Citations in Michigan
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Michigan.
Statistics for Michigan (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Michigan
A hospice resident with heart disease and lung cancer, who was cognitively intact and had clearly chosen DNR status, had that wish documented by hospice and on facility DNR forms completed at admission and again several days later. The facility lost or could not locate the initial DNR paperwork, and when a new DNR form was completed and sent to the physician, the signed form was returned but remained in the DON’s inaccessible email inbox and was never entered into the EHR. Because the resident’s orders still showed FULL CODE, an LPN and other staff initiated CPR, used an AED, and called EMS when the resident was found pulseless, leading to extensive resuscitative efforts that directly contradicted the resident’s documented end-of-life wishes.
A hospice resident with a history of atherosclerotic heart disease and unstable angina, who was cognitively independent, requested and signed DNR paperwork, but the facility failed to complete and implement advance directive and DNR documentation at admission and did not update the EMR code status from "Full Code" after the physician signed the DNR. The DON received the signed DNR via email but did not access it, and no other staff had access to that inbox, so the resident’s record continued to show "Full Code." When the resident was later found unresponsive, an LPN verified the code status in the orders as "Full Code" and staff initiated CPR, used an AED, and EMS provided advanced resuscitative measures, contrary to the resident’s expressed DNR wishes, as also reported by the family and hospice documentation.
Staff failed to provide timely bedside water to multiple cognitively intact and cognitively impaired residents, some with significant comorbidities such as CVA, CHF, COPD, diabetes, and severe protein-calorie malnutrition. During a daytime survey window, several residents were observed without water at bedside; some reported not receiving fresh water since the prior night or since breakfast and described using alternative containers or having cups removed and not replaced. Assigned CNAs acknowledged that they had not yet passed water during their shifts, despite the DON’s expectation that fresh water be passed by mid-morning and before the end of the shift, and despite a facility policy requiring that each resident be provided bedside water.
Surveyors found that meals were not maintained at palatable temperatures when a dietary manager acknowledged that heated bases were available but not used, and plates were observed at 75–85°F without a plate warmer in operation. A test tray placed early on a meal cart with about 25 trays and delivered to a unit was later measured, showing a pot pie at 127.6°F and mixed vegetables at 104°F, despite the manager’s stated expectation that hot foods should reach residents at 135°F or higher. This resulted in decreased food consumption and potential nutritional decline for affected residents.
A resident with diabetes, CHF, CKD, a history of inguinal hernia, and a suprapubic catheter did not receive appropriate assessment, monitoring, documentation, and care planning for multiple active conditions. Hospital instructions and recommendations for hernia management, including use of a support device and strict return precautions, were not clearly documented or followed up, and there was no ongoing hernia assessment despite repeated reports of the hernia being "out" and subsequent hospitalization for small bowel obstruction and incarcerated hernia. The resident’s CKD, hyperkalemia, and hyponatremia were treated with medications such as Lokelma and sodium chloride without documented ongoing lab monitoring or evidence of stability, and CHF management lacked a specific care plan, baseline weight reference, or documented monitoring despite fluid restriction, diuretic, and midodrine orders. Skin assessments showed dry, reddened, and excoriated areas and boggy heels, but care plans did not include a pressure ulcer risk focus, wound interventions, or a pruritis care plan. There was also confusion and conflicting documentation between Foley and suprapubic catheter care, with the resident observed having a suprapubic catheter and excoriated skin at the site while the MAR and care plans contained Foley-focused orders and lacked clear suprapubic catheter interventions.
Two residents reported and staff corroborated that an LPN used profane, harsh, and dismissive language toward residents during and after fall events and when they sought help. One resident with cognitive impairment, depression, and anxiety was found on the floor after a fall, and multiple staff statements documented that the LPN used profanity and expressed annoyance about the resident frequently being on the floor, while the resident responded by calling himself derogatory names. Another cognitively intact resident, admitted with respiratory failure and heart disease, filed a grievance stating that the same LPN had a very bad attitude, told the resident to stay in the room, failed to respond to a medication request, and was "very snotty." This resident also reported that after going to get help for another resident who had fallen and was calling out, the LPN repeatedly ordered the resident back to the room and said that enough was enough, causing the resident to feel angry.
A cognitively impaired resident with Alzheimer’s disease, dementia, anxiety, and hallucinations was subjected to verbal and physical abuse by a podiatrist during a visit in her room. Staff in a nearby room heard thumping, scuffling, and a male voice yelling and swearing, including statements such as not to "f*ck*ng" lay hands on him. A CNA reported seeing the podiatrist push the resident, causing her to fall back onto her bed, while the resident yelled at him to get out. The DOR found the resident on her bed, glasses displaced, arms flailing, yelling, crying, and physically upset. A post‑incident assessment documented redness on the resident’s forearm, a complaint of wrist pain, and her statement that people had been "beating [her] with hammers." The podiatrist had been entering resident rooms alone to provide services, and his conduct toward this resident met the facility’s own definitions of verbal and physical abuse.
A resident with muscle wasting, impaired cognition, and dependence for bed mobility and transfers experienced multiple falls, including being found on the floor near a wheelchair and later on the floor with a facial abrasion, bruising, increased confusion, and episodes of throwing themself to the floor while on Eliquis. Observation also found the resident in bed with feet hanging off the side and the bed not in a low position. Despite these events, review of the fall care plan showed no new fall-prevention interventions were added after the falls or after readmission, even though staff and facility policy indicated that the floor nurse is responsible for timely care plan review and revision after a fall.
