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.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
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.
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 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.
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.
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
Environmental Controls & Physical Security
- Installed keypad locks on kitchen entrance doors to restrict unauthorized resident egress (J - F0689 - MS)
- Began installation of wander guard alarm system on the kitchen loading-dock door for continuous exit monitoring (J - F0689 - MS)
- Posted reminder signage on all exit doors instructing staff and visitors to prevent residents from leaving unaccompanied (J - F0689 - MS) (J - F0610 - MS) (J - F0600 - MS)
Staff, Visitor, and Family Education & Monitoring
- Conducted facility-wide in-services covering exit-door procedures, residents’ rights, abuse prevention, and elopement response (J - F0689 - MS)
- In-serviced Social Services staff on promptly initiating elopement precautions for residents exhibiting exit-seeking behaviors (J - F0689 - MS) (J - F0610 - MS) (J - F0600 - MS)
- Educated front-desk personnel to obtain coverage before leaving the reception area to maintain supervision of the main entrance (J - F0689 - MS) (J - F0610 - MS) (J - F0600 - MS)
- Distributed letters to resident representatives requesting notification of staff when residents express desire to leave and advising caution with entry/exit doors (J - F0689 - MS) (J - F0689 - MS) (J - F0610 - MS) (J - F0600 - MS)
- Established weekday nursing review of 24-hour progress notes to detect exit-seeking behavior and ensure timely interventions (J - F0689 - MS)
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement and wandering risk, resulting in the resident exiting the facility unsupervised. The resident, who had a diagnosis of Schizophrenia and severe cognitive impairment as indicated by a BIMS score of 4, was last seen in the dining room by staff. Despite being equipped with a wander guard bracelet, the resident was able to leave the facility through a kitchen door that was not equipped with a wander guard alert system, unlike other facility exits. The door had a keypad lock, but it was accessible from the dining area and not properly secured to prevent resident exit. Staff did not immediately notice the resident's absence. The resident's walker was left in the dining room, and staff initially assumed the resident had returned to his room. It was only after a phone call from the resident's family and subsequent checks that staff realized the resident was missing. A facility-wide elopement alert was then announced, and staff began searching the premises and surrounding area. The resident was located approximately one mile from the facility, having crossed a busy four-lane highway, and was returned after being unsupervised for about two hours. Interviews with staff and family confirmed that the resident had a history of exit-seeking behavior and had previously expressed a desire to go home. Staff had observed the resident attempting to open exit doors on multiple occasions. The facility's policy required staff to report any resident attempting to leave or suspected of being missing, but in this instance, the resident was able to leave undetected due to the lack of a wander guard system on the kitchen door and insufficient supervision in the dining area.
Removal Plan
- RN #2 performed a head-to-toe assessment with the resident's daughter, Executive Director, and DON present. There were no visible physical injuries.
- A 100% audit of all Wander/Elopement Risk residents were assessed for placement and proper functioning with no adverse findings.
- All the facility's entrance and exit door's alarm systems were checked. All the alarms were functioning properly.
- Resident #1 checked for wander guard placement and properly working. His wander guard was intact and working properly.
- Head-to-toe assessment of Resident #1 completed by the Unit B Manager and DON. There were no negative findings.
- Resident #1 was interviewed by the Unit B Manager. No negative statements were made by the resident.
- Upon Resident #1's return he was placed on 1:1 location monitoring x (times) 72 hours then tapered down to every 15 minutes then every 30 minutes then every hour. The Unit Manager, DON, and Social Services will determine when the resident may be removed from 1:1. The resident was placed on 24 hours charting for the nurses to document and notifying the MD/NP of any significant changes in the resident physical or mental status.
- A keypad lock was placed on the kitchen entrance door in the dining room by the Housekeeping Supervisor. The Housekeeping Supervisor replaced the old door handle on the kitchen door next to Unit-B with a keypad. The code will be given to dietary workers and key staff.
- The Maintenance Supervisor contacted Systronic Alarms Systems on installing a wander guard alarm on the kitchen door leading to the loading dock. A representative from the company will be at the facility.
- Resident #1 was moved closer to the nurses station. He moved from B 118P to B 108P. The Elopement Wander guard book reviewed. The Elopement Book was correct. A 100% check of the Wander/Elopement Risk were assessed for placement and proper functioning.
- The Dietary Workers on shift during the time of the incident received 1:1 Educational In-Services on Exit Doors in the kitchen and written corrective counseling by the Executive Director.
- Educational In-services for the facility's staff conducted by the Staff Development/Executive Director were initiated and included: a) Exit Doors in the kitchen b) Resident's Rights c) Abuse Prevention and Reporting d) Abuse and Neglect e) Residents expression to go home f) Missing Resident/Elopement.
- The Unit B Manager re-schedule Resident #1's eye appointment. Resident's appointment is scheduled as a follow-up consult visit to rule out retinal vein occlusion with macula edema to the left eye.
- Resident #1's care plan and pain assessment up-dated. Social Services Director preformed a Trauma Screen.
