Citations in Mississippi
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Mississippi.
Statistics for Mississippi (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Mississippi
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff failed to immediately report an incident where an LPN used profanity and applied force to a resident. Two CNAs who witnessed the event delayed reporting, assuming others had done so, and another LPN did not recognize the behavior as abuse. The incident was reported to the State Agency but not to the Board of Nursing, contrary to policy, despite staff having received recent training on abuse reporting.
A resident reported pain caused by a CNA during repositioning and filed a grievance, but there was no follow-up or documentation showing the grievance was resolved or discussed with the resident. The grievance was marked as resolved in the log without the resident's signature or confirmation.
The facility did not report multiple allegations of abuse involving three cognitively intact residents to the State Survey Agency as required by policy. Incidents included verbal mistreatment, rough handling, and inappropriate language by CNAs. Although internal actions were taken, the required external reporting was not completed.
Two residents reported being hurt or mistreated by CNAs, but despite these allegations being brought to the attention of the DON and administrator, no formal investigation was conducted as required by facility policy. The CNAs involved were removed from the residents' care, but neither resident was interviewed about the incidents, and the DON considered the complaints to be customer service issues rather than potential abuse.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
Two residents, both cognitively intact and with histories of cerebral infarction, were able to smoke marijuana during a supervised smoking break due to staff being positioned in a way that did not allow full observation of the area. The facility's policy required supervision, but the staff's placement created blind spots, enabling one resident to light and share a marijuana joint with another before staff intervened.
A resident with a history of hemiplegia and pain did not receive ordered Hydrocodone-Acetaminophen for severe pain because an LPN failed to follow facility procedures for obtaining unavailable medication. Despite the facility having policies and an emergency medication supply, the nurse became distracted and did not secure the medication, resulting in a gap in pain management for the resident.
A resident with paraplegia and impaired sensation sustained a second-degree burn on the elbow after an LPN, despite knowing facility policy, set up a portable heater in the resident's room at the resident's request. The injury was discovered by another nurse and CNA, and subsequent infection required antibiotic treatment. Facility policy prohibits space heaters due to fire and burn risks.
The facility did not ensure that new LPNs and CNAs received and completed required skills competency checkoffs before providing care. One new nurse worked independently without a preceptor or skills review, and documentation for two CNAs lacked signatures and verification of completed competencies. The Clinical Educator and Administrator confirmed that skills checkoffs were not completed or documented for these new hires.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Immediately Report and Recognize Abuse Allegations Involving Licensed Staff
Penalty
Summary
The facility failed to ensure that all allegations of abuse were immediately reported to the State Agency and the appropriate licensing board, as required by facility policy and regulations. Specifically, an incident involving a licensed nurse using profanity and applying force to a resident was witnessed by two CNAs, but both delayed reporting the incident until the following day, assuming another staff member had already reported it. Additionally, another LPN who overheard the use of profanity did not consider it abuse and did not report the incident. The incident was eventually reported to the State Agency, but not to the Board of Nursing, as the facility did not substantiate the abuse despite having statements from both CNAs. Interviews with staff confirmed a lack of immediate reporting and a failure to recognize the incident as abuse. The Administrator and DON acknowledged that staff did not follow the policy requiring immediate reporting of abuse allegations and that the required notification to the Board of Nursing was not made. Record review showed that all involved staff had attended a recent in-service training on abuse and neglect, which emphasized the importance of immediate reporting of any suspicion of abuse.
Failure to Resolve and Document Resident Grievance
Penalty
Summary
The facility failed to resolve a grievance submitted by a resident who reported that a CNA caused pain by jerking his legs during repositioning, which hurt his back. The resident stated he reported the incident to staff, but no one followed up with him regarding the complaint. The DON confirmed that a grievance form was completed on behalf of the resident, but the form was not signed by the resident, and there was no documentation indicating that the grievance had been resolved or discussed with the resident. The grievance log listed the complaint as resolved, but there was no evidence of communication with the resident or proper closure of the grievance. Social Services staff confirmed that grievances should be discussed with and signed by residents before being considered resolved.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to ensure that all alleged abuse violations were reported to the State Survey Agency as required by its own policy. The policy mandates immediate reporting of alleged abuse, neglect, or theft to the administrator and appropriate authorities, including the State Survey Agency, within specified timeframes. However, for three of five reviewed cases involving alleged abuse, the facility did not report the incidents as required. In one instance, a resident with a history of major depressive disorder, anxiety, pain, and cerebral palsy reported that a CNA told her to "shut up" when she complained of leg pain during repositioning. The resident reported the incident to the former administrator, who initiated an internal investigation but did not report the allegation to the State Survey Agency, believing it did not constitute abuse. In another case, a cognitively intact resident with paraplegia reported that two CNAs hurt him during care, including being jerked and slapped with a wet towel. The resident stated that no one followed up with him about his complaint, although the CNAs were removed from his care. A third resident, also cognitively intact and with diagnoses including anxiety, pain, and hemiplegia, reported to the DON that a CNA hurt him during care and spoke to him inappropriately. The DON acknowledged receiving the complaint but considered it a customer service issue and did not report it to the state. In all three cases, the facility failed to follow its policy for reporting alleged abuse to the State Survey Agency, as confirmed by interviews with staff and review of facility records.