Surveyors found that the facility did not follow physician and hospital orders for two residents: one had staples from a below-knee amputation stump removed early at the facility instead of according to the hospital After Visit Summary and scheduled vascular surgery follow-up, and another, with a T9–T10 vertebral fracture and severe cognitive impairment, was repeatedly observed out of bed in a wheelchair or chair without the ordered TLSO back brace applied, with no documented refusals despite staff reporting the resident often removed the brace.
Two residents exited the facility without staff awareness or proper LOA documentation, despite established procedures requiring residents to sign out and notify nursing staff. One cognitively impaired resident with a history of alcohol and opioid dependence and frequent falls walked out the front door unchallenged by front-desk staff, went off property to obtain snacks, fell outdoors, and returned with a knee abrasion and skin tear. Another cognitively intact resident who routinely left the building to smoke also departed without signing out, even though reception staff, the DON, and the social worker were aware of the resident’s frequent LOAs and expected that all exits be logged at the nurse station. Staff on the affected unit reported being short-staffed relative to expected nurse and CNA coverage.
Failure to Honor DNR Resulting in Unwanted CPR and Life-Sustaining Measures
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact hospice resident’s clearly expressed wish to be Do Not Resuscitate (DNR), resulting in CPR and other life-sustaining interventions being performed. The resident was admitted on hospice services with diagnoses including atherosclerotic heart disease with unstable angina, lung cancer, heart failure, and a history of malignant neoplasm of the bronchus and lung. Pre-admission hospice documentation faxed to the facility and uploaded into the electronic medical record before admission indicated the resident’s care type as hospice and explicitly listed “DO NOT RESUSCITATE” in the clinical information. The resident’s hospice care plan also stated that the goal was for the resident’s end-of-life wishes to be honored. On the day of admission, the resident, who was documented as cognitively independent and responsible for her own decisions, completed the facility’s DNR form expressing that no one should attempt resuscitation if her heart and breathing stopped. Family members present at admission confirmed that the resident completed and returned the DNR paperwork to the nurse doing the admission, and that hospice had already communicated the resident’s DNR status to the facility. However, the facility later could not locate any advanced directive or DNR forms for the resident during an admission audit. The DON confirmed that consent forms, including advanced directives and DNR, were supposed to be completed on day 1, but for this resident the DNR was not found and was not in place as required. Several days after admission, when the missing DNR was discovered, the DON and an LPN again completed a DNR form with the resident, who remained her own responsible party. This DNR form was signed by the resident and two witnesses and then emailed by the DON to the medical director for physician signature. The physician signed the DNR and returned it electronically to the DON’s individual email inbox approximately seven hours before the resident experienced a code event. The DON, who was not working and was the only person with access to that inbox, did not retrieve the signed DNR, and the resident’s electronic physician orders were never updated from “FULL CODE” to DNR. As a result, when the resident was later found unresponsive on the bathroom floor without a pulse, the LPN checked the physician orders, saw “FULL CODE,” and initiated CPR, used an AED, and called EMS. EMS continued resuscitative efforts, including defibrillation, airway placement, and intraosseous access, until the resident was pronounced deceased. The facility’s own documentation and family interviews confirmed that CPR and other life-sustaining measures were performed despite the resident’s documented and repeatedly communicated wish to be DNR, and that the failure to timely complete, retain, and implement the DNR documentation led directly to the provision of unwanted resuscitative care.
Removal Plan
- Completed a blanket audit of residents to ensure the medical record accurately reflects each resident’s code status and that a signed copy of the advance directive is uploaded into PCC; no concerns or corrections noted.
- Reviewed the CPR and Advanced Directive policy by the NHA and DON and determined it remains appropriate.
- Had the Social Service Director audit all residents to ensure proper code status is in place; no changes required.
- Completed a DON audit of admissions to ensure proper code status is in place for new admissions; no discrepancies noted and no corrections made.
- Reviewed the admission policy and deemed it appropriate.
- Educated all licensed nurses on completing advanced directives paperwork on admission with the designated responsible party and notifying the physician to obtain orders and place into PCC.
- Implemented a process requiring the admitting nurse to meet with the resident/responsible party immediately upon admission to address code status wishes, complete the paperwork, and immediately communicate with the physician to obtain orders for entry into PCC.
- Implemented a process for immediate action on code status documentation: the admitting nurse faxes the document to a preprogrammed fax number that transmits to the provider email; the provider signs and returns via provider phone to facility fax; nurses also call the provider to alert them of the incoming document.
- Initiated weekly DON audits to ensure new admissions’ code status documentation is obtained/completed by the admitting nurse and that facility procedure/policy is followed, continuing until QAPI determines substantial compliance is achieved.
