Citations in Missouri
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Missouri.
Statistics for Missouri (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Missouri
- Provided in-service education for all staff on elopement, check, and door-monitoring policies (J - F0689 - MO)
- Updated elopement risk and Code White procedure books with current risk assessments and procedures (J - F0689 - MO)
- Adjusted alarmed fire and exit door alarms to increase volume for prompt staff recognition (J - F0689 - MO)
- Established ongoing alarmed-door and check audits (J - F0689 - MO)
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A resident with a history of schizophrenia, bipolar disorder, Alzheimer's disease, and vascular dementia, who was assessed as being at risk for wandering and elopement, exited the facility through an alarmed fire exit door without staff knowledge. The resident was ambulatory with a wheelchair, had a severely impaired cognition, and had recently exhibited aggressive behavior, resulting in an order for 15-minute checks. However, staff failed to complete and document the required 15-minute checks during the relevant time period. The door alarm intended to alert staff to unauthorized exits was not loud enough to be heard until staff were already partway down the hall, as confirmed by multiple staff and resident interviews. Neither the resident's roommate nor another resident on the same hall heard the alarm, and staff only became aware of the resident's absence when a call light was noticed and the resident was found missing from their room. The resident's wheelchair was found by the exit door, and the alarm was only heard after staff began searching for the resident. The resident was later found outside the facility by a local citizen, having sustained multiple serious injuries including facial fractures and a subdural hemorrhage. The timeline and interviews indicate that the lack of timely supervision, failure to perform required checks, and insufficient alarm volume contributed to the resident's unsupervised exit and subsequent injury.
Removal Plan
- Conduct an investigation and notify appropriate parties including the police.
- Provide in-service education for all facility staff including elopement policies, check policies and door monitoring policies.
- Complete elopement risk assessments for all residents.
- Update the elopement risk and code white procedure books with current risk assessments and code white procedures.
- Adjust alarmed, fire, exit door alarms to increase the volume of the alarm for staff to recognize the alarm promptly.
- Perform alarmed door audits and check audits and continue ongoing audits.
Latest Citations in Missouri
A resident with a history of sexual outbursts and severe cognitive impairment in a memory care unit inappropriately touched another cognitively impaired resident in a common area. The incident occurred while a CMT was preparing medications nearby, and both residents were unsupervised in close proximity despite known behavioral risks. The facility's abuse prevention measures did not prevent the incident, resulting in a failure to protect residents from abuse.
A resident with multiple medical conditions experienced a broken front tooth and reported pain and difficulty eating, but did not receive timely dental care. After an unsuccessful dental appointment due to transfer issues, no alternative arrangements were made, and the resident later developed a dental abscess treated only with antibiotics. Staff interviews revealed a lack of follow-up and communication, resulting in the resident waiting over a year without appropriate dental intervention.
A resident with cognitive impairment and psychiatric diagnoses was denied smoke breaks by the Social Services Director after exhibiting disruptive behavior during an outing. Staff interviews revealed confusion about residents' rights, with several staff members confirming that withholding smoke breaks as punishment is not permitted for residents who are their own decision-makers. The facility's actions were not consistent with its policy on resident rights, resulting in a failure to treat the resident with dignity and respect.
A resident with dementia and psychiatric disorders made two separate allegations of abuse, which were not reported to the state agency within the required timeframe. Although staff assessed the resident and found no evidence of injury, there was no documentation or confirmation that the allegations were reported to facility administration or DHSS as mandated. Staff interviews revealed confusion about reporting procedures and timeframes, and both the DON and Administrator acknowledged the incidents were not reported as required.
Staff did not fully investigate or document two abuse allegations made by a resident with dementia and psychiatric disorders. The facility failed to interview other staff or residents, did not suspend the accused staff as required by policy, and did not document protective measures during the investigation. Interviews revealed inconsistent understanding and application of abuse protocols among staff and administration.
A resident with heart failure and other complex conditions did not receive several ordered medications, including torsemide, amiodarone, lidocaine patch, and metoprolol, due to delays in ordering, lack of follow-up with pharmacy or hospice, and failure to use available E-Kit medications. Documentation was incomplete, and there was no evidence of timely communication with providers. Additionally, side rails were used after a fall without required assessment or documentation, contrary to facility policy.
The facility did not have an RN on duty for at least 8 hours each day, 7 days a week, as required. The DON was the only RN and was only available on-call, with no RNs scheduled on daily assignment sheets. This affected a census of 140 residents.
The facility did not immediately intervene when a resident with a history of suicidal ideation expressed a desire to commit suicide, resulting in a delay in assessment and supervision. Staff failed to remain with the resident or promptly notify a nurse, and there were gaps in behavioral health follow-up and documentation. Additionally, another resident exhibiting agitation and elopement risk was not appropriately redirected or engaged, contrary to their care plan.
