Citations in North Dakota
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in North Dakota.
Statistics for North Dakota (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in North Dakota
A resident with severe cognitive impairment and a history of sexually inappropriate behaviors engaged in unwanted sexual contact with another resident while both were self-mobilizing in wheelchairs. Despite care plan interventions requiring staff to monitor and intervene, the incident occurred, resulting in a failure to protect residents from abuse as required by facility policy.
A resident with severe expressive aphasia and anxiety disorder, dependent on staff for toileting, was left on a bedside commode for approximately six hours without the call light within reach or regular checks by CNAs. This resulted in skin discoloration to the buttocks and a wrist bruise from attempting to get help, as the care plan requiring call light placement and monitoring was not followed.
A resident with severe expressive aphasia and dependent on staff for toileting was left on a bedside commode for an extended period, resulting in skin redness and a bruise from attempting to get help. The incident, which met the facility's criteria for reporting suspected neglect, was not reported to the State Survey Agency as required by policy.
Staff did not use required safety straps on bath chairs for two residents needing assistance during bathing, resulting in a fall and hip fracture for one resident and leaving another unsecured in a whirlpool tub. The facility's policy required safety belts to be used at all times, but staff failed to follow this protocol and did not perform a nursing assessment after the fall.
A resident sustained a left hip fracture after falling from a bath chair when not secured with a safety strap during bathing. CNAs transferred the resident from the floor using a mechanical lift without prior nursing assessment, and the facility's investigation omitted key details from staff interviews regarding the incident and staff actions.
Staff did not follow established protocols after a resident with dementia and mobility deficits fell from a bath chair and sustained a hip fracture. CNAs moved the resident using a mechanical lift before a nurse performed a full-body assessment, and later used a sit-to-stand lift not included in the care plan. The nurse's assessment was limited to a skin check and basic observation, failing to meet policy requirements for post-fall evaluation.
A resident was injured during van transport when the shoulder strap seatbelt was not secured due to distraction during conversation with the transporter. The resident fell from the wheelchair after the van stopped abruptly, resulting in a leg fracture and subsequent hospitalization. Although van drivers had completed required training and other residents reported feeling safe, the necessary supervision and use of safety devices were not provided in this incident.
Two residents with pressure ulcers did not receive consistent repositioning or timely application of protective devices as ordered, and staff failed to document these interventions. One resident's care plan was not updated to include a repositioning schedule for nearly a month after deep tissue injuries were identified, and there were significant delays in coordinating wound care referrals, resulting in deterioration of wounds and hospitalization.
Two residents with severely impaired cognition, one with a documented history of inappropriate sexual behaviors, were involved in an incident of nonconsensual sexual contact after staff failed to provide adequate monitoring and timely psychiatric intervention, despite existing care plan interventions and known behavioral risks.
Facility staff did not report an incident of nonconsensual sexual contact between two residents, both with severely impaired cognition, to the State Survey Agency as required by policy. Administrative staff confirmed the failure to report the event, which involved one resident being found naked and straddling another resident with his hand in the other's brief.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of sexually inappropriate behaviors, including explicit comments and inappropriate touching due to dementia, engaged in unwanted sexual contact with another resident. The incident took place as both residents were self-mobilizing in their wheelchairs after breakfast, when the resident with dementia reached out and cupped the other resident's breast and blew kisses at her. The care plan for the resident with dementia included instructions for staff to be observant of his interactions with others, intervene as necessary to protect the rights and safety of others, and remove him from situations as needed. Despite these care plan interventions, the incident occurred, indicating a failure to ensure adequate supervision and protection for residents from abuse. The resident who experienced the unwanted contact had intact cognition but expressive aphasia, and was able to confirm the inappropriate touching during a social worker interview. She did not express fear or a lack of safety following the incident. The facility's policy clearly stated that every resident has the right to be free from abuse, but this right was not upheld in this instance.
Failure to Follow Care Plan for Toileting and Call Light Placement
Penalty
Summary
Staff failed to follow the care plan for a resident with severe expressive aphasia and anxiety disorder, who was dependent on staff for toileting. The care plan specifically required that the call light be secured to the bedside commode and within reach when the resident was toileting. On the evening in question, two certified nurse aides transferred the resident to the bedside commode but did not place the call light within reach and did not check on the resident for approximately six hours. As a result of these actions, the resident was found on the commode after an extended period, with blanchable redness to both buttocks, a light purple area on the right buttock, and a bruise on the left wrist, which was attributed to the resident banging on the wall for assistance. The resident, who was unable to verbalize needs due to aphasia, was left without a means to call for help and was not monitored as required by the care plan.
