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
The facility did not report multiple allegations of abuse and misappropriation involving several residents, including an incident where a resident's debit card was allegedly misused by staff and physical altercations between residents with severe cognitive impairment. Despite initial notifications and documentation, required reports to the State Agency were not made, and investigations were not initiated as per facility policy.
The facility did not investigate or report multiple incidents of physical altercations between residents with severe cognitive impairment, despite documented injuries and pain. Incident reports were signed by the NHA after the events, but no investigations or required notifications to state agencies were initiated, contrary to facility policy.
The facility did not follow its abuse and neglect policies when multiple residents with severe cognitive impairment were involved in physical altercations, resulting in pain and minor injury. Incident reports were completed, but the NHA was not notified, did not investigate, and did not report the incidents to the state agency as required by facility policy.
A resident with multiple health conditions and recent functional decline was subjected to mental and verbal abuse by a CNA, who displayed impatience, made derogatory remarks, and failed to provide necessary assistance during toileting. The resident was left to perform personal care alone, resulting in emotional distress. Another resident reported similar treatment by the same CNA, and staff observed the affected resident to be tearful and fearful following the incident.
A resident admitted for short-term rehab with a pelvic fracture and a sacral deep tissue injury did not have a care plan addressing the wound, despite being at risk for skin breakdown. Although interventions such as a foam dressing, specialty bed, and frequent repositioning were reportedly provided, these were not documented in the care plan, resulting in a deficiency for lack of a comprehensive, measurable care plan.
A resident with a history of severe neurocognitive and psychiatric disorders exhibited escalating aggression, including physical and verbal abuse toward staff and other residents. Despite repeated incidents, the care plan was not updated in a timely manner, enhanced supervision was not implemented, and the interdisciplinary team was not notified. Another resident was physically assaulted, and the facility failed to investigate or report the incident as required by policy.
A resident with a history of psychiatric and behavioral issues was alleged to have hit her roommate, but the incident was not reported or investigated according to facility policy. The nurse involved believed the interaction was playful and did not notify the abuse coordinator or administrator, resulting in a failure to follow required abuse reporting procedures.
A resident with multiple complex diagnoses experienced an acute change in condition, including unresponsiveness, high fever, and labored breathing. Facility staff failed to promptly recognize and respond to these changes, with delayed transfer to the hospital and insufficient monitoring and documentation of vital signs and Foley catheter status. Communication lapses and lack of clear care plan interventions contributed to the deficiency.
A resident with severe respiratory conditions and dependent on a mechanical ventilator experienced respiratory distress that was not promptly assessed or escalated by nursing staff. Despite family concerns and abnormal vital signs, the RN delayed contacting a provider and did not document or administer ordered respiratory treatments. The resident's condition worsened, requiring emergency intervention and transfer to the hospital, with documentation and communication failures noted throughout the event.
A resident with advanced end-stage liver disease and limited mobility, who required a two-person assist for bedpan use, was assisted by only one CNA. While unattended, the resident fell from the bed, sustaining a left clavicle fracture and pain, as confirmed by EMS and hospital records. The care plan specifying two-person assistance was not followed at the time of the incident.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or misappropriation of property to the State Agency for four residents, as required by regulation and facility policy. In one case, a resident with a history of alcohol dependence and anxiety disorder was alleged by a family member to have had her debit card taken and used by a staff member. The resident initially confirmed the allegation to the Nursing Home Administrator (NHA) and Director of Nursing (DON), resulting in the suspension of the accused staff member. However, after the family member left, the resident retracted her statement, claiming she felt pressured to make the accusation. Despite the retraction, both the DON and NHA acknowledged that the initial allegation constituted a reportable event, but it was not reported to the State Agency. Additional incidents involved residents with severe cognitive impairment. Two separate altercations occurred between residents, resulting in physical contact and complaints of pain. Incident reports documented these events, including one where a resident's arm was grabbed and another where residents swung at each other, making contact. The NHA, who was responsible for abuse investigations, was not initially notified of these incidents. Upon later review of the incident reports, the NHA agreed that these events met the criteria for abuse allegations and should have been reported and investigated, but no such actions were taken at the time. Facility policy clearly defined abuse to include staff-to-resident and resident-to-resident altercations, and required immediate investigation and reporting of all allegations to the appropriate authorities. Despite this, the NHA signed off on incident reports without ensuring that the required notifications and investigations were completed. The failure to report these incidents as required resulted in a deficiency related to the timely reporting and investigation of suspected abuse, neglect, or misappropriation.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving three residents with severe cognitive impairment. Incident reports documented physical altercations between residents, including one event where a resident removed another's hat, leading to both residents swinging at each other and one making contact with the other's back. Another incident involved a resident becoming agitated, grabbing another resident's arm, and a physical struggle ensued, resulting in pain and minor injury to both residents and a CNA who intervened. Despite these documented events, there was no evidence that the facility initiated investigations or reported the incidents to the appropriate state agency as required by policy. Interviews with the Nursing Home Administrator (NHA), who also served as the facility abuse coordinator, revealed that she was not notified of the incidents at the time they occurred. Upon review of the incident reports during the survey, the NHA acknowledged that the events constituted allegations of abuse and should have been investigated and reported. The NHA also confirmed that she had signed the incident reports after the fact but had not initiated any investigation or reporting process prior to the surveyor's inquiry. Facility policy required immediate investigation and reporting of any suspicion or report of abuse, including resident-to-resident altercations. The policy defined physical abuse to include actions such as hitting, slapping, and grabbing. Despite this, the facility did not follow its own procedures, as the incidents were neither investigated nor reported in accordance with state and federal regulations. The failure to act was confirmed through record review, staff interviews, and the absence of investigation documentation.
