Citations in North Carolina
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in North Carolina.
Statistics for North Carolina (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in North Carolina
- Reviewed and updated the Glucometer Procedure to require individually assigned, labeled devices to strengthen infection-control practices (J - F0880 - NC)
- Implemented a strict DON-controlled protocol for issuing new or replacement glucometers, mandating labeling before first use and prohibiting stock devices on units (J - F0880 - NC)
- Prohibited storage of unassigned or unlabeled glucometers on medication carts or nursing units to eliminate inadvertent sharing (J - F0880 - NC)
- Established a leadership-driven process for after-hours and weekend glucometer assignment to ensure proper labeling and tracking at all times (J - F0880 - NC)
- Revised equipment management protocols to remove and discard glucometers for discharged residents during routine audits preventing future misuse (J - F0880 - NC)
- Provided targeted training to Central Supply and nursing leadership on the new glucometer control procedures to ensure consistent implementation (J - F0880 - NC)
- Placed laminated visual reminders of glucometer use and disinfection steps on all medication carts and rooms and required DON verification after any cart change (J - F0880 - NC)
- Conducted comprehensive in-service education for all licensed nurses on updated glucometer use, storage, and disinfection policies emphasizing prohibition of shared devices (J - F0880 - NC)
- Reinforced hand-hygiene practices and correct supply use during blood-glucose monitoring in staff training to reduce cross-contamination risk (J - F0880 - NC)
- Trained staff on the two-wipe cleaning method for glucometers, including required contact time and air-drying to ensure effective disinfection (J - F0880 - NC)
- Educated staff on procedures for obtaining a properly labeled glucometer when a resident lacks one to prevent ad-hoc sharing (J - F0880 - NC)
- Integrated glucometer education and competency validation into new-hire orientation with annual refreshers creating ongoing staff proficiency checks (J - F0880 - NC)
- Assigned DON, ADON, and scheduler responsibility for maintaining training and competency records to support sustained compliance oversight (J - F0880 - NC)
- Implemented ongoing supervisory surveillance of licensed nurses’ blood-glucose monitoring practices to promptly correct non-compliance (J - F0880 - NC)
Failure to Use and Disinfect Resident-Assigned Glucometer
Penalty
Summary
Facility staff failed to utilize a resident's assigned, labeled blood glucose meter (glucometer) and instead used a loose, unassigned, and unlabeled glucometer from the medication cart to check a resident's blood glucose level. The staff member did not disinfect the glucometer before or after use and had no way to verify if it had previously been disinfected. This occurred despite the facility having a policy that required cleaning and disinfecting glucometers between resident use, following manufacturer instructions and infection control standards. At the time of the incident, there were 11 residents in the facility with known bloodborne pathogens, and 4 of these residents required blood glucose monitoring. The observation revealed that the nurse used the loose, unlabeled glucometer on a resident, even though the resident had a designated, labeled glucometer stored in the medication cart. The nurse admitted to not knowing why she did not use the assigned glucometer and confirmed she did not disinfect the device before or after use. The nurse also stated she was unsure if the glucometer had been disinfected previously and placed it back in the cart without cleaning it. Further interviews and observations indicated that the presence of a loose, unlabeled glucometer in the medication cart was not an isolated incident, as another nurse confirmed the existence of such a device, which was reportedly for emergencies but had no clear disinfection protocol. The facility's infection preventionist and DON acknowledged previous issues with glucometer disinfection and had implemented measures such as audits, education, and visual cues, but these were not consistently maintained. The incident was observed and confirmed by multiple staff, and the facility's leadership was unaware that visual cue cards were missing and that a loose glucometer was still present on the cart.
Removal Plan
- Reviewed and updated the facility's Glucometer Procedure: Use, Cleaning, and Infection Control policy to reflect corrective actions and emphasize use of individually assigned, labeled glucometers.
- All licensed nursing personnel acknowledged receipt and understanding of the updated glucometer policy.
- Conducted a comprehensive, system-wide audit to ensure every resident requiring blood glucose monitoring had an individually assigned, correctly labeled glucometer stored in a designated container.
- Removed and discarded all unauthorized/unlabeled glucometers from circulation.
- Implemented a strict protocol for the introduction of new or replacement glucometers, requiring all new glucometers to be delivered to and distributed from the DON's office, labeled for a specific resident before use.
- Prohibited storage of unassigned or unlabeled stock glucometers on medication carts or in general nursing units outside of DON office control.
- Established a process for after-hours or weekend glucometer assignment, requiring nursing leadership to obtain and assign glucometers from the DON's office.
- Updated protocol for removal and discarding of unused glucometers for discharged residents during routine audits.
- In-serviced the Central Supply Clerk and nursing leadership on the new glucometer control protocol.
- Reviewed and confirmed placement of laminated visual reminders outlining glucometer use and disinfection steps on all medication carts and in medication rooms.
