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)
Latest Citations in Missouri
A resident with schizophrenia, bipolar disorder, HTN, and type 2 DM was admitted with conflicting code status documentation: one page of the face sheet and the emergency book listed DNR, while another page of the face sheet, the physician’s orders, and a signed health care directive defaulted the resident to full code (CPR). One morning, a CNA found the resident unresponsive across the bed and summoned an RN, who noted no pulse, no respirations, and cyanosis but did not initiate CPR, relying on the DNR status shown in the emergency materials. Interviews with CNAs, LPNs, the MDS coordinator, SSD, DON, NP, Medical Director, and Administrator confirmed that, in the absence of a signed DNR or when documentation conflicted, the resident should have been treated as full code and CPR started, but this did not occur, leading to the cited deficiency.
Staff failed to follow facility policy requiring prompt notification of a change in condition and treatment refusals. A resident on hospice for a short stay was found with a lump on the forehead of unknown cause, which an LPN assessed but did not report to a physician or the resident’s representative. On a separate occasion, the same resident refused all scheduled medications, including aspirin, midodrine, diazepam, propranolol, senna, tamsulosin, and carbidopa-levodopa, without any documented notification to the attending physician, hospice physician, hospice staff, or the resident’s representative. In subsequent interviews, the LPN acknowledged forgetting to notify anyone, and the administrator, resident representative, attending physician, and hospice physician all stated they had not been informed and would have expected notification.
Facility staff did not report an allegation of bruises and injuries of unknown origin for a resident to DHSS within the required 24-hour timeframe, as required by the facility’s abuse investigation and reporting policy. A resident’s representative twice informed the DON and the administrator that the resident returned home with a lump on the forehead, a laceration above the ear, bruising under the arm and on the side, and genital excoriation, without specifically alleging abuse or neglect. Despite these reports, the allegation of injuries of unknown origin was not submitted to DHSS until more than 48 hours after it was first reported to facility staff.
Staff failed to complete and document required skin assessments for a hospice patient admitted for a short stay with Parkinsonism, essential tremors, and A-fib. An LPN documented a lump on the patient’s forehead, but no follow-up skin assessment was recorded in the EMR after this change or prior to discharge, despite facility expectations and standard nursing protocol for head-to-toe and skin assessments with new skin changes and before discharge. After the patient returned home, the representative reported additional skin concerns, including a forehead lump, laceration above the ear, bruising to the side/underarm, and genital excoriation, none of which were documented by facility staff.
A resident admitted with a left ankle fracture and a soft cast, and identified as at risk for pressure ulcers, later had a CAM boot applied with orders to keep it on except for hygiene. Nursing documentation repeatedly noted no skin issues other than a Stage I pressure injury on the right great toe, and staff (including an RN, LPN, and CNA) reported they never removed the boot to assess skin or provide hygiene, despite the resident’s ongoing complaints of significant foot pain. The resident stated the boot and underlying sock were never removed for more than two weeks and that staff told them they could not take the boot off. When the resident finally returned to the orthopedic physician after more than three weeks, a large medial ankle/foot ulcer was found, and wound clinic evaluation documented a large unstageable wound with eschar under the CAM boot, which was attributed to the boot not being removed for three weeks. Subsequent surgery revealed a full-thickness ulcer with eschar, partial tendon exposure, and associated hardware infection requiring debridement and hardware removal.
Staff failed to follow professional standards and physician orders in several areas, including wound care, LAL mattress use, and insulin administration. A resident with stage 3 pressure ulcers did not consistently receive ordered peri-wound skin prep and zinc spray during dressing changes, as observed when an RN completed a dressing change without applying the sprays and did not return after being questioned. Another resident at risk for pressure ulcers used a LAL mattress that was repeatedly observed set at 350 pounds, with no corresponding physician order, no care plan entry for the mattress, and no clear staff responsibility for checking settings. Multiple residents with diabetes received insulin from pens that lacked proper labeling and open dates, and an LPN repeatedly did not clean the pen port or prime the pen before administration, while also misunderstanding when priming was required; the DON later described correct labeling, dating, port cleaning, and priming procedures that were not followed.