Failure to Implement and Honor Resident DNR Order Resulting in Full Resuscitation
Penalty
Summary
The deficiency involves the facility’s failure to obtain, process, and implement a resident’s advance directive and DNR order in a timely manner, and the subsequent failure to honor the resident’s DNR status during a cardiac arrest. The resident was admitted on hospice services with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris and was cognitively independent, able to make consistent and reasonable decisions. On admission, the facility did not complete consent forms, including advance directives and DNR paperwork, as confirmed by the DON during an admission audit conducted days later. The facility’s own policy required determination of advance directives on admission and completion of a DNR order form signed by the attending physician and resident, to be placed in the front of the medical record and scanned into the electronic record. The DON reported that after discovering the missing consents during the admission audit, she had an LPN meet with the resident to complete the consents, including the DNR form. The resident, who was her own responsible party, signed the facility DNR form in the presence of the DON and the LPN, and the form was later signed by the physician. The DON emailed the DNR form to the medical director for signature and received the signed DNR back in her individual email inbox at 3:37 PM on the day of the code event. However, the DON was not working that day, did not check her email, and no one else had access to that inbox. As a result, the signed DNR form was not retrieved, the resident’s code status in the electronic medical record was not updated from “Full Code” to “Do Not Resuscitate,” and the DNR form was not placed or scanned into the resident’s record prior to the code event. Later that evening, the resident was found unresponsive on the bathroom floor by an LPN, who checked the code status in the physician’s orders and saw it listed as “Full Code.” Based on that information, staff initiated CPR, brought the crash cart and AED, and called EMS. The facility’s Code Blue documentation and EMS records show that CPR, AED use, airway management, administration of epinephrine, IV fluids, and intraosseous access to the tibia were performed in an attempt to resuscitate the resident, and the resident was later pronounced deceased. The resident’s family member reported that the resident had completed DNR paperwork with the admission nurse on the first day of admission and that hospice had sent preadmission screening documents indicating the resident’s wish to be DNR. The family member expressed concern that the resident’s advance directives and end-of-life care were not honored and that the resident underwent a code despite her stated wishes.
Failure to Provide Timely Bedside Water to Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide timely bedside water to multiple residents, as required to maintain adequate hydration. During the initial screening on 1/27/2026 between 10:00 a.m. and 2:00 p.m., several residents were observed without water in their rooms or at bedside, despite the facility’s oral hydration policy stating that each resident will be provided bedside water. One resident (R94), who was cognitively intact with a BIMS score of 14/15 and had diagnoses including hemiplegia/hemiparesis after cerebral infarction and hypertension, reported that no fresh water had been passed since about 9:00 p.m. on the midnight shift and showed a small iced tea bottle they were using to obtain water from the sink. Another cognitively intact resident (R76), with diagnoses including cerebral infarction, hypertension, and venous insufficiency, was observed in bed with an empty Styrofoam cup out of reach and stated that no cold water had been passed since the midnight shift. A third resident (R18), who had severe protein-calorie malnutrition, dementia, anemia, type 2 diabetes mellitus, and cerebral infarction and was severely cognitively impaired with a BIMS score of 3/15, stated that no one had brought any fresh water at all that day and expressed a desire for cold water. Another resident (R156), cognitively intact with a BIMS score of 15/15 and diagnoses including congestive heart failure, chronic respiratory failure, type 2 diabetes mellitus, and COPD, reported that staff had picked up their water cup around breakfast time and had not brought any fresh water back. A further resident (R62), cognitively intact with a BIMS score of 15/15 and diagnoses including ETOH use, left femur fracture, hypertension, history of falls, carotid artery disease, and COPD, was observed at 1:30 p.m. with no water cup in the room or at bedside and declined interview. Review of staffing assignments showed that CNA T was assigned to several of the affected residents (R62, R76, and R18) on the 7:00 a.m. to 3:00 p.m. shift. At 3:00 p.m., CNA T acknowledged that water had not been passed and stated they planned to pass water later, adding that residents should have had water at the start of the shift. Another CNA (CNA U), assigned to other affected residents (R156 and R94) and working an additional four hours, stated at 4:16 p.m. that they had been very busy and were only then passing water, acknowledging that residents should have received fresh water earlier. The DON later confirmed that staff are expected to pass fresh water multiple times on 12-hour shifts and that on 8-hour shifts fresh water should be passed before 3:00 p.m. and 5:00 p.m., usually by 10:00 a.m., and that fresh water should be passed before 3:00 p.m. regardless, which had not occurred for these residents on the day in question.
Failure to Maintain Palatable and Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure meals were served at palatable temperatures, as identified in two intakes related to concerns that food served to residents was not at palatable temperatures. During an interview, the Dietary Manager stated the facility has heated bases but confirmed they were not in use for the observed meal, and surveyors observed plates measuring between 75°F and 85°F with no plate warmer in use. The Dietary Manager reported that hot food on the steam table should be at least 150°F so residents receive food at 135°F or higher. A regular test tray was plated and placed as one of the first meals on the C unit cart, which then traveled to the unit with approximately 25 meal trays and was fully delivered before the test tray was returned to the conference room. When the test tray was checked with a rapid-read thermometer, the pot pie measured 127.6°F and the mixed vegetables measured 104°F, demonstrating that hot foods were not maintained at the expected temperatures, resulting in decreased food consumption and potential nutritional decline for the residents involved. No additional resident-specific medical histories or conditions were documented in the report beyond the noted decreased food consumption and potential nutritional decline associated with the improperly maintained food temperatures.