Failure to Investigate and Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to implement its own written policies and procedures for abuse and neglect for multiple residents. Specifically, the facility did not initiate investigations or report incidents of resident-to-resident altercations as required by its policy. For example, one incident involved a resident with severe cognitive impairment who was involved in a physical altercation with another resident over a personal item, resulting in physical contact. The incident report documented the altercation, but the Nursing Home Administrator (NHA), who is also the facility abuse coordinator, was not notified and did not investigate or report the event to the appropriate state agency. Another incident involved a resident with severe cognitive impairment and multiple comorbidities who was physically grabbed by another resident, leading to pain and minor injury. The incident report documented the event, including the resident's complaints of pain and the involvement of a certified nursing aide (CNA) who intervened. Despite the documentation and the facility's policy requiring immediate investigation and reporting of suspected abuse, the NHA was not aware of the details and did not initiate an investigation or report the incident to the state agency. Record review confirmed that the NHA signed the incident reports days after the events occurred, but there was no evidence of timely investigation or reporting as required by the facility's abuse, neglect, and exploitation policy. Interviews with the NHA revealed a lack of awareness of the incidents and a failure to follow the facility's procedures for investigating and reporting allegations of abuse, particularly in cases involving resident-to-resident altercations resulting in physical contact and injury.
Failure to Protect Resident from Mental and Verbal Abuse by CNA
Penalty
Summary
A resident admitted for short-term rehabilitation following a fall, with diagnoses including chronic obstructive pulmonary disease, repeated falls, and macular degeneration, was found to be cognitively intact according to the Brief Interview for Mental Status. On the date of the incident, the resident required assistance with toileting and was unable to lock her wheelchair or pull down her pants due to weakness. The assigned CNA displayed impatience, made a disparaging comment about residents needing to help themselves, threw a clean brief at the resident, and left her to complete peri care and brief application without assistance. The resident reported feeling scared, weak, and emotionally distressed, crying during and after the incident, and continued to be affected by the event during the surveyor's interview. A review of statements from the resident's former roommate indicated a similar experience with the same CNA, who was described as rude and unsupportive, making comments about the resident's inability to walk to the bathroom. Another CNA reported that the resident was tearful and reluctant to accept help the day after the incident, and upon inquiry, the resident disclosed the previous day's mistreatment. The facility's abuse policy defines mental, verbal, and physical abuse, and the actions of the CNA were consistent with mental and verbal abuse as described in the policy. The facility terminated the CNA's employment following the incident.
Failure to Develop and Implement Care Plan for Deep Tissue Injury
Penalty
Summary
The facility failed to develop and implement a care plan addressing a deep tissue injury (DTI) for a resident admitted for short-term rehabilitation following a pelvic fracture. Upon admission, the resident was found to have a DTI on the sacrum, as documented in the skin assessment, and was identified as being at risk for skin breakdown based on a Braden Scale score. The resident reported decreased mobility and pain with movement and repositioning, and stated that nursing staff applied a cream to the affected area daily. Despite these findings, a review of the resident's care plans revealed no interventions or strategies in place to address the DTI, prevent further skin breakdown, or promote healing. During interviews, the facility's wound nurse confirmed the presence of the DTI and described interventions such as a foam dressing, specialty bed, cushion, and frequent repositioning, noting that staff assistance was needed to prevent shearing. However, these interventions were not documented in the resident's care plan. The lack of a documented care plan meant that there were no measurable actions or timetables established to address the resident's skin integrity needs, resulting in a deficiency related to the development and implementation of a comprehensive care plan.