The facility failed to honor residents’ financial rights by keeping resident personal funds in the facility’s operating account instead of a separate resident fund account and by not issuing timely refunds. Record review showed that dozens of residents had personal funds, ranging from small amounts to several thousand dollars, held in the operating account, including a large credit balance for a resident who had overpaid for services. Personal fund balance reports for multiple deceased residents were not sent to the state’s Medicaid division until after an investigation began. The BOM reported that a previous BOM had left without processing at least one refund, that refund requests for several residents were only later sent to the home office, and that some residents’ balances had been written off as bad debt rather than refunded.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy for residents with unhealed Stage III pressure ulcers. During a high-contact transfer of a cognitively impaired resident with a buttocks wound, a CNA and a CMT wore only gloves, despite an EBP sign on the door and the facility policy requiring gown and gloves for such care, and no PPE was kept near the room. The CNA believed EBP applied only to certain infections and considered the door sign outdated, while the CMT stated they did not know about the wound or see the sign. For two other cognitively intact residents with Stage III pressure ulcers, EBP signs were posted on their doors, but no PPE was available in proximity to their rooms or on door racks. The DON and IP confirmed that EBP and readily accessible PPE are required for residents with wounds or indwelling devices and acknowledged that appropriate PPE use and placement were not occurring.
Surveyors found that nursing staff repeatedly failed to administer and/or document physician-ordered medications and treatments for multiple residents, despite facility policies requiring accurate transcription and real-time MAR documentation. Residents with conditions such as diabetes, heart failure, Parkinson’s disease, COPD, seizure disorders, chronic pain, and psychiatric illnesses had numerous blank MAR entries for critical medications including insulin (both sliding-scale and long-acting), anticoagulants, anticonvulsants, antihypertensives, diuretics, psychotropics, Parkinson’s agents, inhalers, antibiotics, vitamins, supplements, and GI medications. At least one resident reported missed pain and diabetes medications and described increased pain and high blood sugars, while resident council minutes reflected broader concerns about untimely and missed medications. The absence of required documentation or explanatory notes for these omitted doses demonstrated a systemic failure to follow professional standards and facility policy for medication administration and recordkeeping.
The facility failed to follow its fall policy and acceptable standards of practice by not performing and documenting required neuro checks after unwitnessed falls for three residents. In each case, a resident was found on the floor after an unwitnessed fall, vital signs and basic assessments were completed, and injuries such as skin tears, bruising, or abrasions were addressed, but there was no documentation of 72-hour neuro monitoring as required for unwitnessed falls. Facility leadership stated they expected nurses to complete head-to-toe assessments, initiate neuro checks for unwitnessed falls or head strikes, and document post-fall monitoring each shift, but chart reviews showed these neuro checks were not done.
Failure to Honor Full Code Status Due to Conflicting Documentation and Omission of CPR
Penalty
Summary
The deficiency involves the facility’s failure to provide care consistent with a resident’s advance directives and physician orders when staff did not initiate CPR for a resident who was a full code. The resident’s medical record contained conflicting documentation regarding code status: page one of the face sheet listed DNR, while page two listed CPR in the advance directive field. The resident’s current physician’s order sheet contained an order for CPR, and the health care directive form, signed by the resident’s guardian, indicated that the guardian did not wish to make a health care directive at that time, which staff stated defaulted to full code. The Social Services Director and nursing staff reported that, in the absence of a signed DNR, the resident’s status should be full code and CPR should be initiated if the resident was found unresponsive. On the day of the incident, a CNA checked on the resident around 6:00 A.M. and observed the resident sleeping. When the CNA returned around 7:45 A.M. to assist the roommate, the resident was found lying across the bed, appearing as if they had attempted to sit up and then slumped over, and did not respond. The CNA called for the nurse and then checked the emergency book, which indicated the resident was DNR. RN E responded, found the resident lying across the bed with no heartbeat or respirations, lips blue, and a gray appearance, and did not initiate CPR. RN E instead notified the Administrator, and together they pronounced the resident deceased at 7:55 A.M. without starting CPR. Nursing progress notes documented that the resident was found unresponsive at 7:50 A.M., with ashen face and purple lips, and that the resident was pronounced deceased at 7:55 A.M. Multiple staff interviews revealed inconsistent understanding and use of code status information. Staff reported that code status could be found in several locations, including the emergency binder, the electronic medical record, the resident’s door tag (red sticker for DNR), and the face sheet. LPNs, CNAs, the MDS Coordinator, and the SSD stated that if there was no signed DNR or if code status information conflicted, the resident should be treated as full code and CPR should be started and continued until EMS arrived. The DON, SSD, NP, Medical Director, and Administrator all confirmed that the resident’s health care directive and physician orders supported a full code status and that the resident’s code status should have been consistent throughout the record. Despite this, RN E and the Administrator relied on the DNR notation on the face sheet and the emergency book and did not question the discrepancy or initiate CPR when the resident was found unresponsive.