Failure to Assess, Monitor, and Care Plan for Complex Medical Conditions and Devices
Penalty
Summary
The deficiency involves the facility’s failure to appropriately assess, monitor, document, and care plan for a cognitively intact resident with multiple complex medical conditions, including diabetes, CHF, CKD, benign prostatic hyperplasia, a history of hernia with repair, and a suprapubic catheter. The resident was observed with disheveled hair and scabbing on his head, reporting that he scratched due to itching. A skin assessment documented red, dry bilateral lower extremities with scratch marks, boggy blanchable heels, and red, excoriated posterior thighs, yet the care plan only referenced a history of skin impairment and MASD to the right posterior thigh and did not include a specific pressure ulcer risk focus, wound interventions for the heel, suprapubic exit site excoriation, or MASD prevention. There was also no care plan for pruritis despite orders for topical treatments for itchy skin. Regarding the resident’s hernia and related pain, hospital emergency room notes documented a right inguinal hernia that was reduced with instructions for “strict return precautions,” but these precautions were not clarified or documented in the EMR. A nursing note relayed a hospital recommendation for an over-the-counter hernia support device and instructions to reduce the hernia if it returned, but there was no documentation that the resident ever received the hernia support or that ongoing hernia assessments and monitoring occurred. Subsequent nursing notes described episodes where the resident reported his hernia was “out,” received Norco, and was positioned with head down and feet up, but there was no ongoing assessment or monitoring documented. Later, the resident was sent to the ED with abdominal distention and brown emesis and was diagnosed with small bowel obstruction, right inguinal hernia, pneumatosis intestinalis, and AKI, with hospital records noting an incarcerated inguinal hernia and conservative management with a scrotal support belt; however, the care plan remained vague, not focused on the hernia, and contained no specific hernia-related interventions or updates after hospital return. The facility also failed to adequately monitor and care plan for the resident’s CKD, hyperkalemia, hyponatremia, and CHF. Labs showed elevated potassium and reduced eGFR consistent with CKD stage III, and the practitioner added Lokelma for hyperkalemia, but there were no subsequent potassium labs in the EMR to reflect ongoing monitoring or stability on this medication, despite continued Lokelma orders and the resident at one point declining the medication. Sodium chloride and Lokelma were ordered without documentation of ongoing sodium and potassium monitoring or evidence that the resident was stable on these medications. The resident had CHF with orders for Lasix, a fluid restriction, and midodrine (first scheduled, then PRN for MAP < 65), but there was no documented CHF monitoring protocol, no baseline reference weight clearly established, and no CHF-focused care plan or interventions, despite multiple weight fluctuations and the DON’s acknowledgment that staff likely did not know how to calculate MAP and that the order lacked typical nursing home parameters. In addition, the facility did not maintain accurate documentation or appropriate care planning for the resident’s suprapubic catheter. Staff interviews revealed confusion between a Foley catheter and a suprapubic catheter, with the EMR and MAR listing Foley catheter care orders while the resident actually had a suprapubic catheter. The resident was observed with a suprapubic catheter in place, no T-sponge, and surrounding skin that was red and excoriated, while the MAR contained both Foley catheter care orders and suprapubic catheter care orders, with the suprapubic site care order discontinued. The ADL care plan referenced Foley catheter care and a closed drainage system, but the elimination care plan described a suprapubic catheter in place for obstructive reflux uropathy and increased UTI risk, without specific suprapubic catheter interventions. Overall, the care plans contained incorrect or missing information about the resident’s current medical status and lacked pertinent interventions for the hernia, CKD, hyperkalemia, hyponatremia, CHF, suprapubic catheter, and skin conditions, and the facility did not ensure consistent assessment, monitoring, and documentation aligned with the resident’s needs and medical orders.
Failure to Treat Residents with Dignity and Respect During Falls and Assistance Requests
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and respect in interactions with nursing staff. One resident with Alzheimer's disease, depression, and anxiety, and moderately impaired cognition, had a history of frequent falls. After an unwitnessed fall, the resident was found on the floor beside the bed. Multiple staff witness statements documented that an LPN used profanity and harsh language toward the resident in connection with these falls. One CNA reported that the LPN asked the resident, "Why do you keep doing this sh*t?" and repeatedly questioned why he was on the floor, to which the resident responded by calling himself an "*sshole." An RN reported hearing the LPN say in a harsh and annoyed tone that she was sick of this "sh*t," that the resident's "*ss is always on the God d*mn floor," and that the situation was "bullsh*t," with the resident again apologizing and calling himself an "*sshole." The LPN denied making inappropriate statements, but the witness accounts were documented in the facility-reported incident file. A second resident, admitted with respiratory failure and heart disease and assessed as cognitively intact, reported concerns about the same LPN's attitude and behavior on a grievance form. The resident stated that the LPN had a very bad attitude, told the resident to stay in the room, did not respond to a request for medication, and was "very snotty." In a subsequent interview, this resident described an incident in which another resident across the hall had fallen and was calling out for help for approximately 15 minutes. After going in a wheelchair to find help and notifying a CNA, the resident reported that, while returning to the room, the LPN repeatedly told the resident to go back to the room and said that "enough is enough," which made the resident feel angry. The facility's resident rights policy states that residents have the right to be treated with respect and dignity.
Failure to Protect Cognitively Impaired Resident From Verbal and Physical Abuse by Podiatrist
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from verbal and physical abuse by an ancillary service provider, specifically the podiatrist. The resident had Alzheimer’s disease, dementia, anxiety disorder, osteoarthritis, muscle weakness, unsteadiness on feet, and auditory and visual hallucinations, and was documented as severely cognitively impaired with a BIMS score of 01. She required one-person assistance with ADLs, ambulated with a 4‑wheeled walker, and her daughter was the DPOA and decision maker. On observation the day after the incident, the resident was fully dressed, sitting on the side of the bed with her walker in front of her, talking to herself, not engaging with the surveyor, and appeared calm and free from visible bruises. According to staff interviews, CNA A, the DOR, and PTA D were in a nearby room when they heard thumping, scuffling, loud noises, and a male voice yelling and swearing coming from the resident’s room. CNA A reported hearing the podiatrist say, “Don’t f*ck*ng hit me,” and then, upon entering the hallway, observed the resident about three feet from her bed moving toward the podiatrist. CNA A stated he saw the podiatrist push the resident, causing her to fall back onto her bed, and heard the resident yelling at him to get out. CNA A described the podiatrist attempting to leave the area and trying to get past him, while CNA A blocked his path and instructed him not to go by other residents. PTA D corroborated hearing aggression in the male voice, yelling, swearing, and the resident being upset. The DOR reported hearing a man swearing and clearly saying, “Do not F*ck*ng lay hands on me again,” followed by CNA A stating that the resident needed help and that he had witnessed abuse. When the DOR entered the resident’s room, she found the resident on her bed with glasses askew, arms flailing, yelling, crying, and physically upset. The DON’s documentation and interview indicated that staff had reported raised voices and that the podiatrist was observed yelling at the resident, with staff reporting that the resident was attempting to ambulate past him when he pushed her back onto the bed. A post‑incident assessment noted redness on the resident’s left forearm in a broad irregular shape and a complaint of right wrist pain, though she was able to move the wrist without observable signs of pain. During assessment, the resident was tearful, resistant to touch, and repeatedly hugged a stuffed dog, and she stated that people had been “beating [her] with hammers.” The DON also reported that the podiatrist stated the resident had assaulted him and that he had previously entered resident rooms alone to provide services. These events demonstrate that the resident was subjected to verbal and physical abuse by the podiatrist, contrary to the facility’s abuse policy defining abuse as willful infliction of injury, intimidation, or conduct causing or potentially causing humiliation, fear, or mental anguish.