A resident with a history of suicidal ideation and multiple recent suicide attempts did not receive consistent or documented psychosocial support or medically related social services. After returning from hospitalizations, the resident expressed ongoing distress and a desire for counseling, but staff responses were delayed and uncoordinated. Social Services Designees lacked qualifications and training, and the facility had no qualified social worker or outside behavioral health services, resulting in unmet psychosocial needs.
Surveyors found that multiple opened vials and pens of insulin and PPD were not properly labeled or dated, with some medications being expired or improperly stored. Medication refrigerator temperature logs were incomplete, and an Environmental Aide was able to access the medication room unsupervised using keys kept in the nurses' station. These findings indicate failures in medication labeling, storage, and access control.
Failure to Prevent Resident-to-Resident Sexual Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect a resident from sexual abuse when another resident, both with severe cognitive impairments, was able to physically touch the first resident inappropriately in a common area. The incident occurred when one resident, diagnosed with Alzheimer's disease, dementia with agitation, and delusional disorder, was walking through the memory care unit and was approached by another resident with Alzheimer's disease, a history of traumatic subdural hemorrhage, and mild cognitive impairment. The second resident, who had a documented history of behavior problems related to sexual outbursts and grabbing staff, reached out and ran a hand up the inside of the first resident's thighs, grabbing the genital area as the first resident walked by. At the time of the incident, the first resident had severely impaired cognition, displayed wandering behavior, and was sometimes understood in communication. The second resident also had severely impaired cognition and was noted to have behavior problems, including sexual outbursts, with care plan interventions instructing staff to redirect and distract the resident when inappropriate behaviors occurred. The incident was witnessed by a Certified Medication Technician (CMT) who was preparing medications in the common area and observed the inappropriate contact as it happened. Both residents were in the common area of the memory care unit, unsupervised in close proximity, despite the known behavioral risks associated with the second resident. The facility's abuse prevention policy required protection of residents from abuse by anyone, including other residents, but the measures in place at the time did not prevent the incident from occurring. The event was reported to the charge nurse, and both residents were assessed with no injuries noted.
Failure to Provide Timely Dental Care Following Tooth Injury
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident who experienced a chipped front tooth while at the facility. The resident, who was cognitively intact but dependent for transfers, dressing, and wheelchair locomotion, had multiple diagnoses including diabetes, hemiplegia, stroke, seizures, and malnutrition. The resident's oral/dental status was left blank on the Minimum Data Set, and there was no documentation regarding oral care in the care plan. After the tooth broke, the resident reported pain and difficulty eating, and repeatedly communicated these issues to staff, but did not receive timely dental care. The resident's dental needs were not addressed promptly. Although a dental appointment was scheduled, the resident was unable to be seen due to an inability to transfer to the dental chair. No alternative arrangements were made, and the resident continued to experience pain and embarrassment about the appearance of the tooth. Staff interviews revealed a lack of follow-up and communication regarding the resident's ongoing dental issues, with the social worker and nursing staff each assuming the other was responsible for arranging care. The resident and family made several requests for dental care, but these were not acted upon in a timely manner. The resident eventually developed a dental abscess, for which a physician prescribed antibiotics. However, there was no evidence of further dental intervention or resolution of the underlying dental problem. Staff were unaware of the resident's ongoing pain and the need for dental care, and there was no documentation of follow-up or reassessment after the initial failed dental appointment. The lack of coordination and follow-through resulted in the resident waiting over a year without appropriate dental care.
Resident's Rights Violated by Withholding Smoke Breaks as Punishment
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner and allowed to exercise their rights, specifically regarding the withholding of smoke breaks as a form of punishment. The incident involved a resident with multiple diagnoses, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, and PTSD. The resident was noted to have moderate cognitive impairment and a history of verbal and physical aggression, requiring substantial assistance with activities of daily living. On the day in question, the Social Services Director (SSD) accompanied the resident to the social security office, where the resident exhibited disruptive behaviors, including yelling and making threats about the facility. Following these behaviors, the SSD withheld the resident's smoke breaks for the remainder of the day as a consequence. Interviews with staff revealed inconsistent understanding and application of residents' rights regarding the withholding of privileges such as smoke breaks. Several staff members, including CNAs, a CMT, and the DON, stated that it was against residents' rights to withhold smoke breaks as punishment, especially for residents who are their own legal decision-makers and do not have a guardian. Some staff believed that smoke breaks could only be withheld if a guardian had given explicit permission, but this was not the case for the resident involved. The DON and other staff confirmed that the resident was his/her own person and that the action taken by the SSD was not appropriate. The facility's policy on residents' rights emphasizes the right to a dignified existence, self-determination, and freedom from interference or reprisal in exercising those rights. The SSD's decision to withhold smoke breaks as a punitive measure was not in accordance with this policy, and staff interviews confirmed that this action was recognized as a violation of the resident's rights. The incident was attributed to a miscommunication and a lack of clarity among staff regarding the proper procedures for managing resident behaviors and upholding resident rights.