Failure to Notify Physician and Representative of Change in Condition and Medication Refusals
Penalty
Summary
Facility staff failed to notify the physician and resident representative of changes in a resident’s condition and treatment status as required by facility policy. The facility’s policy on Change in a Resident’s Condition or Status, revised 02/2021, directed staff to promptly notify the resident, attending physician, and resident representative of changes in medical or mental condition, discovery of injuries of unknown source, significant changes in condition, and refusal of treatment or medications two or more consecutive times. For one resident admitted from home with hospice services for a planned five-day stay, staff documented an incident in which a CNA alerted an LPN to a lump on the resident’s left forehead. The LPN assessed the resident as alert and oriented, with a lump present, no discoloration, no pain or discomfort, and no other identified injuries. The incident report and medical record contained no documentation that the physician or resident representative were notified of this potential injury of unknown source. The same resident’s POS listed multiple scheduled medications, including aspirin, midodrine, diazepam, propranolol, senna, tamsulosin, and carbidopa-levodopa. The MAR showed that on one day, the resident refused all of these scheduled medications. There was no documentation that the physician, hospice physician/staff, or resident representative were notified of the medication refusals. In interviews, the administrator stated staff could not determine the cause of the forehead lump and acknowledged an expectation that the nurse notify the on-call physician, hospice physician, and resident representative of both the lump and the medication refusals. The LPN involved stated he/she did not know what caused the lump and admitted he/she should have notified the physician and resident representative but became busy and forgot. The resident representative, attending physician, and hospice physician each reported they had not been notified of the lump or the medication refusals and stated they would have expected such notification.
Failure to Timely Report Injuries of Unknown Origin to DHSS
Penalty
Summary
Facility staff failed to report an allegation of bruises and injuries of unknown origin for one resident to the Department of Health and Senior Services (DHSS) within the required 24-hour timeframe. The facility’s abuse investigation and reporting policy, revised 07/2017, required that alleged violations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property be reported immediately, but not later than 24 hours if the alleged violation did not involve abuse with serious bodily injury. The resident, who had been admitted from home for a planned five-day stay and then discharged back home, had a documented resident representative. The representative first reported to the DON that, after returning home, the resident had an abrasion to the left side, a laceration approximately 0.5 inches above the left ear, bruising under the left armpit, and a lump to the back, but did not specify abuse or neglect or accuse anyone. The next day, the resident representative made a second report to the administrator, again describing a lump to the left forehead, a laceration above the left ear, bruising to the left side/underarm, and excoriation to the genitals. Despite these reports, the facility did not notify DHSS within 24 hours of the initial allegation of bruises and injuries of unknown origin. The DON acknowledged that, based on the information received from the resident representative and staff interviews, DHSS should have been notified within 24 hours of the initial report. The administrator also acknowledged that staff should have made an initial report to DHSS within the required timeframe but did not do so, and the DHSS complaint/facility self-report database contained no report from the facility until more than 48 hours after the allegations were first reported to facility staff.
