which did not occur.
Failure to Provide Resident with Custom-Made Wheelchair for Transport
Penalty
Summary
The facility failed to ensure that a custom-made wheelchair was available and provided for a resident with a leg amputation during transport to a medical appointment. Staff statements and interviews revealed that the resident, who typically used a geri chair or remained in bed, was transferred to a standard wheelchair for an appointment, during which the resident began sliding out of the chair. Multiple staff members intervened to reposition the resident and eventually transferred the resident to a high-back wheelchair with a pillow for support. The resident did not report pain or injury during the incident. Further investigation revealed that the resident's custom-made wheelchair, provided by the VA and specifically fitted to accommodate the resident's needs following a leg amputation, had been lost by the facility on more than one occasion. The resident's daughter reported that the resident was repeatedly placed in other residents' wheelchairs for appointments, and that complaints about the missing wheelchair had been made to various staff and administrators. The facility's NHA confirmed that the custom wheelchair could not be located and acknowledged that there was no follow-up by staff to ensure the resident had access to the appropriate equipment.
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