Failure to Protect Residents from Abuse Due to Inadequate Behavioral Interventions and Supervision
Penalty
Summary
A resident with a history of major depressive disorder, major neurocognitive disorder due to Alzheimer's disease, and psychotic mood disorder was admitted to the facility and exhibited escalating aggressive and disruptive behaviors. Documentation shows that the resident became physically and verbally abusive towards staff and other residents, including making threats of physical harm, entering other residents' rooms, and taking their belongings. Despite repeated incidents of aggression, including physical assaults on staff and threats to other residents, the care plan was not updated in a timely manner to address these behaviors, and enhanced supervision or monitoring was not implemented. The facility failed to notify the interdisciplinary team (IDT) or provider of the resident's escalating behaviors and did not conduct behavior management evaluations or update interventions in response to the resident's aggression. There was also a lack of documentation regarding IDT meetings or behavioral management discussions, and the care plan was not revised to reflect new or worsening behaviors until after the resident was transferred to the hospital. Additionally, the facility did not report or investigate an allegation of resident-to-resident physical abuse, nor did it document provider notification or assessment following incidents of aggression and ineffective medication administration. Another resident was physically assaulted by the aggressive resident, resulting in tenderness to the jaw and the need for non-pharmacologic pain relief. The facility's own investigation confirmed physical contact occurred. The facility's policies required ongoing assessment, care planning, and monitoring for residents with behaviors that might lead to conflict or abuse, but these were not followed. The failure to implement timely interventions, update care plans, and notify appropriate staff and providers contributed to the deficiency in protecting residents from abuse.
Failure to Report and Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy when an allegation of resident-to-resident physical abuse was not reported or investigated. A female resident with major depressive disorder and major neurocognitive disorder due to Alzheimer's disease, who had a history of physical aggression toward staff, was alleged to have hit her roommate on the left hand. The incident was documented in a progress note by a registered nurse, but there was no evidence that the allegation was reported to the abuse coordinator as required by facility policy. The nurse assessed the resident and found no injury, and believed the interaction was playful based on the residents' relationship, but did not document all details in the chart or initiate the required reporting process. Interviews revealed that the nursing home administrator was not made aware of the allegation, and staff did not follow the policy for immediate reporting of abuse allegations. The facility's written policy requires all alleged violations to be reported to the administrator and investigated, but this process was not followed in this case. The failure to report and investigate the allegation resulted in noncompliance with the facility's abuse prevention and response procedures.
Failure to Timely Transfer and Monitor Resident with Acute Change in Condition
Penalty
Summary
A resident with a complex medical history, including gram-negative sepsis, heart failure, and dependence on supplemental oxygen, experienced an acute change in condition that was not promptly recognized or addressed by facility staff. The resident became unresponsive, diaphoretic, and exhibited labored breathing with a high fever and abnormal urine characteristics. Despite these significant changes, there was a delay in transferring the resident to the hospital, and staff failed to provide timely and thorough assessments or interventions during the acute episode. Documentation and interviews revealed that staff did not consistently monitor or document the resident's vital signs or Foley catheter status. The care plan and Kardex lacked specific interventions for ongoing assessment and monitoring of the Foley catheter, and staff were unclear on how to track urine output for residents with catheters. CNA and nursing documentation indicated that only one set of vital signs was recorded during the critical period, and there was no evidence of further nursing care or assessment until EMS arrived. Upon EMS arrival, the resident was found to be in severe distress, with a temperature of 104.1°F, unresponsiveness, and significant respiratory compromise, requiring intubation shortly after arrival at the emergency room. Interviews with facility leadership and staff highlighted gaps in communication, documentation, and escalation of care. Concerns raised by the resident's family regarding decreased mobility and responsiveness were not thoroughly assessed or communicated to the appropriate staff. The lack of clear protocols for monitoring residents with Foley catheters and the absence of timely nursing interventions contributed to the delay in recognizing the severity of the resident's condition and transferring him to the hospital.