Failure to Complete and Document Required Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of quality by not completing and documenting required skin assessments for a resident who developed a lump on the forehead and was later discharged. The resident, admitted from home for a planned five-day stay with hospice services, had diagnoses including Parkinsonism unspecified, essential tremors, and atrial fibrillation. An incident report documented by an LPN noted a lump on the resident’s left forehead with no discoloration, no pain, and no identified injuries. However, the electronic medical record from the date of the incident through discharge contained no documentation that a skin assessment was completed following the identification of the lump. Additionally, there was no documented skin assessment prior to the resident’s planned discharge, despite interviews indicating that it was standard protocol and expectation for nurses to complete a head-to-toe and skin assessment on admission, with any identified skin changes, and prior to discharge. The DON, an LPN responsible for the discharge assessment, the administrator, and the LPN who identified the lump each acknowledged in interviews that a skin assessment should have been completed and documented in these circumstances. After discharge, the resident’s representative reported multiple skin issues, including a lump on the forehead, a laceration above the left ear, bruising to the left side/underarm, and genital excoriation, which were not documented in the facility’s records.
Failure to Monitor Skin Under CAM Boot Resulting in Unstageable Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development of an unstageable pressure injury under a removable medical device for one resident. The facility’s own skin policy required licensed nurses to evaluate skin integrity on admission, weekly, and with significant changes, and required CNAs to observe skin during ADLs and report changes so that licensed nurses could initiate preventive or treatment interventions. On admission from the hospital, the resident had a left ankle fracture, a soft cast/splint applied by the orthopedic surgeon, and no documented skin lesions other than a Stage I pressure injury on the right great toe that was present on admission. The admission MDS identified the resident as at risk for pressure ulcers, with partial to moderate assistance needs for ADLs and diagnoses including ankle fracture, muscle weakness, anxiety, stroke, and dementia. Early nursing documentation repeatedly stated there were no other skin issues besides the right great toe. The resident initially had a soft cast that was not to be removed until an orthopedic follow-up. At the follow-up, the orthopedic physician removed the soft cast and placed a CAM boot on the left ankle, with orders that the boot be left on at all times except for hygiene. Despite this order, multiple nursing staff, including an RN and an LPN, reported they never removed or opened the boot to assess the skin or provide hygiene, stating they believed they should not open it if the order was to leave it in place. A CNA reported the resident complained of a lot of pain in the left foot and that she loosened the boot strap once to assist with pain relief but did not remove the boot. The resident stated that after arriving at the facility, the CAM boot was never removed until the return visit to the physician, that a sock under the boot was left in place for more than two weeks, and that facility staff told the resident they could not take the boot off. The resident reported significant ankle pain but could not distinguish whether it was from the skin or the surgery. When the resident eventually returned to the orthopedic physician after more than three weeks instead of the ordered two-week follow-up, the physician found a medial foot/ankle ulceration measuring approximately 3–6 cm with a fibrous base and mildly erythematous edges. The orthopedic surgeon and wound clinic RN attributed the open wound to the CAM boot not being removed for three weeks, and the wound clinic RN documented a large unstageable wound with eschar on the left ankle/foot measuring 3.3 cm by 3.1 cm by 0.1 cm. The DON acknowledged that, with an order to remove the boot for hygiene, staff should have opened the boot and checked the skin every shift and admitted that the facility did not check the resident’s skin and that this was wrong. The orthopedic surgeon stated it was unacceptable that the boot was not removed and the skin was not checked for three weeks. Subsequent operative documentation showed the resident developed a full-thickness ulcer to the fat layer with large eschar and partial tendon exposure, associated with a hardware infection in the left ankle that required irrigation, debridement, hardware removal, and preparation of the wound bed for a skin graft. The sequence of events shows that, despite the resident’s identified risk for pressure ulcers, the presence of a removable CAM boot, and ongoing complaints of pain, facility staff did not perform periodic skin checks under the device for more than 20 days. Nursing notes during this period continued to document no skin issues other than the right great toe, and staff interviews confirmed that the boot was not removed for skin assessment or hygiene. The NP and Unit Manager both stated they would have expected staff to open the boot and check the skin and pulses, and the Unit Manager stated that an order to check the skin under the boot was not necessary. The failure to follow the facility’s skin monitoring policy and to assess the skin under the CAM boot as ordered for hygiene led to the development of an unstageable pressure injury and subsequent complications documented in the medical record and operative reports.