Failure to Report Suspected Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect to the State Survey Agency as required by its own policy and federal regulations. A resident with a history of anxiety disorder and severe expressive aphasia, who was dependent on staff for toileting, was found left on a bedside commode for an extended period of time. The care plan for this resident specified the need to ensure the call light was secured and within reach during toileting due to impaired communication. A progress note documented that the resident was found with blanchable redness to both buttocks, a light purple area on the right buttock, and a bruise on the left wrist, which was attributed to the resident banging on the wall for assistance. The resident denied pain and showed no signs or symptoms of pain at the time of assessment. Despite these findings, the facility did not report the incident to the State Survey Agency as required by their policy, which mandates immediate reporting of all alleged violations of abuse or neglect. An administrative nurse confirmed during an interview that the incident was not reported. The failure to report this incident constitutes a deficiency in the facility's compliance with abuse and neglect reporting requirements.
Failure to Use Bath Chair Safety Straps and Provide Adequate Supervision During Bathing
Penalty
Summary
Staff failed to provide appropriate supervision and use of assistive devices for two residents who required assistance during bathing. Specifically, staff did not utilize the bath chair safety strap as required by facility policy, which states that safety belts must be used for bathing units and lifts to reduce the risk of injury. One resident, who had impaired balance, limited mobility, and required staff assistance for bathing and transfers, was not secured with the safety strap during a bath. As a result, the resident fell from the bath chair and sustained a left femoral neck (hip) fracture. The incident was confirmed through staff interviews, medical record review, and facility-reported incident documentation. Another resident, who was dependent on staff for bathing and required substantial assistance with transfers, was observed seated in a whirlpool tub with the safety strap not secured. The staff member present stated that the strap had been removed because the resident was sliding down in the chair and admitted to forgetting to reapply it. These actions were in direct violation of the facility's bathing policy and the expectation that the safety belt should always be secured when residents are in the bath chair. Additionally, after the fall, staff failed to perform a nursing assessment prior to moving or assisting the resident off the floor. Interviews with staff revealed inconsistencies in the use of the safety belt and the process followed after the fall. The lack of adherence to safety protocols and failure to assess the resident post-fall contributed to the deficiency identified by surveyors.
Failure to Investigate and Document Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate and document an alleged violation of neglect involving a resident who fell from a bath chair and sustained a left femoral neck (hip) fracture. The incident occurred when the resident was not secured in the bath chair with the safety strap during bathing. The certified nurse aide (CNA) responsible for the resident admitted to not using the safety strap, and the resident fell after reaching for the door on the tub. Following the fall, the CNAs used a mechanical lift to transfer the resident from the floor back to the bath chair without a nurse's assessment, and then later transferred the resident to her wheelchair using a sit-to-stand lift. Staff interviews revealed inconsistencies and omissions in the facility's investigation. The CNAs involved described the sequence of events, including the lack of use of the safety strap and the delay in obtaining additional help. The nurse who later entered the room was informed of the fall only after noticing a lift sheet under the resident and questioning the situation. Nursing progress notes documented the fall, the resident's subsequent pain, and the eventual transfer to the hospital for evaluation and treatment of the hip fracture. The facility's internal investigation did not include all relevant details discovered during staff interviews, such as the failure to secure the resident in the bath chair and the improper transfer of the resident post-fall without prior nursing assessment. The investigation summary concluded there was no willful intent to neglect, attributing the fall to the resident's spontaneous movement, but failed to address the staff actions and omissions that contributed to the incident.
Failure to Follow Post-Fall Assessment and Safe Transfer Protocols
Penalty
Summary
Staff failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall from a bath chair. The facility's policy required that after a fall, the resident should not be moved and a licensed nurse must perform a full-body assessment to determine injury before any transfer. However, after the resident fell from the bath chair and sustained a left femoral neck (hip) fracture, certified nurse aides (CNAs) moved the resident from the floor back to the bath chair using a mechanical lift without waiting for a nurse to assess the resident. The CNAs reported waiting for help for 10-15 minutes before transferring the resident themselves, and only after the transfer did a nurse arrive to perform a skin check and basic assessment. The resident involved had a history of dementia, impaired balance, limited mobility, and weakness, and required assistance of two with a gait belt for transfers. The care plan did not include the use of a sit-to-stand lift, which was used by staff following the incident. The nurse did not perform a full-body assessment prior to the transfer, as required by policy, and the transfer method used was not part of the resident's care plan or assessed for safety. These actions and inactions resulted in a failure to follow established protocols for post-fall assessment and safe transfer, potentially contributing to further injury and pain for the resident.