- Updated equipment management protocol to require DON or nursing leadership to verify and reinstall all necessary signage and visual aids after any medication cart modification, replacement, or repair.
- Conducted immediate in-service training for all licensed nursing staff (including agency nurses) on the updated Glucometer Procedure: Use, Cleaning, and Infection Control policy.
- Emphasized in training the use of individually assigned glucometers, proper storage, and strict prohibition of using unlabeled or shared glucometers.
- Reinforced hand hygiene procedures and correct use of supplies during blood glucose monitoring.
- Detailed and trained staff on the two-wipe method for cleaning and disinfecting glucometers, including required contact time and air drying.
- Educated staff on the updated procedure for obtaining a new, properly labeled glucometer if a resident does not have one.
- Required all staff to sign an acknowledgement form confirming receipt and understanding of the training.
- Completed direct observational competency validation for all licensed nursing staff (including agency nurses) on blood glucose monitoring procedures.
- Incorporated comprehensive education and competency validation into orientation for all new nursing hires and agency staff, with annual competency refreshers.
- Assigned DON, ADON, and scheduler responsibility for maintaining records of all completed training, signed acknowledgement forms, and competency validations.
- Implemented ongoing direct supervisory support and surveillance of licensed nurses, including agency nurses, to ensure continued adherence to correct blood glucose monitoring procedures.
- Terminated the employment of the agency nurse involved in the incident.
- Notified the medical provider and responsible party for Resident #8 of the incident.
- Removed and discarded the unlabeled glucometer used in the incident.
- Completed an immediate inventory check to confirm sufficient individually assigned, labeled glucometers and appropriate EPA-registered disinfectant wipes were available.
- Reported the infection control breach to the local health department and followed their recommendations, including baseline testing for HIV, Hepatitis B, and Hepatitis C for Resident #8.
- Conducted a root cause analysis to identify contributing factors and inform corrective actions.
Failure to Secure Wheelchair in Transport Van Results in Resident Injury
Penalty
Summary
A deficiency occurred when a contracted transport driver failed to secure a resident's wheelchair in accordance with the manufacturer's instructions prior to departing from a dialysis clinic. The wheelchair was not attached to the van's floor securement system, which resulted in the wheelchair flipping backwards during transit. The resident, who remained in the wheelchair, struck her head and back on the van floor, leading to immediate and severe pain. The resident involved had a history of left above-the-knee and right below-the-knee amputations, was dependent on dialysis, and had severe cognitive impairment, requiring staff assistance for transfers and wheelchair mobility. Prior to the incident, the resident's pain was managed with PRN ibuprofen and tramadol, and she was not coded for pain or opioid use on her most recent assessment. On the day of the incident, the resident returned from dialysis reporting severe pain, and staff observed her moaning, crying out, and unable to sit upright in her wheelchair. She was subsequently transferred to the hospital, where imaging revealed a fracture at the superior endplate of the L1 vertebra. Interviews and documentation confirmed that the contracted transport driver was distracted while loading the resident, failed to secure the wheelchair, and did not report the incident to facility staff. The driver admitted to the error after being contacted by the transportation company. Facility staff, including nurses and nurse aides, noted the resident's distress and pain upon her return, and the incident was reported to the facility's DON and administrator. The event was substantiated through interviews with the resident, staff, and the contracted transportation company, as well as review of medical records and pain assessments.
Removal Plan
- Ceased use of the outside vendor responsible for transportation of Resident #1.
- Identified all residents transported by all transportation providers using the facility transportation calendar.
- Social Worker identified alert and oriented residents on this list using the Brief Interview for Mental Status (BIMS) score of 10 and above.
- Social Services interviewed alert and oriented residents to identify any incident where the transport driver failed to safely secure the wheelchair in the transportation van.
- Facility licensed nurses completed a Skin Note and Pain Assessment for all residents with a BIMS of less than 10 who had transportation to identify potential injury.
- Facility completed investigations and appropriate follow-up action for any concerns identified during interviews and assessments.
- Administrator assumed responsibility to ensure investigations and follow-up were completed.
- Administrator spoke with the Contracted Transportation Company Owner regarding the need for education and documentation.
- Contracted Transportation Vendor provided competency training for all contract transport drivers who transport residents from the facility, including a return demonstration of safely securing a wheelchair.
- Training for contracted transport drivers included the manufacturer's instructional Training Video and return demonstration.
- Training documentation for contracted transport drivers to be provided to the Administrator by the Contracted Transportation Company Owner or Designee and maintained at the facility.
- Newly hired contract transport drivers for this vendor will be provided this training prior to being assigned transportation trips for the facility residents, including a return demonstration.
- Facility's transport drivers received competency training related to securing wheelchairs in the van.
- Facility's transport driver training was provided by the facility Maintenance Director using the manufacturer's instructions and included a return demonstration.
- Newly hired facility transportation drivers will be provided this training and include a return demonstration prior to being scheduled to provide transportation trips, provided by the Maintenance Director.