Failure to Timely Revise Fall-Prevention Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to timely implement and revise fall-prevention care plan interventions following multiple falls for one resident. The resident was admitted with muscle wasting and atrophy, had a BIMS score of 5/15 indicating impaired cognition, and required staff assistance with bed mobility and transfers. On one observation, the resident was seen lying in bed with their feet hanging off the side, the bed not in a low position, and a blanket and sling pad underneath them, shortly after returning from the hospital following a fall in which they hit their head while on a blood thinner. Incident reports documented that on one date the resident was found on their right side on the floor in front of their wheelchair before bedtime, with range of motion performed and no apparent injuries noted. A subsequent incident report documented that on another date the resident, described as alert and oriented x1, was observed on the floor with their head down, with an abrasion to the right side of the face, old bruises to the left ring finger and right thigh, increased confusion, inability to follow simple directions, and episodes of throwing themself to the floor and to the side of the bed several times with difficulty redirecting. The resident was also documented as receiving Eliquis 5 mg twice daily. Review of the fall care plan showed no new fall-prevention interventions were added after these falls and after the resident’s readmission to the facility. Staff interviews confirmed that timely interventions should be implemented by the floor nurse after a fall, and facility policy stated that the licensed nurse will review and/or revise the care plan and link it to the resident Kardex, but this was not done for this resident following the documented falls.
Failure to Follow Physician Orders for Staple Removal and TLSO Brace Use
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and hospital after-visit instructions for two residents. One resident was admitted with osteomyelitis of the ankle and foot, a left below-knee amputation, and protein calorie malnutrition, and had severe cognitive impairment. The hospital After Visit Summary specified that staples from the left below-knee amputation stump were to be removed in four weeks at a scheduled vascular surgery follow-up appointment. The day after admission, a physiatry PA entered an order for staple removal per protocol. The wound care LPN and the PA observed that the staples were overgrown with skin and, uncertain how long the staples had been in place and without recalling a review of the AVS recommendations, proceeded to remove the staples at the facility, causing some bleeding. This removal occurred 17 days before the AVS-documented timeframe for staple removal and before the vascular surgeon could see the resident and review the chart. The second resident was admitted with an unspecified fracture of the T9–T10 vertebra and muscle disorders, had severely impaired cognition, and required staff assistance with bed mobility and transfers. Physician orders directed that a TLSO back brace be worn whenever the resident was out of bed and that the brace be applied before the resident was weight bearing. On multiple observations over several days, the resident was seen sitting up in a wheelchair or stationary chair, including in the dining room, without the back brace applied, while the brace was observed on the dresser in the room. A family member stated the resident was supposed to have the brace on whenever out of bed and did not know why it was not applied. The care plan and progress notes contained no documentation of refusals to wear the brace, although an LPN reported the resident tended to remove the brace and acknowledged it should be documented if the resident removed or refused it. A facility policy stated it is the responsibility of the licensed nurse to follow physician orders.
Unsupervised Exits and Failure to Enforce Leave of Absence Procedures
Penalty
Summary
Failure to ensure a hazard-free environment and adequate supervision occurred when two residents exited the facility without following the required leave of absence (LOA) procedures and without staff awareness. One resident with alcohol dependence, opioid dependence, frequent falls, and moderate cognitive impairment (BIMS 11/15) left the building without signing out in the LOA log or notifying staff. This resident had an admission elopement assessment score indicating low risk and a physician order permitting LOA with medications and supervision. Video review showed the resident walking through the lobby toward the front door wearing outdoor clothing, passing the front desk without being acknowledged by the staff member covering the desk, who later stated they were unsure if the person was a resident or a family member. After the cognitively impaired resident exited, staff became aware of the situation only when a CNA received a call from a family member reporting a possible resident off property walking with a walker near a local restaurant, observed to fall to their knees and then continue walking. A nurse then searched outside in dark, cold, and slippery conditions and located the resident inside a nearby restaurant. Upon return, assessment identified an abrasion on the knee and a skin tear below the right anterior knee. In an interview, the resident stated they had simply walked out the front door, spoken with someone's family outside, and proceeded toward a store for snacks, adding that no one spoke to them as they left and that they must have forgotten to sign out. In a separate incident, another resident who routinely exited and re-entered the facility multiple times daily for smoking also left the facility without signing out in the LOA book, meaning nursing staff were not notified of the departure. This resident was documented as cognitively intact with a BIMS score of 15/15 and had been assessed as at no elopement risk. Staff interviews revealed that the resident's frequent LOAs were known to reception staff, the DON, and the social worker, and that the expectation was for LOAs to be logged at the nurse station and for nurses to be informed of departures, even when a CNA accompanied the resident. Staffing on the resident’s wing at the time was reported as two nurses and three CNAs for 68 residents, with staff indicating they should have three nurses and four CNAs and describing frequent short staffing due to call-offs and scheduling.