Failure to Timely Assess and Escalate Care for Resident in Respiratory Distress
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate monitoring, thorough assessment, timely notification to a medical provider, and accurate documentation for a resident experiencing a change in condition. The resident, who had a history of acute and chronic respiratory failure with hypoxia, asthma, anoxic brain damage, dysphagia, and was dependent on a mechanical ventilator, began to show signs of respiratory distress. The family noticed abnormal breathing and alerted the RN, who assessed the resident, took vital signs, and administered pain medication, but did not escalate the situation or notify a medical provider at that time. Despite the resident's elevated heart rate and labored breathing, the RN did not reassess the resident or contact the respiratory therapist or physician promptly. Approximately 30 minutes later, the resident's condition worsened, with lips turning blue and continued respiratory distress. The respiratory therapist was called, provided manual ventilation, and the RN eventually called 911. Documentation was inconsistent, with missing or unclear vital signs, incomplete progress notes, and medication administration records not reflecting the administration of ordered respiratory treatments. Interviews with staff revealed a lack of clear communication and timely intervention. The Director of Nursing stated that the expectation would have been to escalate the situation and contact the medical provider and respiratory therapist for a ventilator-dependent resident with an elevated pulse and respiratory distress. However, this did not occur, and there was no evidence of a facility investigation into the incident at the time of the survey. Facility policy required prompt notification of changes in condition, especially life-threatening situations, but this protocol was not followed in this case.
Failure to Provide Required Two-Person Assist Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with advanced end-stage liver disease and ascites, who required extensive assistance from two staff members for positioning onto a bedpan, was assisted by only one CNA. The resident's care plan specifically documented the need for a two-person assist due to limited mobility and the need for support related to an enlarged abdomen. On the day of the incident, two family members and two EMTs were waiting outside the resident's room while the CNA provided care alone. During this time, the resident was heard yelling about an impending fall, followed by a loud thump. The resident was subsequently found on the floor, approximately ten feet from the bed, having knocked over flowers and a lamp. Clinical records and interviews confirmed that the CNA did not follow the care plan, which required two-person assistance for bedpan use. The resident sustained a left clavicle fracture and reported pain in the left upper extremity as a result of the fall. The incident was corroborated by EMS and hospital records, as well as interviews with facility staff, who acknowledged that the care plan was not followed at the time of the event.
Some of the Latest Corrective Actions taken by Facilities in Michigan
- Implemented Epic worklist tasks for all residents on psychotropic medications to continuously monitor for adverse reactions by medication class and symptom (J - F0605 - MI)
- Educated the Medical Director and Nurse Practitioners on F605 regulations and appropriate psychotropic use (J - F0605 - MI)
- Re-educated nurses and social workers on employing non-pharmacological interventions before initiating psychotropics, requiring completion before staff could work (J - F0605 - MI)
- Established ongoing IDT reviews of behavior logs, care plans, and new symptoms with SBAR communication to providers (J - F0605 - MI)
- Directed the DON/designee to run regular Epic reports on newly prescribed psychotropics to verify consent forms and monitoring tasks (J - F0605 - MI)
- Educated the consultant pharmacist on the psychotropic-medication review process (J - F0605 - MI)
Failure to Identify and Address Elopement Risk Resulting in Resident Exiting Facility Unnoticed
Penalty
Summary
The facility failed to identify and address the elopement risk of a resident with severe cognitive impairment and a history of behaviors requiring constant redirection. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease and Schizophrenia, was initially assessed as low risk for elopement upon admission. Despite exhibiting behaviors such as wandering, loud vocalizations, and hallucinations, no updated elopement risk assessment or care plan interventions were completed after the resident exited the facility on one occasion. On two separate occasions, the resident was able to leave the facility without staff awareness. The first incident occurred when the resident followed staff out the front door after it was unlocked by a receptionist. The second incident involved a newly hired receptionist who mistakenly identified the resident as a visitor and allowed them to exit. In both cases, staff were unaware of the resident's absence until after the fact, and the resident was found outside the facility, once by a staff member driving to work and once by facility supervisors. Interviews with staff revealed a lack of communication and awareness regarding the resident's previous elopement and ongoing behaviors. Key personnel, including the assigned nurse and other staff, were not informed of the prior incident or the need for reassessment. The DON confirmed that no reassessment or new interventions were implemented after the initial elopement, and the administrator stated that only the receptionists were in-serviced following the incidents. The facility's policy required reassessment and intervention upon changes in resident behavior or condition, which was not followed in this case.
Removal Plan
- Resident wander assessment completed for the at-risk resident.
- Resident care plan reviewed by the interdisciplinary team and updated.
- Resident monitored by psychiatry for behaviors and medication management.
- All residents in the facility reassessed for risk of elopement to identify those at risk.
- Audit completed by the facility's clinical management team on all residents who trigger for elopement risk.
- Care-plan review for residents deemed at risk for elopement to ensure appropriate interventions are in place.
- Residents deemed at risk for elopement are included in all facility elopement binders, which are located on the nurse's unit and at the reception area.
