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)
Latest Citations in North Carolina
A resident with severe cognitive impairment was transported in a geriatric wheelchair by an OT who pulled the chair from behind, preventing the resident from seeing where he was going. This action did not respect the resident's dignity, as confirmed by staff interviews and facility training expectations.
A resident with Diabetes Mellitus II received daily insulin as ordered, but the MDS assessment did not accurately reflect the use of hypoglycemic medication during the required lookback period. Staff confirmed the omission was due to human oversight.
A resident with severe cognitive impairment had a family member designated as their Resident Representative (RR), but there was no documentation of care plan meetings or attempts to contact the RR since admission. The RR reported not being invited to participate in care planning and expressed a desire to be included. The Administrator, responsible for sending care plan invitations after the Social Worker left, could not provide evidence that the RR had been contacted.
A resident with a diagnosis of PTSD did not have a person-centered care plan addressing this condition, despite a trauma-informed assessment and staff awareness of potential triggers. Nursing staff confirmed that no care plan was developed for PTSD because the resident had not exhibited related problems since admission, resulting in a deficiency.
A resident with moderate cognitive impairment and chronic pain was found to be self-administering arthritis creams, antacid tablets, and cough drops kept at her bedside without a clinical assessment or physician orders. Facility staff, including nursing and administration, were unaware of the resident's possession and use of these medications, and no care plan or documentation addressed self-administration.
Two residents prescribed psychotropic medications did not have comprehensive care plans developed within the required timeframe after their assessments. Both had diagnoses such as dementia, anxiety, and depression, and their assessments triggered the need for care planning related to psychotropic medication use. Staff interviews revealed that care plans were not created due to human error and unclear responsibility among staff for updating care plans.
A nurse failed to provide privacy for a resident with severe cognitive impairment and an indwelling urinary catheter by leaving the door open and not pulling the privacy curtain during a catheter assessment, resulting in the resident being exposed and visible from the hallway while staff passed by.
A treatment cart containing wound care medications was left unlocked and unattended in a hallway, accessible to staff, visitors, and a resident. The cart contained topical medications that could be dangerous if accessed by residents. Additionally, Astelin nasal spray was found stored horizontally in two medication carts, contrary to manufacturer instructions requiring upright storage. Nursing staff were unaware of the proper storage requirements, and the DON confirmed expectations for compliance with manufacturer guidelines.
Two staff members failed to follow the facility's Enhanced Barrier Precautions policy by not wearing gowns while providing high-contact care to a resident with an indwelling urinary catheter. Both the nurse aide and the nurse performed catheter care and assessment using only gloves, despite the policy requiring both gowns and gloves for such procedures. Both staff later acknowledged the omission and recognized that gowns were required for this type of care.
Surveyors found that PTAC units in several rooms were not properly aligned or sealed, resulting in visible gaps to the outside and crumbled insulation. In one room, water leakage from a misaligned unit led to wet, soiled linens beneath it. Maintenance staff had recently reinstalled the units after electrical work but failed to secure them correctly, and facility leadership was unaware of the issue until the survey.
Resident Transported in Wheelchair Without Regard for Dignity
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired, was transported in a geriatric wheelchair by an occupational therapist (OT) in a manner that did not honor the resident's right to dignity. The OT pulled the wheelchair from behind, positioning the resident so that he was unable to see where he was being taken. This action was observed by surveyors and was confirmed during interviews with the OT, who stated she was unaware that this method of transport was a dignity issue and explained she pulled the chair because it was difficult to push. The resident had an active order for occupational therapy evaluation and treatment. The incident was witnessed during a routine observation, and the OT involved was an agency staff member who had received facility training on treating residents with dignity and respect. The Rehabilitation Manager and the DON both acknowledged that staff should have known this method of transport was inappropriate and a concern for resident dignity.