Failure to Secure Resident with Seatbelt During Van Transport Results in Injury
Penalty
Summary
A deficiency occurred when a resident was being transported back to the facility in a van and was not properly secured with the shoulder strap seatbelt. The transporter and the resident were engaged in conversation while the transporter was securing the wheelchair to the floor of the van, resulting in both parties forgetting to secure the seatbelt that crosses over the resident. During the trip, the van had to stop abruptly at a stoplight, causing the resident, who was leaning forward in the wheelchair, to fall out. The resident sustained an abrasion, bruising, swelling to the right knee, and complained of shooting pain from the knee to the hip, which led to a hospital admission and surgery for a fractured femur. Review of the facility's records and interviews confirmed that the transporter did not realize the shoulder strap was not secured until after the resident fell. Documentation showed that all van drivers had completed competency verification and training prior to becoming transporters, and interviews with other residents indicated that they typically felt safe and were secured with the crossover belt during transport. However, in this instance, the required supervision and use of assistance devices to prevent accidents were not provided, directly resulting in the resident's injury.
Failure to Prevent Worsening of Pressure Ulcers and Delayed Wound Care Referrals
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent the worsening of pressure ulcers for two residents with existing pressure ulcers. For one resident admitted with pressure ulcers to the left ankle and sacrum, the care plan included interventions such as encouraging and assisting with turning, and physician orders required repositioning every two hours and the use of protective boots while in bed. However, the medical record did not show evidence that staff consistently repositioned the resident or applied the protective boots as ordered. An administrative staff member confirmed the lack of documentation for these interventions. For another resident admitted with a diagnosis of spinal cord compression, the initial physician's orders did not identify or address pressure ulcers. Four days after admission, deep tissue injuries to both buttocks were identified, and wound care orders were obtained the following day. The care plan was not updated to include a repositioning schedule until approximately one month after the injuries were first noted, despite wound assessments recommending repositioning every 2-3 hours. The medical record lacked evidence that staff implemented the recommended repositioning schedule. Additionally, the facility failed to process and coordinate timely referrals for wound care. There were delays in following up on wound clinic referrals, and the provider did not evaluate the resident's wound during a bedside visit. The resident's wounds deteriorated, progressing to a stage 4 pressure injury with acute cellulitis, and required hospitalization. The facility also did not provide a policy for processing referrals to outside agencies, contributing to the delay in wound care follow-up.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from nonconsensual sexual contact, resulting in a deficiency related to abuse prevention. According to the report, one resident with a diagnosis of Alzheimer's disease and severely impaired cognition was found in another resident's room. The second resident, also with severely impaired cognition and a documented history of inappropriate sexual behaviors, was observed naked and straddling the first resident, with his hand inside her brief. Staff discovered the incident when a registered nurse and a certified nurse aide were searching for the first resident, who was known to wander into other rooms. Prior to the incident, the care plan for the resident with a history of inappropriate sexual behaviors included interventions such as observing interactions with female residents, separating residents if necessary, and providing supervised socialization. There was also documentation of recent increased sexualized behaviors, including exposing genitalia and fondling himself in front of staff. A request for psychiatric evaluation had been made due to these behaviors, but the psychiatric visit did not occur until after the incident. The facility's policy stated that residents must not be subjected to abuse by other residents. Despite this, the interventions in place were not sufficient to prevent the incident of nonconsensual sexual contact. The failure to implement effective monitoring and timely psychiatric intervention contributed to the occurrence of abuse between the two residents, both of whom had severely impaired cognition and were vulnerable to such incidents.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
Facility staff failed to report an incident of resident-to-resident sexual abuse to the State Survey Agency as required by facility policy. The incident involved two residents, both with severely impaired cognition as identified in their admission Minimum Data Sets. One resident with Alzheimer's disease and psychotic disturbance was found fully clothed on a bed in another resident's room, while the other resident was naked, straddling the first resident, and had his hand in the other's brief. Despite the facility's policy mandating immediate reporting of alleged or suspected abuse to designated agencies, including the State Survey and Certification Agency, administrative staff confirmed that the incident was not reported.
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