Neglect Following Unreported Fall During Resident Transport
Penalty
Summary
A deficiency occurred when a contracted transport driver failed to protect a resident from neglect during transportation from a medical appointment. The resident's wheelchair flipped backwards in the transport van, causing the resident to fall and sustain a head and back injury. The driver, who was not qualified to assess injuries, asked the resident if she was okay, set the wheelchair upright, secured it, and continued the trip without seeking medical evaluation or notifying facility staff of the incident. Upon arrival at the facility, the driver only informed staff that the resident was not feeling well and wanted to go to bed, deliberately withholding information about the fall. The resident later reported severe pain in her neck, shoulders, and back, rating it as 10 out of 10, and staff observed her in significant distress. Despite administration of opioid pain medication, the resident's pain persisted, and she was subsequently transferred to the hospital, where she was diagnosed with a fracture at the superior endplate of the L1 vertebra. The contracted transport driver's actions, including moving the resident without a clinical assessment and failing to report the fall to facility staff, resulted in delayed care and prolonged suffering for the resident. The facility's initial report identified the driver as the accused individual in an allegation of neglect, and the incident was determined to constitute neglect due to the disregard for the resident's need for timely clinical assessment and appropriate care following the fall.
Removal Plan
- Ceased use of the vendor for the company that provided transportation for Resident #1.
- Completed an audit of all facility falls to verify that all residents were assessed by a licensed nurse for injury following a fall and that non-medical staff notified qualified staff to perform a clinical assessment prior to the resident being moved.
- Completed an investigation for any concerns identified during the audit and took appropriate follow-up action based upon the results.
- Provided training for all contract transport drivers from the new Transportation Vendor on notifying 911 to assess the resident for injury prior to moving the resident and the requirement to notify the facility of falls by calling the facility at the time of the fall after calling 911.
- Provided training for contract transport drivers on identifying and reporting neglect, including examples of what constitutes neglect, completed by Contract Transportation Vendor Supervisors.
- Required that all contract transport drivers for the Transportation Vendor complete this training prior to being assigned transportation trips for facility residents, with documentation provided to the Administrator.
- Required that newly hired contract transport drivers for this vendor receive this training prior to being assigned transportation trips for facility residents.
- Re-educated 100% of facility staff regarding the facility policy for Abuse Identification, including indicators of neglect and reporting neglect, with examples.
- Department Supervisors provided this education for their respective staff, and all staff who did not complete this training received it prior to working their next shift.
- Clinical Competency Coordinator responsible for tracking to ensure 100% of staff receive the training, including during general orientation for all newly hired staff.
- Re-educated 100% of facility staff regarding the facility policy not to move the resident after a fall until examined by a licensed nurse for possible injuries.
- Provided training to 100% of the facility's transport drivers related to ensuring the resident is assessed by a qualified professional in the event a fall occurs during transportation and prior to moving the resident, including calling 911 and notifying the facility.
- Required that newly hired facility transportation drivers receive this training prior to being assigned transportation trips for facility residents.
Failure to Ensure Agency Nurse Competency in J-Tube Care
Penalty
Summary
The facility failed to ensure that agency nurses were properly trained and competent to care for residents with jejunostomy tubes (j-tubes). An agency LPN, who was hired without documented competency or specific training on j-tubes, was involved in an incident where a resident's j-tube became dislodged. The nurse did not recognize the need for hospital treatment and instead inserted a urinary catheter tube into the j-tube site, mistakenly assuming it was a gastrostomy tube. This action was performed without a physician's order and without the necessary radiographic or surgical guidance required for j-tube replacement. Record review confirmed that the nurse's employee file lacked evidence of j-tube competency or training, and the facility's orientation for agency nurses did not include specific instruction on j-tubes at the time of her employment. Interviews with the nurse revealed she did not recall receiving j-tube training during orientation at this facility, despite having prior experience elsewhere. The DON stated that the agency was responsible for verifying nurse competencies, and acknowledged that the facility's orientation did not cover j-tube care for agency nurses. The incident was identified during a review of three nurses for competency and three residents with feeding tubes. The nurse's improper handling of the dislodged j-tube created a high likelihood of serious harm, as confirmed by interviews with the nurse practitioner, medical director, staff, and the responsible party. The deficiency was limited to one resident with a j-tube, and no other residents with j-tubes were identified in the facility during the review period.
Removal Plan
- The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers will provide education to Licensed Nurses on Gastrostomy Tube Reinsertion Policy, including what to do if a j-tube becomes dislodged, physician notification, not to attempt reinsertion of the j-tube, risks, and sending the resident to the hospital for surgical reinsertion.
- A quiz was created to validate staff understanding of the material that was taught. Any nurse that cannot answer the quiz questions appropriately will be retrained by the DON or ADON on the material.
- The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty.