Failure to Accurately Code MDS for Hypoglycemic Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the area of hypoglycemic medication use. The resident was admitted with a diagnosis of Diabetes Mellitus II and had active physician orders for both long-acting and sliding scale insulin, which were administered daily as documented in the Medication Administration Record. Despite this, the resident's admission MDS assessment did not reflect the use of hypoglycemic medications, including insulin, during the required 7-day lookback period. Staff interviews confirmed that the omission was due to human oversight and that the MDS should have been coded to indicate the resident's receipt of hypoglycemic medication. The deficiency was identified through record review and staff interviews, which established that the resident received insulin as ordered but the MDS assessment failed to accurately capture this information.
Failure to Include Resident Representative in Care Planning
Penalty
Summary
The facility failed to include the Resident Representative (RR) of a severely cognitively impaired resident in the care planning process. The resident, who was admitted with severe cognitive impairment, had a family member designated as her RR. Review of the medical record showed that the care plan was last revised on 8/18/25, but there was no documentation of care plan meetings, attempts to contact, or conversations with the RR since admission. During a telephone interview, the RR stated he did not recall being invited to any care plan meetings and expressed a desire to be included. The Administrator confirmed that, following the departure of the Social Worker in June 2025, she was responsible for sending care plan meeting invitations but could not provide documentation that the RR had been invited for this resident.
Failure to Develop Person-Centered Care Plan for PTSD Diagnosis
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), despite the resident having a documented history of PTSD, delusional disorders, mood disorder, and major depressive disorder. A trauma-informed assessment was completed, and the resident was found to be cognitively intact with no behaviors noted during the assessment period. However, review of the care plan revealed there was no plan of care addressing the resident's PTSD diagnosis. Staff interviews confirmed that while the resident had some behaviors such as refusal of care and paranoid behavior, these were care planned separately and not specifically linked to PTSD. Nursing staff, including the MDS Nurse and the Director of Nursing, acknowledged that a person-centered care plan should have been developed for the resident's PTSD, including identification of triggers such as loud noises. The MDS Nurse stated that a care plan was not created because the resident had not exhibited any PTSD-related problems since admission. Despite this, the expectation was that staff should be aware of appropriate interventions should a PTSD episode occur. The lack of a specific care plan for PTSD constituted the deficiency identified during the survey.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, resulting in the resident keeping several medications at her bedside without clinical evaluation or physician orders. The resident, who was moderately cognitively impaired and had diagnoses including non-Alzheimer's dementia and chronic pain syndrome, stored and self-administered arthritis cream with 25% capsaicin, arthritis pain relief gel with 2% menthol, chewable antacid tablets, and cough drops. There was no documentation in the medical record of an assessment for self-administration, no physician orders for these medications, and no care plan addressing self-administration. Multiple staff members, including a nurse, unit manager, nurse aide, DON, and the administrator, were unaware that the resident kept and used these medications at her bedside. The nurse reported applying arthritis cream from the medication cart, but was unaware of the resident's personal supply. The DON and administrator confirmed that no assessment for self-administration had been conducted and were unsure how the facility would have known about the medications at the bedside. The lack of assessment and oversight led to the deficiency.
Failure to Timely Develop Comprehensive Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days of completing the comprehensive assessment for two residents who were prescribed psychotropic medications. For one resident with non-Alzheimer's dementia, anxiety, and major depressive disorder, the admission MDS assessment indicated the use of antianxiety and antidepressant medications, and the Care Area Assessment (CAA) was triggered for psychotropic medication use. However, the comprehensive care plan created did not address psychotropic medication use. Staff interviews revealed that the care plan was not created due to human error, and there was confusion among staff regarding responsibility for care plan updates. Similarly, another resident with anxiety, depression, and Alzheimer's dementia was prescribed antianxiety medication, and the CAA was triggered for psychotropic medication use. The care plan for this resident also failed to address psychotropic medication use. Staff interviews indicated that the lack of a clearly identified person responsible for updating care plans after new medication orders contributed to the deficiency. Both the DON and Administrator acknowledged that psychotropic medication use should have been included in the care plans for these residents.