Failure to Follow Wound Care Orders, LAL Mattress Parameters, and Insulin Pen Standards
Penalty
Summary
The deficiency involves multiple failures to follow professional standards of practice and physician orders for wound care, low air loss (LAL) mattress use, and insulin administration. One resident with two stage 3 pressure ulcers on both buttocks had physician orders for licensed nursing staff to clean the wounds with wound cleanser, use skin prep to the peri-wound area, apply collagen powder, and cover with bordered gauze on specified days, as well as to apply a zinc spray to the peri-wound area with dressing changes and daily. During an observed dressing change, the RN removed intact dressings, cleansed the wounds, applied collagen powder, and covered them with bordered gauze, but did not apply the ordered skin prep spray or zinc spray to the peri-wound area. When questioned afterward, the RN stated they believed the sprays were only done with morning and night dressing changes and did not return to complete the ordered treatment. The resident reported that staff were supposed to check the dressings every day shift and apply spray, but that this was rarely done and that primarily one LPN applied the spray. The DON confirmed that the RN should have completed the entire ordered treatment, including the sprays, and that nursing staff should perform treatments as ordered and according to the schedule. Another deficiency involved the use and management of a LAL mattress for a resident who was cognitively severely impaired, dependent on staff for most ADLs, always incontinent, and at risk for pressure ulcers. The resident’s care plan did not address the use of a LAL mattress, and the physician orders contained no order for a LAL mattress or its settings. Multiple observations over several days showed the resident either in bed or out of bed with the LAL mattress consistently set at 350 pounds. When interviewed, an LPN stated they did not know who was responsible for checking the LAL mattress settings and thought it might be housekeeping. The Administrator stated that if a resident was on hospice, hospice should monitor to ensure the LAL mattress was on the correct setting. The facility did not provide a policy for the Drive LAL mattress. Additional deficiencies were identified in insulin administration practices for several residents with diabetes mellitus. For one resident who was cognitively intact and independent with ADLs, orders included blood sugar checks twice daily and Humalog insulin 12 units three times daily with meals. Observation showed the resident checked their own blood sugar and reported a value of 184 to an LPN. The Humalog pen used had no pharmacy label, no open date, and only a handwritten first name and dose on the lid. The LPN did not clean the pen port before attaching the needle, did not prime the pen with two units, and then dialed and administered 12 units. For another cognitively intact resident with diabetes, orders included blood sugar checks before meals and at bedtime and Humalog 8 units three times a day. Observation showed the LPN obtained a blood sugar of 116 and used a Humalog pen that lacked a proper label and open date, with only handwritten initials and dose on the lid. Again, the LPN did not clean the port or prime the pen before dialing and administering 8 units. A further observation of insulin administration for another resident showed the same LPN preparing to administer 12 units of insulin from a pen that had no open date written on it. The LPN had already attached the needle and drawn up the dose without priming the pen or cleaning the port. In a subsequent interview, the LPN stated they believed priming was only necessary when the pen was first opened and described their procedure as simply screwing on the needle and dialing the required amount, without mentioning port cleaning. The LPN acknowledged that insulin pens should be dated when opened. The DON stated that insulin pens should be labeled with the resident’s name, not used if not dated or labeled, the port should be cleaned with alcohol before attaching the needle, and the pens should be primed with two units before each use. The facility did not provide a policy for the use of insulin pens, although existing policies required that physician orders be followed as written and that wound care procedures include applying prescribed medications to the wound or wound area if ordered.