- New hires and Agency Nurses will be educated by the DON or ADON during the orientation process using the Gastrostomy Tube Reinsertion Policy.
- The quiz will be given at the end of their training to validate understanding on what to do if a j-tube becomes dislodged, including physician notification, not to attempt reinsertion of the j-tube, risks, and sending the resident to the hospital for surgical reinsertion.
Failure to Immediately Notify Physician and Inappropriate Tube Replacement
Penalty
Summary
A facility failed to immediately notify a physician when a resident's jejunostomy tube (j-tube) became dislodged. The resident, who had a history of stroke, dysphagia, and was severely cognitively impaired, relied on the j-tube for nutrition and medication administration. On the day of the incident, a nurse aide observed a tube on the bathroom floor but did not report it to the nurse. Hours later, the assigned nurse discovered the j-tube was missing and, without contacting the physician, inserted an indwelling urinary catheter tube into the j-tube site, following advice from the wound nurse who was unaware it was a j-tube. There was no physician order for this action. The nurse was not aware that the tube was a j-tube rather than a gastrostomy tube and did not recognize the need for immediate hospital transfer or physician notification. The nurse only notified the DON after the replacement tube became dislodged a second time, at which point the DON instructed her to contact the provider and send the resident to the hospital. The resident was subsequently transferred to the hospital, where surgical intervention was required to replace the j-tube. Interviews with facility staff, including the nurse, nurse aide, wound nurse, DON, nurse practitioner, and medical director, confirmed that the nurse did not follow proper protocol for physician notification and tube replacement. The medical director and nurse practitioner both stated that it was inappropriate and unsafe for a nurse to replace a j-tube in the facility, especially without a physician's order, due to the risk of serious complications. Documentation review showed that the physician was not notified until after the second dislodgement and inappropriate tube replacement had occurred.
Removal Plan
- The DON, Assistant Director of Nursing (ADON), and Unit Managers re-educated Licensed Nurses and Nurse Aides (NA) on Resident Change in Condition Policy with emphasis on changes that require immediate physician notification and documentation.
- Nurse Aides were educated to notify the charge nurses if any devices, such as enteral feeding tubes, were displaced or not in resident at time of care.
- The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty.
- New Licensed Nurses, Agency Nurses, and Nurse Aides will be educated by the DON or ADON during the orientation process.
- The Director of Nursing will review the Facility Activity Report for any Interact SBAR, Interact Nursing Home to Hospital Transfer Forms, or any Events in the morning Clinical Morning Meeting, which will be held seven days a week, to verify prompt and/or immediate notification is communicated to the Physician and/or Provider.
- If notification to the physician has not occurred, the DON will notify the physician at that time.
Failure to Recognize and Respond to Acute Change in Condition After Fall
Penalty
Summary
A resident with a complex medical history, including atrial fibrillation on anticoagulation therapy, recent pulmonary embolism, traumatic brain injury, hemiplegia, and previous subdural hematoma, experienced an unwitnessed fall from bed. Following the fall, the resident was assessed and found to have no visible injuries, and neurological checks were initiated. The resident reported not hitting his head, and his neurological status and vital signs were documented as within normal limits for the remainder of the shift and into the following day. On the morning after the fall, staff observed that the resident was hard to arouse, nonverbal, unresponsive, and lethargic, which was a significant change from his baseline. Multiple staff members, including nurse aides and therapy staff, noted the resident's altered mental status and reported it to nursing staff. Despite these observations, the response was limited to obtaining orders for bloodwork, urinalysis, and a chest x-ray later in the afternoon, rather than immediate evaluation or transfer to a higher level of care. The resident's condition continued to deteriorate, with ongoing lethargy and unresponsiveness noted by various staff members throughout the day and night. It was not until the following morning, when the resident's family arrived and insisted on hospital transfer, that the resident was sent to the emergency department. Upon arrival, the resident was diagnosed with a large left subdural hematoma with midline shift and was transitioned to hospice care, passing away several days later. The facility failed to recognize the severity of the resident's acute change in condition after the fall and did not promptly notify a medical provider or arrange for timely transfer to a higher level of care, despite clear signs of neurological decline.
Removal Plan
- The DON and Nurse Consultant completed an audit of residents on anticoagulant therapy who have experienced a fall to ensure timely recognition and response occurred if the resident experienced a change in condition.
- The DON and Unit Managers reviewed all residents with changes in condition to ensure immediate notification to the Medical Provider occurred.
- The Administrator, Director of Nursing (DON), President of Risk and Quality Assurance (VPRQA), Nurse Consultant, PA and Medical Director held an Ad Hoc QAPI meeting to discuss the incident to determine root cause analysis of the facility's failure to recognize the severity of a change in condition for Resident #1.
- The Director of Risk and Quality Assurance, Nurse Consultant, Director of Nursing, Administrator, and Physician Assistant reviewed the change in condition and fall policy. No changes were made.