Some of the Latest Corrective Actions taken by Facilities in Michigan
- Educated all licensed nurses on completing advanced-directives paperwork on admission and notifying the physician to obtain code-status orders for entry into PCC (J - F0678 - MI)
- Implemented an admission process requiring the admitting nurse to meet immediately with the resident/responsible party to address code-status wishes, complete paperwork, and immediately communicate with the physician for order entry into PCC (J - F0678 - MI)
- Implemented an immediate code-status documentation workflow using a preprogrammed fax-to-provider-email process with provider signature return and nurse phone notification to the provider (J - F0678 - MI)
- Initiated weekly DON audits of new admissions’ code-status documentation and adherence to facility procedure/policy until QAPI determined substantial compliance (J - F0678 - MI)
- Provided education to licensed nurses on the CPR policy, including confirming code status, when to initiate CPR, when CPR could be stopped, and pronouncing death (J - F0678 - MI)
- Educated licensed nurses on assessment steps prior to initiating CPR (pulse check, chest rise, listen/feel for breathing, and observation of skin/body findings) (J - F0678 - MI)
- Educated licensed nurses on the CPR & BLS policy requiring BLS/CPR for full-code residents prior to EMS arrival unless obvious irreversible-death signs were present, and defined those signs (J - F0678 - MI)
- Educated licensed nurses that the licensed nurse on each shift coordinated and directed the rescue effort until EMS arrived (J - F0678 - MI)
- Educated licensed nurses that death could be declared by a Licensed Physician or Registered Nurse with physician authorization in accordance with state law per policy (J - F0678 - MI)
Failure to Honor DNR Resulting in Unwanted CPR and Life-Sustaining Measures
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact hospice resident’s clearly expressed wish to be Do Not Resuscitate (DNR), resulting in CPR and other life-sustaining interventions being performed. The resident was admitted on hospice services with diagnoses including atherosclerotic heart disease with unstable angina, lung cancer, heart failure, and a history of malignant neoplasm of the bronchus and lung. Pre-admission hospice documentation faxed to the facility and uploaded into the electronic medical record before admission indicated the resident’s care type as hospice and explicitly listed “DO NOT RESUSCITATE” in the clinical information. The resident’s hospice care plan also stated that the goal was for the resident’s end-of-life wishes to be honored. On the day of admission, the resident, who was documented as cognitively independent and responsible for her own decisions, completed the facility’s DNR form expressing that no one should attempt resuscitation if her heart and breathing stopped. Family members present at admission confirmed that the resident completed and returned the DNR paperwork to the nurse doing the admission, and that hospice had already communicated the resident’s DNR status to the facility. However, the facility later could not locate any advanced directive or DNR forms for the resident during an admission audit. The DON confirmed that consent forms, including advanced directives and DNR, were supposed to be completed on day 1, but for this resident the DNR was not found and was not in place as required. Several days after admission, when the missing DNR was discovered, the DON and an LPN again completed a DNR form with the resident, who remained her own responsible party. This DNR form was signed by the resident and two witnesses and then emailed by the DON to the medical director for physician signature. The physician signed the DNR and returned it electronically to the DON’s individual email inbox approximately seven hours before the resident experienced a code event. The DON, who was not working and was the only person with access to that inbox, did not retrieve the signed DNR, and the resident’s electronic physician orders were never updated from “FULL CODE” to DNR. As a result, when the resident was later found unresponsive on the bathroom floor without a pulse, the LPN checked the physician orders, saw “FULL CODE,” and initiated CPR, used an AED, and called EMS. EMS continued resuscitative efforts, including defibrillation, airway placement, and intraosseous access, until the resident was pronounced deceased. The facility’s own documentation and family interviews confirmed that CPR and other life-sustaining measures were performed despite the resident’s documented and repeatedly communicated wish to be DNR, and that the failure to timely complete, retain, and implement the DNR documentation led directly to the provision of unwanted resuscitative care.
Removal Plan
- Completed a blanket audit of residents to ensure the medical record accurately reflects each resident’s code status and that a signed copy of the advance directive is uploaded into PCC; no concerns or corrections noted.
- Reviewed the CPR and Advanced Directive policy by the NHA and DON and determined it remains appropriate.
- Had the Social Service Director audit all residents to ensure proper code status is in place; no changes required.
- Completed a DON audit of admissions to ensure proper code status is in place for new admissions; no discrepancies noted and no corrections made.
- Reviewed the admission policy and deemed it appropriate.
- Educated all licensed nurses on completing advanced directives paperwork on admission with the designated responsible party and notifying the physician to obtain orders and place into PCC.
- Implemented a process requiring the admitting nurse to meet with the resident/responsible party immediately upon admission to address code status wishes, complete the paperwork, and immediately communicate with the physician to obtain orders for entry into PCC.
- Implemented a process for immediate action on code status documentation: the admitting nurse faxes the document to a preprogrammed fax number that transmits to the provider email; the provider signs and returns via provider phone to facility fax; nurses also call the provider to alert them of the incoming document.