Failure to Maintain Separate Resident Fund Accounts and Issue Timely Refunds
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to manage their financial affairs by not placing resident personal funds in an account separate from the facility’s operating account and not issuing timely refunds. Record review of the facility’s Accounts Receivable Aging Report showed that 39 residents had personal funds, totaling $39,158.17, held in the facility’s operating account rather than in a separate resident fund account. Individual amounts ranged from small balances of a few dollars to larger sums exceeding $11,000 for some residents. One resident had a credit balance of $1,834.00 due to paying for two months of services that should not have been paid, and this credit remained unrefunded for a period of time despite the issue being brought to the Business Office Manager’s (BOM) attention. The report also shows that the facility did not provide Personal Fund Account Balance Reports for multiple deceased residents to the Missouri HealthNet Division Third Party Liability Unit until after a case-managed investigation had already begun. These deceased residents’ personal fund balances were not timely reported as required. During interviews, the BOM acknowledged that a prior BOM had left without processing at least one resident’s refund and that refund requests for several residents had only been sent to the home office later. The BOM further stated that he or she was working with corporate staff to determine why some residents’ balances had been written off as bad debt instead of being refunded, indicating that these residents did not receive refunds of their personal funds when due.
Failure to Implement Enhanced Barrier Precautions and Ensure PPE Availability for Residents With Wounds
Penalty
Summary
Facility staff failed to implement their Enhanced Barrier Precautions (EBP) policy for residents with wounds and indwelling devices, resulting in improper use of personal protective equipment (PPE) and lack of readily available PPE. The facility’s March 2024 EBP guidance required gown and gloves for high-contact resident care activities, including transfers and wound care, for residents with wounds or indwelling medical devices, and required PPE to be kept in proximity to the resident’s room with a trash can in the room for disposal. Surveyors found that these requirements were not followed for multiple residents with unhealed Stage III pressure ulcers. For one resident with cognitive impairment, dependence on staff for transfers, and an unhealed Stage III pressure ulcer, surveyors observed a CNA and a CMT enter the room to transfer the resident from bed to a shower chair. Although a sign on the door indicated EBP were required for high-contact care, there was no PPE in proximity to the room. The CNA and CMT donned only gloves, placed a mechanical lift sling under the resident, and transferred the resident without wearing gowns, despite direct contact and the presence of a wound on the upper buttocks. In interviews, the CMT stated EBP are used for residents with catheters, colostomies, or wounds and acknowledged a gown and gloves should have been worn, but said they did not know the resident had a wound and did not see the sign. The CNA stated gowns and gloves are used if staff are told the resident needs them, believed EBP were only needed for certain infections such as C. difficile, shingles, or MRSA, and said the sign on the door was old and did not apply. Surveyors also identified failures to ensure PPE availability for two additional residents with unhealed Stage III pressure ulcers. For one cognitively intact resident who reported having a wound on the bottom, a sign on the door indicated EBP were required for high-contact care, but no PPE was observed in proximity to the room or on a rack inside the room. For another cognitively intact resident who reported wounds on the legs and feet, a similar EBP sign was posted, yet no PPE was available near the door or on a rack inside the room. The DON and the Infection Preventionist confirmed in interviews that EBP should be used for residents with wounds or indwelling devices, that signs should be posted on doors, and that PPE should be available at or on the door, but acknowledged that staff were not using appropriate PPE and that PPE was not in place as required.