- In-servicing for staff initiated by DON/Designee on the elopement guideline.
- Signage made visible throughout the building for staff and visitors to be aware of residents who may be around when walking through doors.
- In-servicing for licensed nurses initiated by the DON/Designee on ensuring a resident is reassessed for wandering when showing behaviors to ensure accuracy of care plan and interventions.
- The DON/Designee will review residents who are at risk for elopement to ensure wander/elopement assessments are current and interventions are accurate.
- Results reported to the QA committee for monitoring and follow-up.
Failure to Prevent Elopement and Inadequate Response to Exit Door Alarm
Penalty
Summary
A deficiency occurred when a resident, identified as being at risk for elopement due to a history of attempts to leave the facility unattended, impaired safety awareness, severe depression with psychotic symptoms, and anxiety, was able to exit the facility without staff knowledge. The resident had a Wanderguard device in place and was care planned for elopement risk, including interventions such as placement and function checks of the Wanderguard, redirection, and 1:1 observation as of the date of the incident. Despite these interventions, the resident was able to leave the facility in a wheelchair and was found approximately 50 yards away on a sidewalk near a road by an off-duty staff member. Staff interviews and record reviews revealed that on the morning of the incident, multiple staff members heard the exit door alarm sounding several times but did not respond appropriately. One CNA deactivated the alarm without fully investigating the cause or ensuring all residents were accounted for, and did not call a code search when the resident's whereabouts were unknown. The DON also deactivated the alarm and returned to her office without first checking outside the building for a missing resident. The alarm system was observed to function properly, sounding when a Wanderguard was near the door, regardless of whether the door code was entered. However, staff failed to follow protocol for responding to exit alarms and did not ensure the safety of residents at risk for elopement. Documentation also showed that the resident's elopement risk assessments were not accurately completed prior to the incident, as they did not reflect the resident's ongoing verbalizations and behaviors indicating a desire to leave. Staff interviews confirmed that the resident had been expressing anger and a desire to leave the facility, but these were not properly documented in the risk assessments. The combination of inaccurate assessments, failure to respond appropriately to exit alarms, and lack of immediate action to locate the resident resulted in the resident eloping from the facility without staff knowledge.
Removal Plan
- DON and nurse assessed Resident #101 in the parking lot and returned him to the facility.
- Resident #101's responsible party was notified.
- Resident #101 was placed in dining room under supervision for breakfast and then on 15-minute checks, escalating to 1:1 supervision after further elopement attempt, until transfer to psychiatric facility.
- Resident #101's elopement risk assessment was updated, and his care plan and orders were reviewed.
- Resident #101's Wanderguard was tested for function and placement upon return to building.
- Elopement books were updated and placed at the front desk and each nurse's station.
- Housekeeping Supervisor and Maintenance Director inspected all emergency exits and completed a Wanderguard test on doors.
- Secure Care was notified to validate door function; maintenance reviewed main door for proper alarm function.
- Secure Care validated and cleared system functions.
- All residents were assessed for risk of elopement; residents determined at risk had care plans reviewed for completeness.
- Maintenance Director or Housekeeping Supervisor/designee checks and logs all exit doors for proper function; Administrator reviews logs.
- DON/designee provided education to staff regarding Elopement policy, including immediate response to door alarms, exiting building for full view, use of light source, and calling code search if no one is observed.
- Staff were educated; remainder received 1:1 education or were educated upon arrival to work before assignment.
- Ongoing staff education on Elopement Policy and procedure, including residents at risk for exit seeking and Wanderguard use.
- Missing Guest Book/Residents with Wanderguards is updated minimally weekly and with any changes by the Interdisciplinary team.
- DON/Designee reviewed all residents at risk for exit seeking and Wanderguards for elopement risk; ongoing assessment upon admission, quarterly, and with change of condition.
- Administrator reviewed the investigation performed by DON and interviewed all staff from relevant shifts.
- Administrator and QAPI committee reviewed the missing guest policy and deemed it appropriate.
- Administrator audited the elopement books for accuracy and currency.
- New employee orientation includes Elopement policy and procedure education.
- Maintenance Director/Designee checks alarmed doors as part of Preventative Maintenance; findings submitted to QAPI committee; Administrator reviews logs.
- Code search drills were held on all shifts; ongoing process of code search drills.
- Medical Director was made aware of the elopement.
- Incident reviewed in ad hoc and monthly QAPI meetings; root cause analysis performed; decision to add light source to reception desk for search.
- Continued education on elopement policy and response to alarms, complete visualization, and calling code search; drills to ensure proper response and reduce alarm fatigue.