Failure to Timely Report Allegations of Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency, as required by both facility policy and federal regulations. Specifically, two separate allegations of abuse made by a resident were not reported to the Department of Health and Senior Services (DHSS) in a timely manner. In both instances, the Social Services Director (SSD) and other staff became aware of the allegations but did not document or ensure notification to facility administration or DHSS as required. The resident involved had a complex medical history, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, PTSD, and physical limitations requiring substantial assistance with activities of daily living. The resident reported to the SSD that two staff members were abusing them and claimed to have bruising, but no bruising was found upon assessment by the SSD and the charge nurse. On another occasion, the resident made further allegations of abuse in a public setting, but again, there was no documentation of notification to administration or DHSS. Interviews with facility staff revealed inconsistent understanding of the reporting requirements, with some staff unsure of the exact timeframes or whether all allegations, regardless of perceived validity, should be reported to the state. The Director of Nursing and Administrator confirmed that the two incidents were not reported to the state, and there was a lack of clear documentation and follow-through on the required reporting process for abuse allegations.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
Facility staff failed to complete and document a full investigation into two separate allegations of abuse made by a resident against staff members. According to the facility's Abuse Prohibition Protocol, all alleged violations involving abuse must be reported, investigated, and documented, with accused staff suspended pending investigation. However, in both incidents, the facility did not conduct or document a comprehensive investigation, including interviews with other staff or residents, nor did they suspend the accused staff as required by policy. The resident involved had a complex medical history, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, PTSD, and physical limitations requiring extensive assistance with activities of daily living. The resident reported being abused by staff and claimed to have bruising, but assessments by the Social Services Director (SSD) and charge nurse found no bruising. Despite these allegations, there was no evidence in the records of a thorough investigation or documentation of steps taken to protect the resident during the process. Interviews with facility staff, including CNAs, CMTs, the DON, and the Administrator, revealed inconsistent knowledge and application of the abuse investigation protocol. Some staff were unaware of the allegations or the required suspension of accused staff, and the Administrator admitted to not completing or being aware of investigations for the reported incidents. The lack of a documented, comprehensive investigation and failure to follow facility policy led to the deficiency.
Failure to Administer Medications and Assess Side Rail Use per Orders and Policy
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, resident preferences, and accepted clinical standards for a resident with multiple complex medical diagnoses, including congestive heart failure, atrial fibrillation, and kidney failure. The resident had orders for several critical medications, including torsemide, amiodarone, lidocaine patch, and metoprolol, but these medications were not administered as ordered for an extended period. Documentation in the medication administration record (MAR) and progress notes repeatedly indicated that medications were on hold, waiting on prescription, or not available, with no evidence of timely follow-up with the pharmacy, physician, or hospice to resolve the issue. Additionally, there was no documentation of pharmacy contact, physician contact, or hospice notification regarding the missed or refused medications. The resident's care plan included interventions to administer medications as ordered and monitor for side effects and effectiveness, but these interventions were not consistently implemented. The MAR showed multiple days where medications were not given, and staff notes often lacked specific details about which medications were affected. The facility's own policies required timely ordering and administration of medications, as well as clear documentation and communication with the pharmacy and prescribers, but these procedures were not followed. The facility also failed to utilize available emergency medication kits (E-Kits) to obtain necessary medications, despite having relevant drugs in stock. In addition to medication administration failures, the facility did not assess or document the use of side rails for the resident, despite their use following a fall. The facility's policy required a side rail assessment, documentation of rationale, and consideration of less restrictive alternatives, but there was no evidence of such assessment or documentation in the resident's record. The resident was found on the floor after a fall and later found in another resident's room, having climbed over side rails, yet there was no order or care plan documentation regarding side rail use. Interviews with staff revealed inconsistent recollections about the resident's cognitive status and the events surrounding the use of side rails.
Failure to Provide RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by policy. Review of the daily assignment sheets over a period of more than a month showed that no RNs were scheduled during this time. The Director of Nursing (DON) confirmed in an interview that she was the only RN on staff and was only available on-call as needed, rather than being present in the facility for the required hours. The facility census at the time was 140 residents. The Administrator also acknowledged the expectation to have an RN present for at least eight hours daily, seven days a week, but this was not being met.