- The Director of Nursing, Nurse Consultant, and Nursing Administration initiated education with all facility and contracted licensed nurses and Certified Nursing Assistants on the facility Notification of Changes in Condition and Fall Prevention policies. Education includes recognizing the severity of a change in condition status post fall to include post fall assessment changes, changes in level of consciousness, and altered mental status away from baseline. Upon licensed nurse's assessment recognizing the severity of the residents change in condition away from baseline post fall, the Medical Provider will be immediately notified.
Failure to Immediately Notify Provider of Acute Change in Condition Post-Fall
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify the medical provider of an acute change in condition for a resident who had recently experienced a fall. The resident, who had a history of atrial fibrillation, pulmonary embolism, cerebral infarction with hemiplegia, and traumatic brain injury, was on anticoagulant therapy with apixaban. After an unwitnessed fall from bed, the resident was assessed by nursing staff, found to have no visible injuries, and was returned to bed. Neurological checks were initiated, and the resident reported not hitting his head. The following day, staff observed that the resident was hard to arouse, nonverbal, unresponsive, and lethargic. Multiple staff members, including nurse aides and therapy staff, noted the resident's significant change from his baseline, describing him as limp, lethargic, and not responding as usual. These observations were communicated to nursing staff and the unit manager. However, the medical provider was not notified of the resident's acute change in condition until late in the afternoon, several hours after the initial signs were observed. During this period, assessments were performed, and vital signs were taken, but the delay in provider notification persisted. The unit manager eventually contacted the provider, who ordered diagnostic tests. The next day, the resident's family found him unresponsive and requested hospital transfer, where he was diagnosed with a large subdural hematoma. Interviews with staff and the medical director confirmed that the provider should have been notified immediately upon recognition of the change in condition, especially given the resident's medical history and anticoagulant use.
Removal Plan
- The DON re-educated the nurse on the notification policy and process to include immediately notifying the Medical Provider when a resident has a change in condition.
- The DON and Nurse Consultant completed an audit of residents on anticoagulant therapy who have experienced a fall to ensure timely notification to the Medical Provider if a change in resident condition occurs.
- The facility reviewed all residents with changes in condition to ensure immediate notification to the Medical Provider occurred.
- The Administrator, Director of Nursing, President of Risk and Quality Assurance, Nurse Consultant, Physician Assistant and Medical Director held an Ad Hoc QAPI meeting to discuss the incident to determine root cause analysis of the facility's failure to immediately notify the Medical Provider when Resident #1 had a change in condition.
- The Director of Risk of Quality Management, Nurse Consultant, Director of Nursing, Administrator, and Physician Assistant reviewed the notification and fall policy.
- The Director of Nursing, Nurse Consultant, and Nursing Administration initiated education with all facility and contracted licensed nurses and Certified Nursing Assistants on the facility Notification of Changes in Condition and Fall Prevention Policies.
- Education includes the licensed nurse's responsibility to immediately notify the Medical Provider of any resident's change in condition, especially post-fall, with a history of stroke and pulmonary embolism on an anticoagulant.
- Certified Nursing Assistants will immediately communicate to the licensed nurses any change in Residents condition.
- The Director of Nursing will ensure all newly hired licensed nurses and Certified Nursing Assistants will be educated during orientation and contracted staff educated prior to taking their assignment.
- The Administrator is ultimately responsible for the implementation and completion of this removal plan.
Latest Citations in North Carolina
A resident with chronic pain did not receive scheduled oxycodone as ordered due to a nurse's lack of awareness about the emergency medication kit and failure to seek assistance or contact the pharmacy or provider. The resident experienced severe pain, which was observed and reported by staff, while documentation showed missed doses and lack of follow-up.
A resident's controlled pain medication (Oxycodone) was misappropriated when one card of tablets and its count sheet went missing despite correct shift-to-shift counts and required signatures. Staff interviews revealed that nurses did not always physically verify the placement of controlled substances on the correct medication cart, and medication cards were sometimes used out of order. The discrepancy was discovered during a narcotic audit, leading to an internal investigation and the removal of a nurse from staffing.
A resident admitted with a history of blood clots, pulmonary embolism, and chronic pain was not provided with a baseline care plan addressing anticoagulant therapy or pain medication within 48 hours of admission. The care plan was delayed due to the absence of the usual staff responsible for its completion and lack of awareness by the weekend supervisor, resulting in the omission of critical interventions for the resident's prescribed therapies.
The facility did not consistently provide accurate and updated daily nurse staffing postings, omitting RN hours worked by the DON and ADON unless they administered medications, and failing to include correct CNA hours and resident census on several occasions. Staff responsible for updating postings were not properly informed or trained, resulting in outdated or missing information.
A resident with muscle wasting and malnutrition was admitted with existing pressure ulcers, but the facility failed to obtain timely treatment orders and did not complete accurate or consistent skin assessments. Wound measurements and staging were omitted, wound care was delayed, and a new deep tissue injury developed without prompt identification. Staff interviews revealed lack of training, missed documentation, and communication lapses, resulting in delayed and inconsistent wound care.