- All staff completed education prior to next shift worked.
Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to properly assess for safety, implement timely and effective interventions, and provide adequate supervision to prevent accidents for a resident identified as high fall risk, a wanderer, and with severe cognitive impairment. The resident had a history of falls with injury and was completely dependent on staff for mobility and transfers. Despite these risks, the resident experienced multiple falls, including incidents on a staircase that resulted in multiple facial fractures, a laceration requiring closure, loss of consciousness, hospitalization, and unnecessary pain. The facility did not ensure the environment was free from accident hazards, as the stairwell was open and accessible to cognitively impaired residents without any deterrents in place at the time of the incidents. Interviews and record reviews revealed that the facility did not follow the resident's care plan, which included interventions such as a perimeter mattress and a soft helmet. The resident was observed without a perimeter mattress or helmet at the time of the falls, and staff were unable to explain why these interventions were not in place. Documentation of the incidents was incomplete or delayed, with missing progress notes, lack of vital sign documentation, and late entries in the medical record. The facility also failed to notify the State Agency of the incidents involving major injuries in a timely manner. Additionally, the facility did not involve the resident's Power of Attorney (POA) in care decisions or care planning, including the initiation of hospice services and notification of falls. The POA reported not being informed of significant events, including additional falls, and expressed concerns about the lack of communication and coordination with the facility. The combination of inadequate supervision, failure to implement care plan interventions, lack of environmental safeguards, and poor communication contributed to the resident's repeated injuries and decline.
Removal Plan
- Nurse management team completed new fall risk assessments for all like residents.
- The interdisciplinary team updated all current resident's plans of care based on new risk assessments.
- Stop sign barrier banners have been placed at the entrance way of the stair well on ascending and descending sides to impede resident usage.
- Measurements for the stairwell have been taken by the Maintenance Director to research and implement a more permanent solution.
Failure to Implement Elopement Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement, severe cognitive impairment due to Alzheimer's disease, and significant visual impairment was able to leave the facility undetected. The resident had previously demonstrated exit-seeking behaviors, including playing with door codes, expressing a desire to leave, and having a documented high elopement risk score. Despite these clear risk factors, the facility failed to implement appropriate interventions or update the resident's care plan to address elopement risk, even after prior incidents where the resident exited the facility and was returned. The facility's own policies required that residents identified as at risk for elopement have these issues addressed in their individual care plans. However, after multiple incidents where the resident left or attempted to leave the facility, there was no investigation, incident report, or care plan developed to mitigate the risk. The resident was also moved out of the memory care unit without documented justification, despite meeting the criteria for continued placement in that secure environment. Staff interviews confirmed that no care planning or interventions were put in place after previous elopement attempts, and the resident's risk was not reassessed or addressed in the care plan. On the day of the incident, the resident exited the facility by following a visitor through a door, walked outside the premises, and was later found at a fast-food restaurant over a mile away after being missing for approximately two hours. The resident's family and staff had previously expressed concerns about his desire to leave and his increased agitation following his wife's death. The lack of timely and appropriate interventions, failure to follow facility policy, and absence of a care plan addressing elopement risk directly led to the resident's undetected exit and the resulting immediate jeopardy situation.
Removal Plan
- R #1 is residing in the Memory Care Neighborhood, a secured unit.
- R #1 Elopement Assessment has been updated, and a care plan has been developed with appropriate interventions.
- All residents have an Elopement Assessment and were audited to ensure that if they have a score higher than 10, they have a care plan in place with appropriate interventions.
- All staff have reviewed and signed a copy of the Facility Elopement Policy.
- The Director of Nursing, or designee, will audit all new admissions for elopement risk and ensure appropriate interventions are in place.
- The Director of Nursing, or designee, will audit residents, based on MDS schedule, to ensure Elopement Assessment is completed and appropriate interventions are in place.
- The Director of Nursing was educated to review Elopement Assessments to ensure that proper care plan interventions are in place, based on the MDS schedule and admissions.
- The Northeast door code has been changed and only staff are allowed to have this code.
- All visitors and staff must enter and exit the facility through the front lobby only.
- All DPOA's and Emergency contacts will be contacted to let them know of the change.
- Signage will be posted.
- Staff education has been sent regarding these changes and to ensure they do not give out the code to the Northeast door and that they all use the front lobby to enter and exit.
- If staff hear the alarm go off, they need to remind the visitor to use the front lobby door, or if they cannot identify who set the alarm off, they need to call a code missing person and start a headcount.