- Initiated weekly DON audits to ensure new admissions’ code status documentation is obtained/completed by the admitting nurse and that facility procedure/policy is followed, continuing until QAPI determines substantial compliance is achieved.
Failure to Act on Change in Condition and Delay in Activating 911 for Unresponsive Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to an acute change in condition for one resident, including failure to follow provider orders for diagnostic testing and failure to promptly activate 911 EMS when the resident became unresponsive and hypotensive. The resident was an elderly female with bipolar disorder, dementia, and delusional disorder who had been evaluated by a nurse practitioner two days prior for fatigue, poor appetite, right flank/low back pain, and lower abdominal tenderness. The NP suspected a UTI and hand‑wrote orders on a Doctor’s Orders sheet for CBC, CMP, and urinalysis with C&S if indicated. These orders were to be entered into the EMR by clinical care coordinators, but the Infection Prevention Manager later confirmed that no such orders were entered and no labs or UA were completed, and there were no results in the lab system. During the overnight shift, multiple CNAs reported that the resident was her usual self at the beginning of the shift but later became very lethargic, unable to keep her eyes open, and then completely unresponsive. CNAs stated they notified the nurse, and that two RNs (one being newly oriented) repeatedly assessed the resident, took vital signs several times, and made numerous phone calls. One CNA recalled that one RN wanted to send the resident to the hospital while the other RN was not convinced this was necessary. The orienting RN reported that both nurses assessed the resident and noted fluctuating vital signs, pain, lack of responsiveness except to painful stimuli (sternal rub), cold hands, and difficulty obtaining pulse oximetry readings. She contacted the on‑call PA, who agreed the resident required hospital evaluation, and she documented that the focus at that time was on facilitating transport and maintaining safety while awaiting transfer. The orienting RN described that she and the other RN were the only two nurses in the building that night and that she was being trained on the transfer process, including completing a transfer checklist and packet. She stated she had already transferred another resident earlier in the shift and had learned that 911 arrived quickly and would not wait for incomplete paperwork, so for this resident she took extra time to complete all transfer forms, call the family, and call report to the ED before calling 911. She reported asking the other RN whether they should call 911 and being told to finish the packet while the other RN went to eat. She then completed the electronic transfer form, including documenting last vital signs and that report was called to the ED, but she did not call 911 and believed the other RN would do so. EMS and 911 records show an abandoned 911 call from the facility, a return call in which staff stated there was no emergency, and subsequent calls from the local ED and ambulance service indicating the facility had called the ED with report on an unresponsive resident but had not sent the patient. EMS ultimately received a dispatch at approximately 5:37 a.m. for a 77‑year‑old female in cardiac arrest, arrived to find the resident unconscious but with spontaneous respirations and a pulse, and documented that no CPR or ventilations were in progress on arrival. The resident was transported emergently to the hospital, where she was found comatose, hypotensive, tachycardic, cool and cyanotic, and later died the same day. The PA who had been contacted by the facility stated that, based on the nurse’s documentation, the resident should have been sent to the hospital right after their call and that he would not have told staff to delay transfer. Additional interviews with leadership clarified that the DON expected nurses to assess residents with a change in condition, call the on‑call provider, complete transfer forms, and call 911 EMS for transport, with immediate transfer for an unresponsive resident. The DON acknowledged that night shift staffing could be as low as two nurses and that she believed there was little to do after evening med pass. The Infection Prevention Manager stated she did not receive any call from the facility during the overnight hours and arrived at work as EMS was taking the resident out on a stretcher. The Nursing Home Administrator reported there was no phone outage on the dates in question, although the facility’s voice‑over‑IP phone system could go down and be switched to another Wi‑Fi connection, and staff were expected to use personal cell phones if needed. 911 service records documented that when 911 returned the abandoned call from the facility, staff told them there was no emergency, and only after subsequent calls from the ED and ambulance service was EMS dispatched for the resident described as unresponsive and in cardiac arrest.
Removal Plan
- All licensed nurses were re-educated that 911 EMS must be called without delay for any resident exhibiting signs of an acute decline, including but not limited to unresponsiveness, hypotension, altered mental status, respiratory distress, or other emergent conditions.
- Staff were instructed that contacting the emergency department or hospital does not replace activation of 911 EMS.
- Emergency response protocol reeducation requiring immediate activation of 911 followed by notification of the supervisor or administrator on call.
- The monthly on call schedule was posted at the nurse's station.
- The Director of Nursing or designee are available 24 hours a day, 7 days a week to support clinical decision-making during all shifts.
- Re-education will be completed in person or by telephone prior to staff’s next scheduled shift being worked.
- No licensed staff will be allowed to start a shift or give care until education is completed.
- Medical director was notified.
- Facility health care providers will enter their own orders into the electronic medical record.
- A facility wide review of all current residents was initiated to identify those at risk for acute clinical decline.
- All residents exhibiting signs of deterioration were immediately assessed and transferred via EMS per the emergency response protocol.
- A licensed nurse will conduct a chart review of all current residents for change in condition and follow through with health care practitioner orders.
- All licensed nurses will receive education prior to their next worked shift, including those on leave of absence upon return.
- Agency licensed nurses will be educated and will complete a competency test prior to their shift worked.
- The facility change in condition policy was reviewed by the interdisciplinary team and updated to clearly require activation of 911.
- Emergency condition decision-support tools were implemented at the nurse's station.
- Leadership oversight was implemented to review all emergency transfers.