Surveyors identified failures in food storage and labeling, including undated and uncovered food items in coolers, freezers, and dry storage, as well as visible spoilage not being addressed. Additionally, dietary staff were observed breaching infection control protocols by handling ice with bare hands and failing to perform hand hygiene after handling dirty dishes, contrary to facility policy.
Staff failed to follow infection control and Enhanced Barrier Precautions protocols, including not donning gowns and not performing proper hand hygiene during incontinence and wound care for residents with pressure ulcers. Multiple staff members either did not understand or overlooked EBP signage and requirements, resulting in care being provided without appropriate PPE and hand hygiene, despite facility policies and available training.
Several dependent residents did not receive necessary assistance with oral hygiene, nail care, and scheduled showers, with observations showing unclean dentures, long dirty fingernails, and missed showers. Staff cited missing supplies, lack of familiarity with residents, and short staffing as reasons for not providing care, and documentation of refusals or missed care was incomplete or absent.
Staffing shortages, especially on weekends, resulted in missed or delayed bathing, incontinence care, and personal hygiene for several residents. Staff and residents reported that insufficient nurse and nurse aide coverage led to delayed medication passes, missed showers, and slower response to call lights, with administrative staff confirming ongoing challenges in maintaining adequate staffing levels.
The facility failed to ensure nurses and nurse aides demonstrated required competencies, resulting in missed documentation of code status, delayed pressure ulcer treatment, incomplete skin assessments, unreported skin irritation during catheter care, medication administration errors, and missed medication doses due to improper prescription management and failure to use the Pyxis system. These deficiencies affected multiple residents and were identified through staff interviews, record reviews, and observations.
Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a complex medical history, including chronic pain and chronic opiate therapy, did not receive scheduled pain medication as ordered. The resident was admitted with orders for scheduled and as-needed oxycodone and tramadol. On the day following admission, the scheduled oxycodone doses were not administered because the nurse on duty, who was new to the facility, was unaware that the medication was available in the emergency controlled medication kit. The nurse did not contact the pharmacy, provider, or other staff to resolve the issue and did not document administration of as-needed tramadol, which she later stated she had given. The resident reported severe pain, stating her pain level exceeded 10 and caused her to cry and almost scream. Nursing staff and a nursing assistant confirmed the resident was in pain and that her medication had not arrived from the pharmacy. Documentation showed that scheduled oxycodone doses were marked as unavailable due to waiting on pharmacy delivery, despite the medication being present in the emergency kit. The nurse did not follow up with the on-call provider or pharmacy and did not seek assistance from other nurses or the DON regarding the missing medication. Interviews with facility leadership and other clinical staff revealed that the emergency controlled medication kit was fully stocked and contained the ordered medication. The DON and Administrator stated that nurses were expected to utilize the emergency kit and seek help if medications were missing. The failure to administer the scheduled pain medication as ordered resulted in unmanaged pain for the resident, as directly observed and reported by staff and the resident herself.
Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from misappropriation of controlled medications. The incident involved a resident who had an active order for Oxycodone HCL 5 mg, with 120 tablets delivered to the facility. The medication was signed in by two nurses and the pharmacy courier, but a subsequent audit revealed that one card of 30 tablets and its corresponding declining count sheet were missing from the medication cart and narcotic records. Multiple shift-to-shift controlled substance counts were documented as correct, but the discrepancy was discovered during a narcotic audit by the Assistant Director of Nursing (ADON), who noted inconsistencies between the electronic Medication Administration Record (eMAR) and the physical count sheets. Staff interviews and written statements indicated that the process for receiving and storing controlled substances involved two nurses and the pharmacy courier counting and signing for the medications. However, it was revealed that the nurses did not always physically verify the placement of the medications on the correct cart. The missing medication card and count sheet were not immediately detected, as shift-to-shift counts appeared correct, and the medication cards were sometimes used out of order. The ADON's investigation found that the number of narcotic cards and count sheets matched, but one card and its sheet could not be located after a thorough search. Further investigation led to the removal of a nurse from staffing after she refused to provide a statement or submit to a drug screen. The Director of Nursing (DON) and other staff conducted a full audit and investigation, confirming that no other residents' medications were missing and that all other counts were correct. The incident was reported to the facility administrator, and the nurse involved was reported to the Board of Nursing. The deficiency was substantiated by the inability to account for the missing controlled medication and the associated documentation.