- The facility prepared a formal letter to mail to each resident's representative. The letter requests that during visits, if the resident expresses wish to leave the facility or return home, the family should inform nurse management, the Executive Director, or Social Services.
- We had a Family Meeting with Resident #1's daughter. The daughter did not express any concerns about her father's care or safety with the facility.
- Nursing will review 24 hour progress notes on the following week day and/or Monday following the weekend for any resident's voicing wanting to go home or exhibits exit seeking behavior to ensure proper intervention are in place.
- A QAPI was implemented with an emergency QA meeting reviewing Resident #1's incident.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Identification
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent the elopement of a resident who had documented new wandering and exit-seeking behaviors for at least a week. The resident, who had diagnoses including bipolar disorder, anxiety, schizophrenia, a history of falls, and was assessed as at risk for falls and requiring supervision for walking, exited the facility unnoticed and was found sitting unsupervised in a staff member's car in the parking lot. The resident had been observed packing belongings, expressing confusion, and making statements about leaving, but these behaviors were not identified as exit-seeking or elopement risk by staff. Despite multiple staff members observing the resident's behavioral changes, including repeated trips to the front entrance and packing bags, the care plan was not updated to reflect the new risk, and no interventions such as wander management devices or increased supervision were implemented prior to the elopement. Documentation of the resident's change in behavior was reported to the primary healthcare provider, who ordered a urinalysis, but the facility did not recognize or address the increased risk of elopement. Staff interviews revealed a lack of awareness and action regarding the resident's behaviors, and no incident report was completed after the resident exited the facility. Additionally, facility policies and procedures were not followed, as evidenced by the absence of an updated care plan, missing elopement binders at the nurses' station, and lack of head counts or elopement drills following the incident. The front entrance could be opened with a code, and the receptionist, who was aware of the resident's behaviors, left the desk unattended without ensuring coverage. The facility did not report the incident to the State Agency in a timely manner, and there was no thorough investigation or immediate implementation of elopement precautions for the resident prior to the event.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to initiate a thorough investigation into an allegation of neglect and an incident of elopement involving one of six sampled residents. On the specified date, a resident exited the facility unsupervised and was found sitting in a staff member's car in the facility parking lot. The resident had left the building unnoticed by staff during a shift change and was able to access an area adjacent to a busy four-lane boulevard. The staff member who discovered the resident escorted her back into the facility and notified the appropriate personnel, including the Executive Director and the Director of Nursing Services. Despite the incident, there was no documentation of the elopement in the facility's accident/incident log, and no incident report was completed. Multiple staff members, including LPNs and the Unit Manager, confirmed that they were aware of the resident's unsupervised exit but did not participate in any investigation or initiate missing resident procedures. No head count of residents was conducted, and the event was not reported to the State Agency as required. The Executive Director stated that the incident was not considered an elopement because the resident claimed she was waiting for her brother, and therefore, no report was made to any agencies. The resident involved had a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, but her most recent assessment indicated no cognitive impairment and no documented wandering or exit-seeking behaviors. The facility's policies required immediate investigation and reporting of such incidents, but these procedures were not followed. The failure to conduct a thorough investigation and report the incident placed the resident and others at risk, as identified by the State Agency, which cited the facility for failing to meet regulatory requirements regarding the investigation and prevention of alleged violations.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who cover the receptionist area, the receptionist was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social Service Assistants and Medical Director. The IP nurse was present by phone.
Failure to Prevent Resident Elopement Due to Lack of Timely Intervention
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not implementing measures to prevent elopement for a resident who had recently begun exhibiting exit-seeking behaviors. The resident, who had diagnoses including bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, began displaying new behaviors such as packing belongings and waiting at the front door, believing her family was coming to get her. Despite these documented behaviors, staff did not update the resident's care plan or implement additional supervision or wander management interventions prior to the incident. On the day of the incident, the resident exited the facility unnoticed and unsupervised. She was found approximately fifteen minutes later by a CNA, sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard. Staff were unaware of the resident's absence until she was brought back inside. There was no incident report completed at the time, and no head count or missing resident protocol was initiated following the event. Interviews with staff confirmed that the resident's care plan had not been updated to reflect her new exit-seeking behaviors, and that elopement drills or additional supervision had not been implemented. The facility's policy required identification and intervention in situations where neglect was more likely to occur, including increased supervision for residents at risk. However, despite multiple staff members observing and documenting the resident's exit-seeking behaviors in the days leading up to the incident, no changes were made to her care plan or supervision level. The lack of timely intervention and failure to follow facility policy resulted in the resident being able to leave the facility unsupervised, placing her at risk.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for residents with behavioral changes that verbalize leaving the facility, exit seeking, wandering, and packing belongings should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all residents who were determined to be at risk for elopement to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident #1 to confirm details of the elopement.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and exiting the facility and to notify staff if a resident verbalizes thoughts of leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. All routine staff who cover the receptionist area were also in-serviced.