Widespread Failure to Administer and Document Physician-Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and treatments were administered and documented in accordance with physician orders and the facility’s own medication administration policies. Facility policies required that all physician orders be complete and accurately transcribed to the MAR/TAR, that medications be administered as prescribed, and that the individual administering the medication document administration directly after giving the dose, including circling and explaining any withheld, refused, or unavailable doses. Resident council minutes documented resident concerns that medications were not being received timely and that doses were being missed. Multiple residents with significant medical conditions had numerous blank entries on their MARs where ordered medications and treatments should have been documented. One cognitively intact resident with diagnoses including heart failure, morbid obesity, anxiety, chronic pain, and hypertension had repeated blank MAR entries for Eliquis, Lasix, potassium chloride, famotidine, ondansetron, gabapentin, Miralax, Tylenol, vitamins, artificial tears, Senna Plus, and a lidocaine patch, among others. This resident reported not receiving medications as ordered and specifically stated that missed gabapentin doses caused increased pain in the feet. Another cognitively intact resident with diabetes, stroke, hemiparesis, and depression had multiple undocumented pre-meal blood glucose checks and corresponding Novolog sliding-scale insulin doses, as well as missed or undocumented doses of long-acting insulin (Tresiba) and metformin, and reported not receiving insulin for several days and having a blood sugar over 200 when it was eventually checked. Additional residents with diabetes, dementia, chronic kidney failure, psychiatric diagnoses, atrial fibrillation, anemia, chronic pain, hypertension, COPD, Parkinson’s disease, seizure disorders, and other chronic conditions also had numerous blank MAR entries for ordered medications. These included missed or undocumented blood glucose checks and insulin doses, anticonvulsants (carbamazepine, Keppra), anticoagulants (Eliquis, aspirin), antihypertensives (metoprolol, carvedilol, amlodipine, hydrochlorothiazide), diuretics (Lasix), psychotropics (mirtazapine, quetiapine, trazodone, duloxetine, buspirone, hydroxyzine), Parkinson’s medications (carbidopa-levodopa, amantadine), COPD and inhaler therapies, eye drops, vitamins, supplements, antibiotics, and various GI and pain medications. For each of these residents, the MARs showed blank spaces without documentation that the medications were administered, held, refused, or otherwise accounted for, contrary to facility policy and professional standards of medication administration and documentation. Across the sampled residents, the pattern of blank MAR entries demonstrated that staff did not consistently administer or document physician-ordered medications and treatments as required. The failures encompassed time-sensitive medications such as insulin and antibiotics, chronic disease management medications, anticoagulants, anticonvulsants, and psychotropic agents. The report does not describe any contemporaneous documentation explaining the omissions, nor does it show that the required notations and explanatory notes were made when doses were not given. These inactions and documentation gaps, combined with resident reports of missed medications and elevated blood sugars, form the basis of the cited deficiency for not meeting professional standards of quality in medication administration and documentation.
Failure to Perform and Document Neuro Checks After Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide post-fall neurological assessments in accordance with its own Fall Evaluation and Prevention policy and acceptable standards of practice for three residents after unwitnessed falls. The policy, dated 8/2020, requires that following a fall, staff promptly evaluate the resident, obtain vital signs, perform a neurological evaluation, and, if the fall is unwitnessed or there is loss of consciousness, initiate neuro checks for at least 72 hours. The Interim DON and Previous Administrator stated they expected nurses to complete a head-to-toe assessment, obtain vital signs, start neuro checks for unwitnessed falls or head strikes, notify the physician, family/Resident Representative, and DON, and document post-fall monitoring once per shift for 72 hours. For one resident with diagnoses including hypertension, anxiety, restless leg syndrome, and spinal pain, an unwitnessed fall from bed occurred in the early morning hours. The incident report documented that the resident was found lying on their back on the floor with a skin tear to the left elbow and bruising on the left scapula, reported pain at a level seven out of ten, and received a skin assessment, vital signs, wound care, and PRN pain medication. The DON and physician were notified, but the family/emergency contact was not notified of the fall, and review of the medical record showed no documentation that neuro checks were completed following this unwitnessed fall. Another resident with moderate cognitive impairment and diagnoses including dementia, Parkinson’s disease, stroke, seizure, and repeated falls experienced an unwitnessed fall when they were found having slid from a wheelchair onto the floor in the hallway, resulting in a facial abrasion. Vital signs were obtained, hospice was contacted, and the resident was assisted to bed, with the DON and physician notified, but the family/responsible party was not notified. Record review showed no neuro checks were completed. A third resident with severe cognitive impairment and a history of prior falls, and diagnoses including seizure disorder, dementia, hypertension, sleep disorder, and osteoarthritis, had an unwitnessed fall while trying to get into bed. The incident report stated the resident did not hit their head, denied pain, and had no observed injuries, and noted that family and physician were aware with no new orders, but listed no people notified on the form. The medical record again showed no neuro checks completed for this unwitnessed fall.
Some of the Latest Corrective Actions taken by Facilities in Missouri
Explore Popular Searches