Failure to Develop Timely Baseline Care Plan for Anticoagulant and Pain Management
Penalty
Summary
The facility failed to develop a baseline care plan that addressed a resident's anticoagulant therapy and pain medication within 48 hours of admission. The resident was admitted with a history of deep vein thrombosis, pulmonary embolism, avascular necrosis of the lower extremities, and was on chronic opiate therapy for pain. Admission orders included Xarelto for anticoagulation and both scheduled and PRN narcotic and non-narcotic pain medications. Despite these orders, the baseline care plan did not include goals or interventions for either anticoagulant therapy or pain management. Interviews with nursing staff and administration revealed that the baseline care plan was typically completed by the Unit Manager, who was not present on weekends. As a result, if a resident was admitted on a Friday evening, the baseline care plan would not be completed until the following Monday, unless the Unit Manager was available. In this case, the baseline care plan was not completed within the required timeframe due to the Unit Manager's absence and the facility's ongoing annual survey. The new weekend supervisor was not aware of the requirement to complete baseline care plans on weekends, contributing to the deficiency.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure accurate and updated daily nursing staff postings for 24 out of 154 days reviewed. On multiple occasions, the hours worked by the DON and ADON, both Registered Nurses (RNs), were not included in the daily postings unless they were directly administering medications, despite their presence for at least 8 consecutive hours. Additionally, there were discrepancies between the posted RN and CNA hours and the actual hours recorded in employee time sheets, resulting in underreporting or omission of staff hours on several days. The resident census was also omitted from the daily postings on several dates, and on one occasion, the posted staffing information was outdated and did not reflect the current date or staff on duty. Interviews with the Regional Clinical Manager and Administrator revealed a lack of awareness that DON, ADON, or Unit Supervisor RN hours should be included in the daily postings when no other RN was scheduled. Furthermore, nurses on duty were not informed or trained to update the daily nursing staff postings in the absence of the Regional Clinical Manager, leading to missed or inaccurate postings. The Administrator confirmed that the daily postings should be completed daily and accurately reflect staffing for each shift, including the resident census.
Delayed Pressure Ulcer Treatment and Incomplete Skin Assessments
Penalty
Summary
The facility failed to obtain timely treatment orders for pressure ulcers identified on a newly admitted resident, resulting in a seven-day delay before wound care was initiated. Upon admission, the resident was noted to have pressure ulcers on the right and left buttock and sacrum, with documentation indicating the skin was not intact and at moderate risk for further breakdown. However, the admission assessment and baseline care plan lacked complete information regarding the size, depth, and stage of the wounds, and no treatment orders were obtained or administered for the pressure ulcers during the first week of admission. Additionally, the facility did not perform accurate or consistent head-to-toe skin checks to identify new or existing pressure ulcers. Several skin assessments and daily skilled charting entries incorrectly documented the resident's skin as intact, despite the presence of pressure ulcers. The nurse responsible for the admission assessment did not measure the wounds or check for blanching, and later admitted to not being trained on the full process for new admissions or daily skilled charting. The Wound Care MD was not notified of the resident's wounds and did not evaluate the resident due to a rescheduled visit and lack of communication from the facility. Further observations revealed that wound care orders were not consistently followed, as the prescribed dressing was not always in place, and some wound care treatments were missed or not documented. A new deep tissue injury was later identified on the resident's left heel, which had not been previously documented. Interviews with staff indicated gaps in communication, training, and adherence to protocols for skin assessments and wound care, contributing to the delay in treatment and failure to prevent the development of new pressure ulcers.
Deficiencies in Food Storage, Labeling, and Infection Control in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and handling within the facility's dietary department. In the walk-in cooler, opened containers of chicken and beef base were found without use-by dates, and one container had an illegible date. Additionally, two apples with visible spoilage were stored with other apples. The Dietary Manager confirmed that these items should have been labeled with use-by dates and discarded if spoiled or past their expiration, and acknowledged that the apples showed clear signs of spoilage. The Administrator stated that all food items should be labeled, dated, and checked regularly for spoilage or expiration. In the dry storage room, opened bags of egg noodles and croutons were found undated, and a plastic bag of red potatoes in the walk-in cooler was also undated. The Regional Director of Operations and the Administrator both confirmed that all opened food items should be dated when opened, and that the Dietary Manager was responsible for ensuring compliance with this policy. In the walk-in freezer, an open box of hamburger patties was found uncovered and undated, which was also confirmed as non-compliant by facility leadership. Surveyors also observed infection control breaches by dietary staff. One dietary aide was seen removing ice from the ice machine with her bare hand, touching ice that remained in the machine, and placing the ice in her personal beverage. Another dietary aide was observed handling dirty dishes and then touching clean items in the kitchen without removing gloves and performing hand hygiene. Both the Regional Director of Operations and the Administrator confirmed that these actions were not in accordance with facility policy, which requires the use of an ice scoop and proper hand hygiene when moving from dirty to clean tasks.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement infection control policies during the provision of care to multiple residents requiring Enhanced Barrier Precautions (EBP) due to the presence of pressure ulcers. In several observed instances, nurse aides and nurses did not don gowns as required by EBP protocols when providing incontinence or wound care to residents with chronic wounds. Specifically, two nurse aides provided incontinence care to a resident with a pressure ulcer without wearing gowns, despite signage and available gowns at the door. These staff members also demonstrated a lack of understanding regarding the EBP signage and had not received education on when to use EBP precautions. Additionally, hand hygiene protocols were not followed during resident care activities. In one case, a nurse aide failed to remove soiled gloves and perform hand hygiene after cleaning stool and before touching other items in the resident's environment. In another instance, two nurse aides wore the same gloves throughout the process of cleaning a heavily soiled resident, applying a clean brief, and handling other items in the room, only removing gloves and performing hand hygiene upon exiting. Both staff members acknowledged that they were trained to remove gloves and perform hand hygiene after contact with body fluids but admitted to oversight during the observed care. Nurses also failed to don gowns when providing wound care to a resident on EBP, only correcting their actions after being prompted by a surveyor. Both nurses stated they had been trained on EBP but overlooked the signage and available PPE. Interviews with the Director of Nursing and the Administrator confirmed that staff were expected to follow EBP signage and hand hygiene protocols, including the use of appropriate PPE and hand hygiene after contact with body fluids.