- All physician orders and physician progress notes have been reviewed for R #1 and have been placed.
- Resident is utilizing nonpharmacological interventions, residing in the memory care unit, and on antidepressant medications, per Behavioral Care Solutions recommendations.
Failure to Prevent Resident Elopement Due to Inadequate Assessment, Supervision, and Door Security
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of progressive neurological disease, diabetes, non-Alzheimer's dementia, anxiety, and depression was not properly assessed for elopement risk, nor adequately supervised, resulting in the resident eloping from the facility undetected for approximately 30 minutes. The resident, who had documented patterns of wandering, was able to exit the building through a 300 Hall door that did not function as intended, opening before the required 15-second delay. Staff failed to notice or respond appropriately to the resident's wandering behaviors, and the resident's care plan did not address wandering or elopement risk until after the incident occurred. Surveillance footage showed the resident wandering unsupervised throughout the facility for an extended period, including multiple attempts to exit the building. Staff were observed to be inattentive, with one LPN using a personal cell phone at the nurses' station and leaving the resident unsupervised. When the exit door alarm was triggered, staff did not conduct a head count or search outside, only resetting the alarm and looking out the window. The resident was later found outside in a ditch, inadequately dressed for the weather, complaining of cold and pain, and required transfer to the emergency department for evaluation. Documentation and interviews revealed that staff did not consistently review progress notes or update elopement risk assessments in response to changes in the resident's behavior. The resident's care plan lacked interventions for wandering prior to the incident, despite multiple documented episodes of nighttime wandering and exit-seeking. Staff were also not fully aware of or did not follow facility policies regarding supervision, response to exit alarms, and use of personal cell phones, contributing to the failure to prevent the elopement.
Removal Plan
- Elopement and Wandering Residents Policy reviewed and updated.
- All staff were made aware of mandatory all staff meeting regarding elopement policy and responsibilities during an elopement.
- Maintenance director inspected and tested 300 Hall exit door, accompanied by Surveyor.
- Additional education to all staff regarding proper functioning door alarms was initiated via text and in person.
Failure to Monitor and Prevent Unnecessary Psychotropic Medication Use Resulting in Resident Harm
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications without adequate indication and failed to monitor a resident for adverse effects after initiating such medication. A female resident with severe late-onset Alzheimer's dementia, a history of recurrent falls, insomnia, and depression was prescribed lorazepam daily. Prior to the prescription, the resident had not experienced any falls since her admission in February. After starting lorazepam, the resident experienced multiple falls in May, with no major injuries initially, but there was no evidence that the facility reviewed her medications or monitored for adverse consequences following these incidents. Documentation revealed that the resident's care plan identified her as being at risk for falls due to impaired balance and the use of psychoactive medications, but there was no policy or clear intervention for visual checks or monitoring for medication side effects. Behavior logs and care plans did not show a focus on monitoring psychotropic medications, and there was no documented increase in wandering or agitation prior to the medication change. The resident's family was not informed or asked for consent regarding the addition of lorazepam, and there was no documentation of consent for the medication. Staff interviews indicated that the resident was independent, not aggressive or combative, and could be redirected, with no significant behavioral escalation documented prior to the medication change. After the initiation of lorazepam, the resident experienced a significant fall resulting in an impacted acetabulum and pelvic fracture, leading to hospitalization and subsequent death. There was no indication that the facility reviewed the resident's medications after each fall to determine if they contributed to the incidents. The consultant pharmacist was not made aware of the increase in falls after the addition of lorazepam, and the facility's medication management policy was not effectively implemented to ensure monitoring and prevention of unnecessary drug use. The lack of monitoring, failure to obtain consent, and absence of medication review after falls directly contributed to the deficiency.
Removal Plan
- Review all residents' charts to identify residents on psychotropic medication to ensure adequate monitoring.
- Create worklist tasks for all residents on psychotropic medications to monitor for adverse reactions, specifying medication class and symptoms to monitor.
- Audit all residents on psychotropic medications for consent forms; complete consent forms for any resident missing one and obtain signature.
- Upload completed consent forms to Epic.
- Educate the Medical Director on F605 regulations, with emphasis on the appropriate use of psychotropic medications.
- Provide a list of all residents on psychotropics to the Medical Director.
- Educate the Nurse Practitioners on F605 regulations.
- Review behavior logs during the Interdisciplinary Team (IDT) meeting, including review of care plans for affected residents.
- Educate nurses regarding the requirement to implement non-pharmacological interventions prior to initiating psychotropics.
- Educate the social worker on the expectation to implement non-pharmacological interventions, and educate the second social worker.