Failure to Provide Privacy During Catheter Assessment
Penalty
Summary
Nurse #2 failed to provide personal privacy for a resident with severe cognitive impairment and an indwelling urinary catheter during a catheter assessment. The nurse entered the resident's room, applied gloves, and proceeded to pull up the resident's gown and pull down his brief to assess the catheter insertion site without closing the door or pulling the privacy curtain. As a result, the resident's bare stomach and penis were visible from the hallway, and staff were observed passing by the open door during the assessment. Prior to this, a nurse aide had performed catheter care for the same resident, closing the door but not pulling the privacy curtain. The resident was in the bed closest to the door, with a roommate present whose privacy curtain was closed. After noticing bloody urine in the catheter tubing, the nurse aide informed Nurse #2, who then entered the room and conducted the assessment without ensuring privacy, leading to the resident's exposure.
Unsecured Treatment Cart and Improper Medication Storage
Penalty
Summary
Surveyors observed that a treatment cart containing medications used for wound care was left unattended and unlocked in a hallway for 25 minutes. During this time, no staff were present with the cart, and several staff members, visitors, and a resident in a wheelchair passed by the unlocked cart. Upon inspection, the cart was found to contain several topical medications, including antiseptic solution, medical grade honey, hydrocortisone cream, corticosteroid cream, and a cream for skin conditions. The Wound Care Nurse acknowledged forgetting to lock the cart and confirmed that these medications could be dangerous if accessed by a cognitively impaired resident. Both the DON and the Administrator confirmed that the cart should have been locked at all times when not in use, as the medications could pose a danger if ingested. Additionally, surveyors found that Astelin nasal spray, which must be stored upright according to manufacturer instructions, was stored horizontally in two separate medication carts. Nurses responsible for these carts admitted they had not read the manufacturer's instructions and were unaware of the proper storage requirements. The DON stated that nursing staff are expected to check carts and follow all manufacturer guidelines for medication storage, including storing the nasal spray upright if indicated.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to its infection control policy regarding Enhanced Barrier Precautions (EBP) during high-contact care for a resident with an indwelling urinary catheter. During an observation, a nurse aide entered the resident's room, washed her hands, and applied gloves but did not don a gown, despite gowns being available and required by the facility's EBP policy for catheter care. The nurse aide proceeded to provide catheter care, noted the presence of bloody urine, and completed the task without ever applying a gown. Upon interview, the nurse aide acknowledged forgetting to put on the gown and recognized, after reviewing the posted signage, that a gown was required for this type of care. A similar observation occurred with a nurse who assessed the same resident's indwelling urinary catheter. The nurse entered the room, washed her hands, and applied gloves but did not wear a gown while lifting the resident's gown and lowering the brief to assess the catheter insertion site. After completing the assessment, the nurse disposed of her gloves and washed her hands. In an interview, the nurse admitted to forgetting to apply a gown and confirmed that it was required for catheter care. Both the Staff Development Coordinator and the Director of Nursing confirmed that the staff should have worn gowns during these high-contact care activities, as outlined in the facility's EBP policy.
Failure to Properly Seal and Install PTAC Units in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to properly install and seal packaged terminal air conditioners (PTACs) in four out of eight resident rooms reviewed across three of four halls. In multiple rooms, the PTAC units were not aligned with the wall, resulting in gaps ranging from one to two inches at the top of the units. These gaps allowed daylight from the exterior to be visible from inside the rooms, and the insulation present was found to be crumbled or in poor condition. In one room, wet, soiled towels and sheets with brown stains were found underneath the PTAC unit, which was leaning inward and not sealed to the wall. During a facility tour with the Maintenance Director, Regional Maintenance Director, and the Administrator, it was confirmed that the PTAC units remained improperly installed and the gaps persisted. The maintenance staff indicated that the PTAC units had been removed and reinstalled recently to replace electrical cords, but only the middle screws were secured during reinstallation, leaving the units misaligned. The facility leadership was not previously aware of these issues until the surveyors' observations.
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.
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