Failure to Provide and Document Required ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several dependent residents, specifically in the areas of oral hygiene, nail care, and scheduled showers. One resident with moderate cognitive impairment and a self-care deficit was observed multiple times with a dirty upper denture and long fingernails with black debris. This resident reported not receiving assistance with denture care or oral hygiene due to missing supplies and lack of staff support, and was unable to locate a denture cup or brush. Staff interviews confirmed that oral hygiene was not provided as required, and nail care was either not offered or not documented as refused, despite visible buildup under the nails. Additionally, the same resident, along with two others, did not consistently receive scheduled showers. Documentation for showers was incomplete or missing, and staff interviews revealed that showers were often missed due to staffing shortages or lack of communication. Residents reported missing scheduled showers, with one stating that he was told he would not receive a shower due to insufficient staff, and another confirming that missed showers were not replaced with bed baths. Staff did not consistently document refusals or missed care, and did not always notify nursing leadership when showers were not provided as scheduled. The affected residents had significant physical or cognitive impairments, including quadriplegia and diabetes, requiring varying levels of assistance with ADLs. Observations and interviews indicated that the lack of assistance and documentation was a recurring issue, particularly on weekends or during periods of short staffing. The facility's failure to provide and document required ADL care, including oral hygiene, nail care, and showers, resulted in unmet care needs for multiple dependent residents.
Staffing Shortages Lead to Missed Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in missed or delayed assistance with bathing, incontinence care, and personal hygiene for four of eight sampled residents. Multiple staff interviews confirmed that staffing shortages, particularly on weekends, led to an inability to get residents out of bed, provide scheduled showers, and deliver timely incontinence and hygiene care. Staff reported that when short-staffed, their focus shifted to only essential tasks such as keeping residents clean, dry, and fed, with other care needs being delayed or omitted. Medication aides and nurses described being assigned to multiple halls and being unable to complete medication passes on time due to inadequate staffing. Nurse aides reported difficulty serving meals, making regular rounds, and responding promptly to call lights. The staffing scheduler and former interim DON acknowledged ongoing challenges with staff call-outs and no-shows, which left shifts uncovered despite efforts to use agency staff and administrative support. The facility's attempts to adjust shift lengths and scheduling practices did not consistently resolve the staffing gaps. Residents participating in a council meeting also voiced concerns about weekend staffing shortages, noting that showers were missed and call lights were answered more slowly. The administrator and staffing scheduler confirmed that the number of nurse aides and nurses on duty was often below the preferred minimums, especially on weekends and certain shifts, and that open positions remained unfilled. These staffing deficiencies directly resulted in unmet resident care needs as observed and reported during the survey.
Deficient Nursing Competency and Medication Management
Penalty
Summary
Nursing staff at the facility failed to demonstrate appropriate competencies and skills necessary to meet the individual care needs of residents. Specifically, a new nurse did not receive effective orientation on the facility's admission process, resulting in failure to obtain and document code status information, secure treatment orders for pressure ulcers, and complete accurate head-to-toe skin assessments. Additionally, a nurse aide did not report observed redness and irritation during catheter care, a nurse administered medications to the wrong resident, another nurse failed to request a prescription when refilling a controlled medication, and a nurse did not utilize available medication resources in the Pyxis system. These deficiencies were identified among five of eight staff reviewed for competency. The report details several resident care issues, including the lack of documentation of advanced directives and code status upon admission, a seven-day delay in treatment for pressure ulcers due to missing treatment orders, and incomplete wound assessments. One resident with a urinary catheter experienced skin breakdown and hygiene issues, with visible redness, irritation, and buildup of a white substance. Medication errors were also noted, including administration of another resident's medications and missed doses due to failure to request prescriptions and use available medication resources. These events were corroborated by record reviews, staff interviews, and observations.
Explore Popular Searches