Failure to Investigate Alleged Abuse Reports
Penalty
Summary
The facility failed to investigate allegations of abuse for two of five residents reviewed, as required by its own policy. One resident reported to staff that two CNAs had hurt him while turning him, and also reported to the administrator that another CNA had slapped his face with a wet towel during a bed bath. The resident stated that after making these reports, the CNAs involved no longer worked with him, but no one from the facility had followed up or interviewed him about the incidents. Another resident reported that a CNA attempted to turn him alone, causing pain, and sometimes spoke to him in an unkind manner. He reported this to the DON, after which the CNA was removed from his care, but again, no investigation or follow-up interview was conducted. Interviews with the DON confirmed awareness of the complaints and that the CNAs were removed from providing care to the residents involved, but no formal investigation was initiated because the DON considered the issues to be customer service concerns rather than abuse. The DON also admitted that an investigation should have been conducted, especially after one resident was sent to the emergency room for back pain following his complaint. The facility's policy requires immediate investigation of any potential abuse or neglect, but this was not followed in these cases. Both residents involved had significant medical histories, including paraplegia and hemiplegia, and were cognitively intact at the time of the incidents.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Inadequate Supervision During Smoking Breaks Led to Marijuana Use
Penalty
Summary
The facility failed to provide adequate supervision during scheduled smoking breaks, which resulted in two residents being able to smoke marijuana in the designated smoking area. According to staff interviews and camera footage, one resident lit a marijuana joint from his cigarette and passed it to another resident, who also smoked it. Both residents were deemed not safe to smoke unsupervised according to their Safe Smoking Evaluations, and staff were present but positioned in a way that did not allow them to fully observe the residents' actions. The staff noticed the smell of marijuana and observed the exchange, but only after the residents had already smoked the substance. Both residents involved were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores, and had medical histories including cerebral infarction and hemiplegia/hemiparesis for one of the residents. The facility's policy required supervision for residents during smoking, but the staff's positioning in the smoking area allowed for blind spots, particularly with one resident facing away from staff and cameras. This lack of adequate supervision directly led to the incident where marijuana was smoked and shared between residents.
Failure to Provide Ordered Pain Medication Due to Staff Inaction
Penalty
Summary
The facility failed to provide an ordered pain medication to a resident who was experiencing pain. The resident, who was cognitively intact and had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and pain, reported back and foot pain and requested pain medication. The nurse on duty informed the resident that the pain medication was unavailable and that he would have to wait until it arrived. The nurse admitted to being distracted by another medical concern and did not follow through with obtaining the medication as needed and ordered, acknowledging this was her mistake. The facility had policies and procedures in place to address medication shortages, including obtaining medications from the pharmacy or the emergency medication supply, but these were not followed in this instance. Record review showed that the resident had an active prescription for Hydrocodone-Acetaminophen to be given every four hours as needed for severe pain. Documentation indicated a gap in administration of the medication, with the last dose given on one date and not administered again until two days later, despite the resident's ongoing pain. The administrator confirmed that the medication system was in place but was not utilized by the staff member, resulting in the resident not receiving the ordered pain medication.
Resident Burned After Unauthorized Use of Space Heater
Penalty
Summary
A deficiency occurred when a portable space heater was used in a resident's room, resulting in a burn injury. The resident, who had a history of traumatic subarachnoid hemorrhage, paraplegia, and autonomic dysreflexia, requested the use of a heater brought by his family due to his tendency to feel cold and sweat excessively. Despite being aware that heaters were not permitted in the facility due to fire and burn risks, an LPN set up the heater approximately three feet from the resident at his request. The resident, who was cognitively intact but had impaired sensation due to his spinal injury, was later found with redness and blisters on his right elbow by another nurse and CNA during their rounds. The resident was unaware of the injury due to his lack of sensation in the affected area. Medical documentation confirmed a diagnosis of a second-degree burn on the resident's right elbow, which subsequently became infected with Enterococcus Faecalis and MRSA, requiring multiple courses of antibiotics. Facility policy review indicated that space heaters were prohibited due to safety concerns, and staff interviews confirmed that the heater was used against established protocols. The incident was identified as a failure to maintain a safe, hazard-free environment, as required by facility policy and regulatory standards.
Failure to Complete Skills Competency Checkoffs for New Nursing Staff
Penalty
Summary
The facility failed to ensure that newly hired licensed nurses and certified nurse assistants (CNAs) received skills competency checkoffs before providing resident care. Three new hires were reviewed, and none had completed or documented skills checkoffs as required by facility policy. One graduate practical nurse reported not being assigned a preceptor, not receiving a skills checkoff form, and not having her skills reviewed before working independently. She also stated she felt overwhelmed with charting and other processes that were not reviewed with her during orientation. The Clinical Educator confirmed that she had not performed any skills checkoffs with the new nurse and was unaware if the previous Director of Nursing had done so. Additionally, the Clinical Educator acknowledged that she had never obtained completed new hire skills checkoffs since starting her role and was often pulled away from her educator duties to work on the medication cart. Review of documentation for two CNAs revealed that required skills checklists and audit tools were either unsigned, undated, or missing staff and trainer names, making it impossible to verify that competencies had been completed. The Administrator confirmed that the facility could not locate any skills review forms for the new nurse and acknowledged that all new hires should have skills checkoffs to ensure competency. The lack of completed and documented skills checkoffs for new hires resulted in the facility's failure to ensure staff competency prior to providing resident care.
Some of the Latest Corrective Actions taken by Facilities in Mississippi
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