Failure to Initiate Timely CPR and Improper Code Status Handling for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely emergency medical care and CPR to a resident who had a documented full code status. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis, and had an advance directive and physician order indicating “Full Resuscitate.” His BIMS score showed intact cognition, and he had signed a CPR consent form requesting resuscitation in the event of cardiac arrest. Therapy and rehabilitation documentation indicated he had good rehab potential and personal goals to walk again and relocate, and staff, including the Director of Rehabilitation and a Nurse Practitioner, later stated they were surprised by his death. On the morning of the incident, a CNA entered the resident’s room to obtain vital signs and found him unresponsive, appearing not to be breathing and not responding to touch or name. The CNA immediately alerted the RN assigned to the hall, who was at the medication cart. The CNA reported that the RN initially responded verbally from a distance, then took approximately two minutes to secure medications before going to the room. Upon arrival, the RN assessed for a pulse at the wrist and ankle, concluded the resident had passed, and covered him completely with a sheet. The RN then left the room to retrieve a stethoscope from the medication cart, administered another resident’s medications, and later returned to listen for an apical pulse and again covered the resident, without initiating CPR or calling a code blue at that time. The RN stated she did not know the resident’s code status during this initial assessment and believed the resident was “very cold and very dead,” and reported observing mottling of the legs. Subsequently, another RN on a different unit learned there had been a death and questioned the situation. This RN asked the first RN for the resident’s code status and observed that the chart being referenced was for a different patient. After directing the first RN to the correct chart, the second RN identified the resident as full code and instructed that CPR be started, a code blue be called, and 911 be contacted. When the second RN entered the room, the resident was fully covered with a sheet, pulseless, and not breathing, but without observed rigor mortis, lividity, or mottling, and not recalled as cold to the touch. CPR and BVM ventilation were initiated, and multiple nurses and CNAs responded to the code. During the code, the first RN contacted the DON by phone; staff in the room reported that the first RN entered and instructed them to stop CPR, stating the DON had ordered it, although the DON later denied giving an order to stop and stated that for a full code, staff were to run the code until EMS arrived or a physician order was obtained. Another nurse recalled the first RN saying she thought the resident had been dead for a couple of hours. During the resuscitation efforts, the first RN also contacted an on-call provider and requested a change in the resident’s code status to DNR because imminent death was suspected. A PA documented being notified that the resident had passed away and that CPR had been started, and recorded that the code status changed to DNR. When questioned later, both the RN and the PA were unable to explain how the code status could be changed from full code to DNR without the resident’s consent and without the statutory requirements for a DNR order being met. A Nurse Practitioner stated that such a change was impossible without the declarant’s signature, a physician signature, and two witnesses, and that qualified staff were obligated to perform CPR on full code residents until an order to stop was received from an on-site physician or medical control. Multiple staff, including a CNA who was a CPR instructor, indicated that too much time elapsed between finding the resident unresponsive and initiating CPR. The facility’s own CPR/BLS policy and the American Heart Association BLS algorithm, as cited in the report, required initiation of CPR for a pulseless, non-breathing full code resident in the absence of obvious signs of irreversible death, which were not consistently observed or documented by responding staff. The Immediate Jeopardy was determined to have begun when the RN first found the resident without pulse or respirations and failed to initiate emergency life-sustaining measures despite his full code status, and the resident was later pronounced dead by a hospital physician. Interviews and record review documented conflicting accounts regarding the resident’s physical condition (coldness, mottling, and signs of irreversible death), the timing of assessments and interventions, and the communication between the RN, DON, and on-call provider about stopping CPR and changing code status. Staff statements consistently described a delay in initiating CPR, initial misidentification of the resident’s code status, and the resident being fully covered with a sheet before a code was called, all in the context of a documented full code order and signed CPR consent. The report also cites state law requirements for executing a DNR order, including that an individual of sound mind or a patient advocate may execute a DNR, and that the order must be dated, voluntary, and signed by the declarant or patient advocate, the attending physician, and two witnesses. These statutory requirements were contrasted with the events in which the resident’s code status was documented as changed to DNR during or immediately after the code, based solely on nursing staff communication to the PA, without evidence of the required signatures or the resident’s participation. Facility policy required staff to provide basic life support, including CPR, for full code residents who did not show obvious clinical signs of irreversible death, and to coordinate rescue efforts until EMS arrival, but the actions described in the report show that these procedures were not followed for this resident. Overall, the deficiency centers on the failure of nursing staff to promptly verify the resident’s full code status, initiate CPR immediately upon finding him pulseless and not breathing, and maintain life-sustaining efforts in accordance with facility policy, professional guidelines, and state law governing resuscitation and DNR orders. The sequence of events, as corroborated by multiple staff interviews and documentation, shows delays in response, premature assumption of death, miscommunication about code status, and an improper attempt to change the resident’s code status to DNR without the required legal process, all occurring before and during the emergency response that ended with the resident’s death.
Removal Plan
- Provide education to licensed nurses on the CPR policy, including confirming code status in the medical record, assessing when to initiate CPR, when CPR can be stopped, and pronouncing death.
- Educate licensed nurses on properly assessing prior to initiating CPR (check for pulse, observe chest rise, listen and feel for breathing, observe skin and body findings).
- Educate licensed nurses on the facility Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) policy, including that full code residents must receive BLS/CPR prior to EMS arrival unless obvious clinical signs of irreversible death are present, and defining those signs (rigor mortis, dependent lividity, decapitation, transection, decomposition).
- Educate licensed nurses that the licensed nurse on each shift is responsible for coordinating the rescue effort and directing other team members during the rescue effort until EMS has arrived.
- Educate licensed nurses that a resident may be declared dead by a Licensed Physician or Registered Nurse with physician authorization in accordance with state law per policy.
Explore Popular Searches