- A 100% audit of elopement binders was conducted by the Social Service Department to ensure the binders' information was reflective of all residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with key facility leadership and the Medical Director to review the incident and corrective actions.
Failure to Timely Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse within the required two-hour timeframe to the appropriate authorities. The incident involved a resident who was found by a CNA on top of another resident in bed, with his hand inside her incontinence brief, performing jabbing motions. Both residents were clothed at the time, but the CNA observed the inappropriate behavior and called for assistance. The male resident became violent when staff attempted to remove him, striking a staff member in the process. Upon assessment, the female resident was found to have scratches and bruising on her upper legs and labia, as well as additional bruising and discoloration on her thigh and eyebrow. Facility records show that the incident was reported internally to the nursing home administrator and social worker shortly after it occurred. However, the administrator did not recognize the event as sexual abuse and did not report it to the State Department within the required two-hour window. Instead, the administrator believed there was a 24-hour reporting window and notified the State Department the following day. The incident was also not reported to local law enforcement immediately, as the administrator did not initially view it as a crime. The facility's policy, in accordance with the Elder Justice Act, requires that any suspicion of a crime involving serious bodily injury to a resident be reported immediately, but no later than two hours after the suspicion arises. The failure to report the incident in a timely manner placed the affected resident and others at risk for further harm. The survey agency identified this as Immediate Jeopardy and Substandard Quality of Care, citing the facility for not adhering to regulatory requirements for reporting alleged violations.
Removal Plan
- Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2.
- Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident.
- A CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit.
- LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted.
- Staff Development Specialist (SDS) performed a full body audit on Resident #56. The findings were red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas.
- Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received.
- NHA notified the Ombudsman of the incident.
- LMSW notified the Responsible Party (RP) of the incident.
- NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident #16 and continuing supervision.
- RP of Resident #16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement.
- LMSW verified that a CNA was placed outside Resident #16's room.
- NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone.
- A follow-up weekly body audit completed on Resident #56. No additional injuries identified.
- Primary physician notified of Resident #16 acceptance at behavioral health facility.
- NHA notified the Attorney General's Office of the incident.
- NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov.
- Resident #16 was transferred to a behavioral health facility.
- NHA notified local law enforcement of the incident.
- Local law enforcement on-site.
- Incident report received from local law enforcement.
- The Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse.
- The Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced.
- The IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced.
- No staff, including the Director of Nursing, will be allowed to work until they are in-serviced.
- An Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM.
- A Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1.
- The Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors.
Failure to Prevent Sexual Abuse and Inadequate Supervision of Resident with Known Sexual Behaviors
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in a serious incident involving two residents on the Special Care Unit. One resident with a history of severe cognitive impairment and Alzheimer's Disease was found in her bed with another resident on top of her, his hand inside her incontinence brief, performing jabbing motions. Staff observed scratches, bruising, and edema on the resident's labia and thigh, as well as bruising to her eyebrow. The incident was witnessed by multiple CNAs and a nurse, who reported that the male resident became violent and struck a staff member when they attempted to intervene. Prior to this event, the male resident had a documented history of sexually inappropriate behaviors, including making explicit comments, grabbing staff, and attempting to touch staff inappropriately. These behaviors had been ongoing since at least November of the previous year, with multiple entries in his medical record noting sexual comments and physical actions toward staff. Despite these documented behaviors, the facility did not implement effective interventions to prevent further sexual behaviors or protect other residents from potential harm. Staff interviews confirmed that the male resident frequently made sexual statements and gestures toward both staff and other residents, and had previously grabbed staff inappropriately. On the day of the incident, he was able to access another resident's room and commit sexual abuse, indicating a lack of adequate supervision and preventive measures. The facility did not assess other residents for signs of abuse immediately following the incident, and no body audits were performed on other residents at that time. The failure to address the ongoing sexually inappropriate behaviors and to implement sufficient interventions led to an incident that caused and was likely to cause serious harm.
Removal Plan
- Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2.
- Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident.
- A CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit.
- LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted.
- Staff Development Specialist (SDS) performed a full body audit on Resident #56. The findings included red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of a quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas.
- Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received.
- NHA notified the Ombudsman of the incident.
- LMSW notified Resident #56's Responsible Party (RP) of the incident.
- NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision.
- RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement.
- LMSW verified that a CNA was placed outside Resident #16's room.
- NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone.
- A follow-up weekly body audit completed on Resident # 56. No additional injuries identified.
- Primary physician notified of Resident # 16 acceptance at behavioral health facility.
- NHA notified the Attorney General's Office of the incident.
- NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov.
- Resident # 16 was transferred to a behavioral health facility.
- NHA notified local law enforcement of the incident.
- Local law enforcement on-site.
- Incident report received from local law enforcement.
- The Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse.
- The Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced.
- The IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced.
- No staff, including the Director of Nursing, will be allowed to work until in serviced.
- An Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM.
- A Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1.
- The Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors.
Explore Popular Searches