Failure to Immediately Intervene for Suicidal Ideation and Behavioral Health Needs
Penalty
Summary
The facility failed to immediately intervene when a resident with a recent history of suicidal ideation and multiple suicide attempts expressed a desire to commit suicide. Despite the facility's policy requiring that residents expressing suicidal tendencies not be left unattended and that staff immediately notify a nurse, there was a significant delay in response. On one occasion, the resident was observed crying and stating a wish to kill themselves, but staff did not remain with the resident or promptly assess their condition. The environmental aide informed the nurse, who was on a phone call and did not immediately check on the resident. The resident remained alone, crying and expressing suicidal thoughts, for over fifteen minutes before a nurse arrived and eventually arranged for hospital transport. The resident had a documented history of depression, anxiety, schizophrenia, and previous suicide attempts, including overdosing and attempting to strangle themselves. The care plan indicated the need for close monitoring and immediate intervention if the resident posed a threat to themselves. However, documentation showed gaps in psychosocial follow-up and a lack of consistent behavioral health services. Staff interviews revealed uncertainty about the frequency and type of behavioral health services provided, and the social services designee admitted to not documenting therapy sessions and being unsure of their own qualifications to provide therapy or assess safety for discontinuing one-on-one monitoring. Additionally, the facility failed to address the behavioral needs of another resident who became agitated and left a secured unit. Staff did not offer alternative activities or explanations, and the resident was left pacing and expressing agitation after being redirected back to the unit. The care plan for this resident identified them as an elopement risk and required interventions to distract and redirect, but these were not implemented during the observed incident. Interviews with the administrator and DON confirmed that staff did not follow expected procedures for managing agitation and supervision.
Failure to Provide Medically Related Social Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide medically related social services to support a resident with a known history of suicidal ideation, resulting in a lack of appropriate person-centered care to meet the resident's highest practical psychosocial well-being. The resident had a documented history of suicide attempts, including overdosing and attempting to strangle themselves, and was diagnosed with anxiety and schizophrenia. The care plan identified suicide risk and outlined interventions such as monitoring, notification of the physician and power of attorney, and redirection to activities. Despite these documented needs, there were significant lapses in the provision and documentation of social services and psychosocial support. After returning from multiple hospitalizations for suicide attempts, the resident did not receive consistent or documented social services follow-up. Progress notes showed gaps in psychosocial or social services documentation, with no entries between key incidents. The resident expressed ongoing distress, including crying, stating a desire to harm themselves, and reporting a lack of access to group or individual counseling. During an observation, the resident was found in bed, crying, and expressing suicidal ideation, but staff response was delayed and uncoordinated. The Social Services Designee present did not check on the resident and deferred to nursing staff, who also did not provide immediate support or intervention. Interviews with staff revealed that Social Services Designees were not qualified to provide medically related social services and had not received formal training in managing residents with suicidal ideation. The facility had been without a qualified social worker for several months, and outside behavioral health services were no longer available. Staff were unclear about the interventions in place for the resident and did not consistently document or provide the required psychosocial support, resulting in a failure to meet the resident's psychosocial needs as outlined in their care plan.
Medication Labeling, Storage, and Access Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices, specifically regarding the labeling and storage of drugs and biologicals. Observations revealed that several opened vials and pens of insulin (Levemir, Lantus, Lispro) and Tuberculin Purified Protein Derivative (PPD) were found in medication carts and rooms without proper labeling or dating. In some cases, staff were unable to identify the owner of the medication or when it had been opened, and some medications were found to be expired. Additionally, an opened and unlabeled bottle of an over-the-counter antifungal medication was found, and a Lispro insulin pen was improperly stored on a shelf instead of in the refrigerator or medication cart as required. Temperature monitoring of medication refrigerators was also deficient. The temperature log for the medication refrigerator showed multiple dates with missing documentation of temperature readings and staff signatures. The Assistant Director of Nursing (ADON) stated that housekeepers were responsible for monitoring refrigerator temperatures, but acknowledged that they may not have had pens to record the readings, resulting in incomplete logs. This practice deviated from the facility's policy, which required daily temperature documentation by nursing staff. Access to medication rooms was not restricted to authorized personnel. An Environmental Aide (EA) was observed obtaining keys from a nurses' station drawer and entering the medication room unsupervised to retrieve residents' cigarettes. The EA reported that this had been standard practice since employment, with keys always accessible in the nurses' station. The Director of Nursing (DON) confirmed that only nurses and Certified Medication Technicians (CMTs) should have access to medication rooms, and non-licensed staff should not enter these areas.
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