- Re-educate nurses, led by the DON, for all nursing leaders and on-duty staff; do not permit any nurse to work until this education is completed.
- The DON or designee will pull an Epic report to identify newly prescribed psychotropics and verify that consent forms and monitoring tasks are in place.
- Review new symptoms during the IDT meeting and communicate to providers using the SBAR format.
- Educate social workers on obtaining consent for psychotropic medications; re-educate one social worker and re-educate the second.
- Educate the consultant pharmacist on the medication review process and confirm understanding.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to adequately supervise and ensure the safety of a resident who was assessed to be at risk for elopement. The resident, who had severe cognitive impairment, dementia, and a history of exit-seeking behavior, was able to leave the premises without staff knowledge and remained missing for approximately 17 hours. Multiple staff interviews and record reviews confirmed that the resident had been displaying exit-seeking behaviors throughout the morning, including asking staff for directions to a hotel and attempting to exit through various doors. Despite these behaviors and a care plan indicating the need for interventions such as one-to-one supervision as deemed necessary, the resident was not placed on one-to-one supervision at the time of the incident. Staff reported that the resident was difficult to keep track of and was observed wandering throughout the facility, setting off door alarms, and repeatedly asking to leave. Several staff members, including CNAs, LPNs, and social services, noted the resident's confusion and persistent attempts to exit. The resident was last seen by staff in the late morning, and after a search of the facility, it was determined that he was missing. The facility's elopement assessment had previously identified the resident as being at risk, and interventions such as wander guard bracelet checks and reassurance were documented, but these measures were not sufficient to prevent the elopement. Interviews with facility leadership, including the DON and NHA, revealed that there was an expectation for staff to implement additional interventions, such as one-to-one supervision, for residents exhibiting exit-seeking behavior. However, on the day of the incident, these interventions were not implemented, and staff did not escalate the level of supervision despite clear signs of risk. The resident was ultimately found by local police and returned to the facility without significant injury, but the failure to provide adequate supervision and prevent the elopement constituted a serious deficiency.
Removal Plan
- Code 7 was paged overhead indicating missing resident.
- Staff began completing a head count and searching for missing resident inside and outside the facility.
- Administration was notified.
- Police were notified.
- All doors, alarms, and wander guard system were tested, and all functional.
- All wander guards were verified for placement and function.
- A facility wide audit of elopement risks was completed to ensure all residents at risk had been identified and had care plans in place.
- Elopement book was reviewed to ensure all residents at risk had pictures and information in place.
- Facility elopement and missing person policy were reviewed.
- All staff present in the facility were educated on the elopement policy and the missing person policy.
- A plan was put in place to educate every staff member prior to their next working shift.
- Facility confirmed all door alarms and wander guard system were operating properly and were monitored for functionality daily.
- The code to the 600 hall door was changed by the maintenance director.
- A sign was placed on the 600 hall door indicating it was not an exit, and visitors should enter and exit through the main entrance.
- Facility ensured signs were posted to educate visitors on the need to avoid assisting any residents through a door.
- Resident #100 was placed on one to one after returning to the facility until he discharged from the facility.
- Facility ensured elopement drills were conducted daily for 3 days.
- Facility ensured elopement drills were conducted weekly.
- All wander guards were verified for placement and function.
- A facility wide audit of elopement risks was completed to ensure all residents at risk had been identified.
- Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement.
- The facility elopement books were reviewed to ensure all at risk residents had pictures and information located in the books.
- The facility policy for elopement and/or exit seeking management and missing person policy were reviewed and deemed appropriate.
- All staff present in the facility were educated on policy, warning signs of elopement, how to identify an at risk resident, what to do if a resident is exit seeking, how to redirect an exit seeking resident, who to notify if a resident is exit seeking, and each staff member was given a laminated check list related to missing resident to attach to their name badge.
- Education of all staff members was completed except for staff members who were on approved leave. The staff members on leave would be educated upon their return to work.
- Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement.
- Facility confirmed all door alarms and wander guard system were operating properly and were monitored for functionality daily.
- The code to the 600 hall door was changed by the maintenance director.
- Daily door alarm checks continued.
- A sign was placed on the 600 hall door indicating it was not an exit.
- Facility ensured signs were posted to educate visitors on the need to avoid assisting any residents through a door.
- Resident #100 was placed on one to one until resident discharged from the facility.
- Facility ensured elopement drills were conducted daily for 3 days.
- Facility ensured elopement drills were conducted weekly.
- Elopement policies, procedures, educations, assessments and root cause were reviewed in QAPI.
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